Every finding on record at Aurelia Osborn Fox Memorial Hospital

Based on record review and interview conducted during a recertification and complaint (Case # NY00345612) survey from [DATE] to [DATE], the facility failed to ensure residents were free from neglect for one (1) (Resident #109) of 23 residents reviewed. Specifically, Resident #109 was assessed by physical therapy on [DATE] as having total dependence on staff and required maximum assistance of two (2) staff members for bed mobility. As a result of the facility's lack of communication for updating the care plan to incorporate the physical therapy assessment, Resident #109 rolled out of bed and suffered a fractured (broken) hip while receiving care from one (1) staff member on [DATE] at 5:05 PM. The failure to provide required staff services and oversight to meet the resident's needs resulted in actual harm to Resident #109 that was not Immediate Jeopardy. This is evidenced by: The facility's policy and procedure titled, Resident Abuse Reporting, last revised [DATE] and last reviewed [DATE], documented the following: All nursing home residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of resident property. All reports of resident abuse, neglect and injuries of an unknown origin shall be promptly and thoroughly investigated by facility management. 'Neglect' means failure to provide timely, consistent, safe, adequate and appropriate services, treatment and/or care to a Nursing Home resident. These services include nutrition, medication, therapies, sanitary clothing and surroundings, and activities of daily living. The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The facility's policy and procedure titled, Comprehensive Care Plans, last reviewed ,d+[DATE], documented the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with their rights. Care plans will include measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. Within 14 days of admission, quarterly and with each significant change, the Inter-Disciplinary Care Plan Team will conduct appropriate assessments, including those in the Minimum Data Set, to determine each resident's physical, mental and psychosocial needs. Assessments will identify strengths, weaknesses, preferences, abilities, and needs and take into consideration the resident's wishes and goals. Charge nurses are responsible for noting all resident changes (including medications, treatments and behaviors) on the 24-hour report. A nurse is designated at each interdisciplinary Tier II morning huddle to document pertinent reported changes on the Daily Changes Report for Care Planning Log. Each item noted will be addressed in the individual's care plan as indicated as soon as possible. Resident #109 was admitted to the facility with diagnoses of generalized osteoarthritis (when the cartilage that cushions the ends of bones in the joints gradually wears away), transient ischemic attacks (a short period of symptoms similar to those of a stroke), and repeated falls. The Minimum Data Set (an assessment tool) dated [DATE] documented the resident could understand and be understood by others. The comprehensive care plan titled Activities of Daily Living, last revised [DATE], documented Resident #109 required assistance with Activities of Daily Living task performance as follows: Effective [DATE], Resident #109 required supervision at mealtime; partial moderate one (1) staff member assist for bed mobility; partial moderate one (1) staff member assist for grooming, bathing and dressing. Partial/moderate one (1) staff member assist for transfers and toileting. Non-ambulatory. Review of an electronic medical record entry titled Physical Therapy Evaluation and Treatment certification period [DATE] to [DATE] documented start of care [DATE] and the following: The Functional Mobility Assessment revealed the resident required total dependence with assistance of two (2) staff members for bed mobility. Physical Therapy clinical impressions documented Resident #109 exhibited increased weakness and instability with functional mobility, and a condition of hypotension (low blood pressure), which could further put the resident at risk for falls. The Treatment Administration Record documented resident requires assistance of two (2) staff members for bed mobility. Review of an electronic medical record entry titled, Physical Therapy Treatment Encounter, dated [DATE], documented Resident #109 required maximum assistance by two (2) staff members for bed mobility including transitioning from lying on their back to sitting, and for repositioning. There was no documented evidence the resident's care plan was updated to include that the resident required two (2) staff members for bed mobility. Incident and Accident report dated [DATE] at 5:05 PM, documented Certified Nurse Aide #1 stated Resident #109 was falling out of bed when in resident's room. They tried to stop resident from falling and they both went to the floor. Resident landed on their left side. Progress notes dated [DATE] at 5:37 PM written by Resident Nurse #2 documented Certified Nurse Aide #1 was getting Resident #109 out of bed and resident rolled and started to fall. Certified Nurse Aide #1 eased resident to the floor. The facility's Investigation and Summary report dated [DATE], documented the following: Resident #109 had a fall incident on [DATE] at 5:05 PM when one (1) staff member provided bed repositioning during incontinence care. Specifically, Certified Nurse Aide #1 assisted Resident #109 with incontinence care in bed. The report documented that Certified Nurse Aide #1 rolled Resident #109 toward them, too close to the edge of the bed. This resulted in Resident #109's head hanging over the edge of the bed, and legs and feet over the side of the bed in a 'V' shape. Certified Nurse Aide #1 was unable to place the resident back into their bed, as most of Resident #109's body weight was leaning on Certified Nurse Aide #1. The report documented that Certified Nurse Aide #1 then lost their balance as they tried to lower Resident #109 to the floor, and both landed on the floor; Resident #109 landed on their left side. Registered Nurse #1 walked by after the incident and heard resident #109 say Ouch. Registered Nurse #1 notified Registered Nurse #2. Resident #109 was assessed as having a singular complaint of pain to their right elbow. Resident #109 reported their pain increased several hours later. The on-call provider was notified. The resident was transferred to the hospital. A progress note dated [DATE] at 10:35 PM by Registered Nurse #3 documented Resident #109 was observed in process of evening care on left lateral position (lying on their side) and inquired if they were in pain. Resident #109 claimed a sharp pain on their right hip with 10 on scale of 1 to 10, with 10 as the worst pain. Upon palpation (medical examination technique that involves using the hands or fingers to feel and assess the condition of an organ or body part) of the pelvic area, resident was moaning of severe pain. Tylenol was given. Covering provider notified of assessment and ordered to transfer resident to the emergency room for further evaluation and management. The Hospital Discharge Summary dated [DATE], documented the following: Resident #109 presented to the hospital after a fall with femoral neck fracture (broken hip), septic shock (infection in the body causing extremely low blood pressure and organ failure), myocardial infarction (heart attack), and respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide in the blood). After family notification and discussion, Resident #109 was placed on comfort care measures and expired at the hospital. Interviews: During an interview on [DATE] at 3:14 PM, Director of Nursing #1 stated there was no suspicion of abuse or neglect tied to the [DATE] incident. They stated that they conducted a limited investigation and determined that there was no violation of Resident # 109's care plan. They further stated that Resident #109 did not return to the facility after being transferred to the hospital. Director of Nursing #1 stated they did not follow up with staff for training and/or education on falls following the [DATE] incident. During an interview on [DATE] at 11:33 AM, Rehabilitation Director #1 stated Resident #109 was discharged from Physical Therapy on [DATE]. They further stated that at the time of discharge, Resident #109's bed mobility was at a maximum assist requiring two (2) staff members, also known a total dependence. During an interview on [DATE] at 11:45 AM, Director of Nursing #1 stated after physical therapy assessed a resident and updated a resident's treatment plan, they would bring a written document of it to nursing staff. Director of Nursing #1 stated that it was the responsibility of the nurse manager or nursing supervisor to update the resident's care plan. They further stated that the [DATE] Physical Therapy note for Resident #109 was not updated in the care plan to indicate that the resident was a maximum assistance with two (2) staff members for bed mobility. During an interview on [DATE] at 11:30 AM, Director of Nursing #1 stated Physical Therapy was to provide documentation after their assessment of a resident, and the resident's care plan would be updated accordingly. They further stated that all care plans were reviewed and updated quarterly, if needed. 10 New York Codes, Rules, and Regulations 415.4(b)

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents were not assisted with care when requested, staff complained of not able to complete all the required tasks assigned and provide resident care, and the staffing sheets provided while on site did not accurately reflect the needs of the facility population. This is evidenced by: Facility Assessment The facility assessment dated ,d+[DATE] documented that the staffing plan was based on the resident population and their needs for care and support. The staffing plan documented the following daily staffing needs: Average daily census: 103 (Unit 1 with 1-24 residents, Unit 2 with 2-45 residents, Unit 3 with 3-34 residents). The total facility's certified beds numbered 130, with one respite bed (Unit 1 with 1-40, Unit 2 with 2-46, Unit 3 with 3-45). Per shift, per unit, the number of minimum staff required were as follows: Days: Unit 1 required 1 nurse and 2 Certified Nurse Aides; Unit 2 required 2 nurses and 4 Certified Nurse Aides; Unit 3 required 2 nurses and 3 Certified Nurse Aides. Evenings: Unit 1 required 1 nurse and 2 Certified Nurse Aides; Unit 2 required 1.3 nurses and 4 Certified Nurse Aides; Unit 3 required 1.3 nurses and 3 Certified Nurse Aides. Nights: Unit 1 required 1 nurse and 1 Certified Nurse Aide; Unit 2 required 1 nurse and 2 Certified Nurse Aides; Unit 3 required 1 nurse and 2 Certified Nurse Aides. [Note: Where Days = 7:00 AM to 3:00 PM, Evenings = 3:00 PM to 11:00 PM, Nights = 11:00 PM to 7:00 AM] Observations: Upon entrance to the facility on [DATE] there were 108 residents residing on 3 units and at no time was the facility census less than 105 residents in the building. During general observations on 4/14/2025 at 11:00 AM, a strong odor of feces was noted in the hallway near room [ROOM NUMBER]. During general observations on 4/15/2025 at 9:30 AM, a strong odor of feces was noted in the 100-unit common room. A Licensed Practical Nurse was made aware and stated that they would tell the aide. After twenty minutes, no care had been provided. Director of Nursing #1 was notified, and they sent a Certified Nurse Aide to assist. During an observation on 4/15/2025 at 10:58 AM, the call bell for room [ROOM NUMBER] was noted to have been on for a number of minutes and was not answered until 11:15 AM by a Licensed Practical Nurse who asked the resident in the room what they needed. The resident stated they needed to go to the bathroom. The Licensed Practical Nurse stated they would be right back, turned off the resident's light, went down the hall, turned off the call bell light going off in room [ROOM NUMBER], and then returned to room [ROOM NUMBER] to provide care. During general observations on 4/16/2025 at 10:49 AM, a foul odor was noted in the Unit 2 hallway near room [ROOM NUMBER] and 208. During general observations on 4/17/2025 at 10:34 AM, a strong urine odor was noted throughout the 200-unit hallways. Staffing Sheets: A review of staffing sheets provided by the facility from 4/14/2025 through 4/22/2025 documented the following: On 4/18/2025, evening shift, Unit 2 and Unit 3 each had only 1 nurse scheduled to work. On 4/19/2025, evening shift, Unit 3 only had 1 nurse scheduled to work, requiring the nurse supervisor to take a cart assignment. On 4/20/2025, evening shift, Unit 3 only had 1 nurse scheduled to work, requiring the nurse supervisor to take a cart assignment. On 4/21/2025, evening shift, Unit 2 had 1 nurse scheduled, and Unit 3 did not have any nurses scheduled to work on the unit. Based on facility census, there were not the required number of Registered Nurses or Licensed Practical Nurses on 4/20/2025, and 4/21/2025. On 4/20/2025, the facility census was 105. There were 14 licensed nurses (Licensed Practical Nurses and Registered Nurses) scheduled to work on that day. The required hours of licensed care for the facility were 115.5 hours based on the census. The licensed staff scheduled accounted for 112 hours of care. On 4/21/2025, the facility census was 108. There were 14 licensed nurses scheduled to work on that day. The required hours of licensed care for the facility were 118.8 hours based on the census. The licensed staff scheduled accounted for 112 hours of care. A review of staffing sheets provided by the facility from 4/14/2025 through 4/21/2025 documented the following: Based on facility census, there were not the required number of Registered Nurses or Licensed Practical Nurses on 4/20/2025 and 4/21/2025. To fulfill the staffing requirement for licensed nursing care (Registered Nurses and Licensed Practical Nurses) per resident per day, a facility with a census of 108 would need to schedule at least 15 staff members with nursing licenses for the entire day. On 4/20/2025, the facility census was 105. The number of scheduled nurses was 14 which equaled 112 hours of nursing care hours. The number of nursing care hours required for a census of 105 residents would be 115.5 hours. On 4/21/2025, the facility census was 108. The number of scheduled nurses was 14 which equaled 112 hours of nursing care hours. The number of nursing care hours required for a census of 108 resident would be 118.8 hours. Based on facility census, there were not the required number of Certified Nurse Aides on any day between 4/14/2025 through 4/21/2025. To fulfill the staffing requirement for Certified Nurse Aide care per resident per day, a facility with a census of 108 would need to schedule at least 33 staff members with Certified Nurse Aides certifications for the entire day. On 4/14/2025, the facility census was 108. The number of scheduled Certified Nurse Aides were 27 which equaled 216 hours of nursing care hours. The number of nursing care hours required for a census of 108 residents was 264.6 hours. On 4/15/2025, the facility census was 108. The number of scheduled Certified Nurse A ides was 30 which equaled 240 hours of nursing care hours. The number of nursing care hours required for a census of 108 residents was 264.6 hours. On 4/16/2025, the facility census was 106. The number of scheduled Certified Nurse Aides were 28 which equaled 224 hours of nursing care hours. The number of nursing care hours required for a census of 106 residents was 259.7 hours. On 4/17/2025, the facility census was 108. The number of scheduled Certified Nurse Aides were 29 which equaled 232 hours of nursing care hours. The number of nursing care hours required for a census of 108 resident was 264.6 hours. On 4/18/2025, the facility census was 108. The number of scheduled Certified Nurse Aides were 30 which equaled 240 hours of nursing care hours. The number of nursing care hours required for a census of 108 resident was 264.6 hours. On 4/19/2025, the facility census was 108. The number of scheduled Certified Nurse A aides were 27 which equaled 216 hours of nursing care hours. The number of nursing care hours required for a census of 108 resident was 264.6 hours. On 4/20/2025, the facility census was 105. The number of scheduled Certified Nurse Aides were 26 which equaled 208 hours of nursing care hours. The number of nursing care hours required for a census of 105 resident was 257.25 hours. On 4/21/2025, the facility census was 108. The number of scheduled aides were 27 which equaled 216 hours of nursing care hours. The number of nursing care hours required for a census of 108 resident would be 264.6 hours. Interviews: During an interview on 4/14/2025 at 12:25 PM, Certified Nurse Aide #3 stated that the facility had lost a lot of staff and even though there was a sign on bonus offered, staffing was still an issue, especially on the weekend. Certified Nurse Aide #3 stated that resident care was affected by the staffing issues because staff only had enough time to do the bare minimum tasks like feeding and changing residents. To the best of their knowledge, residents were not left sitting in soiled clothing, but the work ethic of some of the staff was lacking. During an interview on 4/18/2025 at 10:53 AM, Licensed Practical Nurse #1 stated there were not enough staff on the unit. They stated Unit 2 was the hardest unit in the building and four (4) staff on the unit was not enough. Multiple residents required two (2)-person assistance and the staff struggled to get to everyone in a timely manner. During an interview on 4/22/2025 at 10:07 AM, Registered Nurse #5 stated that they lacked time to do all the paperwork and take care of the residents on the unit. Registered Nurse #5 stated they did a review of care plans but there was not enough time for them to comb through the care plans and ensure that they were updated as often as they should be. During an interview on 4/22/2025 at 11:12 AM, Director of Nursing #1 stated that they were aware of the staffing regulations and that they believed staffing was both a problem and not a problem. Director of Nursing #1 stated that they believed they staffed the facility as well as they could and even helped out on the units by working a medication cart occasionally, if it was needed. Director of Nursing #1 stated they had a lot of nurses and maybe they needed to be repurposed so that the hours per resident day could be fully met. Some nurses were doing so many jobs that they struggled to keep up. Director of Nursing #1 stated that the facility worked with nursing students from the hospital and colleges. The facility advertised at jobs fairs and offered recruitment bonuses. 10 New York Code Rules and Regulations 415.13(a)(1) (i-iii)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for two (2) (Unit 100 and Unit 300) of two (2) Medication Rooms; and three (3) (Unit 100, 200 and 300) of three (3) Medication Carts reviewed. Specifically, (a.) two medications had expired; (b.) one open bottle of tuberculin Purified Protein Derivative (PPD) solution had expired; (c.) one Humalog Kwik pen had an illegible open date; (d.) four open inhalers had no open or expiration date; one unopened inhaler had an open date; (e.) one bottle of eye drops had no open and or expiration date (f.) two bottles of eye drops had open and or expiration date discrepancies; (g.) an unopened Solostar Kwik insulin pen was in medication cart unrefrigerated. This is evidenced by: Regulation 483.45(g) Labeling of Drugs and Biologicals, documents Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. During an observation on [DATE] at 11:35 AM, Unit 300, Medication Room contained 1 bottle of sleep aid stock medication with an expiration date of ,d+[DATE]; and 1 bottle of melatonin stock medication with an expiration date of ,d+[DATE]. Unit 300 medication cart #6 contained 1 Humalog Insulin Kwik pen with an illegible date; 1 unopened bottle of carboxymethylcellulose sodium 0.5% eye drops dated ,d+[DATE]. 1 opened bottle of carboxymethylcellulose sodium 0.5% eye drops with date discrepancy. The box had date of [DATE] the bottle was dated [DATE]. Unit 300 mediation cart #6 also contained an open albuterol inhaler dated [DATE] and no expiration date, and an unopened albuterol inhaler with date of [DATE]. During an interview on [DATE] at 11:35 AM, Licensed Practical Nurse #2 was unable to verbalize open and or expiration dates for insulin, eye drops or inhalers. They were not aware of any resources from pharmacy of medications with shortened expiration dates after opening. During an observation on [DATE] at 12:34 PM, Unit 100 Cart #1 was observed with laptop open revealing medication administration record for Resident #99. Unit 100 medication room contained 1 open bottle of tuberculin Purified Protein Derivative (PPD) that had expired as of [DATE]. Unit 100 cart #1 contained 1 open bottle of Systane eye drops; 2 Breo Ellipta inhalers; 1 Anoro Ellipta inhaler with no open and or expiration dates. During an observation on [DATE] at 1:20 PM, Unit 200 cart #3 contained 1 Breo Inhaler with no open and or expiration dates; 2 Admelog Solostar insulin kwik pens; 1 pen was dated [DATE] with no expiration date; the other pen was unopened and stored in mediation cart. During an interview on [DATE] at 01:20 PM, Licensed Practical Nurse #3 stated unopened insulin should be kept in refrigerator until ready for use. During an interview on [DATE] at 12:04 PM, Director of Nursing #1 stated all nursing staff were responsible for ensuring the medication cart and room they had been assigned to were clean and orderly. All medications should be labeled with an open and expiration date. Medications with shortened expiration dates after opening were covered during initial and annual nurse competencies. In-house pharmacy was available as a resource. 10 New York Codes, Rules, and Regulations 415.18(e)(,d+[DATE])

