Every finding on record at Beechtree Center For Rehabilitation And Nursing

Based on observation, record review, and interview during the recertification and abbreviated (NY00342762) surveys conducted 8/24/2025-8/29/2025 the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in one (1) out of one (1) main kitchen and for two staff (Dietary Aide #1 and Certified Nurse Aide #4). Specifically, in the main kitchen food was not labelled and dated; refrigerator and freezer temperatures were not recorded; cookware was not sanitized appropriately; potentially hazardous food temperatures were not recorded; and the ice machine was unclean. Additionally, Dietary Aide #1 did not wear a beard restraint while preparing meal trays; and Certified Nurse Aide #4 scratched their head and played with their hair while serving food. Findings include:The facility policy Food and Non-Food Storage, revised 01/2025, documented refrigerator temperatures were recorded daily; foods were labeled and dated.The facility policy Kitchen Equipment Maintenance, revised 8/4/2025, documented refrigerator and freezer temperatures were logged at least twice daily, and the ice machine interior was cleaned monthly.The facility policy Safe Food Handling, revised 8/4/2025, documented beards must be covered with a beard net if not closely trimmed.The facility policy Food Temperature and Palatability, revised 8/4/2025, documented hot foods should remain at or above 135 degrees Fahrenheit. If food falls outside of required temperature ranges during service, it would be reheated to 165 degrees Fahrenheit immediately. The product label for the three-bay sink sanitizer documented dishes were immersed in a 200-400 parts per million active quaternary solution for at least 60 seconds while immersed completely. Temperature Logs:During an observation of the main kitchen on 8/24/2025 at 1:39 PM, the temperature logs for the walk-in cooler, walk-in freezer, cook's cooler, and dessert cooler were not completed and missing the following dates and times: -Walk- in freezer: 8/5/2025 AM; 8/6/2025 AM; 8/8/2025 PM; 8/9/2025 AM and PM; 8/10/2025 AM; 8/14/2025 AM; 8/16/2025 PM; and 8/19/2025 AM and PM.-Walk in cooler: 8/5/2025 AM; 8/6/2025 AM; 8/8/2025 PM; 8/9/2025 AM and PM; 8/10/2025 AM; 8/16/2025 PM; and 8/19/2025 AM. -Dessert Cooler: 8/5/2025 AM; 8/6/2025 AM; 8/8/2025 PM; 8/9/2025 AM and PM; 8/10/2025 AM; 8/14/2025 AM and PM; 8/19/2025 AM and PM; 8/23/2025 AM; and 8/24/2025 AM and PM.-Cooks Cooler: 8/5/2025 AM; 8/6/2025 AM; 8/8/2025 PM; 8/9/2025 AM & PM; 8/10/2025 AM & PM; 8/14/2025 AM; 8/16/2025: PM; 8/23/2025 PM. During a meal observation on 8/24/2025 at 6:07 PM, Dietary Aide #1 delivered the food cart to Unit 2 and served the hot food. The temperature log attached to the food cart was blank. Dietary Aide #1 stated they obtained the temperatures after the meal was over, and they were back in the main kitchen.Undated items:During an observation of the walk-in cooler on 8/24/2025 at 1:39 PM, there were three unlabeled and undated cups (one contained an orange substance, one contained a gravel like substance, and one contained a yellow substance) on the top right shelf. The cook's cooler contained unlabeled and undated cheese, fried eggs, and a meat product (staff identified the product as left over pork chop from the previous day).Hair Restraints:During a meal observation on 8/24/2025 at 6:07 PM, Dietary Aide #1 delivered the food cart to Unit 2 and served the hot food. They had chin hair two inches long and was not wearing a beard restraint. During a meal observation on 8/25/2025 at 1:11 PM, Dietary Aide #1 served the lunch meal on Unit 2 without a beard restraint. Their beard was approximately two inches long. Certified Nursing Aide #4 scratched their head and played with long strands of their hair while putting beverages and desserts on resident trays.3-Bay sink:During an observation on 8/26/2025 at 10:35 AM, the three-bay sink's (used for washing pots and pans) first compartment contained sudsy water, the second compartment contained clear water, the third compartment was empty, and there were two pots air drying at the end of the sink. A bottle of quaternary sanitizer, used to sanitize food contact surfaces, was attached to the third sink by a hose which mixed the sanitizer with water. [NAME] #2 stated the pots were sanitized by running the sanitizer and water mixture over the pots for 5 seconds because they were trying to use up the almost empty bottle of sanitizer.Ice Machine:During an observation on 8/26/2025 at 11:00 AM, a black substance was inside the ice machine, along the ridge where the ice drops down into the basin.During an interview on 8/28/2025 at 11:15 AM, Dietary Aide #1 stated they usually obtained food temperatures before they brought the food cart upstairs, prior to serving. They stated they forgot on 8/24/2025 at dinner. They stated they used to wear beard nets but had not seen them available for a while, and they did not tell anyone they were not available. During an interview on 8/28/2025 at 12:00 PM, Certified Nursing Aide #4 stated they were responsible for tray set up of beverages and desserts and had no formal training in food safety. They stated food items should not be touched after they scratched their head and touched their hair. During an interview on 8/29/2025 at 8:56 AM, [NAME] #2 stated the sanitation sink in the three-bay sink should be filled with the sanitizer mix and dishes should be submerged for at least ten minutes, then air dried. They stated staff were not allowed to serve food with uncovered facial hair. During an interview on 8/29/2025 at 9:07 AM, Kitchen Supervisor #3 stated refrigerator and freezer temperatures were recorded every day on the log sheets. They did not know why there were missing dates. They did not know what the three cups of unlabeled and undated product in the walk-in cooler were. They stated everything in the cook's cooler should be labeled and dated. They stated all three bays of the three-bay sink should be filled and staff did not do this on 8/26/2025 to use up sanitizer. They stated the dietary aides took food temperatures before leaving the kitchen with the food cart or before they served the first tray and recorded the data on the food temperature form on the food table. They stated staff were not allowed to serve meals with uncovered facial hair and it was an oversight they ran out of beard nets. 10NYCRR 483.60(i)(1)-(2)

Based on observations and interviews during the recertification survey conducted 8/24/2025-8/29/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of (2) two meals (lunch meals on 8/25/2025 and 8/26/2025) reviewed. Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 8/25/2025 and 8/26/2025. Additionally, Residents #3 and #8 stated the food was not palatable and Resident #34 stated the food was often cold. Findings include: The facility policy Food Temperature and Palatability, revised 9/9/2024 documented all hot food items were maintained at 135 degrees Fahrenheit or greater until served. Cold food items were served at 41 degrees Fahrenheit or below. Resident meals would be palatable, visually appealing, and prepared in a manner consistent with resident preferences and nutritional needs. Resident interviews on 8/24/2025 included the following:-at 3:23 PM, Resident #8 stated the food was not palatable.-at 4:27 PM, Resident # 3 stated the food was not palatable. -at 4:47 PM, Resident #34 stated the food was often cold. During a lunch meal observation on 8/25/2025 at 12:42 PM, Resident #20's meal was tested in the presence of Registered Nurse #22, and a replacement tray was ordered. Food temperatures measured as follows: the baked chicken breast was 96 degrees Fahrenheit and fried potatoes with onions were121 degrees Fahrenheit. The baked chicken was dry and tough to chew. During a lunch meal observation on 8/26/2025 at 1:01 PM Resident #34's meal tray was tested in the presence of Certified Nurse Aide #11, and a replacement tray was ordered. Food temperatures were measured as follows: pork cutlet was 123.6 degrees Fahrenheit, zucchini was 131 degrees Fahrenheit, rice was 114.8 degrees Fahrenheit, applesauce was 53 degrees Fahrenheit, water was 43.3 degrees Fahrenheit, and 2% milk was 45 degrees Fahrenheit. The pork cutlet was bland with mushy breading. During an interview on 8/28/2025 at 11:15 AM, Food Service Aide #1 stated the holding temperature for hot food was 175-180 degrees Fahrenheit. The food was cooked prior to being brought to the units and the food service aides were supposed to measure the temperature of the food prior to serving and record it on their temperature log. If the food was not at the proper temperature, they should notify the supervisor. During an interview on 8/29/2025 at 9:07 AM, Kitchen Supervisor #3 stated the food was cooked in the kitchen and held in the hot holding box or refrigerator in the kitchen until the food service aides brought the food to the units. The food service aides took the temperature of the foods prior to serving the residents and recorded them on their temperature log. If there any issues with the temperature of the food the food service aides should call the supervisor. When hot food was served cold it could affect the palatability of the meal. Hot foods should be served at least 135 degrees Fahrenheit and cold foods should be served at 41 degrees or below Fahrenheit to ensure palatability. 10NYCRR 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00383732) surveys conducted 8/24/2025-8/29/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of seven (7) residents (Residents #8 and #111) reviewed. Specifically, staff did not wear personal protective equipment when entering Residents #8's and #111's rooms, who were on contact precautions.Findings include: 1) Resident #8 had diagnoses including methicillin resistant staphylococcus aureus (antibiotic resistant bacteria) infection and local infection of the skin. The 6/5/2025 Minimum Data Set assessment documented the resident had intact cognition, multidrug-resistant organisms, a wound infection, and required applications of nonsurgical dressings to feet.The 6/30/2025 Comprehensive Care Plan documented the resident had methicillin resistant staphylococcus aureus in the left heel wound. Interventions included bag and transport used linen according to facility protocol, contact isolation, and educate the resident and family regarding the importance of hand washing immediately after activities of daily living, care tasks, and activities.The 8/14/2025 Physician order documented enhanced barrier precautions and contact isolation precautions secondary to wounds and history of methicillin resistant staphylococcus aureus. The Wound culture collected 8/12/2025 documented there was methicillin resistant staphylococcus aureus growth in the left foot wound.The Comprehensive tissue culture collected 8/25/2025 documented there was staphylococcus aureus growth in the left foot wound.The following contact precaution observations were made:-On 8/26/2025 at 8:34 AM, Certified Nurse Aid #11 entered Resident #8's room without donning personal protective equipment and placed a meal tray on the resident's table.-On 8/27/2025 at 9:48 AM, Certified Nurse Aid #18 entered the room without donning and isolation gown or gloves and delivered packages to the resident.During an interview on 8/27/2025 at 10:48 AM, Certified Nurse Aid #17 stated that they knew who was on isolation precautions because of the sign on the door. The sign stated what type of isolation they were on and what to wear. Resident #8 was on enhanced barrier precautions. Surveyor and Certified Nurse Aid #17 observed the door for Resident #8 with a contact precaution sign. They stated they were not sure when the sign was placed as it was not there a day ago. Since they were on contact isolation, one needed a gown and gloves to enter the room.2) Resident #111 had diagnoses including sepsis due to Escherichia coli (a bacteria found in the gut). The 8/11/2025 Minimum Data Set assessment documented the resident had intact cognition, had multidrug-resistant organism infections, and sepsis.The 8/5/2025 Comprehensive Care Plan documented the resident was on contact precautions related to extended-spectrum beta-lactamases (a resistant enzyme produced by Escherichia coli) in their urine and wounds. Interventions included contact precautions.The 8/5/2025 Physician order documented transmission-based precautions: contact precautions secondary to extended-spectrum beta-lactamases in urine.The following observations were made:- On 8/24/2025 at 4:16 PM a contact isolation sign was on the door Resident #111's room.- On 8/24/2025 at 4:20 PM Certified Nurse Aid #19 entered the resident's room without donning gown or gloves, lifted up the resident's blanket and stated they were checking if the resident was dry or needed to be changed.- On 8/24/2025 at 4:27 PM Registered Nurse #20 entered the resident's rooms without donning gown or gloves to deliver food to the resident.During an interview on 8/24/2025 at 4:20 PM, Certified Nurse Aid #19 stated they did not wear a gown or gloves because they did not know the resident was on contact precautions. They had only been working in the facility for three days. They were unsure how to know if a resident was on precautions. They thought that maybe there would be something across the door telling them to stop. They had been in and out of Resident #111's room multiple times and in other resident rooms. They knew they should wear a gown and gloves if someone was on contact precautions but did not know why. They did not remember if they had received education about isolation when they started. They stated that they should have worn a gown and gloves if the resident was on contact precautions. During an interview on 8/28/2025 at 10:50 AM, Assistant Director of Nursing stated staff knew if a resident was on contact precautions by the sign on the door outside the room. The sign indicated what personal protective equipment was required to enter the room. Contact precautions required staff to don a gown and gloves prior to entering the resident's room. Staff received education on this on orientation and annually. Residents #8 and #111 were on contact isolation.During an interview on 8/28/2025 at 1:57 PM, Director of Nursing/Infection Preventionist stated if someone had an active infection they should be on contact isolation. The resident was placed on contact precautions after the result of the culture came back. An order was needed for contact isolation. Staff knew if a resident was on contact isolation by the sign on the door, a doctor order, and it was in the Kardex and Care Plan. Anytime a staff member entered a contact isolation room they were required to wash hands and don gown and gloves prior to entering the room. The rational for wearing personal protective equipment was to decrease the spread of infection. 10 NYCRR 415.19(a)(b)