Based on observations, record reviews, and interviews during the recertification survey, the facility did not ensure that food was prepared by methods that conserved the food ' s nutritive value, flavor and appearance and were palatable for 18 (Resident #s 1, 2, 4, 9, 21, 23, 31, 32, 39, 48, 59, 63, 64, 68, 90, 91, 92, and 94) of 22 residents who were reviewed for palatable and attractive food and drink. Specifically, (a.) During an interview during Resident Council held on [DATE], six (6) residents complained that the food was inedible and cold, that drinks were warm, vegetables were hard and under cooked, and that the meat was tough. (b.) Resident # ' s 1, 9, 21, 23, 31, 32, 63, 64, 68, 90, 91, 92, and 94 complained of food being of not palatable with meat being overcooked and vegetables undercooked, tasteless and without variety. (c.) Residents on one (1) of three (3) units received expired milk. This is evidenced by: The facility policy titled, Resident Rights and Dignity, dated ,d+[DATE], documented that the facility was responsible to offer food substitutes of similar nutritive value if the food offered was refused. Additionally documented was that the facility would provide assistance with eating and special eating equipment or assistive devices and utensils if needed. The facility policy titled, Use and Storage of Food Brought to Resident from Outside the Facility, dated ,d+[DATE], documented that nursing was responsible for keeping the personal refrigerator in the resident ' s room in compliance with food safety by verifying and documenting refrigerator temperatures as well as checking content dates/condition once daily. Maintenance Department would be notified for corrective action if a temperature was found to be non-compliant (above 41 degrees). Dining Service would provide the appropriate training to nursing. During an interview during Resident Council held on [DATE], 6 residents complained that the food was inedible and cold, that drinks were warm, vegetables were hard and under cooked, and that the meat was tough. During an interview conducted during resident lunch service on [DATE] at 1:09 PM, Resident #94 statedthey had complaints about the chicken they received. They stated it was not what they ordered, and it was dry. Resident #94 stated that they had ordered a hamburger, but they were hungry, so they would eat what they were given. During an observation of resident lunch service on [DATE], several residents complained that the chicken was dry and that the rice was not good. During an interview on [DATE] at 10:41 AM, Resident #31 stated the food was not good. During an interview on [DATE] at 11:13 AM, Resident #9 stated the food was not great, and that they did not get what they asked for frequently. During an interview on [DATE] at 11:21 AM, Resident #21 stated that the food was awful, the residents were given bad cuts of meat, and the food was not prepared properly. During an interview on [DATE] at 2:32 PM, Resident #94 stated that food was never what they ordered, did not have any taste and was dry. During a test of lunch trays on [DATE] at 12:30 PM, Resident #92 ' s tray was noted to have the following items (and observed conditions of them in parentheses): Ensure (a liquid nutritional supplemental drink), cooked carrots (which were noted to be hard to bite), potatoes, beef (noted not to have much flavor), juice (which was noted to be warm at 60 degrees), and hot coffee. 48615 During a test of lunch trays on [DATE] at 12:53 PM, Resident #21 ' s tray was noted to have the following items (and observed conditions of them in parentheses): pot roast (noted to be difficult to cut with a knife), roasted potatoes, and cooked carrots and celery (noted to be too hard to be cut with a fork). During a test of lunch trays on [DATE] at 1:04 PM, Resident #31 ' s tray was noted to have the following items (and observed conditions of them in parentheses): whole milk (that expired on [DATE] and warm at 56.1 degrees), orange juice (noted to be warm at 50 degrees), factory packaged diced pears, Ensure (noted to be warm at 68.8 degrees), grilled cheese (noted to be crispy on the bottom and soggy on the top), mixed vegetables (noted to be hard and crunchy), beef with gravy (noted to have some chewy pieces), and mashed potatoes (noted to be watery looking and without taste). Upon discovery of the expired milk on Resident #31 ' s tray (which was one of the last trays to be passed on the unit), Licensed Practical Nurse #7, called down to the kitchen and stated that they needed to check the milk, that expired milk had been sent to the floor and ' you know who found it. ' 48744 During an interview on [DATE] at 12:00 PM, Activities Aide #1 stated residents had been complaining since the food service changes occurred a month ago. They stated residents complainted vegetables and meats were cooked in such a fashion that they were unable to chew, cut, and struggled to chew food served to them. During an interview on [DATE] at 11:33 AM, Food Service Director #1 stated there were some concerns voiced at the food council meeting held on [DATE]. They had been addressing what they believed was the most pressing issue, that food trays were not being delivered in a timely fashion. There were separate food meetings from resident council and that there were concerns and the concerns were being worked on and addressed. They stated the warm temperature juice and milk were most likely because they were in the tray carts with the warm food. They hadn ' t met with any residents individually, just during resident council meetings and food meetings. After they were made aware that expired milk was found on the unit, they were called by the staff and had the kitchen staff go through all of the drinks stored in the kitchen and pull anything outdated. During a telephone interview on [DATE] at 11:40 AM, Clinical Nutrition Manager #1 stated there had been a change in food service, they had some complaints of food being under or over cooked. Clinical Nutrition Manager #1 stated that the residents could have their diets changed to ground meat and pureed vegetables if they were unable to chew the food that was served. Clinical Nutrition Manager #1 stated that they had not met individually with any residents and that they were all still getting used to the new system being used at the facility. The Clinical Nutrition Manager stated that during the menu planning and food service committee meeting, residents complained about a fish dinner that was so inedible that the dish was removed from options for a meal. They stated there were no complaints made regarding food temperatures from residents to the best of their knowledge. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (5) (Resident # ' s 21,35,92, 95, and 99) of 15 residents reviewed for infection control. Specifically, (a.) Resident #s 21, 35, 92, and 95 had wounds that required dressing changes and were not placed on Enhanced Barrier Precautions; and (b.) for Resident #99, infection control practice was not maintained during a dressing change and skin treatment. This is evidenced by: The facility policy, Nursing Home Infection Prevention and Control Program, revised 1/2023, documented the following: Under Policy: There is an active, effective, facility wide infection control program for the surveillance, prevention and control of infections as well as reporting of communicable diseases and increased incidence of infections. Under Responsibility: To maintain a record of incidents and corrective actions related to infections and report them to the Infection Control Committee. The Infection Preventionist will: (a) perform surveillance and investigation to prevent, to the extent possible, the onset and spread of infection; (b) prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions; (c) use records of infection incidents to improve its infection control processes and outcomes by taking corrective actions, as indicated; (d) implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination; and (e) properly store, handle, process, and transport linens to minimize contamination. Resident #21 Resident #21 was admitted to the facility with diagnoses of squamous cell carcinoma of skin of scalp and neck (cancer cells that form on the surface of the skin), type 2 diabetes mellitus with diabetic neuropathy (endocrine dysfunction that causes issues regulating blood sugar that causes damage to nerves in the legs, feet and hands), and morbid obesity (excessive body fat that causes a body mass index of 40 or higher). The Minimum Data Set (an assessment tool) dated 3/07/2025, documented that the resident was able to be understood and understand others, with minimal cognitive impairment. A review of Resident #21 ' s physician orders on 4/21/2025 showed evidence that Resident #21 required a dressing change to their heel every three days, and as needed, and to check the dressing condition every shift, daily. There was no documented evidence that Resident #21 had an order for Enhanced Barrier Precautions. 48615 Resident #35 Resident #35 was admitted to the facility with diagnoses of unspecified benign neoplasm of penis (non-cancerous growth or tumor that arises on the penis), severe protein-calorie malnutrition (a condition characterized by a combination of severe protein deficiency and calorie deficiency, leading to significant physical consequences), and intellectual disabilities (condition characterized by limitations in cognitive functioning and skills). The Minimum Data Set, dated dated dated [DATE], documented the resident to be had minimal cognitive impairment, could be understood, and understand others. A review of Resident #35 ' s physician orders on 4/21/2025 documented Resident #35 required a dressing change to their bilateral heels every 3 days, and as needed. There was no documented evidence that Resident #35 had an order for Enhanced Barrier Precautions. 48744 Resident #99 Resident #99 was admitted to the facility with diagnoses of unspecified severe dementia with agitation (a progressive degenerative memory disease that can cause severe physical or verbal aggression), type 2 diabetes mellitus without complications (an endocrine dysfunction that causes irregular blood sugar levels), and obstructive sleep apnea (a sleep disorder that causes episodes of complete airway collapse or partial collapse with decrease in oxygen saturation). The Minimum Data Set, dated dated dated [DATE], documented that the resident was sometimes understood and sometimes understand others, and had severe cognitive impairment. Resident #99 ' s Comprehensive Care Plan for Skin Integrity, effective 8/22/24 and revised 9/18/2024, documented Resident #99 had bilateral unstageable heel wounds that required care. The note update by Registered Nurse #7 on 11/15/2024 documented Resident #99 ' s treatment; cleanse the right heel, allow to dry, and cover with Mepilex dressing every 3 days and as needed. The left heel was noted to be closed but received the same treatment. The care plan was again updated on 2/14/2025 with Registered Nurse #7 ' s note indicating that the wound care team was following wound progress and interventions were to continue. The Physician order dated 3/21/2025 at 3:44 PM documented Resident #99 was to have the right heel cleansed with Vashe skin cleanser, allow to dry and cover with heel Mepilex dressing every 3 days and as needed. Document/report any signs or symptoms of infection or change. During an observation on 4/21/2025 at 3:20 PM, Licensed Practical Nurse #7 was observed changing the dressing to Resident #99 ' s heel. They applied a gown and gloves and removed the old dressing. Licensed Practical Nurse #7 did not change the gloves they were wearing after removing the soiled dressing. Licensed Practical Nurse #7 washed Resident #99 ' s wound area from the outside in, instead of inside to out with Vashe wound cleanser and when they pulled the clean dressing from its wrapper, Licensed Practical Nurse #7 fanned the open wound with the dressing to help increase drying time. The dry dressing was applied and covered with a heel Mepilex. During an interview on 4/21/2025 at 3:30PM, Licensed Practical Nurse #7 was asked when they were last trained on infection control and dressing changes. Licensed Practical Nurse #7 stated that they had been out for two (2) months and were catching up on their competencies. They stated that they did not know when they had their last training. During an interview on 4/22/2025 at 10:37 AM, Infection Preventionist Supervisor #1 (supervisor of the facility ' s Infection Preventionist) stated they were able to speak to general policies but not specific facility practices. Infection Preventionist Supervisor #1 stated that Enhanced Barrier Precautions were ordered for residents with foley catheters or wounds. Contact Precautions were used for residents with active infections, not residents colonized with multiple drug resistant organisms, like Methicillin-resistant Staphylococcus aureus (a group of gram-positive bacteria that are genetically distinct from other strains of Staphylococcus aureus and is responsible for several difficult-to-treat infections in humans) or Escherichia coli (E coli, a gram-negative coliform bacterium that is commonly found in the lower intestine of warm-blooded organisms). Infection Preventionist Supervisor #1 stated that the facility aimed for the least restrictive barrier precaution and that there were studies that showed that residents with contact precautions received fewer social interactions, and it increased the likelihood of staff avoiding residents with contact precautions. Infection Preventionist Supervisor #1 stated that Infection Preventionist #1 had done audits and observed staff compliance with donning and doffing personal protective equipment, and that the facility strived to have good infection control policies and procedures. During an interview on 4/22/2025 at 11:12 AM, Director of Nursing #1 stated that precautions used were based on devices used by residents, such as foley catheters or central lines, and resident conditions, such as open wounds, and infections. The type of precautions used were based on if infections were active versus chronic. The examples given included a resident with an infected open wound would require Contact Precautions, but a resident with a wound infection that had been treated, and did not require antibiotics, would only need Enhanced Barrier Precautions. When asked if a resident with a multiple drug-resistant organism in their urine, and with a foley catheter, would require Contact or Enhanced Barrier Precautions, Director of Nursing stated that only active infections required Contact Precautions and colonized, but not active organisms, required Enhanced Barrier Precautions. Director of Nursing #1 stated that when Infection Preventionist #1 returned, they would have an in-depth discussion on the difference in precautions and what they should be for residents colonized with multiple drug-resistant organisms, wounds, and foley catheters. Director of Nursing #1 stated that any order for precautions of any kind required a physician ' s order. 10 New York Codes, Rules and Regulations 415.19(a)(b)

Based on observations and interviews conducted during a recertification survey from 4/14/2025 - 4/22/2025, the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, all three units (100, 200 and 300) had foul smelling odors of urine and feces. Unit 100 carpet was soiled with multiple stains throughout; Unit 200 had dirty linens under sink and Unit 300 had smelled consistent with cannabis. This is evidenced by: The Facility ' s Policy and Procedure titled, Personal Appearance, revised 3/17/2025, documented the policy intends to provide a general expectation for personal appearance for facility ' s employees and is not meant to capture all necessary dress and appearance requirements nor represent a complete listing of clothing or items of apparel acceptable throughout the facility. All employees are to take positive steps toward ensuring that they present an overall professional image. Employees with offensive odor upon their person or clothing, including but not limited to tobacco or marijuana, will be sent home to change clothes or eliminate the smell (e.g. brushing teeth, bathing, etc.). During an observation on 4/14/2025 at 11:00 AM, noted strong odor of feces in hallway that included room [ROOM NUMBER]. The carpeted floor had multiple stains. During an observation on 4/15/2025 at 9:30 AM, a strong odor of feces on unit 100 common area was noted. Licensed Practical Nurse #6 was made aware at the time of the observation. They stated they would tell the aide. There was no care provided to any resident sitting in the common area for 20 minutes. During an observation on 4/17/2025 at 10:45 AM, there was a heavy urine and feces smell on 200-unit, outside of room [ROOM NUMBER]. Dirty linen was observed on the floor under the sink. During an observation on 4/17/2025 at 10:53 AM, there was a smell of urine in the hallway outside of room [ROOM NUMBER]. During an observation on 4/17/2025 at 11:40 AM on the 300-unit, a strong odor of smoke consistent with cannabis was noted near Medication Cart #6. During an interview on 04/17/2025 at 11:00 AM, Director of Nursing #1 stated staff identified one (1) resident on unit 100 sitting in common area that required care. They further stated that housekeeping cleaned units throughout the day. Units 200 and 300 carpets were replaced with laminate flooring, but that at this time, the carpet on unit 100 was not budgeted for replacement. During an interview on 04/17/2025 at 11:40 AM, Licensed Practical Nurse #6 stated they recently came in and had smoked prior to coming into the building. Upon this interview, surveyor relayed this interview to Administrator #1, and Licensed Practical Nurse #6 was immediately sent home. During an interview on 04/17/2025 at 12:04 PM, Director of Nursing #1 stated staff were only to smoke in designated smoking areas. They stated staff who enter the building with the smell of smoke were in violation of the facility ' s Personal Appearance Policy, and if identified would be sent home to change into appropriate clothing. During an interview on 04/21/2025 at 12:01 PM, Administrator #1 stated they did not recall the smell of cannabis in the past. They stated they had reports from residents complaining of staff smelling of cigarette smoke. They stated one example was a Certified Nurse Aide who smoked in their car and then came back into building smelling of smoke; the staffer was educated on the facility ' s personal appearance policy. 10 New York Codes, Rules, and Regulations 415.29

Based on observations and interviews conducted during a recertification survey, the facility did not ensure each resident was treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of their quality of life for five (5) (Resident #s 21, 31, 32, 64, and 99) of 23 residents reviewed for dignity and respect. Specifically, (a.) Resident #s 31 and 32 had Foley catheters that were fully visible from the hallway, outside resident rooms and in common areas, and not in cover bags; (b.) Resident #64 reported that staff spoke to them 'like they were retarded' and ignored their requests to open the room dividing curtain when their roommate was not in the room; (c.) Resident #99's repeated request to be toileted was ignored by staff while the surveyor was on the resident's unit; and (d.) Resident #21 stated that staff did not provide care in a dignified way, handled them roughly, and that staff would smell of marijuana and cigarettes which the resident found offensive. This is evidenced by: The Policy and Procedure titled, Resident's Rights and Responsibilities, last reviewed May 2012, read that the resident had the right to privacy during medical treatment and care and in personal hygiene matters. The residents have the right to make choices of their life that were significant to them. The facility would meet the resident's individual needs and preferences to the extent possible, and a right to a homelike environment and to use their personal belongings and furnishing to the extent these can be used in accordance with health and safety regulations. A Right to privacy during medical treatment and care and in personal hygiene matters. 48615 (a) Right to meet the resident's individual needs and preferences. Resident #21 was admitted to the facility with the diagnoses of squamous cell carcinoma of skin of scalp and neck (cancer cell that form on the surface of the skin), type 2 diabetes mellitus with diabetic neuropathy (endocrine dysfunction causing issues regulating blood sugar that causes damage to nerves in the legs, feet and hands), and morbid obesity (excessive body fat causing a body mass index of 40 or higher). The Minimum Data Set, dated dated dated [DATE] documented that the resident was able to be understood and understand others, with minimal cognitive impairment. The Comprehensive Care Plan for Compassionate and Personal Caregiving Visitors, dated effective 6/11/2021, documented that Resident #21 would have access to compassionate and personal caregivers as needed. The interventions documented that the resident or sponsor would designate preferences or changes for designated caregivers as desired but at least quarterly. During an interview on 4/15/2025 at 11:24 AM, Resident #21 stated that most of the staff were fine, however there were a few staff that were rough with residents. Resident #21 stated that they had told the administrator about it but nothing was done. Additionally, staff smoked marijuana outside the facility and came into work smelling of marijuana that the resident found very bothersome. During an interview on 4/21/2025 at 12:01 PM, Administrator #1 stated that they had no recall of anyone reporting smelling of marijuana recently but had had an issue of Certified Nurse Aide #4 that was reported for smelling of cigarette smoke but had been educated on staff expectations. Administrator #1 stated that they had received reports of rude and/or inappropriate interactions with some Certified Nurse Aides. Administrator #1 stated that some Certified Nurse Aides had louder voices that might be misconstrued as rude. Additionally, Administrator #1 stated that Resident #21 and Certified Nurse Aide #3 had a personal history outside of the facility and that there had been previous conversations with Certified Nurse Aide #3 regarding their shared history. Administrator #1 stated that any issues were addressed as soon as they were brought to their attention. Resident #99 was admitted to the facility with the diagnoses of unspecified severe dementia with agitation (a progressive degenerative memory disease that can cause severe physical or verbal aggression), type 2 diabetes mellitus without complications (an endocrine dysfunction that causes irregular blood sugar levels), and obstructive sleep apnea (a sleep disorder that causes episodes of complete airway collapse or partial collapse with decrease in oxygen saturation). The Minimum Data Set, dated dated dated [DATE], documented that was sometimes understood and sometimes understand others, with severe cognitive impairment. The Comprehensive Care Plan for Compassionate and Personal Caregiving Visitors, effective 8/09/2024, documented the goal of the resident will have access to compassionate and personal caregivers as needed. The Comprehensive Care Plan for Cognitive impairment/poor judgement/memory loss, effective 8/20/2024, documented the resident would participate in self-care within mental and physical limitations. Interventions documented to encourage self-performance in making decisions and assisting with care needs each day. The Comprehensive Care Plan for Elimination: Urinary Incontinence, effective 8/22/2024, documented the goal of the resident will not experience complications related to incontinence as evidenced by no signs or symptoms of urinary tract infections, skin breakdown or rashes, and utilize prompted voiding every one to two (1-2) hours with positive reinforcement. During an observation on 4/16/2025 at 10:01 AM, Resident #99 was noted to be in the common area of the unit while activities took place in dining room. Resident #99 was observed repeatedly requesting to go to the bathroom. At the time of the observation, Licensed Practical Nurse #6 was made aware that the resident was asking repeatedly to go to the bathroom. Licensed Practical Nurse #6 stated that Resident #99 had just gotten off the commode and that Certified Nurse Aide #11 would get to them. Resident #99 was eventually taken to the bathroom at 10:50 AM, after Certified Nurse Aide #12 came from another unit to assist Certified Nurse Aide #11. 48744 (B) Right to privacy during medical treatment and care and in personal hygiene matters. Resident #31 was admitted to the facility with the diagnoses of morbid obesity (severe form of obesity characterized by a significantly excessive amount of body fat), acquired absence of a leg above the knee (amputation of one leg above the knee joint), and neuromuscular dysfunction of the bladder (condition where the bladder's muscles and nerves don't function properly due to damage to the brain, spinal cord, or nerves that control bladder function). The Minimum Data Set (an assessment tool) dated 2/28/2025, documented the resident usually could be understood, understand others, and was significantly cognitively impaired. Resident #31's Comprehensive Care plan for Elimination related to Foley catheter, dated 7/22/2024 and last reviewed 4/20/2025, documented that the resident would not experience complications related to catheter as evidenced by no signs or symptoms of urinary tract infection or kinked tubing. There was no documented intervention of placing the Foley bag in a cover bag to provide the resident privacy regarding their medical conditions. A Physician order dated 3/07/2025 at 10:45 AM documented that the resident had a Foley catheter to gravity drainage to be changed monthly and as needed. During an observation on 4/15/2025 at 10:43 AM, Resident #31's Foley catheter was visible from the hallway, not covered, hanging from the resident's bed. During an observation on 4/18/2025 at 9:00 AM, Resident #31's Foley catheter was visible from the hallway, not covered, hanging from the resident's bed. Additionally, there was a urine smell emanating from the resident's room. Resident #32 was admitted to the facility with the diagnoses of obesity (disorder that involves having too much body fat), acute gastroenteropathy due to Norwalk agent (a viral infection that causes inflammation of the stomach and intestines, leading to symptoms like vomiting, stomach cramps, and fever), and neuromuscular dysfunction of the bladder (condition where the bladder's muscles and nerves don't function properly due to damage to the brain, spinal cord, or nerves that control bladder function). The Minimum Data Set, dated dated dated [DATE], documented the resident was able to understand others, able to make themselves understood, and was cognitively intact. Resident #32's comprehensive care plan for Foley catheter dated 2/19/2024 and last reviewed 5/23/2025, documented that the resident would maintain clear yellow urine via Foley catheter and will have no urinary tract infection during the review period. There was no documented intervention of placing the Foley bag in a cover bag to provide the resident privacy regarding their medical conditions. A Physician order dated 3/11/2025 at 10:49 AM documented that the resident had a Foley catheter to gravity drainage to be changed monthly and as needed. During an observation on 4/16/2025 at 9:58 AM, Resident #32's Foley catheter was visible from the hallway, not covered, hanging from the resident's bed. During an observation on 4/17/2025 at 11:47 AM, Resident #32's Foley catheter was visible from the hallway, not covered, hanging from the resident's bed. During an observation on 4/18/2025 at 10:41 AM, Resident #32's Foley catheter was visible from the hallway, not covered, hanging from the resident's bed. (c) Right to make choices of their life that were significant to them. Resident #64 was admitted to the facility with the diagnoses of obesity, type 2 diabetes mellitus (an endocrine dysfunction causing irregular blood glucose levels), and obstructive sleep apnea (a condition involving constriction of the airways and difficulty or discomfort in breathing). The Minimum Data Set, dated dated dated [DATE], documented the resident was able to understand others, able to make themselves understood, and was cognitively intact. The Comprehensive Care Plan for environmental check dated 1/15/2025 documented keeping the floor uncluttered, kept dry, bed in lowest position, and that water, food and personal items were kept within reach. There was no documented intervention of keeping the resident's privacy curtain open when Resident #64 was alone in their room. During an interview on 4/16/2025 at 10:33 AM, Resident #64 stated that they felt the staff treated them like they were a retard and that they had requested the staff leave the curtain open when their roommate was not in the room, but the staff refused to answer their request. During an observation on 4/17/2025 at 10:53 AM, Resident #64's call bell was going off. It was not answered until 11:03 AM. At that time, the staff member that entered Resident #64's room stated they would come back. By 11:34 AM, no staff had returned to the room, except one other staff that turned off the resident's light and stated they would be back. Resident #64 stated they had been trying to be changed since 9:30 AM but the staff had not been able to get to them yet. The curtain was observed to be open, and Resident #64 was in the room with their family member. During an observation on 4/21/2025 at 10:58 AM, Resident #64's curtain was open. During an interview on 4/22/2025 at 9:44 AM, Registered Nurse #4 stated that dignity was part of annual education and that Foley should be covered in a blue bag. During an interview on 4/22/2025 at 10:44 AM, Resident Nurse #5 stated that Foley bags should have been covered with a blue bag, or if those were not available a pillowcase could be used, and that Foley should be not visible to the public eye. Registered Nurse #5 had returned from vacation that day and saw that multiple Foley bags were not covered. Registered Nurse #5 could not state why the staff were not following the rules. During an interview on 4/22/2025 at 11:12 AM, Director of Nursing #1 was asked for examples of issues that might arise that would impact resident's feelings of being treated with dignity. Director of Nursing #1 stated that people being covered up so that personal body parts were not visible would be an example. Additionally, knocking on resident's doors before entering would be considered dignified, speaking to the residents in kind and respectful ways, and making sure that Foley catheters were covered and not visible to visitors. 10 New York Codes, Rules, and Regulations 415.5(a)

Based on record review and interview conducted during a recertification and abbreviated survey (Case # NY00345612), the facility did not ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for two (2) out of three (3) residents (Resident #s 3 and 109) reviewed for care planning. Specifically, (a.) Resident #109 ' s comprehensive care plans for Activities of Daily Living, Bed Mobility were not revised following Physical Therapy assessment and recommendations on 3/08/2024. Resident #109 was assessed by physical therapy on 3/08/2024 as having total dependence on staff and required maximum assistance of two (2) staff members for bed mobility. As a result of the facility not communicating the physical therapy recommendations, Resident #109 rolled out of bed and suffered a fractured (broken) hip while receiving care from one (1) staff member on 4/28/2024 at 5:05 PM. Specifically: (b.) Resident #3 ' s comprehensive person center care plan for antipsychotics had not been revised with goals and interventions when a gradual dose reduction was performed on 4/02/2025, and the residents Zyprexa was decreased from 2.5 milligrams to 1.25 milligrams daily. This is evidenced by: 48615 The facility ' s policy and procedure titled, Comprehensive Care Plans, last reviewed 05/2024, documented the following: The facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with their rights. Care plans would include measurable objectives and timeframes to meet a resident ' s medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment. Within 14 days of admission, quarterly and with each significant change, the Inter-Disciplinary Care Plan Team would conduct appropriate assessments, including those in the Minimum Data Set, to determine each resident ' s physical, mental and psychosocial needs. Assessments would identify strengths, weaknesses, preferences, abilities, and needs and take into consideration the resident ' s wishes and goals. Charge nurses were responsible for noting all resident changes (including medications, treatments and behaviors) on the 24-hour report. A nurse was designated at each interdisciplinary Tier II morning huddle to document pertinent reported changes on the Daily Changes Report for Care Planning Log. Each item noted would be addressed in the individual ' s care plan as indicated as soon as possible. 48744 Resident #109 Resident #109 was admitted to the facility with diagnoses of generalized osteoarthritis (when the cartilage that cushions the ends of bones in the joints gradually wears away), transient ischemic attacks (a short period of symptoms similar to those of a stroke), and repeated falls. The Minimum Data Set (an assessment tool) dated 2/09/2024 documented the resident could understand and be understood by others. The comprehensive care plan titled Activities of Daily Living, last revised 4/11/2024, documented Resident #109 required assistance with Activities of Daily Living task performance as follows: Effective 1/08/2024, Resident #109 was a supervision at mealtime; partial moderate one (1) staff member assist for bed mobility; partial moderate one (1) staff member assist for grooming, bathing and dressing. Partial/moderate one (1) staff member assist for transfers and toileting. Non-ambulatory. There was no documented evidence the resident ' s care plan was revised on 3/08/2024, to include the resident required a maximum of two (2) staff members for bed mobility. During an interview on 4/21/2025 at 11:33 AM, Rehabilitation Director #1 stated Resident #109 was discharged from Physical Therapy on 3/08/2024. They further stated that at the time of discharge, Resident #109 ' s bed mobility was at a maximum assist. requiring two (2) staff members, also known a total dependence. During an interview on 4/21/2025 at 11:45 AM, Director of Nursing #1 stated after physical therapy assessed a resident and updated a resident ' s treatment plan, they would bring a written document of it to the nursing staff. Director of Nursing #1 stated that it was the responsibility of the nurse manager, or nursing supervisor, to update the resident ' s care plan. They further stated that the 3/08/2024 Physical Therapy note for Resident #109 was not updated in the care plan to indicate that the resident was a maximum assistant with two (2) staff members for bed mobility. Resident #3 Resident #3 was admitted to the facility with diagnoses of Non-Alzheimer ' s dementia (condition that occurs with memory loss and cognitive functioning) without behavioral disturbances, hypertension (a condition where the force of your artery walls blood against your artery walls is consistently too high), and depression (a persistent feeling of sadness and loss of interest or pleasure in the activities of daily living). The Minimum Data Set, dated dated dated [DATE], documented the resident was sometimes understood and could sometimes understand others with severely impaired cognition for daily decision making. A Physicians Order dated 3/2025, documented Resident #3 was to receive Zyprexa (an antipsychotic, a medication ordered to treat mental health conditions) 2.5 milligrams one (1) time a day. Physicians Order dated 4/02/2025, documented Resident #3 was to receive Zyprexa (an antipsychotic, a medication ordered to treat mental health conditions) 1.25 milligram one (1) time a day. An electronic Medication administration record dated March 2025 documented Resident #3 received Zyprexa 2.5 milligrams 1 time a day for 31 days. An electronic Medication administration record dated April 2025 documented Resident #3 received Zyprexa 2.5 milligrams one (1) time a day for one (1) day on 4/01/2025. An electronic Medication administration record dated April 2025 documented Resident #3 received Zyprexa 1.25 milligrams one (1) time a day for 20 days beginning on 4/02/2025 through 4/21/2025. A psychiatric tele health progress note dated 4/02/2025 documented a trial gradual dose reduction was being attempted and the resident ' s antipsychotic medication was being decreased to 1.25 milligrams beginning 4/02/2025. Review of Resident #3 ' s comprehensive care plan for psychotropic medications implemented on 10/16/2023, did not include the gradual dose reduction performed on 4/02/2025, and did not include goals and intervention with signs and symptoms to monitor while the gradual dose reduction was being attempted. During an interview on 4/21/2025 at 11:17 AM, Registered Nurse #6 stated that Resident #6 had been seen by telehealth and had a gradual dose reduction performed. The gradual dose reduction should have been documented in the resident ' s care plan under behaviors or in the psychotropic care plan. Registered Nurse #6 could not provide any evidence that demonstrated documentation had been placed in the resident ' s comprehensive care plan, but it should have been updated when this was done in case the resident had complications with the decrease in the medications. During an interview on 4/22/2025 at 11:30 AM, Director of Nursing #1 stated Physical Therapy was to provide documentation after their assessment of a resident, and the resident ' s care plan would be updated accordingly. They further stated that all care plans were reviewed and updated quarterly, if needed. 10 New York Codes, Rules, and Regulations 415.11(c)(2)(i-iii)

Based on observation, record review, and interview during a recertification and abbreviated survey (Case # NY00343395), the facility did not ensure that all allegations of abuse were thoroughly investigated for one (1) (Resident #3) of seven (7) residents reviewed for abuse. Specifically, Certified Nurse Aide #8 reported an allegation of verbal abuse and rough treatment of Resident #3 during care on the evening shift on 5/24/2024, to the evening supervisor. The facility initiated the investigation on 5/24/2024 at 11:00 PM, when informed of the allegation. There was no documented evidence that all staff involved were interviewed before the determination was made that the allegation was inconclusive. This is evidenced by: The facility's policy titled Resident Abuse Reporting revised on 11/29/2021 and last reviewed on 10/24/2024 documented: 1. When there is reasonable cause to suspect resident abuse the responsible individual would immediately be suspended without pay while the investigation is being conducted. 2. All claims of abuse and allegations are thoroughly investigated. The designated Nursing Supervisor initiates investigation and notifies the Director of Nursing. 3. Identify the following: a. Name of person or persons suspected of abuse, b. Mistreatment or neglect, name of the resident, c. Name of witnesses, d. Date, time and place incident occurred e. Nature and extent of abuse, mistreatment or neglect 4. Notify the Administrator as appropriate 5. All relevant staff who may have information about the abuse allegations would be obtained from all witnesses, to include an accurate description of the occurrences. These would be signed and dated. These statements will be kept confidential and will be provided to the investigator from the New York State Department of Health/Attorney General's Office, et al. If there are any staff who are not interviewed the facility must document, why that staff was not interviewed. 6. Interviewers questions should be documented. Resident #3 was admitted to the facility with diagnoses of non- Alzheimer's dementia (condition that occurs with memory loss and cognitive functioning) without behavioral disturbances, hypertension (a condition where the force of your artery walls blood against your artery walls is consistently too high), and depression (a persistent feeling of sadness and loss of interest or pleasure in the activities of daily living). The Minimum Data Set (an assessment tool) dated 3/06/2025, documented the resident was sometimes understood and could sometimes understand others with severely impaired cognition for daily decision making. An ACTS (Aspen Complaints Tracking System) complaint/incident report date 5/28/2024 documented that a complaint was submitted to the New York State Reporting division on 5/25/2024 at 2:01 AM, that alleged Resident #3 had been verbally abused with rough handling during care on 5/24/2024 during the 3:00 PM to 11:00 PM shift by Certified Nurse Aide #9. The facility investigation and summary dated 5/29/2024 documented a log of 9 witnesses were listed on the investigation that were working the night the incident occurred on 5/24/2024 on the 3 to 11 PM evening shift. Certified Nurse Aide #8 was orienting Certified Nurse Aide #9, and they were providing care for Resident #3 preparing the resident for bed. Certified Nurse Aide #8 reported to the Licensed Practical Nurse #4 at the end of the shift that Certified Nurse Aide #9 had handled Resident #3 roughly during care and used foul language during transferring the resident and said they had them leave the room and looked at the residents back to see if there was any injury and found none. Certified Nurse Aide #9 stated they had hurt their back and left the building before Certified Nurse #8 reported the incident. The incident was reported to the Registered Nurse Supervisor #1 who then notified the Director of Nursing. The resident was interviewed by the Registered Nurse Supervisor #1 and a skin assessment was done with no injury found, Resident #3 could not recall the incident and denied psychological harm. Staff was interviewed and reported no care concerns with Certified Nurse Aide #9, who was interviewed and denied allegations. Certified Nurse Aide #9 was suspended at 5/25/2024 at 1:30 AM, pending the outcome of the investigation. The outcome of the investigation was inconclusive because the allegation could not be verified or refuted because there was insufficient information to determine whether the allegation had occurred. During an interview on 4/21/2025 at 11:47 AM, Director of Nursing #1 stated all interviews of staff involved were not completed. Some of the staff interviews were done by phone because the incident was reported to the nurse at the end of the shift and Certified Nurse Aide #9 had already left the building. The investigation was started on 5/24/20/24 at 11:30 PM, and called into the New York State Department of Health reporting bureau as soon as it was reported to the supervisor, who immediately contacted the Director of Nursing #1 within 2 hours of the allegation being reported. The facility was unable to come to a determination that the allegation was substantiated. The resident had no injuries, and they had no witnesses that could collaborate Certified Nurse Aide #8's allegation of abuse by other staff or residents. Certified Nurse Aide #9 was suspended until the outcome of the allegation was investigated. Certified Nurse Aide #9 never returned to the facility and accused staff of behaving unprofessional in front of residents and resigned. A signed letter by Certified Nurse Aide #9 was sent to the facility and allegations of inappropriate language and care around residents was reported to the facility. Director of Nursing stated they followed up with interviews about these allegations but had no written or signed statements by staff when this was done. Some of the staff were no longer employed by the facility. There was reeducation started immediately with abuse and neglect and reporting done by the Registered Nurse Educator #1. Certified Nurse Aide #8 was given a verbal warning and reeducated because they had delayed reporting the incident to the Supervisor. 10 New York Code of Rules and Regulations 415.4(b)(2)

Based on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for three (3) (Resident # ' s 9, 31, and 91) of 23 residents reviewed. Specifically, there was no documentation that a Preadmission Screening and Resident Review (PASARR, New York State Department of Health Form 695) was completed for these three (3) residents by a qualified screener prior to admission to the facility. This is evidenced by: A facility policy titled, Pre-Admission Screening & Resident Review (PASRR) Assessments, effective 9/2005 and last reviewed 7/2023, documented that all residents admitted for placement at the facility who met the requirements of mental disability via the Level 1/Level 2 Screen would have a referral completed to the appropriate agency for a federal per-admission screening and resident review (PASARR). The Purpose documented was to assure residents with diagnoses of mental retardation or mental illness were assessed by the appropriate Preadmission Screening and Resident Review agency to determine if specialized services were indicated. Under General Information, the policy documented that all residents who sought admission to this Skilled Nursing Facility would have a Level 1 Screen completed by the referring agency/hospital. If a resident ' s Level 1 Screen demonstrated a potential need for specialized services, the referring agency/hospital would contact the appropriate agency for a Preadmission Screening and Resident Review to be completed. Resident #9 Resident #9 was admitted to the facility with the diagnoses of bipolar disorder (a mood disorder associated with episodes of mood swings ranging from depressive lows to manic highs), acute respiratory failure with hypoxia (a condition where the lungs fail to adequately oxygenate the blood, leading to a low oxygen level in the blood), and pneumonia (lung inflammation caused by bacterial or viral infection). The Minimum Data Set (an assessment tool) dated 4/01/2025, documented the resident was able to understand others, be understood, and was minimally cognitively impaired. Resident #9 ' s Preadmission Screening and Resident Review, dated 3/12/2025, documented ' No ' for Question #23 that read, ' Does this person have a serious mental illness? ' There was no documented evidence that Resident #9, who had a diagnosis of bipolar disorder, was screened for a serious mental illness. There was no documented evidence that the Preadmission Screening and Resident Review was completed prior to admission to the facility on [DATE]. Resident #31 Resident #31 was admitted to the facility with the diagnoses of morbid obesity (severe form of obesity characterized by a significantly excessive amount of body fat), adjustment disorder with anxiety (a mental health condition characterized by a strong emotional or behavioral reaction to a stressful event or change in life, specifically involving anxiety as a primary symptom), and depression (a mood disorder characterized by persistent feelings of sadness and loss of interest or pleasure in activities). The Minimum Data Set, dated dated dated [DATE], documented the resident could be understood, was usually understand others, and was significantly cognitively impaired. Resident #31 ' s Preadmission Screening and Resident Review, dated 10/17/2024, documented ' No ' for Question #23 that read, ' Does this person have a serious mental illness? ' There was no documented evidence that that Resident #31, who had a diagnoses of adjustment disorder with anxiety and depression, was screened for a serious mental illness. There was no evidence that the Preadmission Screening and Resident Review was completed prior to admission to the facility on [DATE]. Resident #91 Resident #91 was admitted to the facility with the diagnoses of depression (a mood disorder characterized by persistent feelings of sadness and loss of interest or pleasure in activities), panic disorder (a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks), and multiple sclerosis (a chronic, neurological disease that affects the central nervous system, primarily the brain and spinal cord). The Minimum Data Set, dated dated dated [DATE], documented the resident was able to understand others, be understood, and was cognitively intact. There was no evidence that the Preadmission Screening and Resident Review was completed prior to admission to the facility on [DATE]. During an interview on 4/22/2024 at 11:12 AM, Director of Nursing #1 stated that social work reviewed the Preadmission Screening and Resident Review before residents were admitted to the facility. During an interview on 4/22/2024 at 11:35 AM, Director of Social Work #1 stated that Preadmission Screening and Resident Review were filled out prior to admission by the hospital or facility sending the resident. Director of Social Work #1 stated that the dates on the screens could be confusing because a resident might go back and forth from the hospital or go home and come back, causing the admitted s and screen dates look like they did not line up. Additionally, Director of Social Work #1 stated that for a resident to have been considered to have a serious mental illness, they would have had to have inpatient treatment for treatment of the mental illness, or the mental illness would have to be an active issue at the time of the screen. If the resident was not presenting as having psychiatric issues, they would have a screen that would reflect no mental illness. It was not enough just to have a diagnosis of a serious mental illness. Director of Social Worker #1 stated that if the Preadmission Screening and Resident Review no longer matched the psychiatric presentation of the resident, they would complete a new screen. Additionally, Director of Social Work #1 stated that all 3 of the residents with questionable Preadmission Screening and Resident Reviews were being provided psychiatric services either through the facility or had community providers they continued to see and that all 3 residents were appeared stable and had not had any issues. 10 New York Code of Rules and Regulations 415.11(3)