Based on observations, record review, and interviews during the recertification survey conducted 8/24/2025-8/29/2025, the facility did not ensure planned menus were followed for two (2) of two (2) residents (Residents #3 and #8) reviewed. Specifically, Residents #3 and #8 did not receive double portions as planned.Findings include:The facility policy Tray Ticket Accuracy, revised 9/9/2024, documented tray tickets would be accurate, up to date, and verified prior to tray assembly and service. The facility would ensure all resident meal trays were prepared and served according to the physician's diet orders and individual food likes/ dislikes as documented in the resident's plan of care. Staff assembling meal trays strictly matched the food items to the tray ticket; before releasing the meal tray staff verified accuracy by comparing the tray contents with the tray ticket; and if discrepancies were noted during meal service, the tray was returned for immediate correction. The facility policy Food Temperature and Palatability, revised 9/9/2024, documented resident preferences and dislikes were honored and documented in the resident's care plan. Reasonable efforts were made to accommodate resident choices and preferences. The 7/10/2025 Resident Council Minutes documented a Food Committee Meeting was held and residents had complaints regarding the portion sizes provided at meals. 1) Resident #3 had diagnoses including end stage renal disease (kidney failure), diabetes, and unspecified protein-calorie malnutrition. The 7/24/25 Minimum Data Set assessment documented the resident had intact cognition, required set-up or clean-up assistance with eating, weighed 195 pounds, and had no significant weight changes in the past six months. The Comprehensive Care Plan, initiated 11/27/2024 and revised 8/28/28, documented the resident had an activity of daily living deficit and required assistance of 1 person with set-up and clean-up assistance at meals. The 2/5/2025 revised Comprehensive Care Plan documented the resident was at risk for altered nutritional status related to chronic kidney disease and was on hemodialysis (a machine that filters the blood). Interventions included to provide a regular liberalized diet, honor preferences and offer alternative items, and provide supplements and diet as ordered. The care plan did not include a plan for double portions. The 3/25/25 physician orders documented the resident was to receive Nepro (oral nutrition supplement for kidney disease) four days a week on non-dialysis days. The 3/28/25 physician orders documented the resident received a regular texture, regular thin liquid diet, with coffee mugs, and sip lids to promote oral intake. The undated care instructions documented to ensure the resident's needs were met, including thirst and hunger. The resident required set-up and clean-up assistance of 1 person at meal, coffee mugs with sip lids, a regular liberalized diet, honor preferences, and offer alternatives. Serve diet as ordered and provide supplements as ordered on non- dialysis days. During an interview on 8/24/25 at 4:27 PM, Resident #3 stated they were supposed to get double portions at meals, but the portion sizes were small. During a meal observation on 8/25/25 at 12:57 PM, Certified Nurse Aide #13 served Resident #3 their lunch meal tray. The meal ticket documented the resident received a regular diet and double portions of protein/meats. The meal ticket documented three ounces of baked chicken breast. The meal tray had one baked chicken breast. At 1:29 PM, the resident ate 100% of their meal and was not provided or offered an additional baked chicken breast or additional entree. The 8/27/2025 facility Meal Distribution Sheet (production sheet) documented the 1st floor received 28 portions of three (3) ounces of oven roasted turkey and one (1) double portion. During an interview on 8/27/25 at 12:22 PM, Food Service Aide #12 stated the production sheet indicated the serving size for each item served at the meal. The cook prepared the food and plated the items according to the meal ticket. According to the production sheet, each slice of roast turkey was supposed to be three ounces. If a resident's meal ticket documented they should receive double portions of the entree, and two slices of turkey was provided. The food service aides should follow each resident's meal ticket and provide the items listed. If they ran out of something or did not have an item, they were supposed to call the kitchen to get the items listed on the meal ticket. During an observation on 8/27/2025 at 1:00 PM, Certified nurse aide #11 provided Resident #3 their lunch meal. The meal ticket documented the resident received a regular diet and double portions of protein/ meats. The ticket indicated three ounces of oven roasted turkey, two ounces of poultry gravy, 1/2 cup bread dressing, 1/2 cup broccoli and cauliflower florets, 1/2 cup mandarin oranges, four ounces of 2% milk, and eight ounces of water. The resident had one slice of oven roasted turkey on their plate that appeared smaller than three ounces. During a follow up interview on 8/27/2025 at 1:01 PM, Food Service Aide #12 stated they were unsure why Resident #3 did not receive double portions of the oven roasted turkey. During an interview on 8/27/25 at 1:03 PM, [NAME] #2 stated they prepared and sliced the oven roasted turkey served at the lunch meal today. The production sheets indicated the portion sizes required for each item. The serving size for the roasted turkey was two ounces, and each slice of turkey should be two ounces. When they sliced the roasted turkey, they calibrated the scale and measured two ounces, set the slicer to the correct thickness, and sliced the portions to provide two ounces. They did not realize the portion size of the oven roasted turkey listed on the production sheet was supposed to be three ounces and they made a mistake. During an interview on 8/27/25 at 1:37 PM, Kitchen Supervisor #3 stated they oversaw the production of the lunch meal today. The cooks were provided with a production sheet indicating the portion sizes and number of portions for each meal. It was their responsibility to ensure the meats were cut to the correct portion size. The production sheet indicated the portion size for oven roasted turkey was three ounces for a single serving, and residents whose meal tickets listed double portions should receive six ounces. The supervisors did not verify the correct portion sizes were prepared. The cooks should ensure the correct portions sizes were prepared, and the food service aides should read the meal tickets and provide what is listed. During an interview on 8/27/2025 at 1:50 PM, Certified Nurse Aide #11 stated the food service aides plated the food items according to the resident's meal tickets. Resident #3 was supposed to receive double portions as indicated on their meal ticket. When they served the resident their meal there was one slice of oven roasted turkey on their plate. During a telephone interview on 8/29/2025 at 12:39 PM, Registered Dietitian #15 stated they did not provide oversight to the kitchen staff. In the past they had heard the residents complain about food portion sizes at the facility. The Food Service Director, who was currently out on medical leave, educated staff on portion sizes and following the meal tickets. The menu indicated the residents were supposed to receive three ounces of oven roasted turkey and the cooks should be following the production sheets. If the residents did not receive the correct portion sizes it could impact their nutritional status and lead to possible weight loss. Resident #3 was on dialysis, their weight was stable, and they requested double portions per their preference. Their meal ticket indicated double portions of protein and meats. 2) Resident #8 had diagnoses including depression, morbid obesity, and diabetes. The 6/5/2025 Minimum Data Set assessment documented the resident had intact cognition, was independent with eating, was 61 inches tall, weighed 348 pounds, had no significant weight changes in the past six months, and was on a therapeutic diet. The Comprehensive Care Plan initiated 10/9/2024 and revised 3/3/2025, documented the resident was at risk for an alteration in nutritional status related to weight changes and need for a therapeutic diet order. Interventions included preferences would be honored and diet served as ordered. The 5/28/2025 physician orders documented the resident received a regular consistency, low concentrated sweets, no added salt diet. The undated care instructions documented to provide diet as ordered and honor preferences. During an interview on 8/24/2025 at 3:23 PM, Resident #8 stated the food did not taste good. During a dinner meal observation on 8/24/2025 at 6:37 PM, Resident #8's meal ticket documented they were to receive three ounces of turkey and Swiss cheese sandwich with double portions of meat and cheese. The resident received one slice of turkey and one slice of cheese. During a lunch meal observation on 8/26/2025 at 1:09 PM, Resident #8's meal ticket documented they were to receive one tossed salad with dressing, three ounces of breaded pork cutlet, double portions, 1/2 cup of herbed rice, 1/2 cup seasoned zucchini, 1/2 cup applesauce, 1/2 slice of Texas garlic toast, four ounces of 2% milk, eight ounces of water, six ounces of coffee, and one serving of pita bread and hummus. The resident's tray was missing tossed salad and dressing, and they received one three-ounce portion of breaded pork cutlet and did not receive the pita and hummus. During an interview on 8/26/2025 at 1:13 PM, Resident #8 stated they were disappointed they did not receive all the items on their meal ticket. During an interview on 8/28/2025 at 10:06 AM, Certified Nurse Aide #21 stated the food service aide plated the resident's meal according to their meal ticket and the nursing staff who served the resident their meal tray checked it again prior to serving the resident to make sure all items were the correct consistency and on the tray. If they noticed anything was missing from the tray they asked for the items. The meal ticket also documented if the resident received double portions. They never observed Resident #8 receive double portions and was unaware they were supposed to receive double portions. During an interview on 8/28/2025 at 10:50 AM, the Assistant Director of Nursing stated nursing staff was responsible to double check the residents' meal tickets against the items on their tray prior to serving the resident. If a resident's meal ticket documented double portions, they should receive double portions. On 8/29/2025 at 10:42 AM, Registered Dietitian #15 stated during a telephone interview Resident #8's meal tickets documented they were supposed to receive double portions per their preference. The resident had expressed an interest in weight loss and wanted double portions at meals to aide with decrease snacking between meals. Resident's meal preferences should be honored to assist them with their nutritional goals. 10NYCRR 415.14(c)(1-3)

Based on observations, record review, and interviews during the recertification survey conducted 8/24/2025-8/29/2025, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for one (1) of three (3) medication carts (Unit 2 medication cart) reviewed. Specifically, the Unit 2 medication cart had expired multidose medications. Findings include: The facility policy Medication Storage, reviewed 3/2025, expired, discontinued, or contaminated medications were removed from storage and disposed of in accordance with facility policy and manufacturer guidance. All medications were stored in an orderly manner and remain properly labeled and identifiable until use.During a Unit 2 medication cart observation on 8/25/2025 at 1:36 PM with Licensed Practical Nurse #5, the following was observed:-cyclopentolate ophthalmic solution (eye drops) with an expiration date of 8/2023.-albuterol with an expiration date of 11/8/2024.-unspecified eye drops opened on 7/7/2025 and labeled as good for 28 days. During an interview on 8/26/2025 at 10:16 AM, Licensed Practical Nurse #5 stated expired medications should be discarded and not left in the medication cart. The eye drops opened on 7/7/2025 should have been discarded because they were only good for 28 days after opening. Expired medications should not remain in the medication cart and should be removed and placed in the medication room so pharmacy could dispose of them.During an interview on 8/26/2025 at 1:57 PM, the Director of Nursing stated when insulin, nasal spray, or eye drops were opened, they should be discarded once the manufacturer's recommended timeframe expired. Expired medications should be removed from the cart and returned to the pharmacy for disposal. The pharmacy consultant and night shift nurse checked carts for expired medications and disposed of them when necessary. 10NYCRR 415.18(d)

Based on observations, record review, and interviews during the recertification survey conducted 8/24/2025 - 8/29/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (1) of one (1) resident (Resident #113) reviewed. Specifically, Resident #113 did not have their blood pressure monitored as ordered. Findings include:Resident #113 had diagnoses including coronary artery disease, peripheral vascular disease, and hypertension. The 8/7/2025 Minimum Data Set assessment documented the resident had intact cognition.The Comprehensive Care Plan initiated 12/20/2024 and revised 5/2/2025, documented the resident had hypertension. Interventions included antihypertensives as ordered, monitor for side effects, monitor for edema, monitor/document/report signs and symptoms of malignant hypertension (severe form of high blood pressure). There was no documentation regarding monitoring of blood pressure. The August 2025 Medication Administration Record documented:-lisinopril (antihypertensive) 30 milligrams at bedtime for hypertension- hold if systolic blood pressure (top blood pressure number) is less than 120 or if heart rate is less than 60 with a start date of 12/23/2024 and a discontinue date of 8/11/2025. An area for blood pressure readings was included on the administration record for the lisinopril. -lisinopril 40 milligrams at bedtime for hypertension- hold if systolic blood pressure (top blood pressure number) is less than 120 or if heart rate is less than 60 with a start date of 8/11/2025 and a discontinue date of 8/27/2025. There were no areas to record blood pressure readings on the administration record for the lisinopril. There was no documented evidence the resident's blood pressures were obtained prior to the administration of lisinopril from 8/11/2025-8/26/2025. The August 2025 Treatment Administration Record documented vital signs one time a day for hypertension for 14 days with a start date of 8/16/2025, resident requesting blood pressure be taken manually as machine hurts their arm. The 8/21/2025 blood pressure reading was the only reading corresponding to the nurse who administered the lisinopril on that day.The 8/23/2025 at 2:20 PM Licensed Practical Nurse #5 progress note documented the resident refused their blood pressure because the machine hurt them. A manual blood pressure cuff was not found. There was no documented evidence why the blood pressure was attempted to be taken several hours before the scheduled administration of lisinopril. The 8/26/2025 at 1:50 PM Licensed Practical Nurse #5 progress note documented the resident refused to have their blood pressure taken with the electronic machine. There was no documented evidence why the blood pressure was attempted to be taken several hours before the scheduled administration of lisinopril. During an interview on 8/24/2025 at 4:15 PM, Resident #113 stated they refused the blood pressure machine because it was very painful, but staff refused to obtain manual blood pressures. They stated their blood pressure had been running very high, and the physician was changing their medications around.During an interview on 8/28/25 at 1:09 PM, Licensed Practical Nurse #5 stated the blood pressure order documented the resident preferred manual blood pressures and when they were the only nurse on the unit, they got very stressed and only offered the machine. They stated if Resident #113 refused the blood pressure they did not try a manual one.During an interview on 8/29/2025 at 10:45 AM, Registered Nurse #6 stated they were not aware Resident #113 was missing blood pressures. They stated if Resident #113 refused the blood pressure machine they expected staff to get a manual cuff and respect the resident's wishes.During an interview on 8/29/2025 at 11:10 AM, Physician Assistant #7 stated Resident #113 had daily blood pressures ordered because they had high blood pressure readings. They expected manual blood pressures were taken based on their order. They stated nurses should have informed them blood pressures were refused. They stated they were not aware staff were not obtaining manual blood pressures after the resident refused the machine. 10NYCRR 415-12

Based on observation and interview during the recertification and abbreviated (NY00315667) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (11/14/2023 and 11/15/2023 lunch meals). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures. Findings include: The facility's undated Hot Foods Policy documented the kitchen would assure that hot foods were held so that all parts of the food met current temperature regulations for hot holding. Potentially hazardous food must be held and served at 135 degrees Fahrenheit (F) or above (or at the temperature dictated by the local health regulations). The facility policy Test Trays dated 5/2009 documented three times a week the food and nutrition supervisor would make up a test tray from either the lunch or supper meal. The cook would let the tray set for up to 15 minutes to properly gauge the food temperatures on the nursing floors. After the proper time of letting the tray set the supervisor would start taking temperatures of the food and beverage items. They must also make notes of whether the food was good, if it was dry, salty, and was the correct texture for the diet. During an observation on 11/14/2023 at 1:19 PM, a lunch tray was delivered to resident room [ROOM NUMBER]. The tray was tested , and a replacement was ordered for the resident. At 1:21 PM, the food temperatures were measured with the following results: the taco meat was 119 degrees F; the corn was 110 degrees F; the Spanish rice was 140 degrees F; and the milk was 51 degrees F. The taco meat was salty with an off taste, the corn was not hot, and the Spanish rice was bland. During a resident group meeting on 11/15/23 at 10:54 AM, seven residents stated they had long standing food issues that had not been addressed. They had a food council that met right before resident council. The residents stated the food remained flavorless and was not hot most of the time. The food seemed to be cooked too long and with too much salt, or it was just bland. During an observation on 11/15/2023 at 1:04 PM, a lunch tray was delivered to resident room [ROOM NUMBER]. The lunch tray was tested , and a replacement was ordered for the resident. At 1:06 PM, the food temperatures were measure with the following results: the roast beef was 115 degrees F; the mashed potatoes were 147 degrees F; the carrots were 124 degrees F; and the pudding was 37 degrees F. The roast beef and carrots were not hot to taste. During an interview on 11/16/2023 at 12:05 PM, The Food Service Director stated the hot food should be served to the residents at 135 degrees F, and cold food items should be served at 44 degrees or lower. They stated the corn temperature of 110 degrees F, the roast beef of 115 degrees F, and the carrots of 124 degrees F were not acceptable hot temperatures. The taco meat was difficult to keep hot when placed on a cold tortilla and with items on top of it. The milk temperature of 51 degrees F was not acceptable. The residents had made complaints that the taco meat was too salty, and the Spanish rice was not flavorful. There were no complaints about under seasoned and/or over seasoned food in the last months. They stated they usually tested on e tray on each floor once a week and they did not have any issues with those test trays. 10NYCRR 415.14(d)(2) 44838