Based on record reviews and interviews conducted during the recertification survey, the facility did not ensure the development of comprehensive person-centered care plans, that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (1) (Resident #72) of 23 residents reviewed for comprehensive care plans. Specifically, for Resident #72, comprehensive care plan was not developed to address the resident's medical issues requiring medications. This is evidenced by: The facility policy titled, Comprehensive Care Plans, last reviewed date 5/2024, documented the purpose to meet each resident's preference and goals, and address each resident's medical, physical, mental, and psychosocial needs. Under Procedures, documented routine data was collected, e.g. physical signs and symptoms, lab values, resident history, medications, activities of daily living, preferences and resident goals from the time of admission. Charge nurses were responsible for noting all resident changes (including medications, treatments and behaviors) on the 24-hour report. A nurse was designated at each interdisciplinary Tier II morning huddle to document pertinent reported changed on the Daily Changes Report for Care Planning log. Each item noted would be addressed in the individual's care plan as indicated as soon as possible. The date completed was noted on the log. Non-nursing departments were likewise responsible for noting non-significant, but pertinent changes would be noted on the care plan with the indicated problem, goal and/or approach changes at the time such were noted. 48744 Resident #72 was admitted to the facility with the diagnoses of unspecified dementia, moderate, with agitation, anxiety disorder (a mental condition characterized by excessive fear or apprehension about real or perceived threats), and functional intestinal disorder, unspecified (a group of conditions where the digestive tract does not operate properly). The Minimum Data Set, dated dated [DATE] documented resident had severe cognitive impairment, could be usually understood, and understand others. Resident #72's Comprehensive Care Plan for Psychotropic Drug Use: Anxiety State/Dementia, dated 6/29/2023, documented the resident was taking Seroquel. The goal listed was resident would not experience negative side effects from psychotropic med use. The interventions documented monitor for side effects of medication such as: No documented side effects were listed in the comprehensive care plan. The Physician Order dated 3/22/2025 at 10:14 AM, documented Seroquel 25 milligram tablet, give 0.5 tablet (12.5 milligrams) by oral route once daily at bedtime for unspecified dementia, moderate, with agitation, daily at 9:00 PM. The original order date was noted to be 1/31/2025, and the resident had a gradual dose reduction completed, lowering the dose from 25 milligrams to 12.5 milligrams. During an interview on 4/22/2025 at 10:07 AM, Registered Nurse #5stated that care planning was lacking because they did not have enough time in the day to take care of all the resident's needs on the unit, and review or revise resident care plans. They stated that they did the best that they could and that Register Nurse #5did a lot of the care plan paperwork. Registered Nurse #5 did not have an answer as to why no side effects were listed on the comprehensive care plan. During an Interview on 4/22/2025 at 11:22 AM, Director of Nursing #1 stated that Registered Nurse #7 worked mostly remote and did a lot of the work on care plans. All facility Registered Nurses were responsible for updating care plans, but Registered Nurse #7 did mostly the initial care plans, and some updating. In specific regards to Resident #71's care plan, Director of Nursing #1 stated that the side effects should have been listed. 10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for one (1) (Resident #35) of 3 residents reviewed. Specifically, Residents #35, was not provided with any meaningful, accommodating activities to maintain their highest quality of life. This is evidenced by: The facility's Policy and Procedure Titled Activities Department Policy, revised 12/2024, documented it's policy is: To help residents maintain their optimal level of physical, mental, psychosocial, spiritual, and emotional functioning and independence. Facility promotes individual achievements, self-expression, creativeness, recognition, security, growth through diversified activities, to assist in developing social relationships, a sense of usefulness, a sense of pride in accomplishments, and a sense of self-respect. The Activities Department would document progress every 90 days, indicating participation in activity programs. Provide materials and supplies for residents based on their needs and interests. Offer appropriate accommodations for each resident based on their sensory requirements. Provide 1:1 visit offer large/small group activities to socially engage, cognitively/sensory stimulate, comfort, educate, and offer physical activity depending on residents needs and likes. Resident #35 was admitted to the facility with diagnoses of macular degeneration (a disease that affects a person's central vision); legally blind; and polyneuropathy (multiple nerves become damaged). The Minimum Data Set (an assessment tool) dated 3/22/2025, documented resident had intact cognition, could be understood, and understand others. The Patient Centered Comprehensive Care Plan titled, Focus Activity dated 1/22/20255 documented, Resident is alert/oriented and makes their needs known regarding activity involvement. Resident has no interest in attending group activities at this time. Resident does have independent activities of interest and notes their husband visits daily. Resident does have bilateral hearing deficit and utilizes bilateral hearing aids. Resident is legally blind. Resident requires occasional invitations to see if their interest in attending group activities changes. Resident would maintain independent activities that were enjoyable and interest them daily. Resident would express satisfaction with supplies for independent activities and level of socialization. Interventions: Offer materials to aid in intended activities of interest: (TV channel guide, large print, magnifier, audiobooks). During an observation on 4/14/2025 at 01:29 PM, Resident #35 was sitting in recliner with feet elevated in their room. Resident was able to engage in conversation with surveyor. Resident's hearing was adequate. There were no assistive devices noted in room. During an interview on 4/14/2025 at 1:29 PM, Resident #35 stated they did not really come out of their room due to poor vision. They preferred to stay in their room. Resident #35 stated they could only see a few things likes shapes and colors. They love to read but no longer could read due to macular degeneration. Resident stated they had no adaptive devices. During an interview on 4/18/2025 at 10:04 AM, Director of Activities #1 stated Resident #35 preferred to stay in their room, they did not want to attend group activities. Resident #35 liked to do things in their room, such as watch television or listen to music. Upon admission, Resident #35 was assessed for social preferences and needs. They were offered audio books in January of 2025 and declined. Since then, they had not been offered any other audio books. There were no documented 1:1 visit. During an interview on 4/18/2025 at 10:36 AM, Social Worker #1 stated residents who were hearing and visually impaired were assessed by Speech and Language Therapy. Communication Boards and visual aids were provided as need by therapy. Resident #35 had no visual aids or accommodations. Social Worker #1 stated Resident #35's sister-in-law visited daily and they were hoping to have Resident #35 move into the same room as their husband who is also a resident at the facility. During an interview on 04/18/2025 at 10:30 AM, Resident #35 stated they would very much like to listen to audio books but thought they might be expensive. They stated if there were no cost, they would really like to listen to audio books. During an observation on 4/21/2025 at 10:00AM, Resident #35 was noted to have audio book playing in their room. Resident #35 stated they were very appreciative, and looking forward to doing this daily. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed five (5) percent for two (2) (Resident #s 4 and 78) of four (4) residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of eight (8) percent. This is evidenced by: The facility ' s policy and procedure titled, Medication Administration, revised 5/01/2024, documented, medications may be administered by Registered Nurses and Licensed Practical Nurses after satisfactory completion of the medication orientation requirements. Oral Medications: Read Electronic Medical Record, remove medication from drawer and compare label with Electronic Medical Record. Open medication into medicine cup, read label, and leave package. Blister pack must be initialed and dated when blister is opened. Record review of Manufacturer guidelines assessed at https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022516lbl.pdf documented the following: 'Cymbalta (duloxetine extended release) should generally be administered once daily without regard to meals. Cymbalta should be swallowed whole and should not be chewed or crushed, nor should the capsule be opened, and its contents be sprinkled on food or mixed with liquids (2.1).' Resident #4 was admitted to the facility with diagnoses of squamous cell carcinoma scalp and neck (a type of cancer that starts as a growth of cells on the skin), depressive disorder (a common mental disorder that involves a depressed mood or loss of pleasure or interest in activities), and urinary tract infection. The Minimum Data Set (an assessment tool) dated 2/14/2025, documented the resident was cognitively intact, could be understood, and understood others. Resident #78 was admitted to the facility with diagnoses of type two (2) diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), dementia (loss of memory, language, problem-solving and other thinking abilities) and depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities). The Minimum Data Set, dated dated dated [DATE], documented the resident had severe cognitive impairment, could be understood and usually understood others. During an observation on 4/17/2025 at 9:03 AM, Licensed Practical Nurse #7 reviewed Resident #4 ' s Medication Administration Record. They stated Resident #4 was to receive Duloxetine 60 milligram capsule, delayed release at 9:00 AM, pulled the medication blister pack from medication cart, and then showed the surveyor. Upon observation, it was noted the Medication Administration Record showed order for Duloxetine 60 milligrams to be given at 9:00 AM, but the blister packet given to surveyor was for Doxycycline, 100 milligram capsule. The surveyor pointed out discrepancy to Licensed Practical Nurse #7 at the time of observation. During an interview on 4/17/2025 at 9:03 AM, Licensed Practical Nurse #7 stated they picked up the wrong medication in error and always checked medication again before administering it to residents. During an observation on 4/17/2025 at 9:38 AM, Resident #78 ' s Medication Administration Record documented to give Duloxetine 30 milligrams, delayed release at 9:00 AM. Licensed Practical Nurse #9 removed one (1) Duloxetine, 30 milligrams delayed release capsule, opened the capsule, and poured into a 30-milliliter medication cup. During an interview on 4/17/2025 at 9:38 AM, Licensed Practical Nurse #9 stated they were allowed to crush medications for Resident #78 and that they crushed all medications for this resident. During an interview on 4/17/2025 at 12:04 PM, Director of Nursing #1 stated all nurses had undergone medication administration training upon hire in general orientation, during preceptorship, and with annual competencies. They stated that all nursing staff who administered medication followed the facility policy including the six (6) rights for medication administration: 1. Right Patient, 2. Right Medication, 3. Right Time, 4. Right Dose, 5. Right Route, 6. Right Documentation. Director of Nursing #1 stated instructions for how resident took their medication was located in the information box in electronic medical records They further stated that staff would confirm with the hospital pharmacy that Duloxetine extended-release capsules should not be opened or crushed. Director of Nursing #1 stated Resident #78 took their medication crushed and that the pharmacy and or physician should had been notified so that an alternative drug could had been prescribed. 10 New York Codes, Rules, and Regulations 415.12 (m)(1)

Based on observations and interviews conducted during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the automatic dishwashing machine was not sanitizing, floors were not clean, and concentration of the chemical sanitizing rinse in the 3-compartment sink was low. This is evidenced by: During observations on 4/14/2025 at 10:32 AM through 11:08 AM: The automatic dishwashing machine thermometer read 140 degrees Fahrenheit during the final rinse cycle. The walk-in freezer floor and floor under cooking equipment was soiled with food particles and/or a black build-up. The concentration of quaternary ammonium compound that was used to sanitize food contacted equipment in the 3-compartment sink was zero parts per million of quaternary ammonium compound measured at 74 degrees Fahrenheit. During an interview on 4/14/2025 at 10:52 AM, Food Service Worker #1 stated that the automatic dishwashing machine drain lever may have been dislodged from the closed position by a bus cart; this would cause the dishwashing machine to keep cycling new and lower temperature water into the sanitizing final rinse, would not achieve 180 degrees Fahrenheit, and would cause a low thermometer temperature. During an interview on 4/14/2025 at 11:09 AM, Culinary Director #1 stated that they would contact the vendor to have the concentration of chemical sanitizer adjusted and would have the floors cleaned. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14-1

Based on observation, record review and interviews during an abbreviated survey (Case #NY00297324 and NY00311039), the facility did not ensure residents were free from neglect for 2 (Resident #1 and #2) of 2 residents reviewed for neglect. Specifically, Resident #1, who required two staff to transfer via mechanical lift, was injured when Certified Nursing Aide # 3 transferred Resident #1 by themselves. Additionally Resident #2, who was care planned for having a chair alarm, sustained injury when they attempted to transfer themselves and no chair alarm was present. This is evidenced by: The facility Abuse Prohibition policy and procedure revised 12/31/2021 documented all nursing home residents had the right to be free from verbal, physical, sexual, and mental abuse. All claims of abuse, neglect or mistreatment must be investigated. The facility Mechanical Lift policy and procedure revised 11/19/2021 documented all mechanical lifts required two-person assist. Resident #1 Resident #1 was admitted to the facility with diagnoses of venous insufficiency (when leg veins become damaged and struggle to send blood back up to the heart), age-related osteoporosis (weakening of bones), and shortness of breath unspecified. The Minimum Data Set (an assessment tool) dated 12/13/2023, documented the resident could be understood, could understand others, and was cognitively intact. Comprehensive Care Plan titled, Activities of Daily Living, revised on 2/05/2022, documented Resident #1 required two staff-person assist with mechanical lift using medium-sized sling. Resident Care Kardex (resident care card) dated 3/04/2021 documented Resident #1 was two-person-assist with transfers. The Facility Investigative Report dated 6/12/2022 documented Certified Nurse Aide #3 transferred Resident #1 via mechanical lift without assistance from another caregiver. Resident #1 was care planned as a 2-person assist transfer. Resident #1 complained of pain to groin area during transfer that lined up with straps from mechanical lift pad. Registered Nurse assessment identified 5 centimeter by 5 centimeter bruising to right groin. Certified Nurse Aide #3 admitted to transferring resident independently. Certified Nurse Aide #3 stated they were unable to locate a second caregiver. They acknowledged understanding that Resident #1 was a two-person assist transfer per care plan. Certified Nurse Aide #3 did not know why they failed to approach the nurse for assistance. Nursing progress note dated 6/11/2022 documented Resident #1 complained of swollen area on right inner thigh with bruising noted. Resident #1 stated it occurred during transfer when mechanical lift sling pushed into their leg. During an interview on 3/06/2024 at 2:00 PM, Resident #1 stated they had a bruise on their right thigh after the transfer. During an interview on 3/07/2024 at 10:40 AM, Director of Nursing #1 stated they interviewed Resident #1, who stated they received a bruise from mechanical lift transfer on 6/11/2022. Director of Nursing #1 further stated that Resident #1 indicated Certified Nurse Aide #3 did the transfer alone. Director of Nursing #1 interviewed Certified Nurse Aide #3, who stated they were in a rush to get the resident up and did not get help with mechanical lift transfer They stated training on mechanical lift transfer was given upon hire and annually; and abuse and neglect training was given upon hire, annually and when there was an allegation of abuse or neglect. Resident #2 Resident #2 was admitted to the facility with diagnoses of morbid obesity; epilepsy (a seizure disorder), and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). The Minimum Data dated 1/28/2023, documented the resident could be understood and could understand others. Resident # 2 was cognitively intact. The Comprehensive care Plan titled, Falls Risk, dated 11/07/2022, documented use of a chair alarm for Resident #2 at all times. The facility Incident Report dated 2/16/2023 documented, Resident #2 was found on the floor with abrasion to left knee 0.5 centimeters by 0.8 centimeters, a pink area on top of head, left cheekbone with pinkish 3 centimeters by 2 centimeters area and 1 centimeter by 1 centimeter light purple bruise to left bridge of nose towards left eye from glasses nose piece. Resident #2 stated they wanted to transfer from straight back chair to recliner. Resident #2's Care Kardex documented chair alarm to be placed on resident at all times. Certified Nurse Aide #2 stated they forgot to place chair alarm on the resident after caring for them. The Facility Investigative Report dated 2/20/2023 documented Resident #2's chair alarm was not placed on the resident, and resident sustained injury during fall. Certified Nurse Aide #2 admitted to failing to place chair alarm on resident's wheelchair. During an interview on 3/08/2024 10:54 AM, Certified Nurse Aide #2 stated they worked until 7:00 PM on 2/16/2023, sat the resident in their chair and forgot to put chair alarm on them. After they left the room, Resident #2 stood and fell to floor. During an interview on 3/08/2024 at 11:40 AM, Director of Nursing #1 stated Certified Nursing Aide #2 had worked a double shift on 2/16/2023 and was re-educated on reading Resident Care Card and Resident safety. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i)

Based on record review and interviews during an abbreviated survey (Case # NY00304461), the facility did not ensure residents were free from any significant medication errors for 2 (Resident #'s 5 and 6) of 3 residents reviewed for significant medication errors. Specifically, Resident #'s 5 did not receive their Synthroid on 3/27/2022, and Resident #6 did not receive Aspercreme patch applied on 10/27/2022 as ordered. This is evidenced by: The Policy and Procedure titled, Medication Administration Documentation, revised on 5/2023, documented omission of medications was unacceptable except in the case of resident refusal, or when warranted by resident condition. Resident #5 Resident #5 was admitted to the facility with diagnosis of mild cognitive impairment; hypothyroidism (the thyroid gland does not make enough thyroid hormone), and chronic venous insufficiency (leg veins do not allow blood to flow back up to your heart). The Minimum Data Set (an assessment tool) dated 8/17/2022, documented the resident could be understood and could understand others with a Brief Interview of Mental Status indicating moderate impairment. The Medication Administration Record documented Resident #5 had an active order initiated on 10/26/2022, for levothyroxine (Synthroid) 50 microgram tablet. 1 tablet by mouth once daily before breakfast. On 10/27/2022 the medication was signed given by Licensed Practical Nurse #1. Resident #5 was originally prescribed 75 micrograms Synthroid. On 10/26/2022 dosing of Synthroid was decreased to 50 micrograms. During the facility investigation on 10/27/2022, Synthroid 50 micrograms was found in the sharps container. Synthroid 75 micrograms was not removed popped from the blister pack. During an interview on 3/07/2024 at 11:30 AM, Resident #5 stated some mornings they did not receive their 5:00 AM Synthroid medication. Resident #6 Resident #6 was admitted to the facility with diagnosis of Cerebral Palsy (a group of conditions that affect movement and posture), essential hypertension (high blood pressure), and osteoarthritis of both hips. The Minimum Data Set, dated dated dated [DATE], documented the resident could be understood and could understand others and was cognitively intact. The Medication Administration Record dated 3/27/2022, documented Resident #6 had an active order initiated 4/25/2021, for Aspercreme (lidocaine HCL) 4% topical patch. Apply 1 patch by topical route once daily to left groin area, 12 hours on and 12 hours off. On 10/27/2022 the Aspercreme (lidocaine HCL) 4% topical patch was signed given by Licensed Practical Nurse #1. The Investigative Report dated 11/02/2022, documented Resident #6 reported they did not receive their Aspercreme patch on 10/27/2022. Undated skin assessment revealed there was no Aspercreme patch on Resident #6. Aspercreme patch count was the same before and after alleged administration for which Licensed Practical Nurse #1 signed for the medication administration. Resident #6 stated they usually received their medicine but sometimes on overnights they did not receive their Aspercreme patch. Resident #6 stated when they did not receive their pills, they had back pain and felt shaky. During an interview on 3/07/2024 at 2:15PM Licensed Practical Nurse #2 stated Resident #5 had not informed them [Licensed Practical Nurse #2] that they did not receive their medication. During an interview on 3/08/2024 at 11:42 AM, Director of Nursing #1 stated the plan of correction was discontinued May 2023 as it was not doable. They continued to monitor alert and oriented residents that medications were being administered as ordered. During the investigation on 10/27/2022, Synthroid 50 micrograms was found in the sharps container and Synthroid 75 micrograms was not popped from the blister pack. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Based on observation, record review, and interviews during a recertification survey and an abbreviated survey (Case #NY 532) dated 5/22/2022 through 5/26/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 6 (Resident #'s 25, 35, 50, 54, 69, 81) of 20 residents reviewed. Specifically, the facility did not ensure that a care plan was developed for Resident #25 to address the stage 2 pressure ulcer [NAME] was identified on their left heel on 5/11/2022; for Resident #35, the facility did not ensure the resident's toileting schedule was followed in accordance with the care plan for urinary incontinence; for Resident #50, the facility did not ensure the CCP addressed the resident's bowel and bladder incontinence, did not ensure the Activities of Daily Living (ADLs) care plan was implemented to consistently assist the resident with eating and did not ensure the At Risk for Skin Breakdown care plan was implemented for turning and positioning every 2 hours; for Resident #54, the facility did not ensure the Certified Nursing Assistant (CNA) implemented the care plan to provide the resident with an extensive assist of 2 when transferring the resident from the bed to the wheelchair which resulted in the resident being lowered to the floor and sustaining a skin tear to the top of their left hand; for Resident #69, the facility did not ensure personalized interventions were included in the comprehensive care plans for dementia, behavior symptoms and mood state; and for Resident #81, nursing care plans were not developed to address the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: The Policy and Procedure titled Comprehensive Care Plans dated 11/26/2019, documented a Comprehensive Care Plan will be initiated on admission and completed within 21 days on all residents in the Nursing Home and reviewed quarterly by each discipline and as needed as the resident's condition warrants. The nursing instructions will be initiated upon admission by the Registered Nurse (RN) completing the RN Assessment. Especially important are entries relating to active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing instructions including ADLs and Certified Nursing Assistant (CNA) care will be printed and kept inside the residents' closet. These will be reprinted by the Unit Secretary when needed. All disciplines will be involved in care plan development. Resident #25: Resident #25 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 3/5/2022, documented the resident was usually able to make themselves understood, usually able to understand others, and moderately cognitively impaired. A Wound and Skin assessment dated [DATE], documented an unavoidable (the resident developed a pressure ulcer/injury even though the facility had evaluated the resident's clinical condition and risk factors) stage 2 (shallow open ulcer) pressure ulcer on the resident's left heel measuring 0.4 cm x 0.05 cm. The Comprehensive Care plan (CCP) did not include a care plan to address the stage 2 (partial-thickness loss of skin with exposed dermis) pressure ulcer on the resident's left heel. During an interview on 05/25/22 at 12:13 PM, Registered Nurse (RN) #1 stated when a new pressure ulcer was identified on a resident, a new care plan must be developed. When Resident #25's stage 2 pressure ulcer on their left heel was identified on 5/11/2022, no care plan was initiated, and as of 5/25/2022, one had not yet been developed. RN #1 stated that their care plans were not as up to date as they should be. During an interview on 05/25/22 at 01:44 PM , the Director of Nursing Services (DON) stated that care plans were initiated by the facility's MDS Coordinator upon admission, and after that the Registered Nurses were responsible for their continued development and implementation. When a new pressure injury was detected on a resident, a new care plan addressing the actual pressure injury needed to be developed, even if the resident was already care planned as At Risk for skin integrity concerns. The DON stated that Resident #25 did not currently have a care plan in place addressing the stage 2 pressure injury on their left heel, and that this should have been in place. Resident #54: Resident #54 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 4/6/2022 documented the resident was cognitively intact, could usually understand others and could usually make self understood. The Resident Nursing Instructions dated 7/7/2021, documented the resident required extensive assistance of 2 for transfers. A Physical Therapy (PT) progress note dated 7/7/2021, documented the resident was for a PT evaluation due to increased difficulty in transfers and ambulation. The resident required an extensive 2 assist with a front wheeled walker for transfers. The Facility Investigation dated 9/21/2021, documented during a transfer from the bed to the wheelchair, Resident #54 was lowered to the floor after they started to sit prior to reaching the chair. The resident was an assist of 2 and was transferred with an assist of 1 with a gait belt. The resident obtained a 1 x 1 centimeter horseshoe shaped skin tear to the top of their left hand. The CNA did not follow the care plan when transferring the resident which resulted in a minor injury. A review of CNA documentation for the month of 9/2021, documented the resident required extensive assistance of 2 for transfers. The Comprehensive Care plan (CCP) for Activities of Daily Living (ADLs) updated 9/26/2021, documented the resident required assistance with ADL (activities of daily living) tasks and required a 2 assist stand pivot for transfers. Prior to 9/26/2021, the care plan documented the resident required a 1 assist stand pivot transfers. During an interview on 5/24/2022 at 1:29 PM, CNA #2 stated they recalled the incident with Resident #54. CNA #2 was transferring the resident by themself when they had to lower the resident to the floor because they did not have the strength to hold the resident up on their own. The resident got a skin tear on their hand. CNA #2 stated they knew the resident was an assist of 2 for transfers. CNA #2 stated it was just one of those times when CNA #2 wanted to get the resident transferred from the bed to the wheelchair and tried to do it without the assitance of another staff. CNA #2 stated they learned about changes to a resident's care plan on the kiosk through an email notification and by looking at the residents' statuses on the TAR (Transfer, Ambulation, Range of Motion) sheets printed by therapy that were hung in the staff break room on the unit for staff to refer to as needed. During an interview on 5/24/2022 at 1:48 PM, Physical Therapist (PT) #1 stated Resident #54 was a 2 assist for transfers since 7/7/2021. PT #1 stated the resident was difficult to stand with a 1 assist and required extensive assistance of 2 staff to be tranferred. The resident's transfer status as a 2 assist had not changed since July 2021 and therapy had made the nursing unit aware by sending an updated TAR sheet printed that was hung in staff break room. During an interview on 5/25/2022 at 1:17 PM, the Director of Nursing (DON) stated Resident #54 required the assistance of 2 staff to be transferred and the nursing instructions were updated in the CNA kiosk when the CNA transferred the resident with a 1 assist. The DON stated CNA #2 knew that Resident #54's care plan documented the resident required an assist of 2 for transfers and stated the CNAs were instructed to follow the care plan/care card as written and to provide the assistance that was documented on the care card. The DON stated the care plan was not followed by CNA #2. The DON stated they were always reinforcing to the staff to check the residents' care cards because things could change in a second. The nurses on the unit were responsible for overseeing that care plans were being followed. The monitoring was done by observing staff on the unit. Resident #69: Resident #69 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 4/20/2022, documented the resident had severe cognitive impairment, could sometimes make self understood and sometimes could understand others. The Psychiatric Follow-up Note dated 12/06/2021 documented: Psychiatric follow-up note; Resident was seen today, was quite tearful. Resident had numerous complaints about the food and care. Resident appears with worsening depression since the change in the antidepressant. Resident is also experiencing worsening anxiety and hallucinations. The comprehensive care plan (CCP) titled Dementia-Impaired Judgement dated 10/22/2019 documented; resident is noted with cognitive deficits with episodes of confusion and forgetfulness. At times resident becomes disoriented with the need for redirection and reorientation. There were no personalized interventions documented for staff to utilize when caring for the resident. The CCP titled Behavior Symptoms-Verbal abuse-Hallucinatins-Delusions dated 01/22/2020, documented the resident has a history of displaying verbal abuse to staff inclusive of using profanity. There were no personalized interventions documented for staff to utilize when caring for the resident. The CCP titled Mood State-Depression-sadness-husband has passed away dated 10/30/2020, documented the resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no personalized interventions documented for staff to utilize when caring for the resident. During an interview on 05/25/2022 at 09:39 AM, the Director of Nursing (DON) stated personalized interventions for Resident #69 should be in the care plan. The DON stated the Nurse Managers try to review care plans for completion and thoroughness and the MDS Coordinator reviews care plans as well and starts some of them. During an interview on 05/24/2022 at 10:35 AM, the Director of Social Work (DSW) stated their dementia care was not a formal dementia care program, but they do have dementia care plans for those residents with dementia. There were many things Resident #69 likes, such as 1:1 visits, their stuffed puppy, reminiscing and pets. The care plan needs to be more personalized to include those things. During an interview on 05/24/2022 at 02:06 PM, the DON stated each department does their own care plans, and the care plans should be individualized to each resident. During an interview on 05/25/2022 at 09:44 AM, MDS Coordinator #1 stated that for the care plans that are triggered from the MDS, they try to look at them and personalize them from their perspective. MDS Coordinator #1 stated they knew the care plans were weak and needed to be more personalized. 10NYCRR 415.11(c)(1)

Based on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Food preparation and serving areas are to be kept clean, kitchen equipment is to be kept in good repair, and a test kit is to be available to measure the parts per million (ppm) concentration of the solution used to sanitize equipment. Specifically, doors in the main kitchen were not clean, plumbing for sinks in the main kitchen was not in good repair, and a compatible test kit to measure concentration of chemical sanitizer used to manually sanitize food contract equipment (test kit) was not provided. This is evidenced as follows: During observations of the main kitchen on 05/22/22 at 11:15 AM, the door to the linen closet and the back door were soiled with black grime; the faucet handles on the handwashing sink were stripped; and the entire faucet on the preparation sink was very loose and not secured to the sink. The label of the chemical concentrate used to manually sanitize food equipment titled J-512 Sanitizer and dated 2019 documented that the active ingredients are [MEDICATION(S)] [MEDICATION(S)] ammonium chloride and [MEDICATION(S)] ethyl [MEDICATION(S)] ammonium chloride. The label of the test kit being utilized titled Virex II 256 Test Paper and dated with an expiration date of 4/15/22 documents that the test kit measures n-alkyl [MEDICATION(S)] [MEDICATION(S)] and/or n-alkyl [MEDICATION(S)] ethyl [MEDICATION(S)] ammonium chloride. The Food Service Director stated in an interview on 05/22/22 at 12:44 PM that the wrong test papers were put in the kitchen, and the manufacturer will be contacted about getting the correct test papers; the doors will be cleaned; and the plumbing fixtures will be repaired. The Administrator stated in an interview on 05/22/22 at 2:44 PM that the issues with the test kit, faucet repairs, and cleanliness will be addressed. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.112(c), 14-1.140, 14-1.171

Based on observation, record review and interviews during the recertification survey from 05/22/2022 through 05/26/2022, the facility did not ensure residents who use [CONDITION(S)] drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, to discontinue these drugs for 1 (Resident #s 69) of 5 residents reviewed for [CONDITION(S)] drug use. Specifically, the medical record for Resident #69 did not include documentation to address a GDR for [MEDICATION(S)] (antidepressant) between 11/09/2020 and 05/25/2022. This was evidenced by: The Policy & Procedure titled [CONDITION(S)] Medication Tapering dated 9/18/2021 documented; [CONDITION(S)] medication will be prescribed only as necessary to treat a specific diagnosed condition and subsequent to a comprehensive assessment. Those receiving a [CONDITION(S)] medication will have gradual dose reductions and behavioral interventions unless clinically contraindicated. Within the first year after admission or medication initiated, a GDR (gradual dose reduction) must be attempted in two separate quarters with at least one month between the attempts, unless clinically contraindicated. Resident #69: Resident #69 was admitted to the facility with the diagnoses of dementia with behavioral disturbance, anxiety disorder and hallucinations. The Minimum Data Set (MDS-an assessment tool) dated 4/20/2022, documented the resident had severe cognitive impairment, could sometimes make self understood and sometimes could understand others. The physician orders dated 05/16/2022 documented; [MEDICATION(S)] (antidepressant) 7.5 mg (milligrams) once daily at bedtime, for depression. The original order date was 11/09/2020. The comprehensive care plan (CCP) titled Mood state-Depression-sadness-husband has passed away dated 10/30/2020, documented resident has a diagnosis of depression, continues to be very sad at the passing of her husband, however, will say they are in a better place now. Resident #69 has been expressing her grief as she desires. Intervention documented to encourage verbalization of feelings and encourage decision making. The comprehensive care plan (CCP) titled [CONDITION(S)] Drug Use dated 10/25/2019 documented the resident is on an antidepressant related to diagnosis of depression. The interventions did not include a GDR. A review of Physician notes, Nurse Practitioner notes and Physician Assistant notes did not include documentation of a clinical contraindication or attempted GDR from 11/09/2020 to 05/25/2022. A review of Physician orders did not include documentation of a [MEDICATION(S)] dose reduction between 11/09/2020 and 05/25/2022. A review of monthly pharmacy reviews did not include a recommendation to attempt a GDR of the [MEDICATION(S)] between 11/09/2020 and 05/25/2022. During an interview on 05/25/2022 at 09:15 AM, the Director of Nursing (DON) stated, the note from Doctor #1 dated 12/21/2021 stated no changes in medications. The DON stated we do GDRs, not sure about the GDR for the [MEDICATION(S)]. The DON stated they were not aware of all the regulations about GDRs, assumed the documentation of no changes in medications was sufficient. During an interview on 05/25/2022 at 09:31 AM, Pharmacist #1 (Pharm) stated when the pharmacist did the chart reviews, they would look at the psychiatry notes and Doctor notes and if they did not document something Pharm #1 would let them know that maybe it should be looked at. If the Doctor notes documented to continue medications as is Pharm #1 did not try to interject. Did not know why they did not address the [MEDICATION(S)]. Pharm #1 stated they did not know there was an actual schedule to be followed or tracked for GDRs, they had always gone off of doctor notes and made suggestions. During an interview on 05/25/2022 at 09:44 AM, MDS Coordinator #1 (MDSC) stated in order to complete the MDS section for the date of the last GDR they would look into the bimonthly doctors notes where they list all of the medications a resident was on, look at the medication administration record (MAR) to see the dates the medication was ordered and will do a search of those medications that require a GDR to find the dates. MDSC stated from my perspective, when they were doing the doctor notes, they are making a determination to continue the medications or not. During an interview on 05/25/2022 at 02:02 PM, Physician Assistant (PA) #1 stated it was their understanding that the pharmacist was doing the GDRs. We did provide the DOH Surveyor with the Doctor note that they documented, to continue all medications for Resident #69. I did not know there had to be a note with more information documented about the specific medication. During an interview on 05/26/2022 at 09:15 AM, the Administrator (Adm) stated before they worked here, the facility discontinued the monthly GDR meetings, and they were now planning on starting new GDR monthly meetings. The Adm stated they were not aware GDRs were not taking place, the pharmacist was thought to be looking at the GDRs. 10NYCRR415.12(l)(2)(i)

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping services. Specifically, the facility did not ensure that floors were clean on 2 of 3 resident units. This is evidenced as follows: During observations on 05/22/22 during the initial tour at 11:08 AM and 11:22 AM, floors were sticky in resident rooms numbered 218 and 232. During observations on 05/25/22 at 10:30 AM, floors were soiled with old wax, black build up, scuff marks or dirt in corners in resident rooms numbered 218, 216, and 207, 307, 311, 315, and 330. During an interview on 05/22/22 at 2:58 PM, a resident representative reported that their resident had dropped a soda a couple weeks ago and it was many days before it was mopped up. During an interview on 05/26/22 at 9:45 AM, the Operations Manager of Environmental Services stated that the floor cleaning has not been kept up since some staff have been on vacation during the last few weeks. During an interview on 05/26/22 at 10:02 AM, the Administrator stated that though housekeeping has returned to full staff, perhaps the training on cleaning floors is not complete, and the soiled areas should not have been found. 483.10(i)(3); 10 NYCRR 415.5(h)(4)

Based on observation, record review, and interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible, for one (Unit #1) of three (3) units, during the recertification survey. Specifically, the facility failed to ensure a hot steam table in the Unit 1 dining room was at an appropriate temperature, before leaving the steam table unattended. Residents were left in the dining room with direct access to a hot steam table, and wandering residents were not prevented from potential access to the hot steam table. This resulted in Immediate Jeopardy, and Substandard Quality of Care to resident health and safety. This is evidenced by: During an observation on 8/18/15 at 9:15 am, the Unit 1 steam table was plugged in, and one light on the steam table was on. There were two (2) residents in the dining room, and one (1) resident was observed coming into the dining room area. At that time a Dietary Aide (DA) #1 was bussing the tables in the dining room. At 9:29 am, there were five (5) residents observed in the dining room, and no staff observed in the dining room. The steam table was unplugged, the steam table temperature was 180 degrees, and steam was coming from the well of the table. There was no line barrier (separates, prevents access) around the steam table, and the four (4) doors to the dining room were open. At 9:38 am, a staff member came into the dining room. A resident wheeled herself into the kitchen area through the Unit 1 kitchen door, past the steam table, and into the dining room. At 9:50 am, DA #1 brought a cart into the kitchen area, and used an accordion-style door to close off the kitchen area from the activity/dining room area. During an observation on 8/18/15 at 1:23 pm, a resident was in the activity end of the dining room seated at a table, and another resident walked past the steam table on her way out of the dining room through a kitchen door. There were no staff in the dining room. Three surveyors noted that the steam table was hot to touch, and this was verified by obtaining a surface temperature. The steam table temperature was measured at 165 degrees. There was no rope barrier observed around the steam table. During an interview on 8/18/15 at 11:46 am, the Unit 1 Registered Nurse Manager (RNM) identified six (6) resident's (#'s 5, 8, 13, 18, 28 and #38) who were at risk for elopement, and/or unsafe wandering, and were able to ambulate with walkers, or to wheel themselves around the unit. The RNM stated Resident #5 sometimes went into the kitchen, and that staff had to watch her. Resident #13 had Dementia, and was known to take himself into the dining room. Resident #18 was known to enter the kitchen to get ice. Resident #28 had Dementia. Resident #38 was confused at times, and went into the dining room by herself. The RNM stated the residents were allowed to go to where they wanted on the unit, including the dining room. During an interview on 8/18/15 at 1:23 pm, DA #1 described the process for setting up meals. He stated that he plugged in the steam table for breakfast around 6:30-6:45 am, and for lunch about 11:00 am. The wells in the steam table were all connected, and stayed at the same temperature. He stated they do not check the temperature of the wells, but check the temperature of the food, when it was put into the wells. At the end of the meal service, the food was returned to the kitchen, and the steam table was to be unplugged. Then he does the clean up in the dining room, which he thought took about 20-30 minutes. He then takes the dirty dishes, linens, etc. back downstairs (to the main kitchen). He stated he was on his way back upstairs to wrap silverware for the next meal. He unplugged the steam table at 12:45 pm. He thought the steam table remained hot for about 20 minutes. He leaves the prep table next to the steam table, to keep residents safe from the steam table. He did not think he was trained about keeping the steam table safe from residents. He stated he never uses the barrier posts on his unit. He was never told he should use them. He stated that residents do come into the kitchen area for activities, and the curtain gets pulled. At 2:01 pm, the DA was in the kitchen area. He said the steam table was still very hot. During an interview on 8/18/15 at 2:04 pm, Certified Nurse Aide (CNA) #1, working on Unit 1, stated that residents do wander around the units. They are allowed to go into the dining rooms, and are allowed to go into the kitchens to get drinks. She stated that the steam tables are hot when they are plugged in, but cool quickly when unplugged. She thought they were not hot, when the Food Service Workers were done with their work. She stated that a while ago, on her unit, the steam table was still hot. They called the kitchen, and found it was still plugged in. During an interview on 8/18/15 at 2:10 pm, the Food Service Director (FSD) stated that for breakfast (at 6:30 am), lunch, (at 11:00 am), and dinner (at 4:30) pm, the DAs, one for each unit, bring the dishes, etc. from the kitchen to the units, turn on the steam table, set the tables, make iced beverages, and coffee. Then, the food arrives from the kitchen, is put into the steam tables, and temperatures taken. The food is plated by the DAs, and served by staff. The expectation was that the DAs are to remain in the dining rooms, after turning on the steam table. They are trained to remain in the dining room from the time they arrive, till after meal cleanup. The retractable line barriers are by the steam tables to rope them off. They are usually used after meals are over, not during set up. After meal service, the DAs were expected to put up the line barriers. The FSD stated it likely takes a couple of hours for steam tables to cool. She stated that Food Service Management was not notified of any concerns about the steam table being hot after meals, or any other time. The FSD was not aware of a written policy regarding the steam tables. Note: the line barriers were not observed to have been in place after breakfast, and lunch meals during the first two (2) days of survey on any unit. During interview on 8/18/15 at 2:10 pm, CNA #2, working on Unit 1, stated that residents are allowed to go into the dining rooms, they usually go to the tables. The resident's who are able are allowed to go into the kitchens to get drinks. For the most part, someone is by the steam table when hot. During interview on 8/18/15 at 2:18 pm, CNA #3 for Unit 1, stated that residents who are independent are allowed to wander/walk where they want, into the kitchen/dining room. She stated that Resident #5 is allowed to wheel herself, if in the wheelchair. She wants food constantly and you have to watch her. She comes out the dining room through the kitchen, by herself. She said Resident #18 goes into the kitchen by himself, he is with it, but may not be if he is not feeling well. She stated that Resident #13 wheels around the unit, was alert and oriented for the most part, and she had not seen him in the kitchen. Resident #28 can wheel herself into the dining room. Resident #38 goes into the dining room, and can be very obsessive. The CNA stated that that there was kitchen staff in there, when the steam table was hot, so it was not an issue. During an interview on 8/18/15 at 2:00 pm, the Administrator stated that staff were always present when meals were being served, and the steam tables were in use. He stated that it had never come up that the steam tables were still hot, when the dining staff left them unattended after a meal. He was not aware of a system for monitoring the steam tables for cooling, before staff left them unattended. During an interview on 8/18/15 at 2:05 pm, the Director of Nursing (DON) stated that Nutrition Services personnel were responsible for monitoring the steam tables before, during, and after meals. She also stated that a couple weeks prior to this interview, staff were concerned that a steam table was too hot. Dietary Services was asked to check the steam table, and found that there was no problem with it. During interview on 8/20/15 at 7:14 am, DA #2, for Unit 1, stated that she had turned the steam table on at about 6:30-6:45 am. She stated that the steam table gets very hot, and she has burned herself on it. At 7:24 am, she took the temperature of the steam table well and it was 165 degrees. The steam table well was steaming, when she lifted the lid. She stated that you cannot keep your hand on the base. During interview on 8/20/15 at 7:23 am, the Physical Therapy Aide stated that Residents #5, #28, and #38, wheel themselves around the unit without help. During an interview on 8/20/15 at 10:20 am, the Quality Assurance Registered Nurse stated that a recent meeting had determined that the person who had initially set up the steam tables for the facility, should have developed a Policy and Procedure for monitoring the tables for safe cooling after meals. Residents: Resident #29 was one of the five residents observed on 8/18/15 at 9:15 am, in the dining room. She was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 6/9/15, assessed that the resident understands, was understood, and had a Brief Interview for Mental Status (BIMS) of 11 of 15, or moderately impaired cognitive ability. This resident was also observed later in the day, at 1:23 pm, identified as the resident walking past the steam table on her way out of the dining room. Resident #5 was identified by facility staff, as a resident who wanders into the kitchen area of Unit 1 by herself. She was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 5/20/15, assessed that she understands, was understood and had a BIMS of 9 of 15, or moderately impaired cognition. Resident #18 was identified by facility staff, as a resident who takes himself into the Unit 1 kitchen. The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 7/7/15, assessed that he understands, was understood, and had a BIMS of 10 of 15, or moderately impaired cognition. Resident #28 was identified by facility staff, as a resident who wanders, and wheels herself into the dining room. The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 7/14/15, assessed that the resident understands, was understood, and had a BIMS of 7 of 15, or severely impaired cognition. Resident #38 was identified by facility staff, as a resident who wanders, and goes into the dining room by herself. She was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 7/7/15, assessed that the resident understands, was usually understood, and had a BIMS of 7 of 15, or severely cognitively impaired. 10NYCRR415.12(h)(1)