44838 Based on observation, record review, and interview during the recertification and abbreviated (NY00315978) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for three isolated areas (the shower room across from room [ROOM NUMBER], the bathroom in resident room [ROOM NUMBER], and the main kitchen dish machine room). Specifically, the floor in the shower room across from room [ROOM NUMBER] was damaged; the wall in resident room [ROOM NUMBER] bathroom had a hole in it; and a hand wash sink in the main kitchen dish machine room was leaking. Finding include: During an observation and interview on 11/15/2023 at 10:03 AM, the floor in the shower room across from room [ROOM NUMBER] had cracked and peeled sections where water could get under the vinyl flooring material. The Maintenance Director stated that they were not aware that the vinyl flooring had lifted around the floor drain. During an observation and interview on 11/15/1023 at 10:10 AM, the bathroom wall in resident room [ROOM NUMBER] had a 4 inch by 12 inch hole. The Maintenance Director stated they were not aware of the hole and the wall had probably been damaged by a mechanical lift. During an observation on 11/16/2023 12:40 PM, the main kitchen dish machine room had a handwash sink that was leaking and dripping water into a 5 gallon bucket. The water was dripping from one of the loose, bent pipes under the sink. There were no documented work orders for the damaged vinyl flooring material in the shower room across from room [ROOM NUMBER], the hole in the bathroom in resident room [ROOM NUMBER], or the leaky hand wash sink in the main kitchen dish machine room. During an interview on 11/16/2023 at 2:08 PM, the Maintenance Director stated that it was important for staff to utilize the existing facility work order system properly, and that there were work order books on each floor by the nursing station and outside the maintenance office door. They stated all staff were trained upon hire and annually to document work orders on the facility work order system. The Maintenance Director stated there were no work orders for the flooring in the shower room, the hole in the bathroom in resident room [ROOM NUMBER], or the leaking handwash sink in the main kitchen dish machine area. They stated that a work order was submitted for the kitchen sink on 11/16/2023, and they were not sure when the sink had started leaking. This leak had not been previously mentioned by any kitchen staff members. During an interview on 11/17/2023 at 10:03 AM, food service worker #1 stated the handwash sink in the main kitchen dish machine area had been leaking for two weeks, and they had told a maintenance worker about the water leak. They were aware of the facility work order system and stated that a logbook existed outside the maintenance director's office. They stated that they did not put a work order in the book the day that they had identified the water leak. 10 NYCRR 415.29(j)(1)

Based on observation, record review and interview during the recertification survey completed 11/13/2023-11/17/2023, and abbreviated survey (NY00326712) the facility did not ensure residents received dental services in a timely manner for 1 of 1 resident (Resident #49) reviewed. Specifically, the resident's lower denture was reported missing in March 2023 and the resident did not see the dentist for an evaluation until June 2023. Findings include: The facility policy titled Dental Visits revised 5/2020 documented residents agreeing to dental interventions by a licensed and currently registered dentist would be scheduled for and receive a complete oral examination by the dentist at the next dental visit date. An individual oral hygiene plan will be implemented. Residents would be referred to the dentist for emergency care as needed. Resident #49 was admitted to the facility with diagnoses including diabetes mellitus type 2 and hypertension (high blood pressure). The Minimum Data Set (MDS) assessment completed on 9/8/2023, documented the resident was severely cognitively impaired, required extensive assistance of 1 staff for activities of daily living, required tray set up for eating and the oral and dental status for broken or loosely fitting full or partial denture or mouth or facial pain, discomfort or difficulty with chewing was not applicable. The comprehensive care plan (CCP) updated 4/5/2023 documented dental as an area of focus. Interventions included a dental consult per physician order, maintain dentures within reach at all times, ensure the dentures were kept clean, observe for changes in eating patterns, and notify the physician/nurse practitioner (NP) for any changes in condition of their mouth. On 10/24/2023 the resident's family member stated in 3/2023 the resident's bottom dentures were missing and they reported the missing denture to the unit staff. The family member was told the dentures may have been lost in the bed sheets and the outside laundry company would be contacted. In 4/2023 the family member asked registered nurse (RN) Unit Manager #2 the status of the dentures and was told the dentist took measurements and impressions for bottom dentures the previous week. RN Unit Manager #2 did not know when the dentures would arrive. The family member continued to inquire about the status of the resident's dentures and requested the process be expedited. During a care plan meeting on 6/29/2023 the family member was told the resident was seen by the dentist on 6/27/2023. The family member made an appointment with an outside dental office scheduled for 10/30/2023. When the family member visited the resident on 10/19/2023 they noticed the resident did not have a top denture in and was informed it was missing. Nursing progress notes from 3/6/2023-6/28/2023 did not include documentation of the resident's dental status or dental visits. A 6/27/2023 dentist #7 progress note documented the resident was placed on the dental list for new dentures. The resident was evaluated by the dentist. There was no documented evidence the resident was seen by the dentist prior to 6/27/2023. A 6/29/2023 at 8:47 PM registered nurse (RN) Unit Manager #2 progress note documented the resident's family member was present at the care plan meeting and requested an update on the resident's dentures. The family member was told the dentist completed molds of the resident's mouth. The dentist was expected back in three weeks. A 7/5/2023 at 12:44 PM nursing staff #13 (unidentified title) progress note documented the resident was seen by the dentist that day. The dentist note was given to nurse practitioner (NP) #10 for review. A 7/25/2023 dentist #7 progress note documented the resident was measured for new lower denture and the tooth color was picked. An 8/21/2023 dentist #7 progress note documented the attempt to fit the new lower denture, but it was not sized correctly. The plan was to send the denture for readjustment. A 9/28/2023 at 1:42PM by RN Unit Manager #2 progress note documented the resident's family member reported it had taken too much time for the resident's dentures to be completed and requested a new dentist. They would need to check with management. A 10/23/2023 dentist #7 progress note documented the resident remained edentulous (no teeth). They attempted to place the lower denture and discovered the upper denture was not available. They asked the nursing staff about the upper denture and was told the upper denture was lost. They advised nursing staff that the lower denture could not be placed properly without an upper denture. The plan was to wait for a week to see if the upper denture could be found. A progress note written on 10/23/2023 at 3:53PM, by RN Unit Manager #2 documented the resident's family member called regarding the dentist. The family member stated they did not want the resident seen by the facility dentist to complete the dentures. The family member reported some concerns with the dentist's practice standards. The family member stated that the resident had lost the top dentures as of the previous Sunday. Family member stated they would bring the resident to a community based dental practice for denture replacement. The family member was told twice that the cost of the resident's care at a community based dental practice would not be covered by the facility. The family member stated they wanted the resident to have lower/upper dentures replaced as quickly as possible. A 10/30/2023 at 11:05 AM RN Unit Manager #2 progress note documented the resident had a dentist appointment at a community based dental practice on this date. During an observation and interview on 11/13/2023 at 2:44 PM, the resident stated their upper/lower dentures were being fixed. The resident was lying in bed and was edentulous (without teeth). The resident stated they could eat softer foods and not having their dentures prevented them from eating foods they enjoyed. The resident was unable to state when they last had both dentures in their mouth. A 11/14/2023 at 7:44 PM licensed practical nurse (LPN) #4 progress note documented the resident was out of the facility at a community based dental practice for an appointment for a denture consult. The next appointment at the community based dental practice was scheduled for 11/18/2023 and would include the molding of new dentures. During an interview on 11/15/2023 at 9:19 AM, certified nurse aide (CNA) #3 stated the resident had upper dentures until about 2 weeks ago. They stated they did not know how long the lower dentures were missing. They stated they worked on the unit for six months and could not recall a time the resident had lower dentures. During an interview on 11/15/2023 at 9:41AM, LPN #4 stated the resident's dentures were lost for about a month. They stated the resident's family member took the resident to an outside dentist yesterday to have the dentures replaced. During an interview on 11/16/2023 at 11:16 AM, CNA #6 stated the resident's dentures had been missing for a while, they thought maybe two or three months. During an interview on 11/16/2023 at 11:22 AM, RN Unit Manager #2 stated the resident's lower dentures had been missing since March 2023. They stated the resident was not referred to the facility dentist until June 2023. They were unable to offer a reason for the delay in dental referral. They stated the dentist came to the facility every 4 to 6 weeks and the dentist started the replacement process but the resident's family member decided they did not want the facility dentist to complete the process. During a telephone interview on 11/17/2023 at 8:19 AM, dentist #7 stated they had a contract with the facility to visit one time per month. They stated they would make an earlier visit to the facility, if needed, for an urgent dental issue. They stated the first referral they received for the resident's denture was in June 2023. They stated they evaluated the resident on 6/27/2023. Dentist #7 stated replacement of a denture took a minimum of 4 visits to complete based on the monthly visit schedule and the resident had a series of measurements and fittings for the lower denture between June and August 2023. They stated they were prepared to deliver the final lower denture in September 2023; however, they were not able to report to work at the facility at that time. They stated on 10/23/2023, they visited the facility with the lower denture completed and realized the resident's upper denture was not available. They stated they could not place a lower denture properly without an upper denture in place. They stated they had a telephone conversation with the resident's family member on 10/27/2023 and was asked to replace both the upper and lower denture. During a telephone interview on 11/17/2023 at 9:49 AM, the resident's family member stated the resident's lower denture was lost in March 2023 and the resident's upper denture was missing for approximately 2 weeks now. They stated they were concerned that the facility knew the lower denture was missing in March 2023, but did not consult the facility dentist until June 2023. They stated they did not understand why it took so long for the resident's denture to be replaced. During an interview on 11/17/2023 at 10:34 AM, the Director of Nursing (DON) stated they expected if a resident lost a denture, they would be evaluated by the facility dentist to start denture replacement at the next scheduled time the dentist was scheduled to visit the facility. They stated a resident without dentures could have difficulty with eating, speaking, and dignity. 10NYCRR415.17 (a-d)

Based on observation, record review, and interview during the recertification and abbreviated (NY00315667) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure that prompt efforts were made to resolve grievances that residents may have for 1 of 3 residents (Resident #31) reviewed. Specifically, Resident #31 ordered a streaming device that was delivered to the facility, the resident did not receive the device, and the facility did not reimburse the resident for the missing item. Findings include: The facility policy, Grievances last reviewed 4/20/2023, documented complaints and/or grievances may be submitted orally or in writing. Upon receipt of a complaint or grievance, staff must immediately attempt to address and resolve the issue. Resident #31 was admitted to the facility with diagnoses including schizoaffective disorder, cerebral infarction (stroke), and depression. The 8/5/2023 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance with most activities of daily living (ADLs) and did not have behavioral symptoms. A lost/missing item report dated 3/9/2023 and signed by the Director of Social Services and the facility Administrator documented Resident #31 had ordered a streaming device that was never delivered to the resident's room. The resolution documented the resident was to reorder the device or ask for their money back since the device was not delivered. There was no documented evidence the facility investigated why the device was not delivered to the resident. During an interview on 11/13/2023 at 11:34 AM, Resident #31 stated they had ordered a streaming device earlier in the year and had never received it. They were told the device had been delivered to the facility but had not been delivered to their room. They stated that the Activities Director had helped them place the order using the resident's credit card. The resident stated they had reported the problem to social worker #31, who filled out a grievance form. The resident asked for reimbursement but had still not been reimbursed for the missing item. During an interview on 11/16/2023 at 2:56 PM, the Director of Social Services stated that on admission the concierge would make sure all resident belongings were documented on an inventory sheet. Any items ordered from outside the facility were delivered by activities staff and they were not sure if those items were added to the resident inventory sheet. Missing items should be reported to the social worker so a grievance form could be initiated. Staff would then look for the item. After the search was completed, the resolution would be decided on. The Director of Social Services remembered Resident #31 had reported their missing streaming device and believed the facility had reimbursed the resident after the item was not found. During an interview on 11/17/2023 at 8:53 AM, the Business Office Manager stated they handled personal funds accounts for residents. They stated residents were encouraged to have activities help with ordering items. Resident #31's resident funds ledger dated 11/14/2022-11/17/2023 did not include a facility reimbursement for the missing streaming device. During an interview on 11/17/2023 at 9:09 AM, the Activities Director stated mail and packages were delivered to residents by the activity department. Packages were delivered the day or day after arrival. Activities did not add items received to the personal inventory lists but kept track of delivered items received. Resident #31 ordered a streaming device with their own credit card with the assistance of activity staff. The Activities Director stated they remembered the package coming to the facility as it was ordered in their name, and they opened it. The device was then set to be delivered by activity staff. They stated the list of delivered items did not contain the streaming device being delivered to Resident #31. Activities Director stated they notified social work of the missing item and the resident's wish to be reimbursed. There was no documentation of the device being delivered to the resident, and in that case, the facility should have replaced or reimbursed the resident. During an interview on 11/17/2023 at 9:29 AM, the Administrator stated missing property was usually reimbursed to the resident. Activities kept records of items ordered by residents, and who delivered to resident's rooms. The facility was usually responsive to replacing or reimbursing for missing items. Resident #31 was missing a streaming device earlier this year. The Administrator remembered signing the grievance form, and thought the resident was reimbursed. 10NYCRR 415.3(c)(1)(i)

Based on observation, record review, and interview during the recertification and abbreviated (NY00315667, NY00315978, and NY00326712) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 3 of 16 residents (Residents #4, #71, and #91) reviewed. Specifically, Resident #4 did not receive medications as ordered; Resident #71 had a dressing applied to their left index finger without an order and the dressing was observed soiled; and Resident #91 did not have heel pressure reducing booties in place as planned. Findings include: The facility policy Pressure Ulcer Prevention Strategies reviewed 8/3/2023 documented the facility uses multiple pressure relieving strategies for the prevention of pressure injuries including heel lifts/booties/elevate heels off the bed. 1) Resident #4 was admitted to the facility with diagnoses including cholelithiasis (gall stones) without obstruction, benign prostatic hyperplasia (enlarged prostate) with urinary retention, chronic respiratory failure, and generalized anxiety disorder. The 6/10/2023 Minimum Data Set (MDS) assessment documented the resident had intact cognition, did not reject care, had an indwelling urinary catheter, and received antianxiety and diuretic medications daily. The comprehensive care plan (CCP) documented: - effective 1/6/2022 the resident had generalized anxiety disorder. Interventions included administer clonazepam and monitor response. - effective 5/6/2022 the resident had respiratory failure. Goals included episodes of wheezing to be relieved by treatment. - effective 9/20/2022 the resident had a suprapubic catheter for obstructive uropathy. Interventions included flush catheter per physician order. - effective 9/28/2022 the resident had cholelithiasis (gall stones) without obstruction. Interventions included provide meds as ordered. Physician orders documented: - on 11/18/2022 ursodiol (used to treat gallstones) 300 milligrams (mg) every day at 9:00 AM and 7:00 PM. - on 5/5/2023 acetazolamide (used to treat swelling caused by heart disease) 250 mg tablet every day at 9:00 AM. - on 9/13/2023 acetic acid 0.25% irrigation solution infuse 30 milliliters (ml) by irrigation route two times per day for use to irrigate suprapubic catheter (drains urine from the bladder through an incision in the abdomen). - on 10/17/2023 (renewed order) clonazepam (used to treat anxiety) 2 mg three times a day at 9:00 AM, 3:00 PM, and 9:00 PM. The May 2023 Medication Administration Record (MAR) documented: - clonazepam 2 mg tablet 3 times per day at 8:00 AM, 1:30 PM, and 7:00 PM with original order date of 12/29/2022. Clonazepam was documented as not administered on 5/15/2023 at 1:30 PM and 7:00 PM by LPN #38 due to the medication being out of stock/reorder; on 5/16/2023 at 1:30 PM by LPN #39 due to pharmacy called, delivery in progress (documented as being administered at 8:00 AM by LPN #39); and on 5/23/2023 at 1:30 PM with no initials or reason for not receiving. - ursodiol 300 mg twice daily at 9:00 AM and 7:00 PM. Ursodiol was documented as not administered on 5/15/2023 by LPN #38 due to the medication being out of stock. - acetic acid 0.25% irrigation solution infuse 30 ml by irrigation route 2 times per day at 6:00 AM- 2:00 PM, and at 2:00 PM- 10:00 PM. Acetic acid solution was documented as not administered on 5/27/2023 at 2:00 PM- 10:00 PM by LPN #40 due to on order. The November 2023 MAR documented: - acetazolamide 250 mg tablet every day at 9:00 AM was documented as not administered by LPN #41 on 11/6/2023 due to on order. There was no documented evidence the physician was notified of the missed doses of clonazepam, ursodiol, acetic acid irrigation, and acetazolamide. During an interview on 11/17/2023 at 9:54 AM, registered nurse (RN) #37 stated they worked part time as a medication nurse on unit 1. They stated they had run into not having a medication available. If the medication was a new order, they could go to PXYIS (an automated medication dispensing system) to see if the medication was available. The nurse could also call the pharmacy and get the medication that afternoon or evening. They stated when the last of a blister pack of medications was used, the nurse should check for reserve (extra blister packs). RN #37 stated when the medication was down to 5 days or less the nurse should order the medication. They stated not all nurses did this. RN #37 stated if a resident did not receive their ordered medications, they could have exacerbation of symptoms depending on the medication. If a medication was not administered the Unit Manager and nurse practitioner (NP) should be made aware. During an interview on 11/17/2023 at 11:45 AM, RN Unit Manager #24 stated medication nurses were responsible for reordering medications. They stated there was a way to order right in the MAR if medications were getting low. They stated the pharmacy took a couple of days turnaround once the medications were ordered. RN Unit Manager #24 stated they should be told by the nurses if medications were missed, and they should notify medical if ordered medications were not given. They stated medications had a purpose and if they were not given it could have negative effects on the resident depending on the medication. Nurses should document in the medical record if they spoke to medical regarding missing medications. During an interview on 11/17/2023 at 12:11 PM, the Director of Nursing (DON) stated they were not sure of a specific policy regarding missing medications or ordering medications. They stated there was a possibility for negative effects if a resident did not receive medications as ordered. The DON stated medical should be notified of a resident not receiving meds as ordered. During an interview on 11/17/23 at 12:53 PM NP #10 stated they expected medications to be given as ordered. They stated they should be notified if a medication was not available or not given. The resident may need to have an alternate intervention ordered. The pharmacy was out of town and could take a day or two to deliver medications. They stated the nurses should order medications when they were getting low. A resident could experience negative effects if not given meds as ordered. There should be follow up done by nursing and they were not sure if nursing always let them know. 2) Resident #71 was admitted to the facility with diagnoses including dementia, adult failure to thrive, and osteoarthritis. The 9/15/2023 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required supervision for transfers, walking, locomotion on the unit, and eating, limited assistance of 1 for locomotion off the unit, dressing, toileting, and personal hygiene, and had no functional limitations in their arms or legs. The 9/16/23 updated comprehensive care plan (CCP) documented the resident was at risk for skin breakdown, required assistance with activities of daily living (ADLs), was on anticoagulants (blood thinners), and had dementia. Interventions included the nurse was to check skin on shower days, monitor skin during care every shift, assist with dressing/bathing/toileting/transfers/locomotion, monitor for bleeding/bruising, and anticipate needs. The 11/13/23 hospital summary documented the resident was seen on 11/11/23 in the ER (emergency room ) for an evaluation after a fall. The resident had a scalp hematoma (bruise) and left wrist and hand bruises. Left wrist x-rays showed no changes, dislocations, or fractures. The resident was discharged back to the facility on [DATE] as there were no neuro changes during exams and the resident was stable. There was no documented admission skin assessment for the resident when they returned from the hospital. The following observations of Resident #71 were made: - on 11/13/23 at 12:05 PM lying on their back in bed. Both hands were bruised, and the left index finger had an undated gauze bandage wrapped around it. The bandage appeared unclean and had dried blood on it. - on 11/14/23 at 11:52 AM lying in bed. The gauze dressing on the left index finger was undated, unclean and had dried blood on it. - on 11/15/23 at 9:15 AM lying in bed. The gauze dressing on the left index finger was undated, unclean, and had dried blood on it. - on 11/16/23 at 9:10 AM lying in bed. The gauze dressing on the left index finger was undated, unclean, and had dried blood on it. Nursing progress notes from 11/12/2023-11/15/2023 did not include the presence of a skin tear or dressing to the resident's left index finger. The 11/2023 treatment administration record (TAR) did not include a treatment order for the left index finger until 11/16/2023. The TAR documented to the skin tear on the left pointer finger apply bacitracin (antibiotic ointment), wrap with non-stick gauze every other day until healed with a start date of 11/16/2023. The TAR did not document a dressing was done on 11/16/2023 and the TAR was grayed out for 11/17/2023 out of date range. During an interview on 11/16/23 at 11:35 AM, licensed practical nurse (LPN) #17 stated Resident #71 had a fall recently and went to the hospital. They stated Resident #71 had a laceration on the right forehead and possibly a band aid on their right hand. The LPN stated they noticed the bandage and there was no specific order to change it. The LPN stated they would change the band aid if they noticed it was dirty, but they had not noticed. Any nurse was able to enter a physician order into the medical record after notifying the physician of the need for a dressing. LPN #17 looked at the resident's finger and stated the dressing had dried blood on it and was dirty. LPN #17 removed the dressing, and a 1.5 centimeter (cm) laceration was noted across the middle of the finger between the middle knuckle and hand and was bleeding. The LPN stated there should have been an order to change the dressing for dignity, cleanliness, and sanitary purposes. During an interview on 11/16/23 at 11:51 AM, LPN Unit Manager #14 stated they did not think the resident had an order for a finger dressing. The LPN Manager stated the resident fell on [DATE] and the LPN Manager was on duty when the resident returned from the hospital for evaluation. The LPN Manager stated they saw the laceration and dressing on the resident when Resident #71 went to the hospital. The LPN Manager stated the hospital put a dressing on the finger. They stated not having an order for the dressing was an oversight made during the head to toe assessment done on return to the facility. The LPN Manager stated they knew the dressing was on the finger, the physician assessed the resident upon return, no order to change the dressing was obtained, and there should have been an order. The LPN Manager stated they did not check to ensure there was an order and should have as it was their responsibility. During an interview on 11/16/23 at 12:17 PM, CNA #18 stated they saw a dressing on the resident's finger on 11/14/2023 and did not think it looked dirty. The CNA stated they washed the resident's hands the morning of 11/16/2023 and failed to notice the dressing. If they noticed the dressing was dirty, they would have made the nurse aware. During an interview on 11/17/23 at 12:18 PM, the Director of Nursing (DON) stated the resident should have been assessed by a registered nurse (RN) upon return to the facility and called the physician for any new orders including a dressing. They stated nurses should have seen the dressing. CNAs should inform the nurse of any changes or dirty dressings. Dressing changes were done to prevent infection, for hygiene purposes, and for resident dignity if the dressing was dirty. 3) Resident #91 was admitted to the facility with diagnoses including stroke, hemiparesis/hemiplegia (one-sided weakness/paralysis), and dementia. The 8/25/2023 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance of 2 with most activities of daily living (ADLs), used a wheelchair, was at risk for developing pressure ulcers, and had an unstageable (full thickness tissue loss in which the base is covered with dead tissue) pressure ulcer. The 8/15/2023 updated comprehensive care plan (CCP) documented the resident had dementia, was at risk for skin breakdown, and had hemiplegia/hemiparesis. Interventions included booties in and out of bed, place in high visibility areas when awake, anticipate needs, and a cushion in their wheelchair. The 9/12/2023 physician order documented heel float boots on at all times. The 11/10/2023 through 11/16/2023 Resident #19 care instructions documented Resident #19 was totally dependent for dressing, locomotion, personal hygiene, transfers, and was to have off-loading booties every day at all times. Resident #91 was observed: - on 11/13/2023 from 12:00 PM until 1:33 PM in the unit dining room sitting in their wheelchair and not wearing heel booties. The resident's blue heel booties were on the resident's bed. - on 11/15/2023 from 9:15 AM until 12:43 PM sitting in their wheelchair in the unit dining and not wearing heel booties. The blue booties were in their room on the nightstand. - on 11/16/2023 from 9:10 AM until 11:35 AM sitting in their wheelchair in the unit dining room not wearing heel booties. The blue booties were on a nightstand in the resident's room. The 11/2023 treatment administration record (TAR) documented heel float boots at all times. The TAR documented the heel boots were applied on all shifts from 11/1/2023 day shift until 11/16/2023 day shift. During an interview on 11/16/2023 at 11:23 AM CNA #16 stated CNAs should check their residents' care instructions at least once a week. Resident #91 had an open area on their right heel that was closed now. The resident was to have blue booties on while in bed. The CNA stated they last looked at Resident #91's care instructions the morning of 11/16/2023. The CNA stated they usually worked the evening shift and last put the booties on the resident the evening of 11/15/2023. During an interview on 11/16/2023 at 11:51 AM, licensed practical nurse (LPN) Unit Manager #14 stated they relied on the unit nurses to ensure the resident had the proper equipment on. Resident specific care was documented on the care instructions and care plans. The LPN Manager stated that all CCP changes were their responsibility. The LPN Manager expected care to be provided per the care instructions and care plan. Resident #91 used to have a heel pressure ulcer and the blue booties were to prevent a reoccurrence. The LPN Unit Manager stated they knew the booties were being applied at night, but the blue booties were supposed to be on the resident at all times. The nurses were supposed to check and sign for them on the TAR. During an interview on 11/17/2023 at 12:18 PM, the Director of Nursing (DON) stated the LPN Unit Manager was expected to check the residents. The DON stated they expected the care plans to be carried out and the unit nurses and Unit Managers should ensure the resident equipment was used as planned. The blue booties should be signed for in the TAR and all refusals documented. The booties were used as a pressure ulcer preventative measure. 10 NYCRR 415.12 44838

Based on observation and interview during the recertification survey conducted 11/13/2023-11/17/2023, the facility did not maintain an effective pest control program so that the facility was free of pests for 1 of 3 nursing floors (second floor). Specifically, fruit flies were present on the the second floor. Findings include: The second floor pest control log identified gnats on 9/9/2023, 10/24/2023, and 11/6/2023. The third party pest control vendor service reports from 1/10/2023 to 10/6/2023, did not identify fruit flies in the facility. On 11/13/2023, the following observations were made on second floor: - at 11:10 AM, there were fruit flies in resident room [ROOM NUMBER]; - at 12:00 PM, there were fruit flies in resident room [ROOM NUMBER]; - at 12:30 PM, there were 3 fruit flies in the second floor hall outside the short hall shower room. - at 12:41 PM, there was 1 fruit fly in the second floor short hall shower room. - at 12:52 PM, there was 1 fruit fly in the second floor food preparation area. - at 12:58 PM, there were 5 fruit flies in the second floor food preparation area. - at 3:09 PM, there were fruit flies in the hall outside of resident room [ROOM NUMBER]. - at 3:24 PM, an unidentified staff member was overheard telling another staff member a fruit fly just flew in your hair. During an observation on 11/15/2023 at 12:17 PM, there were 2 fruit flies in the second floor food preparation area. During an interview on 11/16/2023 at 9:17 AM, the Maintenance Director stated they were not sure when the fruit flies started to appear on the second floor. They verified that the second floor pest control log documented fruit flies on 9/9/2023 and that there was no mention of fruit flies on the third party pest control service report dated 9/20/2023. They stated that after the 10/6/2023 third party pest control vendor service report there were two separate fruit fly sightings documented on the second floor pest control log, and the vendor did not come onsite. During an interview on 11/16/2023 at 11:50 AM, the Food Service Director stated they did not know about the fruit flies on second floor until 11/13/2023. They stated that if bugs were seen in the kitchen, they would tell the maintenance department and write in the work order book located outside of the Maintenance Director's office. During an interview on 11/17/2023 at 10:19 AM, certified nurse aide (CNA) #21 stated that fruit flies started to appear in resident rooms in 9/2023 and had spread to the rest of second floor in 10/2023. They stated from 9/2023 to the present time they did not see any vendors come to the floor to investigate the fruit flies. They stated there was a pest control log located at the second floor nursing station, and they were annually in serviced to fill out the pest logbook when pests were observed. 10NYCRR 415.29(j)(5)