Based on medical record review, and staff interviews, during a recertification survey, it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, for one (Unit 1) of three (3) units, the facility failed to ensure a hot steam table in the Unit 1 dining room, was at an appropriate temperature, before leaving the steam table unattended. Residents were left in the dining room with direct access to a hot steam table, and wandering residents were not prevented from potential access to the steam table. This resulted in Immediate Jeopardy, and Substandard Quality of Care to resident health and safety. This was evidenced by: Refer to F 323 - Quality of Care - Scope/Severity K During an interview on 8/18/15 at 2:00 pm, the Administrator stated that staff were always present when meals were being served, and the steam tables were in use. He stated that it had never come up that the steam tables were still hot, when the dining staff left them unattended after a meal. He was not aware of a system of monitoring the steam tables for cooling before staff left them unattended. During an interview on 8/18/15 at 2:10 pm, the Food Service Director (FSD) stated that for breakfast, lunch, and dinner, one Dietary Aide (DA) for each unit brought the dishes, and other meal service supplies from the kitchen to the units, turned on the steam table and set the dining tables. When the food arrived from the kitchen, it was put into the steam tables, and temperatures were taken. The expectation was that the DAs were to remain in the dining rooms after turning on the steam table. They were trained to remain in the dining room from arriving till after meal cleanup. She was not aware of a written policy regarding the steam tables. There were retractable line barriers by the steam tables to rope them off, which were usually used after meals, but not during setup. After the meal service, the DAs were expected to put up the line barriers. The FSD stated that it likely took a couple of hours for the steam tables to cool. She stated that Food Service Management was not notified of any concerns about the steam table being hot after meals, or any other time. During an interview on 8/18/15 at 2:05 PM, the Director of Nursing stated that Nutrition Services personnel were responsible for monitoring the steam tables before, during, and after meals. She also stated that a couple weeks prior to this interview, staff were concerned that a steam table was too hot. Dietary Services was asked to check the steam table, and found that there was no problem with it. The Immediate Jeopardy at tag 323, identified on 8/18/15, was removed on 8/19/15, when the facility took the following measures: A new Policy and Procedure (P&P) on securing the area while the steam tables were not cool to touch was developed. Ten (10) of thirteen (13) Nutrition Department staff were trained on the revisions of the P&P, with a plan to train the remaining three (3) staff members, prior to their next work shift. A line barrier was to be placed across the steam table area to prevent residents from touching the table, and the steam table slide rails were to be up at all times. On Unit 1, the accordion doors were to be pulled shut at the end of meals, and the steam tables, and the heat lamps were to be unplugged. 10 NYCRR 415.26

Based on medical record review and staff interviews during a recertification survey, the facility failed to provide a Quality Assessment and Assurance (QAA) Program that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents. Specifically, the facility QAA program failed to identify that there was not an effective system in place to monitor the safe cooling of steam tables before being left unattended for one (Unit 1) of three (3) units. This resulted in Immediate Jeopardy and Substandard Quality of Care to resident health and safety. This was evidenced by: Refer to F 323 - Quality of Care - Scope/Severity K During an interview on 8/18/15 at 2:05 pm, the Director of Nursing, a member of the Quality Assurance Committee, stated that a couple weeks prior to this interview, staff were concerned that a steam table was too hot. Dietary Services was asked to check the steam table, and found that there was no problem with it. During an interview on 8/20/15 at 10:20 am, the Quality Assurance Registered Nurse stated that, to his knowledge, steam table cooling, and supervision had not been discussed, or monitored by the Quality Assurance committee. He also stated that he had not been aware of any concerns related to the steam tables. During an interview on 8/18/15 at 2:00 pm, the Administrator, a member of the Quality Assurance Committee, stated that it had never come up that the steam tables were still hot, when the dining staff left them unattended after a meal. He was not aware of a system of monitoring the steam tables for cooling before staff left them unattended. During an interview on 8/18/15 at 2:10 pm the Food Service Director, a member of the Quality Assurance Committee, stated that she was not aware of a written policy regarding the steam tables, and that Food Service Management was not notified of any concerns about the steam table being hot after meals, or any other time. The Immediate Jeopardy at tag 323, identified on 8/18/15, was removed on 8/19/15, when the facility took the following measures: A new Policy and Procedure (P&P) on securing the area while the steam tables remained hot was developed. Ten (10) of thirteen (13) Nutrition Department staff were trained on the revisions of the P&P, with a plan to train the remaining three (3) staff members prior to their next work shift. A line barrier was to be placed across the steam table area to prevent residents from touching the table, and the steam table slide rails were to be up at all times. On Unit 1, the accordion doors were to be pulled shut at the end of meals, and the steam tables, and the heat lamps were to be unplugged. 10 NYCRR 415.26

Citation Text for Tag 0309, Regulation FF09 Camilli, Tracey Based on interview and record review during an abbreviated survey (#NY 993), the facility did not insure that necessary care and services were provided to maintain the highest practicable physical, mental and psychosocial well-being for two residents (#2, # 37) of fifteen reviewed. Specifically, Resident #2 was assessed as requiring the assistance of two staff for a stand pivot transfer, the resident had been unable to participate in a stand pivot transfer for at least a month, and required the CNAs to lift and carry the resident. Resident #2 was noted with a bruise of unknown origin on 2/21/13, was not assessed by a Registered Nurse (RN) until the following day, she was then transferred to the emergency room for evaluation and was diagnosed with [REDACTED].# 37, the facility did not ensure that the resident's injuries from a burn were properly monitored or that pain sustained from a burn was managed, after the resident sustained [REDACTED]. This resulted in actual harm that is not immediate jeopardy. This was evidenced by: Resident #2: The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. Resident Nursing Instructions last updated on 3/4/13, documented that Resident #2 required the extensive assistance of two persons with a stand pivot transfer. Physical Therapy Annual Evaluation dated 12/6/13 signed by the Physical Therapist documented that Resident #2 had poor to unable static standing and dynamic standing balance. The evaluation further documented that Resident #2 required total assistance for mobility and transfer functions and that the resident was non-ambulatory and required total assistance for wheelchair mobility. The 24 Hour Report Sheet dated 2/21/14 documented on the evening shift "bruise to right thigh". The Nurse's note dated 2/22/14 at 2:05 am signed by Licensed Practical Nurse ( LPN) #3 documented "no complaints from bruise to right thigh". There was no documentation in the nursing notes prior to this regarding the presence of a bruise to the right thigh. The Nurse's note dated 2/22/14 at 3:00 pm signed by RN #1 documented that the "resident was noted to have a dark purple bruise to the posterior knee. Noted that the entire right knee is swollen and bruised with a slight superficial abrasion to the right kneecap. Resident also noted to have a dark purple bruise to the right groin. Resident with no non-verbal signs of pain or discomfort" The Nurse's Note dated 2/22/14 at 6:30 pm signed by RN #1 documented that upon inspection of resident's thigh it was further noted that resident "now has swelling to the right hip. Dark bruise travels from the knee to the inner thigh into the groin area. Resident with external rotation of right thigh, noted this resident has a history of contractures of this joint. Resident with facial grimacing during assessment, the physician was made aware and no new orders were given" The Nurse's note dated 2/23/14 as 10:17 am signed by RN #1 documented that the resident has "decreased swelling to the right knee and thigh, noted to have new onset over the right hip. Resident noted to have facial grimacing when moved or area touched. Noted to be crying at times. Resident positioned in bed with support provided to the right extremity to reduce any stress on right leg. Physician was notified and ordered to the hospital for evaluation and x-ray", delaying [DIAGNOSES REDACTED]. The Nurse's note dated 2/23/14 at 12:24 pm signed by LPN #1 documented that a "Tylenol suppository was administered at 9:50 am for pain to right leg/hip, resident with facial grimacing during assessment and tears rolling down her cheek this morning." Radiological Interpretation dated 2/23/14 documented an examination of the right hip which revealed an intratrochanteric comminuted fracture, of the right hip. A note dated 2/24/14 at 1:30 pm initialed by the Director of Nurses (DON) documented that "a meeting was held with the Director of Radiology who reported that the resident's bones were in very good condition and that the impression was that significant trauma, i.e.: fall, hard hit to wheelchair arm or bed frame would have been required to cause this injury. Could not have occurred with routine care, Likely occurred 48-hours to five days before bruising observed." During an interview on 3/6/14 at 10:15 am, the DON stated that Resident #2 was noted with a new bruise on the evening shift of 2/21/14 and reported to LPN #2 who stated during the investigation that she notified the evening Registered Nurse Supervisor #2 (RNS #2). The DON stated that RNS #2 denies being informed and there was no indication that the resident was assessed at that time. The DON stated that during shift change from evenings to nights, LPN #2 informed LPN #3 of the bruise and LPN #3 entered a note into the resident's medical record, but the resident was not assessed by a Registered Nurse. The DON stated that day RNS #1 was notified of the bruise on 2/22/14, assessed the resident, contacted the resident's physician and began an investigation. The DON stated that Resident #2 was transferred to the emergency roiagnom on [DATE] and diagnosed with [REDACTED]. The DON stated that she conducted an investigation, interviewed all staff back through the weekend prior to the incident and could not determine the origin of the injury. During an interview on 3/6/14 at 12:45 pm, the Physical Therapist (PT) stated that she has been the PT for the facility since December of 2013. The PT stated that Resident #2 was one of the first residents that she had concerns about when she started. The PT stated that a couple of weeks ago she observed aides transferring Resident #2 by carrying her across the room. The PT stated that she immediately in-serviced the aides that they should not transfer the resident that way. The PT stated that Resident #2 transferred with the assistance of two staff in a stand pivot transfer. The PT stated that she reported her concerns to the Director of Physical Therapy at the time she witnessed the CNAs picking up and carrying the resident to the chair and that they were working on evaluating residents for proper transfer status as this was a concern. During an interview on 3/6/14 at 1:45 pm, CNA #1 stated that she was assigned to Resident #2 and according to the resident's care card, she should be transferred via a 2 person stand pivot transfer. CNA #1 stated that since last December, Resident #2 had progressively gotten worse and the aides were carrying 100% of the resident's weight during transfers. CNA #1 stated that the aides had discussed amongst themselves the resident's difficulty with transfers and that they wanted to have the resident's transfer status re-evaluated but "we never did it and I don't know why" During an interview on 3/6/14 at 2:30 pm, the Registered Nurse Manager (RNM) stated that she was new to the facility in February but knew Resident #2. RNM #1 stated she thought that there was concern about this resident from the CNAs but wasn't sure if they had reported that she wasn't transferring properly. The RNM stated "I can't say that they did, I can't say that they didn't, I was pretty overwhelmed." During an interview on 3/6/14 at 3:00 pm, CNA #2 stated that she had assisted in the transfer of Resident #2 in the days just prior to the incident and at that time the resident was unable to bear any weight during the transfer. During an interview on 3/7/14 at 10:10 am, the day RNS #1 stated that on 2/22/14 she received shift report from LPN #3 that Resident #2 had a bruise on the back of her right thigh. The day RNS #1 stated that she and LPN #1 observed the back of the right knee, the knee was quite swollen and a there was a bruise to the groin area. The day RNS #1 stated that later in the day she was called to assess the resident again as the CNA reported that the Resident's whole thigh was bruised and the bruise ran from the hip to the knee. The day RNS #1 stated that she contacted the physician, informed him of the resident's bruises, that the resident had active pulses in her feet but that there was something wrong. RNS #1 stated that she expressed her concern to the physician because she was very concerned there was some form of injury. The day RNS #1 stated that the physician advised her to monitor the resident with assessments and circulation checks. The day RNS #1 was asked if she was concerned about the physician's response based on her physical assessment of the resident and the day RNS #1 stated, "I don't like to question physician's decisions but yes, I thought she needed an x-ray." The day RNS #1 stated the next morning she was called to Resident #2's room again as it became obvious to the CNAs that the leg that is usually very contracted, was now moving freely with positioning. The day RNS #1 stated she was very concerned, contacted the physician again and got the okay to send to the emergency room . During an interview on 3/7/14 at 12:00 pm, Resident #2's physician stated he was contacted by RNS #1 on 2/22/14 and informed that Resident #1's thigh was swollen, but that the resident's circulation was okay, The physician stated he told the day RNS #1 to "leave her be and reassess in the morning" as he considered the resident to be medically stable. The physician stated that he was contacted the next day and ordered the resident be transferred to the emergency room for evaluation. The physician stated that he was advised by the DON and the Administrator that Resident #2 was diagnosed with [REDACTED].#1 on 2/22/14," I used my judgement at the time, I was just told of swelling of unknown origin." During an interview on 3/7/14 at 12:30 pm, CNA #3 stated that she had assisted in transfers of Resident #2 and knew that her transfer status was a two assist stand pivot transfer but they were lifting all of her weight because she was unable to bare weight. CNA #3 stated that the aides were hoping that the resident could be changed to a pad lift. During an interview on 3/7/14 at 1:10 pm, CNA #4 stated that Resident #2 was an extensive assist of two with a gait belt but the RNM was trying to make her a pad lift. CNA #4 stated that two people would hold the resident under each arm and lift 100% of her weight. CNA #4 stated on 2/22/14 at about 3:00 pm she and CNA #5 saw the resident in bed and noticed that her leg that is usually contracted was straight and they immediately reported to RNS #1. CNA #4 stated that RNS #1 contacted the physician who told her to wait until the morning. CNA #4 stated that it looked really bad, bruised on the inside of the thigh, outside of the knee and her leg was straight rather than contracted. CNA #4 stated that when they moved the resident, she was in pain and they reported to RNS #1, and she noticed it too. During a follow-up interview on 5/6/14 at 9:30 am, the PT stated that she conducted an annual PT evaluation of Resident #2's transfer status on 12/6/13. The PT stated that it was at that time that she observed CNAs performing a stand pivot transfer, which was more of a stand and drag to the transfer surface as the CNAs were required to bare most of Resident #2's weight during the transfer. The PT stated at that time, her primary concern was the proximity of the transfer surface, the chair. The PT stated at that time, she retrained three CNAs to place the chair very close to the bed for transfer. The PT stated that she reviewed her annual evaluation of Resident #1 with the PT Director after being interviewed by DOH on 3/6/14, realized that based on the resident's mobility and transfer ability which required total assistance to achieve in December, Resident #2 should have been transferred by mechanical lift. During an interview on 5/7/14 at 12:30 pm, the hospital Director of Radiology stated that he had a conversation with the DON after the x-rays revealed a fracture. The Director of Radiology stated that the main concern was whether the injury could have been a result of routine care or did something else happen. The Director of Radiology stated that based on his impression of the x-rays, the injury was as a result of a fairly significant trauma and that type of fracture "doesn't just happen." The Director of Radiology stated that he would anticipate pain with the type of fracture, however, it was less than likely, but possible that Resident #1 was not in pain. The Director of Radiology stated that the presence of bruising would have been an indicator of a potential fracture. Resident # 37 The resident was admitted to the nursing home on 9/5/12 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have moderate cognitive impairment with memory impairment. It was documented that she is usually understood and usually understands. A facility form titled "Accident/Incident Report" dated 5/15/14 at 5:00 pm, documented that hot chocolate was served on the table, the resident reached and pulled it towards her and spilled it on her chest and abdomen. Red area two inches of sternum, down and over navel on abdomen, left thigh, due to hot fluid. Under the section titled "Nature of Incident" it was documented "Burn". Under the section titled "rective action form" it was documented "tepid water/not hot/ served for all fluid coffee/chocolate." Under the section titled "resident's version, it was documented "yes it hurts." "I'm OK." Under the section titled staff's version, it was documented "hot chocolate was set on the table and the resident picked it up and the fluid was on the sternum and abdomen and left thigh, causing redness of the skin. The resident received cool pack for ten minutes twice. The doctor was notified. The daughter was notified." This was signed by the Registered Nurse Supervisor #1 (RNS) on 5/16/14. The Progress note dated 5/15/14 at 5:38 pm by the RNS #1 documented that the resident was served a cup of hot chocolate; she reached on the table and pulled it over to herself and spilled it over all of her chest and abdomen. It documented that a cool wet towel was applied for ten minutes. The Progress note dated 5/15/14 at 6:09 pm by the RNS #1 documented that the doctor was in agreement with the first aide that was provided to the resident and agreed to hold the shower and give a bed bath in tepid water. A unit 24-hour report sheet dated 5/15/14 documented under the resident's name for the evening shift; bed bath due to hot liquid spilled on skin. On 5/16/14 it documented under night shift; slight redness and there were no entries for the day or evening shift. On 5/17/14 it documented under the night shift no red area, and no entries for this resident on the day or evening shift. On 5/18/14 it documented on night shift, a rash with intact blister on left chest and lower abdomen and that the resident was placed in the doctor book (a book to communicate problems to the doctor), and on the day shift it documented a bruise on the left upper leg. A supervisor's 24-hour report dated 5/15/14 did not include documentation that the resident was burned during dinner. The Progress note dated 5/15/14 at 11:54 pm by the RNS #1 documented that the areas were checked at 11:00 pm and reddened skin remained that same as it was after initial contact with the hot chocolate. The Progress note dated 5/16/14 at 1:46 am by the night Registered Nurse (RN) documented that slight redness remained. The Progress note dated 5/16/14 at 4:54 pm by the LPN documented that the resident had no notable injury related to the hot cocoa being spilled on torso. There was no documentation about the resident ' s skin. The Progress note dated 5/17/14 at 12:00 am by the RNS documented areas of chest and abdomen had no redness, no signs of burned areas. The Progress note dated 5/18/14 at 5:18 am by the night RNS documented resident with red rashy area on the left chest wall with intact blister and on lower abdomen possibly after hot cocoa spill from 5/15/14. Resident placed in book for physician evaluation on Monday. There is no documented evidence of a referral to Occupational Therapy for any adaptive equipment until 5/20/14, five days after the resident was burned. There is no documented evidence of a care plan to address the burn or interventions to prevent reoccurrence. A review of the MD Book (communication book between nursing and the providers) did not include documentation of the resident burning herself or a request that resident be seen prior to 5/18/14. A nursing wound and skin initial assessment dated [DATE], five days after the incident, documented "burns to left chest. area surrounding blister 7cm x 14cm, an irregular shaped scabbed blister to the left chest 3.5cm x 3cm, a left chest left of midline 1cm x 6.5cm, burn below left breast 4.5cm x 9.3cm with unaffected skin in the center, left abdomen 5cm x 2.8cm, left outer thigh 4.5cm x 2.8cm, inferior and medial to larger area on left thigh a 0.5cm x 0.8cm and inferior and lateral to larger area on left thigh a 0.8cm x 0.7cm area". A progress note dated 5/20/14 at 6:20 pm by the physician documented that the resident was being seen for follow-up of a scalding burn after the resident apparently spilled hot chocolate on her chest on 5/15/14. It documented the skin on her chest had scattered areas of redness and that there was an open area on her chest and another on her lower abdomen. Under assessment it documented; partial thickness burn of chest and abdomen. During a meal time observation on 5/19/14 at 12:00 pm the resident was given a full cup of hot cocoa. She was trying to hold it in her right hand as she balanced it on her chest with her left hand that was in a fist. There was a cloth napkin placed between the resident's chest and the cup. A straw was placed in the cup and the resident was holding the cup on her chest trying to get the straw in her mouth by moving her head. During an observation on 5/20/14 at 9:20 am the resident was noted with large red areas to her mid and left chest and breast with a scabbed area on the left chest. There was a second large area noted on the resident's abdomen and a smaller area on her left thigh. During an observation on 5/20/14 and 5/21/14 the resident was noted with minimal movement of her upper extremities. Her right hand was in a loose fist and she was unable to open on command or extend either arm out in front of her. The resident also had limited shoulder motion and had minimal movement of arms away from her sides. During an interview on 5/20/14 at 10:00 am the resident stated that she got burnt on her hot chocolate. She stated that no one was there to help her so she tried to get it herself. The resident stated that [MEDICAL CONDITION]"hurt her a lot and she was in a lot of pain when she did it", but she did not recall if she was given anything for the pain. During an interview on 5/20/14 at 11:30 am the resident's physician stated that that one of his colleagues was contacted at the time that the resident got burned but that he had not yet seen the burn. After seeing the wound, the physician stated that based on the size of the area, a provider should have seen it prior to today; and that it occurred on Thursday 5/15/14; and that the nurse practitioner was in on Friday 5/16/14 and should have seen the area. During an interview on 5/20/14 at 12:10 pm the DON stated that she would not do a care plan for a one time burn. The DON stated that there was no investigation and she had not yet seen an incident report. During an interview on 5/20/14 at 2:00 pm CNA # 1 stated that on 5/15/14 at approximately 5:30 pm she poured the resident's hot cocoa, placed a cover on it and placed it on the table. She was in the kitchenette area with CNA # 2 when they heard the resident screaming. They brought the resident from the dining room into their break room, removed her dress and covered her with wet towels and got the supervisor. CNA # 1 stated that the resident's chest, breast, abdomen, and left thigh were instantly red. CNA # 1 stated that the resident does not usually reach, but does drink by herself when the cup is handed to her. The cup will rest on the resident's chest, she holds it with her left hand and steadies the cup with her right hand which is in a fist. During an interview on 5/20/14 at 3:45 pm CNA # 2 stated that on 5/15/14 she was in the kitchen area of the dining room and heard a "terrible scream" she came around the corner and saw hot chocolate all over the resident and the floor. The resident was screaming to take my dress off. The resident was taken to the break room where cold compresses were applied and CNA # 1 ran for the supervisor. CNA # 2 stated that the resident was crying that her chest hurt and burned for approximately 1 hour. CNA # 2 stated that she reported to the nurse that the resident was having pain but did not know if she was medicated. CNA # 2 further stated that when she came in the next evening 5/16/14 that the resident's skin was not as red and there was a blister on her chest. During an interview on 5/20/14 at 3:15 pm the RNS #1, who was also working on the unit the night of the incident, stated that she had assessed the burn at the time and the resident's skin was bright red on her sternum, it fanned out over her abdomen and on her left thigh. She stated that she notified the doctor on call and he told her that if the area opened or had bleeding to send the resident to the emergency room but that she did not document on the physician order [REDACTED]. " The RNS #1 stated that she had to go back in later in the evening and put cold clothes on the area again and it looked the same. The next day she stopped on the unit at the change of shift and asked staff about the burn. The RNS #1 stated that she was told the area was clear and that she did not actually look at the resident's burns, but when she documented (on 5/17/14 at 12:00 am, that that there was no signs of redness and no signs of burned areas), that she documented based on what she was told when she asked at change of shift. The RNS #1 stated that she does not usually do the care planning because she is the only RN on, so she would do the incident report and the care planning would be done by the day shift. The RNS #1 further stated that the resident did not complain of pain but that she gave the resident's scheduled 9:00 pm Tylenol at 8:00 pm. The RNS stated that she questioned the CNAs about the feasibility of the resident being able to get the cup of hot chocolate off of the table because of the limited movement of the resident's upper extremities, but did not get statements. During an interview on 5/21/14 at 4:05 pm CNA # 3 stated that she was on break at the time the resident got burned but when she returned and saw the burn, she went to the supervisor and told her that she was concerned and did not think the resident could not get the cup off of the table because her arm movement is so limited. CNA # 3 stated that when she saw it on the 15th the skin was very red and raised but did not have blisters. She stated she saw the resident again on 5/17 and there was an actual blister on the resident's skin and on the rest of her chest, abdomen, and thigh was red with blotchy white areas. 10NYCRR 415.12