44838 Based on observation, interview, and record review during the recertification survey conducted [DATE]-[DATE], the facility did not ensure storage, preparation, distribution, and service of food in accordance with professional standards for food service safety for 2 of 3 resident dining room refrigerators (Units 1 and 2). Specifically, Unit 1 and Unit 2 had expired and undated food in their dining room refrigerators/freezer. Findings include: The facility policy Refrigerator Monitoring and Cleaning dated ,d+[DATE], documented refrigerators and freezers located in the resident dining rooms would be monitored and logged daily by the Dietary Department. Temperatures would be recorded into a log sheet and maintained by the Dietary Department. Refrigerators would be cleaned at least weekly and as needed by the Dietary Department. Any food/beverage items that were not appropriately labeled and dated would be discarded. Any outdated food/beverage items would be discarded. On [DATE], the following observations were made: - at 11:50 AM, the Unit 1 dining room refrigerator had an unopened package of 6 bagels, that was dated for use by [DATE]; and an opened package of 4 bagels with mold with an expiration of [DATE]. - at 12:41 PM, the Unit 2 dining room refrigerator had 4 bagels in a paper bag with no expiration date. The freezer had 2 English muffins in a plastic bag and 3 bagels in a plastic bag and both items were not dated. During an interview on [DATE] at 12:44 PM, the Food Service Director stated that they were not aware of the expired and moldy bagels. They stated the kitchen staff checked the unit refrigerators twice a day for proper temperatures, and food and beverages should also be checked and discarded if they were expired or undated. They stated staff should write dates of when the food came into the facility. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the recertification and abbreviated (NY00326712) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 8 residents (Resident #49) reviewed. Specifically, Resident #49 had an unplanned weight loss and the resident's care plan was not updated to include the unplanned weight loss, broken and lost dentures, and the need for modified food consistency. Additionally, when the resident's diet consistency was changed to mechanical soft, the change was not reflected on the resident's meal ticket. Findings include: The facility policy Weight Protocol dated 9/2019 documented the registered dietitian (RD) would review weights and communicate to the Minimum Data Set (MDS) coordinator, interdisciplinary team, and the Director of Nursing (DON) at morning report. The residents would be weighed monthly by the 5th of each month. A resident would be reweighed if the resident presented with a 5-pound weight difference for one month or if the weight seemed inaccurate. The [NAME] would meet and discuss the residents' weight loss/gain to determine if the weight change met the criteria for a significant change. The facility policy Texture and Consistency- Modified Diets dated 8/2021 documented texture and consistency- modified diet would be individualized with the modifications made by the speech language pathologist (SLP) and physician in conjunction with the RD or designee and the Director of Food and Nutrition services. A written order was needed. Residents that required dentures would be reminded to have dentures for meals and snacks as needed. If the dentures did not fit properly, facility staff would refer for a dental consult. Resident #49 was admitted to the facility with diagnoses including diabetes, GERD (gastroesophageal reflux disease), and vitamin deficiency. The 9/8/2023 Minimum Data Set (MDS) assessment, documented the resident had severe cognitive impairment, required extensive assistance of 1 for activities of daily living (ADLs), required supervision with set up for eating, did not have a swallowing disorder, weighed 190 pounds, and did not have a weight loss/gain greater than 5% in the last month or greater than 10% in the last 6 months, received a therapeutic diet, and did not receive a mechanically altered diet. The comprehensive care plan (CCP) documented: - effective 12/6/2021 the resident had a dental focus with interventions including dental consult per physician order; maintain dentures within reach at all times; observe for changes in eating patterns; and notify physician/nurse practitioner (NP) for any changes in mouth condition. On 9/15/2022 to dentist yesterday for broken denture repair, no current issues, continue plan of care. The last review of the CCP was documented as 4/5/2023. - effective 12/6/2021 the resident had a nutrition focus with goals including ensuring consumption of 75% or more of the meals/fluids offered and receiving adequate nutrition to maintain stable weight. Interventions included NAS (no added salt), regular consistency diet with thin liquids; monthly weights; monitor and encourage oral intake; refer to SLP as needed; and explore potential reasons for decreased intake such as swallowing problems, mouth pain, and depression. The last review of the CCP was documented as 4/5/2023. Physician orders documented: - on 12/6/2021 monitor weights monthly. - on 10/26/2023 by nurse practitioner (NP) #10 food consistency mechanical soft related to broken dentures. - on 11/2/2023 by NP #10 dental consult for dentures scheduled for 11/8/2023. - on 11/7/2023 by physician #12 dental consult for dentures on 11/14/2023. - on 11/14/2023 by physician #12 return to dentist this week 11/16/2023 for dentures molding/consult. - on 11/16/2023 by NP #10 consultation with dentist on 11/20/2023. The CCP was not updated to include a consistency change to mechanical soft or broken/lost dentures. The following weights were documented in the electronic medical record: - on 9/4/2023 190.9 pounds - on 10/1/2023: 188.2 pounds - on 11/1/2023 184.4 pounds (3.4% loss in 2 months). A 9/5/2023 RD #9 progress note documented the resident had excellent intakes, received a regular consistency diet, weighed 190.4 pounds, had no significant weight changes, and no chewing or swallowing difficulties. There was no documented evidence the registered dietitian (RD) assessed the resident weight loss and a change in food consistency after 9/5/2023. Nursing progress notes documented: - on 10/23/2023 resident's family did not want the resident to be seen by the facility dentist and reported the resident's top denture was also missing. Family to keep appointment with outside dentist and they would make both top and bottom dentures. The family wished the resident to receive dentures as quickly as possible. - on 11/14/2023 resident returned from dentist for molding of new dentures. A return appointment was set for 11/16/2023. During an observation and interview on 11/13/2023 at 3:05 PM, the resident stated their dentures were broken. They stated they had not had their dentures in months and could not eat foods they enjoyed since their dentures were not available. They stated they did not know if they had gained or lost any weight recently. The resident was observed picking pieces of cabbage, served at lunch earlier in the day, out of their mouth and stated they were not able to chew the cabbage. During an observation on 11/15/2023 at 12:57 PM, the resident was seated in the dining room for lunch. The resident was served roast beef, sliced carrots, and scalloped potatoes. The resident did not have natural teeth and was not wearing dentures. The roast beef was cut, by the staff, in half-dollar sized pieces. The resident's meal ticket did not document mechanical soft consistency as ordered. During an observation on 11/16/2023 at 12:55 PM, the resident was seated in the dining room for lunch. The resident was served meatloaf, mashed potatoes with gravy, whole broccoli, cornbread, frosted cake, and applesauce. The resident's meal ticket did not document mechanical soft consistency as ordered. During an interview on 11/15/2023 at 12:37 PM, RD #5 stated they were not aware the resident had lost weight. The RD reviewed the resident's weights and stated the resident was obese and some weight loss would be acceptable. The RD stated they would be concerned if the resident lost equal to or greater than 4 pounds in one month. The RD stated weight loss was not care planned as a goal for the resident. They stated they were recently made aware that the resident's dentures were missing, so the diet consistency was changed to mechanical soft to maximize the resident's intake at meals. The RD stated that lack of dentures could be a factor in the resident's weight loss. During an interview on 11/17/2023 at 11:46 AM, registered nurse (RN)/Unit Manager #2 stated the resident's lower dentures had been missing since March 2023. The resident's upper dentures had been missing since September 2023. They stated they were not aware of any weight loss for the resident. They stated they tracked weights monthly and would have been concerned if they realized the resident was losing weight. They would have consulted the RD, the medical provider, and the dentist to determine what could be done for the resident to prevent additional weight loss. During an interview on 11/17/2023 at 1:16 PM, nurse practitioner #10 stated they were aware of the resident's recent weight loss but was not sure how much weight was lost. They stated the weight loss was due to the loss of the resident's dentures. They stated the denture issue had been going on for close to 9 months. The resident was listed as obese per their BMI (body mass index), and a planned weight loss would be acceptable. They stated a 15-pound weight loss in 6 months was concerning especially since the dentures should have been replaced sooner. They stated the resident was not able to enjoy the foods they liked. 10NYCRR415.12(i)(1)

Based on observation, record review, and interview during the recertification and abbreviated (NY00315667, NY00315978, and NY00326467) surveys conducted 11/13/2023-11/17/2023, the facility did not ensure that residents who were unable to carry out activities of daily living (ADLs) were provided the necessary services to maintain good grooming and personal hygiene for 2 of 4 residents (Residents #11 and #416) reviewed. Specifically, Resident #11 was not assisted with shaving and Resident # 416 was not provided timely incontinence care. Findings include: The facility policy Activities of Daily Living (ADL) revised 3/6/2019 documented that residents would be encouraged to maintain independence with ADLs and if they were unable to complete the tasks attempted, then nursing staff would be responsible to provide care based on the resident's care plan. 1) Resident #11 was admitted to the facility with diagnoses including diabetes, anxiety disorder, and chronic obstructive pulmonary disease (CPOD, lung disease). The 9/9/2023 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, did not reject care, and required limited assistance of 1 with personal hygiene. The comprehensive care plan (CCP) last reviewed 9/21/2023 documented the resident had a functional decline in capabilities with the need for assistance with ADLs and required limited one-person physical assistance with personal hygiene. The CCP did not include the resident's shaving preferences. Observations of Resident #11 included: - on 11/13/2023 at 11:45 AM sitting in the dining room in a wheelchair with facial hair approximately 1/2-inch long. - on 11/14/2023 at 9:36 AM with facial hair approximately 1/2 inch long. - on 11/15/2023 at 10:05 AM the resident stated they did not have a razor and they wanted to be shaved. They had facial hair approximately 1/2-inch long. - on 11/16/2023 at 10:51 AM with facial hair approximately 1/2-inch long. The resident stated staff did not help them shave, and they rubbed their face and stated they did not like looking grubby. The November 2023 certified nurse aide (CNA) Documentation Record documented the resident received assistance with personal hygiene twice on 11/13/2023 and 11/14/2023; three times on 11/15/2023; and once on 11/16/2023. During an interview on 11/17/2023 at 9:54 AM, registered nurse (RN) #37 stated the medication nurses provided oversight of the certified nurse aides (CNAs), but ultimately the resident's personal care was the CNA's responsibility. During an interview on 11/17/2023 at 10:09 AM, CNA #33 stated their duties included providing care to residents. The computer included care information for each resident. They were to document in the computer when tasks were completed. If a task was signed for it meant it was done. Personal hygiene included providing clean clothes, washing peri area, washing face, applying deodorant, shaving, and oral care. They stated they had not been assigned to Resident #11 this week. During an interview on 11/17/2023 at 10:28 AM, CNA #36 stated the resident care information was found in the computer. They stated personal hygiene included washing face and hands, peri area, combing hair, shaving, and oral care. They stated they were assigned to Resident #11 on this day and the resident did not always allow care. They stated the resident could use a shave, but they did not offer shaving this morning. because they did not have time yet today. It was important for a resident's dignity to be neatly groomed. During an interview on 11/17/2023 at 11:45, RN Unit Manager #24 stated resident care information was available in the care card in the electronic health record. It gave information on the amount of assistance needed for care. Personal hygiene consisted of combing hair, oral care, and shaving and should be offered at least daily. The stated if a task was documented as completed it meant it was done. They had not received reports of Resident #11 refusing shaving this week and the resident was not able to shave themself. 2) Resident #416 was admitted to the facility with diagnoses including morbid obesity, chronic respiratory failure, and depression. The 10/20/2023 Minimum Data Set (MDS) documented the resident had intact cognition, was dependent with toileting, was occasionally incontinent of urine, was continent of bowels, was at risk for the development of pressure injury, and had moisture associated skin damage (MASD, incontinence associated dermatitis). The nursing care instructions dated 9/1/2023-11/17/2023 documented the resident required extensive assistance of 2 for bed mobility, supervision with set-up help for personal hygiene, was totally dependent on 2 for transfers with a mechanical lift, was totally dependent for toilet use, and used a bedside commode. The comprehensive care plan (CCP) effective 11/11/2019 documented the resident was at risk for impairment in skin integrity. Interventions effective 3/24/2020 included toilet the resident every 2-4 hours and as needed (prn) and provide incontinence care every 2-4 hours and prn. The CCP did not include ADL level of assistance or interventions prior to 11/16/2023. During an observation and interview on 11/15/2023 at 11:08 AM, Resident #416 stated that they were not going to get up today, as they hurt too much. Certified nurse aides (CNAs) #22 and #27 were present and providing AM care. At 11:19 AM, they rolled the resident onto their right side and the resident called out in pain during the movement. The resident's entire back and bottom was red with raised bumps. The bed linens (bottom sheet, 2 incontinence pads, and an incontinence brief) were saturated from the resident's head to their ankle region. CNAs #22 and #27 stated the resident was usually a full bed change when they provided AM care because of their level of bladder incontinence. During an interview on 11/16/2023 at 8:41 AM, Resident #416 stated they got changed in the morning, afternoon and then at bedtime. They were always wet and would never refuse care as they wanted to get better to return home. During an observation and interview on 11/16/2023 at 10:49 AM, CNA #27 and registered nurse (RN) #23 were providing morning care for the resident. The resident's 2 incontinence pads and brief were saturated. The lower edge of the bottom sheet had dried brown stains and the bottom sheet was wet from the shoulder region to below the resident's knees. CNA #27 stated they came to work at 6:00 AM and was unsure when the resident was last changed. Their mattress had dried stains and dark wet areas. The resident had deep dark pink excoriated (reddened) areas with 2 open (pencil eraser size) bleeding areas to the left side of their back and their left back leg. During an interview on 11/16/2023 at 11:41 AM, CNA #25 stated they knew how to care for residents from the care instructions in the computer. They had not provided care for Resident #416 since arrival at 6:00 AM and night shift would have last provided care near 5:00 AM. During an interview on 11/16/2023 at 1:59 PM, Resident #416 stated they did not get woken up at night for incontinence care and repositioning. During an interview on 11/17/2023 at 9:17 AM, CNA #25 stated that CNAs were responsible for ADL care and nurses would help when needed. Resident #416 was their responsibility and required a full bed change during morning care. During the morning shift report staff said the resident required a full bed change during the overnight. During an interview on 11/17/2023 at 9:58 AM, CNA #22 stated that Resident #416 had skin concerns and they should be checked for incontinence and changed every 2 hours. They stated they were not able to check for incontinence and change every 2 hours because they did not have enough staff. The CNA stated they provided the resident care in the morning, usually after breakfast, and then again after lunch. They stated It was not good for a resident to lie in urine as it could ruin their skin and the resident already had open sores. During an interview on 11/17/2023 at 10:12 AM, RN #23 stated that ADL care was the responsibility of the CNAs, but everyone assisted as needed. Resident #416 should receive incontinence care every 2 hours. They stated the resident almost always required a full bed change because of bladder incontinence. The resident's skin should be kept as dry as possible because they already had open areas, and they did not want secondary infections or additional open areas. During an interview on 11/17/2023 at 10:28 AM, RN Unit Manager (UM) #24 stated that ADL care would be directed in the computer and all responsible staff had access. Resident #416 should be checked for incontinence every two hours with repositioning. The resident was in bed a lot and they already had skin conditions so their skin should be kept as dry as possible to prevent infections and additional sores. They stated it was not pleasant for the resident to be wet. They stated they did not want the resident to be uncomfortable, in pain or have odors associated from urine incontinence. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review during the recertification and abbreviated (NY00315667 and NY00326467) surveys conducted 11/13/23-11/17/23, the facility did not ensure each resident had the right to a dignified existence for 2 of 5 residents (Residents #33 and #91) reviewed. Specifically, Resident #33 had an unclean incontinence pad in their recliner and Resident #91's wheelchair head rest cover was in disrepair with exposed foam. Findings include: The facility policy Resident Rights dated 4/2/2023 documented the facility must focus on assisting the resident in maintaining and enhancing their self-esteem and self-worth. Each resident was to be treated with respect and dignity. The facility policy Wheelchairs dated 9/7/2023 documented wheelchairs were issued by the therapy department. Wheelchair maintenance was performed by the maintenance department in conjunction with therapy and adaptations included headrests. Wheelchairs would be cleaned according to policy. 1) Resident #33 had diagnoses including osteoarthritis, chronic obstructive pulmonary disease (COPD) and hypertension (HTN). The 9/8/2023 Minimum Data Set (MDS) documented the resident had moderately impaired cognition, required limited assistance of one with toileting and transfers, extensive assistance of 1 with dressing, and was always continent of bowel and urine. The comprehensive care plan (CCP) initiated 3/4/2020 and revised 7/13/2023 documented the resident required limited assistance of one staff for activities of daily living (ADLs) including toileting. They were continent of bowel and bladder and would use the toilet or a urinal. The care instructions dated 2/7/2020 and revised 11/10/2023 documented the resident required supervision with ADLs including toileting and was incontinent of bowel. The resident's recliner was observed in their room: - on 11/14/2023 at 8:51 AM with an incontinence pad with a 5-inch dried area of brown discoloration and 2 quarter sized, dark brown areas in the center. - on 11/17/2023 at 9:04 AM with an incontinence pad with a 6-inch dried round area of brown discoloration. At 9:06 AM the incontinent pad was lifted from the recliner exposing the white side which had an 8-inch dried area of light brown discoloration with a half dollar size dark brown area in the center. During an interview on 11/17/2023 at 9:17 AM, certified nurse aide (CNA) #25 stated Resident #33 needed the incontinence pad in their recliner to protect the chair from incontinence episodes. They stated the resident was incontinent of bowel and bladder and the incontinence pad should be changed when it was soiled. The CNA stated It was not homelike to leave dirty items in the resident's room. During an interview on 11/17/2023 at 9:58 AM, CNA # 22 stated they were assigned to Resident #33, and they had not noticed the recliner had a soiled incontinence pad on it. They stated they should have picked up the soiled item when they assisted the resident to breakfast. It was not homelike to have soiled or dirty items left in the room. During an interview on 11/17/2023 at 10:12 AM, registered nurse (RN) # 23 stated that CNAs were responsible for ADL care, but all staff should assist with resident needs. They stated Resident # 33 could toilet themself and was mostly continent of bowel and bladder, but they could not handle soiled clothing or linens themselves. RN #23 stated the resident had an incontinence pad on the recliner to protect it from incontinence episodes. The incontinence pads were supposed to be placed white side up, to better absorb liquid spills, urine, or stool. They stated if the pad was soiled it should have been changed. It was not good for visitors to see the pad and it could produce odors that would not be homelike. During an interview on 11/17/2023 at 10:28 AM, RN Unit Manager (UM) #24 stated soiled linens should not remain in resident rooms and the CNAs were responsible to remove them. They stated Resident #33 would sleep in their recliner and occasionally had incontinence episodes, requiring an incontinence pad. The white side of the incontinence pad should be upright, to protect the cushion. They stated residents should not sit on wet or soiled linens as it could create skin conditions or odors. Soiled linens in the room were not homelike. 2) Resident #91 had diagnoses including stroke, hemiparesis/hemiplegia (one-sided weakness/paralysis), and dementia. The 8/25/2023 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance of 2 with most activities of daily living (ADLs), and used a wheelchair. The 8/15/2023 updated comprehensive care plan (CCP) documented the resident had dementia, was at risk for falls, was at risk for skin breakdown, and had hemiplegia/hemiparesis. Interventions included physical therapy (PT) as needed, place in high visibility areas when awake, anticipate needs, provide emotional support, support self-esteem, and cushion in wheelchair The 10/31/2023 Unit 3 therapy equipment audit documented there was no damage to Resident #91's wheelchair. During observations on 11/13/2023 at 12:56 PM, 11/14/2023 at 11:52 AM, 11/15/2023 at 9:15 AM, 11/15/2023 at 12:43 PM, and 11/16/2023 at 9:10 AM, Resident #91 was sitting in their wheelchair in the unit dining room. The headcover from the wheelchair's headrest was missing and the entire foam headrest was exposed. During an interview on 11/16/23 at 11:23 AM, certified nurse aide (CNA) #16 stated they were assigned to the resident that day. Headcovers for wheelchairs came from the therapy department. They stated the exposed headrest could not be cleaned, would be unsanitary, did not look nice, and could pull on the resident's hair. All staff were able to put in a work order for it or call therapy to make them aware. The CNA stated they told licensed practical nurse (LPN) #15 a couple weeks ago that the head cover for the resident's wheelchair was missing. The CNA stated they assumed the LPN took care of it. During an interview on 11/16/23 at 11:51 AM, LPN Unit Manager (UM) #14 stated they relied on the unit nurses to ensure equipment was in proper condition. They stated they had not noticed the head cover to the resident's headrest was missing. Wheelchair headrest covers came from the therapy department and any staff member could call therapy for a replacement. The foam should not be exposed for infection control purposes and resident dignity. During an interview on 11/16/23 at 12:21 PM, the Director of Therapy stated the resident's wheelchair headrest had a nylon cover that looked as if it had been torn off. They stated therapy relied on nursing staff to notify them if there was an issue with equipment. Therapy performed facility wide monthly audits regarding equipment condition. They stated the foam on the headrest should be covered to prevent the foam from becoming unsanitary and for the resident's dignity. During an interview on 11/17/23 at 9:31 AM, LPN #15 stated unit staff noticed the missing headrest cover and thought they notified therapy. The LPN stated they did not document it and should have. The purpose of the cover was so the headrest was able to be cleaned and disinfected and to be more aesthetically pleasing. 10NYCRR 415.3(a) 48632

Based on record review and interview during the abbreviated survey (NY 180) the facility failed to ensure a resident who was diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed. Specifically, Resident #1, with a known history of major depressive disorder and [CONDITION(S)], made a suicidal statement on [DATE] and there was no documented evidence facility staff addressed the statements. Medical, social services, and psychiatry were not notified. On [DATE], the resident made a suicidal statement, had an active plan of drinking vape liquid (used with electronic cigarettes), and had access to vape liquid. There was no further follow-up from nursing staff. Medical, social services, and psychiatry were not notified, and the resident continued to possess the vape liquid. Subsequently on [DATE], the resident drank approximately 100 milliliters (ml) of vape liquid which contained nicotine, [MEDICATION(S)] [MEDICATION(S)], flavorings, and other chemicals. The resident expired in the hospital and the hospital reported the ingestion of vape solution led to [MEDICATION(S)] [MEDICATION(S)] and nicotine toxicity which resulted in [CONDITION(S)]. This resulted in actual harm that was Immediate Jeopardy and Substandard Quality of Care to Resident #1 and Immediate Jeopardy to the facility's additional 109 residents who were at risk for psychological disturbance. Findings include: The ,d+[DATE] Suicide Prevention policy documented: - Indications of suicidal intent would be acted upon immediately. The staff member who witnessed the verbalization of individual ideation or attempt will report the incident to the Charge Nurse immediately and staff were not to leave the resident unattended at any time. - The resident would be immediately placed on 1:1 (individual monitoring) to ensure safety until the nursing Supervisor, social worker, or physician could provide a more specific plan of care. The Director of Nursing (DON), nursing Supervisor, social worker, and Administrator will be made aware. - The resident would be questioned and assessed by the nursing Supervisor and the psychological services provider would be notified for suggestions. - Based on physician, nursing, and psychological assessment, appropriate interventions would be implemented to ensure safety. All items that have the potential to cause harm will be removed from the room. - A Suicide Prevention Monitor form will be initiated and updated as per the frequency period identified. The resident would be re-evaluated to determine the duration of the monitoring. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Minimum Data Set (MDS) assessment documented the resident had intact cognition and mild to moderate depression. The resident felt down, depressed, or hopeless nearly every day, felt tired or had little energy ,d+[DATE] days, had trouble falling or staying asleep or sleeping too much nearly every day, and had a poor appetite or overeating nearly every day. The resident required extensive assistance of 2 for bed mobility, was dependent on staff for transfers, required extensive assistance of 1 for dressing, toileting, hygiene, and ate with supervision and set-up assistance. The resident had upper extremity impairment on both sides. The comprehensive care plan (CCP) initiated [DATE], last revised [DATE], and last reviewed [DATE] documented: - The resident had behavior problems including refusal to eat and socially inappropriate behaviors. Interventions included focusing on strengths, encourage to verbalize needs and concerns, provide emotional support, and praise improved behaviors. - The resident had major depressive disorder and the goal was to be free of [CONDITION(S)]. Interventions included: encouragement participation in social activities, emotional support, medications administered as ordered, and evaluation or treatment by mental health professional. The resident was seen by psychiatric nurse practitioner (NP) #37 monthly from [DATE] through [DATE] for suicidal ideation. Medication changes were made with recommended follow-up by psychotherapy. The resident was seen by the licensed clinical social worker (LCSW) #35 for individual psychotherapy: - on [DATE], services were planned for once per month to reduce emotional symptoms. The resident used tobacco, was distant and arrogant. Their answers were usually one word and dismissive and they reported their goal in life was to drink beer and smoke dope with their best friend. There was no further information in the progress note. - On [DATE], individual psychotherapy was provided to reduce emotional symptoms, and behavioral modification therapy were planned for 1 to 4 times per month. The resident isolated themselves and was bitter about the accident which caused their injury. The resident stated they and their best friend will smoke pot and drink alcohol when they received their settlement. Continue with the current treatment plan. There was no documented evidence of any further psychotherapy sessions by the LCSW. The [DATE] at 8:35 PM, licensed practical nurse (LPN) #9's progress note documented the resident was upset about an antibiotic they were taking and wanted it changed. They stated their whole body felt numb, their arms were cold, they did not want to live anymore, did not want to be at the facility, and started crying. LPN #9 comforted the resident and reported to the on-call physician the resident had low urine output. Clysis (hydration under the skin) was started at 6 PM and at 8 PM, and the resident stated they were feeling better. LPN #9 suggested to the resident it was not healthy to stay in their room in the dark all the time. During a telephone interview with LPN #9 on [DATE] at 10:37 AM, they stated when they documented on [DATE] the resident said they wanted to die, they would have reported it to the Supervisor on duty. LPN #9 stated they did not know if they did report it to a SUpervisor but if they did, they could not recall who it was. They stated the resident said things like that sometimes because they wanted to get out of the facility. LPN #9 stated they did not remember much more and thought the resident perked up later that shift. LPN #9 stated they worked per diem and did not think they worked on the resident's unit again after that date so did not know if any action was taken. There was no documented evidence of follow-up from the medical provider, psychiatric nurse practitioner (NP) #37, social worker, or nursing related to the resident's [DATE] statement. The [DATE] Report of Investigation, completed by the DON documented: - On [DATE] at approximately 8 AM, staff received a call from the resident's family member stating the resident drank their vape liquid and LPN #8 responded to the resident's room. - The resident was found in bed, diaphoretic (perspiring heavily), their family member was on the phone, and an empty bottle of vape liquid was on the bedside table. - The resident stated, I just want to die and they drank one whole bottle of the vape liquid. LPN #8 called 911 and remained in the room. - Emergency Medical Services (EMS) arrived approximately 10 minutes later. The empty container of vape liquid was given to EMS for identification with poison control. - The resident required extensive assistance with ADLs and bed mobility, required supervision and set-up for meals, had adaptive equipment for meals, and was able to use their cell phone for calls, entertainment, and online ordering. - The conclusion of the investigation documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . - The DON documented it appeared the resident drank vape liquid with suicidal intention and did so while on the phone with their family member. - Statements were obtained from certified nurse aides (CNA) #3,10,12, and 36 and LPN #4, who reported having no knowledge of the incident. CNA #10 was the only staff to have been asked by the facility if they opened any containers for the resident and CNA #10 reported they did not. - LPN #8's statement included they responded to concerns from staff the family member called and upon entering the room, heard the family member on the phone stating the resident drank it all. LPN #8 found 2 bottles of unknown liquid, one empty and one with approximately ,d+[DATE] of the liquid remaining. The [DATE] hospital report documented the resident was brought in after [CONDITION(S)] secondary to ingestion of vape solution as suicidal intention. This led to [MEDICATION(S)] [MEDICATION(S)] and nicotine toxicity. The neurological assessment showed the resident was not brain dead, however sustained severe brain injury and was having continuous seizures. On [DATE], the family made the decision to withdraw ventilation support and place the resident on comfort care. The resident then expired. During a telephone interview with the hospital Intensive Care Unit (ICU) NP #38 on [DATE] at 1:20 PM, they stated the resident had [MEDICATION(S)] [MEDICATION(S)] and nicotine in their system. It was unknown how much was consumed, and they overloaded the resident's system leading to [CONDITION(S)]. During a telephone interview with the resident's family member on [DATE] at 10:03 AM, they stated on [DATE], they were on the phone (on speaker) with the resident at 7:29 AM and the call lasted for 44 minutes. During the call, the resident said staff had opened 2 bottles of vape liquid and the resident was going to drink it to kill themselves. The family member told the resident to ring the call bell. When staff arrived, the resident told them they were going to drink the vape juice and kill themselves. The family member said through the phone to get the vape juice away from the resident. The staff were heard saying no you don't want to do that, let me show you pictures of my puppy. Shortly after another staff member arrived and asked what was going on, the resident repeated their intentions to drink the vape liquid. The staff member suggested the resident go outside for fresh air. During an interview on [DATE] at 1:26 PM, CNA #2 stated on [DATE] or [DATE], they entered the resident's room in the morning during breakfast and overheard the resident talking on the phone saying they did not want to live anymore, and they were going to drink their vape liquid. CNA #2 heard the person on the phone saying, don't do that or you don't want to do that and CNA #2 said the same thing to the resident. CNA #2 did not see any bottles of vape fluid. LPN #4 was directly outside the room and CNA #2 reported to LPN #4 what the resident said. LPN #4 told CNA #2 the resident had been saying that for a few days, registered nurse (RN) Manager #18 was aware, and then went into the room. CNA #2 did not hear what LPN #4 said to the resident. There were no further instructions communicated to CNA #2 following the report made to LPN #4. During an interview on [DATE] at 2:14 PM, LPN #4 stated they were not made aware of any suicidal statements the resident made prior to [DATE]. LPN #4 worked on [DATE] and could not recall if they went into the resident's room. LPN #4 stated they usually avoided doing anything that would upset the resident and they were afraid of the resident because they were grumpy and did not want to be bothered. LPN #4 observed the resident crying at times and would offer the resident to go outside and get some fresh air but did not recall doing so on [DATE]. At times, the resident would say they were sick of it, or sick of feeling like that. LPN #4 did not report specific statements or crying episodes, rather they would report if the resident had a good or bad day. LPN #4 stated they never saw any vape supplies or vape liquid in the resident's room. During an interview on [DATE] at 3:09 PM, CNA #6 stated the resident had made comments in the past about not wanting to live any longer, wanting to die, or not wanting to be there. The CNA stated they thought the resident knew not to say they wanted to kill themselves or they would get sent out to the hospital. The nurses were aware, and it was common for the resident to say things like that. The CNA could not recall which nurses were aware or if the CNA had reported it to anyone. During an interview with CNA #7 on [DATE] at 9:56 AM, they stated on [DATE], they entered the resident's room to respond to the call bell between 8:00 AM and 8:30 AM. The resident asked about a shower, the CNA left to ask, returned to tell them they had one the day prior, offered a warm washcloth, turned up the heat, and refilled the water pitcher. CNA #7 heard no comments about drinking vape fluid or the resident wanting to end their life. CNA #7 stated they had not observed any vaping materials. During an interview on [DATE] at 10:20 AM, LPN #8 stated on [DATE], they were notified by the Medical Records Coordinator the resident's family member was on the phone and said the resident drank vape fluid. LPN #8 immediately ran to the resident's room and called 911. There were 2 bottles of vape fluid on the bed, one empty and one had about ,d+[DATE] of the bottle gone. The LPN gave them to the EMS personnel. The LPN had not previously observed any vaping materials and had not been aware of any suicidal statements. During an interview with the facility NP #20 on [DATE] at 1:46 PM, they stated they were not made aware of the resident's suicidal statements on [DATE] or [DATE] and were unaware the resident used vaping materials. Daily and after weekends, the RN Manager reviewed the notes and brought any issues to the morning meeting, and nothing was brought to them. When NP #20 reviewed notes prior to seeing residents, they scrolled down the first page in the electronic record. The whole note was not able to be read unless the individual note is opened fully, otherwise only the first few lines of the note was viewed. The NP and RN Manager #18 reviewed the provider book on the unit and were unable to locate the pages for dates surrounding [DATE]. The NP stated they expected staff would notify them immediately of any suicidal statements. The resident should be assessed, not left alone, and any dangerous items to be removed from their room. The vape liquid should have been removed as soon as it was known the resident had vaping materials, as it was lethal to the resident. During an interview with RN Manager #18 on [DATE] at 11:50 AM, they stated they were not made aware of the resident's suicidal comments on [DATE] or [DATE]. If a resident made suicidal comments, they expected staff to report to a supervisor immediately, stay with the resident, and social work, medical and/or psychiatric providers should be notified for further assessment. The RN heard staff mention in passing the resident used vaping materials and did not inquire further. During an interview with the DON on [DATE] at 12:32 PM, they stated they were unaware of the resident's suicidal statements on [DATE] and [DATE]. Staff should have immediately reported to a nurse or Supervisor, remained with the resident, and the social worker, medical provider and psychiatric provider should have been notified. It was not up to the staff to determine if the resident had actual intent. There was a policy that all staff should be aware of to follow these steps to ensure proper response. During a telephone interview with the Medical Director on [DATE] at 12:30 PM, they stated they had not received any reports of active suicidal ideation. Anytime a resident expressed suicidal intent, they should be monitored continuously, all unsafe or potentially harmful items should be removed, and the medical provider should be notified. The Medical Director was not made aware the resident was utilizing vaping materials. During a telephone interview with the psychiatric NP #37 on [DATE] at 12:45 PM, they stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The psychiatric NP was available for emergency appointments or consult. When a resident made suicidal statements, they should be monitored continuously, not left alone, any dangerous items removed from the room, and assessed by a medical or psychiatric provider for next steps. The psychiatric NP was unaware the resident used vaping materials and if staff were aware they should have reported to a supervisor. _____________________________________________________________________ Immediate Jeopardy was identified, and the facility Administrator was notified on [DATE] at 4:45 PM. Immediate Jeopardy was removed on [DATE] at 2:35 PM, prior to survey exit based on the following corrective actions taken: - Resident #1 was no longer in the facility. - The facility identified 109 residents under psychiatric care. The residents were assessed for mood/depressive/suicidal ideation utilizing the PHQ-9 (Personal Health questionnaire). - Residents scoring moderate to severe signs of depression or who responded they no longer wished to live will have a secondary assessment from the medical provider. - Residents identified at risk of self-harm/suicide were immediately placed on 1:1 supervision pending further medical/psychological assessment and planning. - All staff will be educated on suicidal ideation, appropriate steps to take, and dangerous items including vape liquid and related supplies. 10NYCRR 415.12(f)(1)