Based on observation, medical record review and staff interviews the facility failed to ensure that they provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for 3 (# 1, #2, # 5 ) of 5 residents reviewed during a Post Survey Review (PSR). Specifically, the facility did not ensure that when Resident # 1 sustained a witnessed skin tear which was treated with steri strips, there was no monitoring or treatment. Resident # 2 sustained an unwitnessed fall, the Registered Nurse Supervisor documented an immediate intervention of, Resident not to be in dayroom without supervision on the the Incident Report (I&A) and did not communicate the intervention or place on the care plan. Resident # 5 slipped off the edge of her bed while transferring self to bed. Registered Nurse Supervisor (RNS) who assessed the resident wrote on the Corrective Action form for, immediate interventions to, evaluate for necessity of alarm, and there was no documentation that the alarm was evaluated or initiated. This was a pattern of incidents that resulted in no actual harm with the potential to cause more than minimal harm that was not Immediate Jeopardy. This is evidenced by the following : P&P titled "Incident Reports" (I&A), dated as revised 5/2014 documented, Incident reports will be completed for all incidents. To assure that actual or potential risks to residents are identified and reported in a timely manner. Documented under General Information: a Quality Assurance (QA) investigation must be initiated immediately when origin of injury is unknown; corrective actions will be incorporated in the Comprehensive Care Plan (CCP) as appropriate, check if CCP updated, note all care givers for last 24 hours if applicable; all incidents that result in an injury are to be charted on in nurses notes every shift for 72 hours; Policy & Procedure (P&P) titled "Falls Assessment", dated as revised 6/2013 documented, An Incident Report and a Post Falls Assessment will be completed after every fall. Documented under Post Fall Assessment: an Incident Report and a Post Fall Assessment are to be completed after each fall, with or without injury by the Charge Nurse; the Registered Nurse (RN) will initiate any necessary corrective measures; Residents are to be documented on progress notes every shift for 72 hours post fall. P&P titled Comprehensive Care Plans and dated as revised 7/2013. Documented under the heading "General Information" included; each discipline will review the CCP and nursing instructions quarterly, adding their approaches to already listed problems, and develop additional problems as appropriate, date all entries; if the resident's condition changes the CCP needs to be updated by the responsible disciplines. Documented under the heading "Re-evaluation date," all disciplines should update care plans as patient's condition warrants. Documented under the heading "Outcome," review concerns, add any additional interventions necessary, change date for evaluation, add any comments, and initial. Resident # 1: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident is alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15, according to the Minimum Data Set ((MDS) dated [DATE]. I&A dated 7/22/14 at 5:15 pm documented Resident received a 2 centimeter (cm) by 2.5 cm skin tear to outer right elbow while entering daughters car. "Resident's version of incident" documented, I hit it on the door while getting into my daughter's car. Staff's version of incident documented, resident's version the same as the daughter's, three steri strips placed to prepped area. Corrective Action Form dated 7/22/14 documented for "immediate measures taken to prevent further incidents", Resident will be reminded to keep her arms in during transport. For the question, "is corrective action on Nursing Care Plan," it is documented, no. Resident condition report (24 hour report, used to communicate resident condition to nurses from shift to shift) dated 7/22/14 documented, Resident # 1 had a skin tear to the outer aspect of right elbow. Review of Resident Condition Report through 7/28/14 revealed no further documentation of the skin tear. Nursing progress notes revealed there was no documentation of the skin tear on 7/22/14. Nursing progress note dated 7/23/14 at 2:18 pm (first nurse note referring to skin tear) documented reported from night nurse that Resident had a skin tear to the right elbow. Steri strips dry and intact. Resident voices no complaints or discomfort. Nursing progress note dated 7/25/14 at 11:24 am documented, steri strips on right elbow are dry and intact. There was no further documentation in regards to skin tear. Treatment Administration Record (TAR, listing all procedural orders) dated July, 2014 revealed there was no documented instructions to care for the skin tear. Care plan titled, skin integrity documented, at high risk for skin breakdown related to Braden Scale Score (a tool for predicting Pressure Sore Risk), decreased mobility, and [MEDICAL CONDITION]. There was no documentation in regards to the skin tear. During an interview on 7/31/14 at 1:00 pm the Medical Director stated that skin tears should be monitored until healed. During an interview on 7/30/14 at 2:40 pm the DNS stated, the top portion of the Corrective Action Form is completed on the shift when the incident occurs. Immediate safety measures are put into place at the time following the incident, and placed on the care plan. A skin tear should be transcribed on the TAR to be monitored. During an interview on 7/31/14 at 11:00 am the RN Educator (RNEd) stated that if a skin tear they would need to check clothing, chair, look at transfers and see if staff need to be retrained. After the I&A and documentation there should be an initial nurse note and it should be documented on Supervisor report. RNEd was not sure where nursing would put the skin tear to ensure it was being monitored and treated. During an interview on 7/31/14 at 3:20 pm LPN # 1 stated that in the event of skin tears that were witnessed, a statement would be obtained and an I&A would be completed. The new intervention should be placed on the care plan and the care instructions, the treatment would be placed on the TAR. During an interview on 8/11/14 at 1:50 pm RNS # 2 stated that when there is a skin tear an I&A is completed and an order would be placed in the computer and communication would be placed in the MD book. If it was more than a small skin tear the MD would be called then. The treatment would be put in the computer on the electronic TAR for nurses to complete and monitor. RNS # 2 stated that the nurses would document in the progress notes following their signing the TAR for completion. Did not know why Resident # 1 did not have the skin tear placed on the TAR. Resident #2: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had long and short term memory problems with severely impaired decision making according to the MDS dated [DATE]. Fall Risk assessment dated [DATE] documented for history of falls (past 3 months), fall one to two times. Documented a fall risk of 13 at a high risk for falls I&A dated 7/25/14 at 4:15 pm documented, resident found on floor in dining room, Resident unable to articulate pain, unable to move left hip without crying. Resident transferred via maxi lift to stretcher and transferred to emergency room per physician (MD) order. Corrective Action Form (attached to the I&A) documented for "immediate safety measures to prevent similar incidents," continue with alarm, Resident not to be in dayroom without supervision. Physician Bi-Monthly Progress Note dated 7/25/14 documented for diagnosis, Dementia, history of falls, status [REDACTED]. Nursing progress note dated 7/25/14 at 8:39 pm documented, resident at the nurse desk area beginning of shift to be monitored. Noted that Resident was having increased tremors as he was falling asleep, but then subsided as he was sleeping. Nursing progress note dated 7/26/14 at 2:17 am documented, on July 25th at 4:00 pm the resident was seated in the geri chair at the dining room table and his alarm was going off. Resident had fallen from the geri chair. Resident was taken to the emergency room as he voiced pain on each side of his hips, right rib area and his elbows. Resident returned at approximately 9:30 pm, Cat Scan of the head was resulted with no injury, pelvis Xrays were negative for fracture. [MEDICATION NAME] 100 mg was given to the resident as the [MEDICATION NAME] blood level was low. CCP titled Falls and dated as effective 6/30/14 documented, at high risk for falls related to incidence of fall in the past thirty days. Documented interventions included, use appropriate assistive device and level of assistance as needed, clip alarm at all times, mat on floor by side of bed near door. There was no documentation in regards to Resident not being left in dining room without supervision. Resident Nursing Instructions documented for the section of safety; precautions, elopement, falls, history of accidents; protective measures, low bed, falling star program; alarms, clip alarm, wanderguard (device used to protect people when they are at risk for wandering); anti-tippers on wheelchair. There was no documentation in regards to Resident not being left in dining room without supervision. During an interview on 7/31/14 at 9:50 am RNUM # 1 stated the immediate intervention of not to be left in dayroom unattended should have been placed on the care plan and the care instructions. Not sure why the intervention was not put in care plan, the 3:00 pm to 11:00 pm (evening) shift Nursing Supervisor took over the I&A when she came in. During an interview on 8/11/14 at 1:50 pm RNS # 2 stated that on 7/25/14 she completed the I&A for Resident # 2 when she arrived for work on the 3:00 pm to 11:00 pm shift. The new intervention of not being left in the dining room without supervision should have been documented in the care plan. Did not know why it was no care planned. When entering information in the computer for the care plans it automatically goes into the Resident Nursing Instructions. RNS # 2 does not print out the new Resident Nursing Instructions when updating the care plan, does not know when the new Resident Nursing Instructions are printed out. Resident # 5: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had severe cognitive impairment with a BIMS score of 7, according to the MDS dated [DATE]. Fall Risk assessment dated [DATE] documented a fall risk of 13 at a high risk for falls. I&A report dated 7/24/14 at 7:45 pm documented for the "Narrative Description", Slipped off the edge of the bed while transferring self from walker to bed. No injury was found at time of assessment. Documented for "contributing factors" was pre-existing medical condition/weak, unexpected movement. Post fall assessment (attached to I&A) dated 7/24/14 documented for the "Resident's account of occurrence," I fell off the side of my bed, just slid off, no I did not hit my head. "Staff account of occurrence" documented, roommate called out that resident was on the floor, resident had fallen off the side of the bed, as in slipped to the floor. No injury found at the time of the incident. Corrective Action Form (attached to I&A) dated 7/24/14 for "immediate safety measures taken to prevent similar incidents" documented, evaluate for necessity of an alarm. Section to be completed for "Caregivers in the last 24 hours" was blank. Resident's Version of Incident form (attached to I&A) dated 7/24/14 documented for "resident's version," I slipped off the side of my bed, I am not hurt though. Documented for "Staffs Version of Incident," roommate came out to the hallway and yelled that resident had fallen off the side of her bed while getting into the bed. MDS dated [DATE], section G (functional status) documented Resident # 5 was extensive assistance of one person for transfer, walk in room, walk in corridor, locomotion on unit (how resident moves between locations on unit). Resident # 5 was documented as using a walker and wheelchair under the section mobility devices. Resident Nursing Instructions, documented for the section of "safety," falling star program, safe to be unattended in high fowlers (upright sitting position), abilities vary day to day. Documented for transfer, was extensive assistance on one person and for walk in corridor, was limited assistance of one person. Comprehensive Care Plan titled Falls, dated as effective 6/5/13 documented falls risk, resident frequently attempts to transfer independently. Documented for interventions, keep call bell within reach and encourage resident to call for help if needed, answer in a timely manner, remind to keep walker in reach at all times when ambulating. Nursing progress note dated 7/25/14 at 12:46 am documented, after dinner the resident was seated on her walker and attempted to get into her bed, slipped from the edge of the bed to the floor. The roommate witnessed the fall, no injury was noted at the time of the assessment. During an interview on 7/30/14 at 2:40 pm the DON stated, the top portion of the Corrective Action Form is completed on the shift when the incident occurs. Immediate safety measures are put into place at the time following the incident, and placed on the care plan. If a Nursing Supervisor feels an alarm is necessary they should initiate it, not wait for the weekly falls meeting to review the I&As and determine the intervention. During an interview on 8/11/14 at 1:50 pm RNS # 2 stated that she documented on the I&A to, evaluate for necessity of alarm because she had put an alarm on Resident # 5 three to four months ago and the facility took it off, so she documented to evaluate for the alarm. Would normally put an alarm on a resident if it was thought to be necessary. 10 NYCRR 415.12

Camilli, Tracey Based on medical record review and staff interview during an abbreviated survey (Case # NY 294) the facility did not ensure the resident's environment remained as free from accident hazards as is possible and that each resident received adequate supervision and assistive devices to prevent accidents for three (Resident #'s 1, 36 &, 37) of fourteen residents reviewed. Specifically, Resident #1 was transferred via Hoer lift with a sling that was too large, the resident fell through the sling and sustained a head laceration that required sutures; Resident # 37 who required extensive assist with eating attempted to reach for hot cocoa and spilled it on her chest, abdomen, and thigh, causing partial thickness burns and was not assessed by occupational therapy for adaptive equipment to prevent reoccurrence, and Resident # 36 was found with a softball size bruise to her left breast and side; interventions that were documented on the facility Accident/Incident report to prevent re-occurrence were not implemented. This resulted in actual harm for Resident #1, and no actual harm with the potential for more than minimal harm that is not immediate jeopardy for resident # ' s 36 and 37. This was evidenced by: Resident #1 The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having severely impaired cognition. The Care Card printed on 3/4/14 documented that Resident #1 required a one-person physical assist for transfers using a Hoer lift. The Accident/Incident Report dated 3/1/14 at 8:16 am documented that Resident #1 slid onto the floor from the maxi lift during a transfer from the bed to a chair sustaining a hematoma and laceration to the left side of her head. The Nurse's Note dated 3/1/14 at 8:22 am documented that Resident #1 slid out of the maxi sling during transfer. "Resident with a laceration to posterior head, large amount of bleeding noted." The physician was notified and ordered to send the resident to the emergency room . The Nurse's note dated 3/1/14 at 2:38 pm documented that Resident #1 returned to the facility with four staples to the lower left back of the head. The Investigation Summary of a fall during transfer regarding Resident #1 on 3/1/14 at 8:20 am, signed by the Director of Nursing (DON) documented that CNA #6 was transferring the resident with a Maxi lift from her bed to the chair when Resident #1's upper body slid out of the sling resulting in a laceration to her scalp. The DON's investigation revealed that Resident #1 was being transferred utilizing an extra large sling, meant for a person weighing 308 - 440 lbs and the resident's weight was 124 lbs. The investigation documented that the sling size was not listed on Resident #1's care card, but that the resident usually used a medium size sling, which according to CNA #6 was not available. The summary documented that CNA #6 did ask her coworkers about the sling size and was told that she didn't need to use any special sling. The investigative summary documented that the Root Cause of the incident was a system error that the care cards indicated the type of lift to be used but did not include recommended sling size(s). During an interview on 3/6/14 at 10:00 am, the DON stated that she investigated Resident #1's incident and determined that the root cause of the incident was that the wrong sling size was used by the CNA. The DON stated that the facility does not expect that the CNAs will determine the appropriate size and that upon review after the incident, she realized that the sling sizes were not listed on any of the resident's care cards. The DON stated that the facility immediately reviewed and updated all residents in the facility who were transferred using mechanical lifts and updated their care cards to include the appropriate sling size. The DON stated that the family of the resident informed her that they had called the incident into the Department of Health (DOH) Compliant Hotline for investigation. When asked by the DOH surveyor if the incident was a reportable incident to the DOH, the DON stated, yes, but when I discussed the incident with the Administrator, he stated that I didn't need to report it because the family had already done so. During an interview on 3/6/14 at 12:45 pm, the Physical Therapist (PT) stated that she has been the PT for the facility since December of 2013. The PT stated that the issue of sling size is being reviewed and believed it was the nursing staff's responsibility to determine the sling size as well as the number of staff required to assist during the transfer. The PT stated that the PT Department had been identifying Maxi lift for all transfers for those resident's that needed it, but that she and the Director of Physical Therapy were looking at the issue now. During an interview on 3/6/14 at 2:45 pm, the Director of Physical Therapy stated that the PT Department was responsible for identifying the type of lift for residents but not the sling size or the number of staff needed to perform the lift with the maxi lift. The Director of PT stated that due to staffing, she was without a physical therapist for some time and was doing everything herself. The Director of PT stated that while the therapy department would be the best department to determine the safest way to transfer resident, for example for spastic or unexpected movements that would impact the transfer, during her time of covering, she "didn't look at that level of detail." During a follow-up interview on 3/6/14 at 5:30 pm, the DON reviewed a resident's care card and stated stated that there was no sling size identified on the care card. The DON stated, 'I'll take care of it." Resident # 37 The resident was admitted to the nursing home on 9/5/12 with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that the resident had moderate cognitive impairment with memory impairment. It documented that she is usually understood and usually understands. The MDS assessed the resident as requiring extensive assist of one for eating. The Comprehensive Care Plan titled Activities of Daily Living (ADLs), dated 6/14/13, documented the resident requires extensive to total assistance with all ADLs due to chronic weakness, osteoarthritis degenerative joint disease and pain. Specific interventions listed for eating were " resident will feed self after trap prep; assist as needed to complete meals. " The Progress note dated 5/15/14 at 5:38 pm by the Registered Nurse Supervisor (RNS)documented that the resident was served a cup of hot chocolate; she reached on the table and pulled it over to herself and spilled it over all of her chest and abdomen. It documented that a cool wet towel was applied for ten minutes. There is no documentation that a care plan was initiated to address the burn or interventions to prevent reoccurrence. During a meal time observation on 5/19/14 at 12:00 pm the resident was given a full cup of hot cocoa. She was holding the cup in her right hand as she balanced it on her chest with her left hand that was in a fist. There was a cloth napkin placed between the resident's chest and the cup. A straw was placed in the cup and the resident was holding the cup on her chest trying to get the straw in her mouth by moving her head. During an observation on 5/20/14 at 9:20 am the resident was noted with large red areas to her mid and left chest and breast with a scabbed area on the left chest. There was a second large area noted on the resident's abdomen and a smaller area on her left thigh. During an observation on 5/20/14 and 5/21/14 the resident was noted with minimal movement of her upper extremities. Her right hand was in a loose fist and she was unable to open on command or extend either arm out in front of her. The resident also had limited shoulder motion and had minimal movement of her arms away from her sides. During an interview on 5/20/14 at 12:10 pm the DON stated that there was no investigation and she had not yet seen the incident report. She further stated that she would not do a care plan for a one time burn. During an interview on 5/20/14 at 2:00 pm the Director of therapy stated that she was not aware that the resident had gotten a burn and was not aware of any referral to occupational therapy for an adaptive equipment evaluation. During an interview on 5/20/14 at 3:15 pm the Registered Nurse Supervisor who was also working on the unit the night of the incident stated that she does not usually do the care planning because she is the only RN on so she would do the incident report and the care planning would be done by the day shift and she did not send a referral to occupational therapy for an evaluation. The RNS stated that she questioned the CNAs about the feasibility of the resident being able to get the cup of hot chocolate off of the table because of the limited movement of the resident's upper extremities, but did not get statements. During an interview on 5/21/14 at 4:05 pm CNA # 3 stated that when she saw the resident's burns on the 15th the skin was very red and raised did not have blisters. She stated she saw the resident again on 5/17 and there was an actual blister on the resident's skin and the rest of her chest, abdomen, and thigh was red with blotchy white areas. CNA # 3 further stated that there were no changes to the care plan as to adaptive equipment to prevent burns after the incident. Resident # 36 The resident was admitted to the nursing home on 10/11/13 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented that the resident had moderate cognitive impairment and short and long-term memory deficits. A facility Accident /Incident report dated 5/15/15 at 6:00 am documented that the resident had a softball sized purplish area on her left breast that appeared to be located where the resident slides herself down along the armrest of her Geri chair when she is agitated/confused. It documented under follow up the resident would be repositioned as needed using pillows/rolled blankets to maintain position. Under care givers for last 24 hours the day and evening slots are blank. A progress noted dated 5/15/14 at 7:33 am by the RN documented that the CNA reported a bruise on the resident's left breast to side. She was assessed for a softball size purplish area that appeared to be where the resident scoots herself down in her chair. There is no further documentation of this bruise after the 5/15/14 entry at 7:33 am A unit 24-hour report sheet dated 5/14/14 on the evening shift documented that the resident was given a bed bath. On 5/15/14 night shift documented that the resident slept well and was noted with a bruise to the left breast. There was no further documentation regarding the bruise. There is no documented evidence on the supervisor's 24-hour report that the resident was discovered with a bruise. The comprehensive care plan had no documented evidence of the safety measures that were to be implemented according to their accident/incident to prevent reoccurrence. A wound and skin initial assessment dated [DATE] documented a purple area on the side of the left breast, measuring 13.5cm x 13.4cm and that it was first noted on 5/15/14. There is no documented evidence that the incident was thoroughly investigated to rule out abuse, neglect, or mistreatment. During an interview on 5/20/14 at 3:45 pm the CNA stated that she and two other CNAs were toileting the resident on 5/15 when the bruise was noted on her left side but that they were told by the nurse (can ' t recall which one), that it was reported already. She further stated that no one had said anything about the bruise since. During an interview on 5/21/14 at 9:00 am the interim RNM stated that she had only been there in that position for 1 week and had just become aware today that the resident was on coumadin and aspirin. She stated that she would expect monitoring of the area and would expect that care planning would be done. 10NYCRR 415.12(h)(1)