Based on record review and interviews during the abbreviated survey (NY 180) the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents. Specifically, the facility's non-smoking policy did not include vaping. Staff were not aware if vaping fell under the non-smoking policy and when staff were made aware Resident #1 was vaping within the facility, the staff did not address the issue or remove the vaping materials. Findings include: Public Health Law, Article 13-E prohibits the smoking of tobacco in nearly all indoor and certain outdoor public and work places. Effective November 22, 2017, the law also applies to vaping, which is the use of electronic cigarettes and similar devices. The amendment to the New York State Public Health Law prohibits smoking outdoors on the grounds of hospitals and residential health care facilities. Smoking is prohibited within 15 feet of building entrance or exit and within 15 feet of the entrance to or exit from the grounds. Effective November 22, 2017, the law also prohibits vaping (use of electronic cigarettes and similar devices). The 1/2019 Resident Smoking policy documented: - The facility was a smoke free facility. No smoking or use of smoking materials was allowed in the building, its grounds, an/or parking lot. - No smoking or use of smoking materials was allowed - Residents will be offered smoking cessation products with physician and family support. The policy did not address vaping or include vaping and related materials as related to smoking materials. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/5/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition and required extensive assistance of 2 for bed mobility, was totally dependent for transfers, required extensive assistance of 1 for dressing, toileting, hygiene, and ate with supervision and set up assistance. The resident had upper extremity impairment on both sides. The 6/28/19 Safe Smoking Assessment completed by the Director of Nursing (DON) documented Resident #1 was able to hold a cigarette in their mouth, flick ashes on the ground. The resident threw the cigarette butt on the ground and was not able to put it out. The assessment did not address vaping. Smoking assessments dated 5/21/21, 6/3/21, and 7/2/21 documented the resident did not smoke. The assessment did not address vaping. The 6/8/22 Report of Investigation, completed by the Director of Nursing (DON) documented on 6/8/22 at approximately 8 AM, staff received a call from the resident's family member stating the resident drank their vape liquid. The 6/12/22 police report documented: - The hospital notified them of the resident's overdose. - On 6/13/22, the police arrived at the facility to investigate and took multiple photographs including: - a plastic wash bin with 3 refillable vape pods (square devices approximately 2 ½-3 inches by 2 ½ to 3 inches with a mouthpiece for inhalation), 2 lanyards, a bottle cap, a container of chewing tobacco, and 2 white boxes marked 2 refillable vape pods in each. - An empty 60 mL bottle, showing a nicotine liquid company logo, nicotine warnings, and 50 milligrams (mg) nicotine. - A view of the 60 mL bottle label with ingredients including vegetable [MEDICATION(S)], [MEDICATION(S)] [MEDICATION(S)], nicotine, and artificial flavorings. The warnings on the label included: the product was not intended for people with medical conditions such as heart disease, high blood pressure, diabetes, depression, or asthma. Ingestion could be poisonous and lead to severe illness and/or death. During an interview with certified nurse aide (CNA) #2 on 6/23/22 at 1:26 PM and on 6/27/22 at 11:20 AM, they stated they previously observed the resident using a vape device CNA #2 did not think the resident was able to fill the vape device on their own and had not observed them to do so. CNA #2 stated they reported the vape device to licensed practical nurse (LPN) #4 who stated they knew the resident had it and they were not legally allowed to take it away. CNA #2 stated it was common knowledge the resident used the vape device and thought it was all right since other staff knew about it. During a telephone interview with social worker (SW) #11 on 6/23/22 at 4:57 PM, they stated at one point, they were unsure when, staff alerted them to the resident having smoking or vaping materials in their room. They searched the room with the resident's permission and removed smoking materials. There was another instance in 2020 when SW #11 saw a package delivered that was clearly marked with e-cigarette/vaping type of supplies. The resident was approached and advised they could not have the smoking materials. SW #11 stated they were not made aware the resident continued to vape or order vaping supplies. They had no visitors since 2020, when the pandemic began. During an interview with CNA #15 on 6/24/22 at 11:45 AM, they stated they observed the resident with a vape device on a lanyard around their neck and in their hand. The CNA did not report it as it was obvious the resident had it, it was not the CNA's regular unit, and they thought other staff must have known. During an interview on 6/27/22 at 10:36 AM, CNA #16 stated they observed the resident with the vape device in their hand all the time. It was on a lanyard around their neck and the CNA observed the resident to puff on the vape device. The CNA did not report it as they thought the resident was allowed to vape in their room since they did not go outside and that it seemed like other staff knew, so it must have been allowed. During an interview with registered nurse (RN) Manager #18 on 6/27/22 at 11:50 AM, they stated they had heard other staff talk about the resident vaping in their room. The RN Manager did not see any vaping paraphernalia, although they would not know what to look for as they were not familiar with vaping or related materials. The RN Manager did not ask the resident or follow up with staff. The RN stated they should have inquired, although they were not sure it was the same as smoking, since nothing had to be lit and it did not seem to be a fire hazard. The RN Manager was aware of a prior instance with smoking materials were taken away when the resident used to go outside with their friend to smoke. During a telephone interview with the Administrator on 7/7/22 at 11:00 AM, they stated the facility was non-smoking and the smoking policy did not specifically address vaping. The Administrator thought the inclusion of smoking materials in the smoking policy would be understood as all types of smoking, including vaping and was uncertain as to how staff specifically were aware of vaping and related materials. Any staff that were aware the resident was vaping and did not report it were in direct violation of the smoking policy. 10NYCRR415.29(a)(1)

Based on interview and record review during the abbreviated survey (NY 180), the facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for 1 of 5 residents (Resident #1) reviewed. Specifically, Resident #1 made prior [CONDITION(S)], intentionally drank vape liquid resulting in their death, and was found to have amphetamines and cannabis in their system. Following the incident, the facility did not complete a thorough and complete investigation to determine how staff responded to the prior [CONDITION(S)], how the resident obtained and utilized the vape liquid, cannabis, and amphetamines, or if staff had prior knowledge of the resident's possession of these items. Findings include: The Accident/Incident Reporting and Investigating policy revised 4/2019 documented: - The Nurse Manager or designee was to determine the root cause by investigating the incident and environment, situation, and interview staff, residents, etc. - The IDT (interdisciplinary team) members will review the incident and root cause in morning report. - If further investigation was required, the Nurse Manager was to keep the form for completion after investigation. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/5/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition and had a mood score that indicated mild to moderate depression. The resident required extensive assistance of 2 for bed mobility, was dependent for transfers, required extensive assistance of 1 for dressing, toileting, hygiene, and ate with supervision and set- up assistance. The resident had upper extremity impairment on both sides. The 6/8/22 Report of Investigation, completed by the Director of Nursing (DON) documented: - On 6/8/22 at approximately 8 AM, staff received a call from the resident's family member stating the resident drank their vape liquid. - The resident was found in bed, diaphoretic (perspiring heavily), and their family member was on the phone and an empty bottle was on the bedside table. The resident stated, I just want to die and drank one whole bottle of the vape liquid. - The resident required extensive assistance with activities of daily living (ADL) and required supervision and set- up for meals. They had adaptive equipment for meals and was able to use their cell phone for calls, entertainment, and online ordering. - The facility obtained statements from certified nurse aides (CNA) #3, 10, 12, 36 and licensed practical nurse (LPN) #4, who reported having no knowledge of the incident. CNA #10 was the only staff noted to have been asked if they opened any containers for the resident and they reported they did not. - LPN #8's statement included they responded to concerns from staff that the family member reported and upon entering the room, heard the family member on the phone stating the resident drank it all. LPN #8 found 2 bottles of unknown liquid, one empty and one with approximately 1/3 of the liquid remaining. - The conclusion of the investigation included the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff statements obtained by the facility and included with the 6/8/22 investigation did not address if staff were aware of the resident's vaping or possession of vape liquid prior to the incident. The 6/17/22 hospital report documented the resident was brought in after [CONDITION(S)] secondary to ingestion of vape solution as suicidal intention. This led to [MEDICATION(S)] [MEDICATION(S)] and nicotine toxicity. The laboratory report documented a presumptive positive (detects presence of substance and does not show a specific level of the drug) result for amphetamines and cannabis. The 6/12/22 police report documented: - the hospital notified them of the incident due to the suspicious nature of the resident's overdose. - The Intensive Care Unit (ICU) nurse practitioner (NP) reported concerns due to the resident's limited use of their hands to open the bottles of vape liquid and consume them. - The resident's family member was contacted and reported they were on the phone with the resident on 6/7/22 at 7:29 AM. The resident told the family member they had 2 bottles of vape liquid that staff had opened for them and intended to drink them in order to commit suicide. The family member encouraged the resident to use their call bell to get help instead of drinking the vape fluid. The family member remained on the phone, as it was set to speaker. Additionally, the family member reported on 6/8/22, they were on the phone with the resident at 7:42 AM. The resident said they had 2 bottles of vape fluid that staff had opened for them, and they were going to drink it. The family member heard the resident drinking the liquid and called the facility. - On 6/13/22, the police arrived at the facility to investigate. Multiple photographs of the resident's room and belongings were taken at that time and included: - a plastic wash bin with 3 refillable vape pods (square devices approximately 2 ½-3 inches by 2 ½ to 3 inches with a mouthpiece for inhalation), 2 lanyards, a bottle cap, a container of chewing tobacco, and 2 white boxes marked 2 refillable vape pods in each. - An empty 60 ml bottle, showing a nicotine liquid company logo, nicotine warnings, and 50 milligrams (mg) nicotine; - A view of the 60 ml bottle label with ingredients including vegetable [MEDICATION(S)], [MEDICATION(S)] [MEDICATION(S)], nicotine, and artificial flavorings. The warnings on the label included: the product was not intended for people with medical conditions such as heart disease, high blood pressure, diabetes, depression, or asthma. Ingestion could be poisonous and lead to severe illness and/or death. - On 6/14/22, the police investigator informed the facility's Administrator that on 6/7/22, the resident informed staff of their intention to drink vape liquid. The investigator requested to speak to the staff member who responded to the call bell. - On 6/20/22, the Administrator notified the investigator CNA #7 was the staff member who responded to the call bell on 6/7/22. Following notification from the police department, the facility did not investigate the resident's suicidal intent on 6/7/22. The facility did not obtain statements from CNAs #2, 5, 6, 7, and 17, who worked 6/7/22 day and evening shifts. Following receipt of the hospital report that included identification of amphetamines and THC (tetrahydrocannabinol, the main psychoactive compound found in cannabis) in the resident's system, there was no further investigation from the facility. There were no other statements from staff who regularly provided care or worked on the resident's unit to address if they had knowledge of the usage of vaping materials, THC gummies, and amphetamines. There was no documentation related to the findings of vape materials or chewing tobacco in the resident's room following their death. During an interview with the DON on 6/27/22 at 12:32 PM, they stated they completed their investigation on 6/8/22. They stated they asked staff generally what they knew about day or so prior to the resident's death. The DON did not ask staff about how the resident may have accessed or utilized their vaping supplies as they figured they obtained the items via online orders and managed it themselves. The DON was not certain if the resident was physically able to manipulate the vaping device, open packages, or access their nightstand drawer independently. After they received the additional information from the police that staff heard of the resident's suicidal intent and vaping liquid the day prior to the incident, the DON asked CNA #7 and did not ask other CNAs who were working that day. The DON stated they had general conversations with other staff but did not specifically ask other staff if they were aware of the statements made on 6/7/22.The DON did not call the resident's family member who was on the phone and overheard the staff responding to the resident. They did not provide a reason for not following up with the family member. Following receipt of the hospital report, the DON was aware that amphetamines and cannabis were detected in the resident's system. The DON stated they were uncertain what presumptive positive meant on the laboratory report and did no further investigation. During an interview with the Administrator and DON on 7/7/22 at 11:00 AM, they stated the Administrator was ultimately responsible for the review and completion of facility investigations. The DON stated it was not addressed how the resident was able to obtain and retain vaping materials in their room. It was thought the resident did so independently through online ordering. The Administrator stated they thought it was addressed by seeing the resident received packages from companies that sold the materials, as they knew the resident had no visitors. The Administrator stated they were made aware by the DON and police investigator of the hospital report regarding the amphetamines and cannabis detected in the resident's system. This area was not investigated and should have been as it was important to understand the factors related to how the resident had access to harmful items. The Administrator stated the areas including the prior suicidal ideation, the findings in the room of the additional vaping devices and chewing tobacco, and the subsequent findings of the presence of the amphetamines and cannabis in the resident's system all should have been investigated further to ensure the facility was aware of the factors contributing to this incident and to ensure a complete and thorough investigation. 10NYCRR 415.4(b)(3)