Based on interview and record review during an abbreviated survey (#NY 993), the facility failed to insure that necessary care and services were provided to maintain the highest practicable physical, mental and psychosocial well-being for one resident (#2) of xx reviewed. Specifically, Resident #2 was assessed as requiring total assistance with all mobility and transfers, required the assistance of two staff for a Stand Pivot transfer, and without a reported incident, Resident #2 was noted with a bruise of unknown origin on 2/21/13. The resident was not assessed by a Registered Nurse (RN) until the following day, the bruising to the resident became significantly larger and was transferred to the emergency room for evaluation on 2/23/14 after Resident #2 was noted crying in pain with tears rolling down her face. Resident #2 was diagnosed with [REDACTED]. According to the Certified Nurses Assistants (CNAs), Resident #2 had been unable to participate in a Stand Pivot Transfer for at least a month, which required the CNAs to lift and carry Resident #2 to the transfer destination. This resulted in actual harm that is not immediate jeopardy. This was evidenced by: Resident #2 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Resident Nursing Instructions last updated on 3/4/13, documented that Resident #2 required the extensive assistance of two persons with a stand pivot transfer. Physical Therapy Annual Evaluation dated 12/6/13 signed by the Physical Therapist documented that Resident #2's had poor to unable static standing and dynamic standing balance. The evaluation further documented that Resident #2 required total assistance for mobility and transfer functions and that the resident was non-ambulatory and required total assistance for wheelchair mobility. 24 Hour Report Sheet dated 2/21/14 documented "bruise to right thigh" on the evening shift. Nurses note dated 2/22/14 at 2:05 am signed by Licensed Practical Nurse ( LPN) #3 documented no complaints from bruise to right thigh. There was no documentation in the nursing notes prior to this regarding the presence of a bruise to the right thigh. Nurses note dated 2/22/14 at 3:00 pm signed by RN #1 documented that the resident was noted to have a dark purple bruise to the posterior knee. Noted that the entire right knee is swollen and bruised with a slight superficial abrasion to the right kneecap. Resident also noted to have a dark purple bruise to the right groin. Resident with no non-verbal signs of pain or discomfort. Nurses Note dated 2/22/14 at 6:30 pm signed by RN #1 documented that upon inspection of resident's thigh it was further noted that resident now has swelling to the right hip. Dark bruise travels from the knee to the inner thigh into the groin area. Resident with external rotation of right thigh, noted this resident has a history of contractures of this joint. Resident with facial grimacing during assessment, the physician was made aware and no new orders were given. Nurses note dated 2/23/14 as 10:17 am signed by RN #1 documented that the resident has decreased swelling to the right knee and thigh, noted to have new onset over the right hip. Resident noted to have facial grimacing when moved or area touched. Noted to be crying at times. Resident positioned in bed with support provided to the right extremity to reduce any stress on right leg. Physician was notified and ordered to the hospital for evaluation and x-ray. Nurses note dated 2/23/14 at 12:24 pm signed by LPN #1 documented that a Tylenol suppository was administered at 9:50 am for pain to right leg/hip, resident with facial grimacing during assessment and tears rolling down her cheek this morning. Radiological Interpretation dated 2/23/14 documented an examination of the right hip and showed a intratrochanteric, commuted [MEDICAL CONDITION] hip. A note dated 2/24/14 at 1:30 pm initialed by the Director of Nurses (DON) documented that a meeting was held with the Director of Radiology who reported that the resident's bones were in very good condition and that the impression was that significant trauma, i.e.: fall, hard hit to wheelchair arm or bed frame would have been required to cause this injury. Could not have occurred with routine care, Likely occurred 48-hours to five days before bruising observed." During an interview on 3/6/14 at 10:15 am, the DON stated that Resident #2 was noted with a new bruise on the evening shift of 2/21/14 and reported to LPN #2 who stated during the investigation that she notified Registered Nurse Supervisor #2 (RNS #2). The DON stated that RNS #2 denies being informed and there was indication that the resident was assessed at that time. The DON stated that during shift change from evenings to nights, LPN #2 informed LPN #3 of the bruise and LPN #3 entered a note into the resident's medical record, but the resident was not assessed by a Registered Nurse. The DON stated that RNS #1 was notified of the bruise on 2/22/13, assessed the resident and contacted the resident's physician and began an investigation. The DON stated that Resident #2 was transferred to the emergency roiagnom on [DATE] and diagnosed with [REDACTED]. The DON stated that she conducted an investigation, interviewed all staff back through the weekend prior to the incident and could not determine the origin of the injury. During an interview on 3/6/14 at 12:45 pm, the Physical Therapist (PT) stated that she has been the PT for the facility since December of 2013. The PT stated that Resident #2 was one of the first resident that she had concerns about when she started. The PT stated that she observed aides transferring Resident #2 by carrying her across the room. The PT stated that she immediately in-serviced the aides that they should not transfer the resident that way. The PT stated that Resident #2 transferred with the assistance of two staff in a stand pivot transfer. The PT stated that she reported her concerns to the Director of Physical Therapy at the time she witnessed the CNAs picking up and carrying the resident to the chair and that they were working on evaluating residents for proper transfer status as this was a concern. During an interview on 3/6/14 at 1:45 pm, CNA #1 stated that she was assigned to Resident #2 and according to the resident's care card, she should be transferred via a 2 person stand pivot transfer. CNA #1 stated that since last December, Resident #2 had progressively gotten worse and the aides were carrying 100% of the resident's weight during transfers. CNA #1 stated that the aides had discussed the resident's difficulty with transfers and that they wanted to have the resident's transfer status re-evaluated but we never did it and I don't know why. During an interview on 3/6/14 at 2:30 pm, the Registered Nurse Manager (RNM) stated that she was new to the facility in February but knew Resident #2. RNM #1 stated she thought that there was concern about this resident from the CNAs but wasn't sure if they had reported that she wasn't transferring properly. The RNM stated "I can't say that they did, I can't say that they didn't, I was pretty overwhelmed." During an interview on 3/6/14 at 3:00 pm, CNA #2 stated that she had assisted in the transfer of Resident #2 in the days just prior to the incident and at that time the resident was unable to bear any weight during the transfer. During an interview on 3/7/14 at 10:10 am, RNS #1 stated that on 2/22/14 she received shift report from LPN #3 that Resident #2 had a bruise on the back of her right thigh. RNS #1 stated that she and LPN #1 observed the back of the right knee, the knee was quite swollen and a there was a bruise to the groin area. RNS #1 stated that later in the day she was called to assess the resident again as the CNA reported that the Resident's whole thigh was bruised and the bruise ran from the hip to the knee. RNS #1 stated that she contacted the physician, informed him of the resident's bruises, that the resident had active pulses in her feet but that there was something wrong. RNS #1 stated that she expressed her concern to the physician because she was very concerned there was some form of injury. RNS #1 stated that the physician advised her to monitor the resident with assessments and circulation checks. RNS #1 was asked if she was concerned about the physician's response based on her physical assessment of the resident and RNS #1 stated, "I don't like to question physician's decisions but yes, I thought she needed an x-ray." RNS #1 stated the next morning she was called to Resident #2's room again as it became obvious to the CNAs that the leg that is usually very contracted, was now moving freely with positioning. RNS #1 stated she was very concerned, contacted the physician again and got the okay to send to the emergency room . During an interview on 3/7/14 at 12:00 pm, Resident #2's physician stated he was contacted by RNS #1 on 2/22/14 and informed that Resident #1's thigh was swollen, but that the resident's circulation was okay, The physician stated he told RNS #1 to "leave her be and reassess in the morning" as he considered the resident to be medically stable. The physician stated that he was contacted the next day and ordered the resident be transferred to the emergency room for evaluation. The physician stated that he was advised by the DON and the Administrator that Resident #2 was diagnosed with [REDACTED].#1 on 2/22/14," I used my judgement at the time, I was just told of swelling of unknown origin." During an interview on 3/7/14 at 12:30 pm, CNA #3 stated that she had assisted in transfers of Resident #2 and knew that her transfer status was a two assist stand pivot transfer but they were lifting all of her weight because she was unable to. CNA #3 stated that the aides were hoping that the resident could be changed to a pad lift. During an interview on 3/7/14 at 1:10 pm, CNA #4 stated that Resident #2 was an extensive assist of two with a gait belt but the RNM was trying to make her a pad lift. CNA #4 stated that two people would hold the resident under each arm and lift 100% of her weight. CNA #4 stated on 2/22/14 at about 3:00 pm she and CNA #5 saw the resident in bed and noticed that her leg that is usually contracted was straight and they immediately reported to RNS #1. CNA #4 stated that RNS #1 contacted the physician who told her to wait until the morning. CNA #4 stated that it looked really bad, bruised on the inside of the thigh, outside of the knee and her leg was straight rather than contracted. CNA #4 stated that when they moved the resident, she was in pain and they reported to RNS #, and she noticed it too. During a follow-up interview on 5/6/14 at 9:30 am, the PT stated that she conducted an annual PT evaluation of Resident #2's transfer status on 12/6/13. The PT stated that it was at that time that she observed CNAs performing a stand pivot transfer, which was more of a stand and drag to the transfer surface as the CNAs were required to bare most of Resident #2's weight during the transfer. The PT stated at that time, her primary concern was the proximity of the transfer surface, the chair. The PT stated at that time, she retrained three CNAs to place the chair very close to the bed for transfer. The PT stated that she reviewed her annual evaluation of Resident #1 with the PT Director after being interviewed by DOH on 3/6/14, realized that based on the resident's mobility and transfer ability which required total assistance to achieve in December, Resident #2 should have been transferred by mechanical lift. During an interview on 5/7/14 at 12:30 pm, the hospital Director of Radiology stated that he had a conversation with the DON after the x-rays revealed a fracture. The Director of Radiology stated that the main concern was whether the injury could have been a result of routine care or did something else happen. The Director of Radiology stated that based on his impression of the x-rays, the injury was as a result of a fairly significant trauma and that type of fracture "doesn't just happen." The Director of Radiology stated that he would anticipate pain with the type of fracture, however, it was less than likely, but possible that Resident #1 was not in pain. The Director of Radiology stated that the presence of bruising would have been an indicator of a potential fracture. 10NYCRR 415.12

Based on medical record review and staff interview during an abbreviated survey (Case # NY 294) the facility did not ensure the resident's environment remained as free from accident hazards as is possible and that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #1) of xx residents reviewed. Specifically, Resident #1 required the use of a mechanical lift for all transfers. Resident #1 was transferred via the mechanical lift using an extra large lift sling, and during the transfer fell through the sling. Resident #1 was transferred the emergency room and returned with four sutures to the back of her head. This resulted in actual harm that is not immediate jepordy. This was evidenced by: Resident #1 was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Brief Interview for Mental Status (BIMS) dated 1/15/14 assessed the resident as having severely impaired cognition. Care Card printed on 3/4/14 documented that Resident #1 required a one-person physical assist for transfers using a Maxi lift. Accident/Incident Report dated 3/1/14 at 8:16 am documented that Resident #1 slid onto the floor from the maxi lift during a transfer from the bed to a chair sustaining a hematoma and laceration to the left side of her head. Nurses Note dated 3/1/14 at 8:22 am documented that Resident #1 slid out of the maxi sling during transfer. Resident #1 with a laceration to posterior head, large amount of bleeding noted. The physician was notified and ordered to send the resident to the emergency room . Nurses note dated 3/1/14 at 2:38 pm documented that Resident #1 was returned to the facility with four staples to the lower left back of the head. Investigation Summary of a fall during transfer regarding Resident #1 on 3/1/14 at 8:20 am, signed by the Director of Nursing (DON) documented that CNA #6 was transferring the resident with a Maxi lift from her bed to the chair when Resident #1's upper body slid out of the sling resulting in a laceration to her scalp. The DON's investigation revealed that Resident #1 was being transferred utilizing an extra large sling, meant for a person weighing 308 - 440 lbs and the resident's weight was 124 lbs. The summary documented that the sling size was not listed on Resident #1's care card, but that the resident usually used a medium size sling, which according to CNA #6 was not available. The summary documented that CNA #6 did ask her coworkers about the sling size and was told that she didn't need to use any special sling. The investigative summary documented that the Root Cause of the incident was a system error that the care cards indicated the type of lift to be used but did not include recommended sling size(s). During an interview on 3/6/14 at 10:00 am, the DON stated that she investigated Resident #1's incident and determined that the root cause of the incident was that the wrong sling size was used by the CNA. The DON stated that the facility does not expect that the CNAs will determine the appropriate size and that upon review after the incident, she realized that the sling sizes were not listed on any of the resident's care cards. The DON stated that the facility immediately reviewed and updated all resident in the facility that were transferred using the maxi lift and updated their care cards to include the appropriate sling size. The DON stated that the family of the resident informed her that they had called the incident into the Department of Health (DOH) Compliant Hotline for investigation. When asked by the DOH surveyor if the incident was a reportable incident to the DOH, the DON stated, yes, but when I discussed the incident with the Administrator, he stated that I didn't need to report it because the family had already done so. During an interview on 3/6/14 at 12:45 pm, the Physical Therapist (PT) stated that she has been the PT for the facility since December of 2013. The PT stated that the issue of sling size is being reviewed and believed it was the nursing staff's responsibility to determine the sling size as well as the number of staff required to assist during the transfer. The PT stated that the PT Department had been identifiying Maxi lift for all transfers for those resident's that needed it, but that she and the Director of Physical Therapy were looking at the issue now. During an interview on 3/6/14 at 2:45 pm, the Director of Physical Therapy stated that the PT Department was responsible for identifying the type of lift for residents but not the sling size or the number of staff needed to preform the lift with the maxi lift. The Director of PT stated that due to staffing, she was without a physical therapist for some time and was doing everything herself. The Director of PT stated that while the therapy department would be the best department to determine the safest way to transfer resident, for example for spastic or unexpected movements that would impact the transfer, during her time of covering, she "didn't look at that level of detail." During a follow-up interview on 3/6/14 at 5:30 pm, the DON reviewed a resident's care card and stated stated that there was no sling size identified on the care card. The DON stated, 'I'll take care of it." 10NYCRR 415.12(h)(1)

Based on medical record review and staff interviews during an abbreviated survey (Case #NY 502) it was determined for one (Resident #1) of two residents reviewed, that the facility did not ensure that the resident's environment remained free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not care plan for, or communicate to the certified nurses aides (CNA), the number of staff required to assist the resident with safe bed mobility. Subsequently, the resident fell from bed and sustained a fractured nose and subdural hematomas. This was actual harm that is not immediate jeopardy. This is evidenced by the following: Resident #1: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident had severe cognitive impairment, and required total assistance of two plus people for bed mobility. The annual Physical Therapy assessment form dated 12/14/11, documented that the resident was unable to perform bed mobility independently. The annual Occupational Therapy assessment form dated 10/7/11 documented that the resident was dependent for all aspects of Activities of Daily Living (ADL). The Comprehensive Care Plan (CCP) dated 6/7/12 and titled "Falls", documented that the resident is at risk for falls due to multiple contractures and spastic movements. One of the approaches documented to prevent falls included a concave mattress with an air mattress. The CCP, titled ADL function, dated 6/7/12 documented that the resident was total assist for all ADLs due to mild mental retardation and [DIAGNOSES REDACTED] from Parkinson's, and contractures to both upper and lower extremities. Under the approach section, it was documented that bed mobility was provided by staff, but did not indicate how many staff are needed. A facility document titled "Day Group Data Listing Report" which is used by the Certified Nursing Assistants (CNA) (to know what care to provide to residents), does not include any documentation regarding the resident's bed mobility. The facility form titled Accident/Incident (A/I) Report dated 6/29/12 at 3:15 am documented that while the CNA was providing care, the resident rolled out of the bed onto the floor. The head of the bed was elevated and the bed was not in the lowest position. Review of a form titled "Administrative Investigation of Fall with fracture/Laceration/Subdural Hematoma" dated 6/29/12 documented that the resident was transferred to the emergency room for evaluation. The resident sustained [REDACTED]. Review of the manufacturer's information sheet for the mattress received from the facility documented that the mattress with the defined perimeter bolsters slope up from the mattress surface to define the edge and reduce the risk of rolling off while lying down. Additionally, it was documented that the design of the mattress addressed pressure relief and safety needs for all residents. During an interview on 7/30/12 at approximately 1:30 pm the Physical Therapist (PT) Director stated that the resident was assessed for bed mobility which is usually done by the Occupation Therapist (OT). He stated that usually residents who require a mechanical assist for transfer status would require total assistance from staff, and depending on the weight and [DIAGNOSES REDACTED]. The PT was not able to demonstrate where the bed mobility status was documented on the resident's care plan. During an interview on 7/30/12 at 2:00 pm the OT stated the resident was assessed to require total assistance with all aspects of care. He stated that there wasn't any documentation of how many people the resident required for assistance, but that depending on the resident's weight and [DIAGNOSES REDACTED]. During an interview on 7/30/12 at 2:30 pm the CNA who was providing care to the resident on 6/29/12 during the night shift stated that at approximately 1:00 am the resident was repositioned in bed with the assistance of the nurse. The CNA demonstrated how the resident was positioned in the bed. The CNA demonstrated adding a pillow under the sheet, on top of the air mattress, creating an angle over the elevated bolsters on the defined perimeter mattress (DPM). The CNA stated that the air mattress "contradicts" the purpose of the DPM' s use. The CNA then demonstrated how she provided care to the resident by herself at approximately 3:15 am on 6/29/12. She stated she would provide care up to a point, then she would need help from the nurse. The CNA demonstrated how she positioned the resident, on her right side, then on her back, when the CNA turned to get equipment for care, she heard the resident hit the floor. The CNA stated she then turned around, and the resident was face first on the floor. Observation of the resident's mattress on 7/30/12 at approximately 2:30 pm revealed the defined perimeter mattress with a filled air mattress in between the sloped up bolsters, defeating the purpose of the perimeter mattress. The identified perimeter was no longer able to provide a barrier to prevent the resident from falling out of bed. During an interview on 7/30/12 at 4:30 pm the Director of Nursing stated that residents' bed mobility status changed everyday. 10 NYCRR 415.12(h)(1)(2)