Based on record review and interview during the abbreviated survey (NY 180), the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for 1 of 5 residents reviewed (Resident #1) Specifically, Resident #1 had vaping supplies including vape liquid (containing nicotine, [MEDICATION(S)] [MEDICATION(S)], flavorings, and other chemicals) and vaping devices (battery powered vaporizer that heats vape liquid to create vapor), chewing tobacco, and THC (tetrahydrocannabinol, the main psychoactive compound found in cannabis) infused gummy candies in their possession while at the facility. The resident consumed approximately 100 millimeters (ml) of vape liquid which subsequently caused their death. Amphetamines (synthetic, addictive, mood-altering drug, used illegally unless prescribed for certain medical conditions) and cannabis were also detected in the resident's system at the hospital and the facility did not ensure a plan was in place to prevent access to accidents hazards or to ensure adequate supervision was provided. Findings include: The 1/2019 Resident Smoking policy documented: - The facility was a smoke free facility. No smoking or use of smoking materials was allowed in the building, its grounds, and/or parking lot. - No smoking or use of smoking materials was allowed. - Residents will be offered smoking cessation products with physician and family support. The facility did not provide a drug use policy prior to the survey exit. Resident #1 had diagnoses including [CONDITION(S)] (paralysis of the lower body), [CONDITION(S)] ([CONDITION(S)]), nicotine dependence, and major depressive disorder. The 5/5/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition and mild to moderate depression. The resident required extensive assistance of 2 for bed mobility, was totally dependent for transfers, required extensive assistance of 1 for dressing, toileting, hygiene, and ate with supervision and set up assistance. The resident had upper extremity impairment on both sides. The comprehensive care plan (CCP) initiated 10/11/19 documented: - for smoking, the resident was alert and oriented and followed the smoking rules. No goals or interventions were included. - The resident had a Safe Smoking assessment on 6/28/19 and found the resident was an unsafe smoker, could not safely hold, light, or extinguish a cigarette. - The CCP was last reviewed on 3/26/21 with notes the resident did not smoke and to continue the plan of care. - The CCP did not include any documentation related to vaping. The CCP, effective 7/4/20, documented: - The resident was non-compliant related to cognitive impairment, desire to manipulate, and chronic mental illness. No goals or interventions were included. - The CCP was last reviewed 3/26/21 with notes the resident refused to get out of bed, refused positioning, refused meals and to continue the plan of care. - The CCP did not include any documentation related to vaping or non-compliance with the smoking policy. The Resident Nursing Instructions, effective 5/1/2022, documented: - The resident required extensive assistance of 2 for bed mobility, utilized bilateral siderails, required extensive assistance of 1 for dressing and hygiene, and ate with supervision after set-up with adaptive equipment. - The resident was a non-compliant smoker and did not currently smoke. The 6/8/22 Report of Investigation, completed by the Director of Nursing (DON) documented: - On 6/8/22 at approximately 8 AM, staff received a call from the resident's family member stating the resident drank their vape liquid. - The resident was found in bed, diaphoretic (perspiring heavily), and their relative was on the phone and an empty bottle was on the bedside table. - The resident stated, I just want to die and that he drank one whole bottle of the liquid that was there. - Licensed practical nurse (LPN) #8's statement included they responded to concerns from staff the relative called and upon entering the room, heard the relative on the phone stated the resident drank it all. The LPN found 2 bottles of unknown liquid, one empty and one with approximately 1/3 of the liquid remaining. - The DON documented it appeared the resident drank vape liquid with suicidal intention and did so while on the phone with their family member. The 6/12/22 police report documented: - The hospital notified them of the resident's overdose. - On 6/13/22, the police arrived at the facility to investigate. Multiple photographs of the resident's room and belongings were taken at that time. The photographs included: - a plastic wash bin with 3 refillable vape pods (square devices approximately 2 ½-3 inches by 2 ½ to 3 inches with a mouthpiece for inhalation), a lanyard, a bottle cap, a container of chewing tobacco, 2 white boxes marked 2 refillable vape pods in each; an empty 60 ml bottle, showing a nicotine liquid company logo, nicotine warnings, and 50 milligrams (mg) nicotine. The label of the 60 ml bottle documented warnings the product was not intended for people with medical conditions such as heart disease, high blood pressure, diabetes, depression, or asthma. Ingestion could be poisonous and lead to severe illness and/or death. The 6/17/22 hospital report documented the resident was brought in after [CONDITION(S)] secondary to ingestion of vape solution as suicidal intention. This led to [MEDICATION(S)] [MEDICATION(S)] and nicotine toxicity. The laboratory report documented a presumptive positive (detects presence of substance and does not show a specific level of the drug) result for amphetamines and cannabis. During a telephone interview with the hospital Intensive Care Unit (ICU) nurse practitioner (NP) on 6/24/22 at 1:20 PM, they stated the resident had cannabis and amphetamines in their system in addition to the [MEDICATION(S)] [MEDICATION(S)] and nicotine. The NP reviewed the resident's chart and found no medications from the nursing home or hospital that would cause the presence of those substances. The only way for the resident to have shown positive for the substances was to have ingested them. [MEDICATION(S)] is an illegal street drug unless prescribed in a medication that would typically treat attention deficit disorder (ADD) and the resident was not on any such medications. It was unknown how much of the cannabis, amphetamines, [MEDICATION(S)] [MEDICATION(S)], and nicotine was consumed, and they overloaded the resident's system leading to [CONDITION(S)]. During an interview with certified nurse aide (CNA) #2 on 6/23/22 at 1:26 PM and on 6/27/22 at 11:20 AM, they stated they previously observed the resident using a vape device and did not observe bottles of vape liquid. CNA #2 described the vape device as a square, approximately 3 inches by 3 inches that fit into the palm of the resident's hand. It also had a lanyard attached which the resident had around their neck. CNA #2 stated they did not think the resident was able to fill the vape device on their own and had not observed them to do so. The CNA stated they reported the vape device to LPN #4 who stated they knew the resident had it and they were not legally allowed to take it away. CNA #2 stated the resident had THC gummies as well as they saw the letters THC on the package. The resident was forthcoming with staff about the gummies. The resident said they had always smoked marijuana with their friend. The gummies were purple gum-drop shaped pieces. The CNA reported the gummies to LPN #4 who replied it was known they had the gummies, and RN Manager #18 was aware. The CNA stated it was common knowledge the resident used the vape device and the gummies and thought it was all right since other staff knew about it. During a telephone interview with social worker (SW) #11 on 6/23/22 at 4:57 PM, they stated in the past, they were unsure of how long ago, staff alerted the SW the resident had vaping supplies. The items were located in the resident's room and removed. There was another instance, possibly in 2020, a package was delivered that was clearly marked with smoking paraphernalia. The SW approached the resident and reviewed the smoking policy advising them they could not keep the package. The SW was not made aware the resident continued to use vaping materials or that they had chewing tobacco. During an interview with CNA #15 on 6/24/22 at 11:45 AM, they stated they observed the resident with a vape device on a lanyard around their neck and held in their hand. The CNA did not report it as it was obvious the resident had it and they thought other staff must have known. The CNA had observed the gummies in the past as well. The resident asked the CNA to get them from a manilla envelope from their bedside drawer. The CNA did not know what kind of gummies they were. The CNA did not report the gummies as they thought the regular caregivers knew and it was allowed. During an interview with NP #20 on 6/24/22 at 1:46 PM, they stated they were not made aware of the resident vaping or using THC gummies. The NP would expect to be notified in order to address the risks, side effects, and explore smoking cessation. Use of the nicotine vape device posed multiple medical risks and was just as potentially harmful as smoking cigarettes. The NP was not aware the resident used THC or amphetamines and stated they could also compromise the resident's health. Any knowledge of the substances the resident was known to use or consume should have been brought the attention of the medical providers. The vape liquid should have been removed as soon as it was known the resident had vaping materials, as it was lethal to the resident. During an interview on 6/27/22 at 10:36 AM, CNA #16 stated they observed the resident with the vape device in their hand all the time. It was on a lanyard around their neck and the CNA observed the resident to puff on the vape device. The CNA had not observed vape fluid in the room and had not assisted the resident in filling the vape device. The CNA did not report it as they thought the resident was allowed to vape in their room since they did not go outside and that it seemed like other staff knew, so it must have been allowed. The CNA observed the gummies before, as the resident asked the CNA to get them from their drawer. The gummies were purple, in a package with a clear front and solid back. The CNA did not know what kind of gummies they were and assumed they were the candy type. During an interview with registered nurse (RN) Manager #18 on 6/27/22 at 11:50 AM, they stated they had heard other staff talk about the resident vaping in their room. The RN Manager did not see any vaping paraphernalia, although they would not know what to look for as they were not familiar with vaping or related materials. Staff did not directly report the vaping to the RN, rather they heard it through casual staff conversation. RN #18 did not ask the resident or follow up with staff and was not certain of the reason they did not. The RN stated they should have inquired, although they were not sure it was the same as smoking, since nothing had to be lit and it did not seem to be a fire hazard. The RN Manager was aware of a prior instance with smoking materials were taken away when the resident used to go outside with their friend to smoke. The care plan should have included any instances of smoking or vaping based on the resident's history to ensure other staff were alerted to the potential for recurrence. The RN Manager was unaware of any THC usage or other illicit drug usage. LPN #4 had previously mentioned in passing that the resident received packages about once a month with gummies. The RN did not inquire further and thought the LPN referred to candy gummies. Any staff who had knowledge of vaping, vaping materials, or drugs in the resident's possession should immediately report to a Supervisor. During an interview with the DON on 6/27/22 at 12:32 PM, they stated staff should have reported any knowledge of vaping or drug usage to the nurse, supervisor, DON, or Administrator. Vaping materials, tobacco, and gummies posed a risk to the resident and any other resident on the unit. The DON was not made aware the staff knew of THC gummy usage and expected staff to bring it to a nurse or Supervisor's attention if they were not sure what they were. The DON had heard following the resident's passing that the staff were aware of vaping and thought it was allowed. 10NYCRR 415.12(h)(1)(2)

Based on record review, observation and interview conducted during the abbreviated survey (NY 567), it was determined the facility did not ensure that 1 of 4 residents reviewed for pressure ulcers (Resident #1) did not develop a pressure ulcer after admission, and did not ensure treatment and services were provided to promote healing of the pressure ulcer. Specifically, Resident #1 experienced harm when the resident developed a pressure ulcer that became necrotic, unstageable, and required debridement. The facility did not obtain a bariatric bed in a timely manner, did not turn and position, or provide incontinence care, per care plan, and did not obtain a physical/occupational therapy (PT/OT) evaluation in a timely manner. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 2/6/2015 documented the resident was at risk for skin impairment due to decreased mobility and incontinence. Documented interventions included weekly skin audits, with the wound team updated for any issues; skin checks with AM and PM care; assist with positioning/promote independence; toilet or incontinence care every 2-4 hours and as needed; and encourage adequate nutrition/hydration. The CCP was updated on 4/10/2015 with interventions listed as turning and positioning (T&P) every 2 hours and at 8 PM; assist with toileting/incontinence care every 2-4 hours and at 8 PM; and a wheelchair cushion. The care plan was reviewed on 5/21/2015, 8/21/2015 and 11/19/2015, with no changes made. The Minimum Data Set assessment dated [DATE] documented the resident had severe cognitive impairment; he required extensive assist of 2 persons for transfer, and extensive assist of 1 person for bed mobility. The assessment documented the resident had no pressure ulcers. Preventative skin measures included pressure relieving devices for the resident's chair and bed, a turning and positioning program, and the application of ointments. A nutrition assessment dated [DATE] documented the resident weighed 267 pounds; had a pressure area; and had intake of 2231 calories and 90 grams protein. Eight ounces of power milk was added at lunch and a power cookie was added at dinner. Nutrition assessments dated 7/29/2015, 8/28/2015, 11/6/2015 - 11/21/2015, and 1/21/2016 each documented the resident's intake was sufficient to meet his needs. The wound care nurse documented on 8/11/2015 the resident was awaiting a physical therapy evaluation. The Weekly Wound Round Records documented the resident had pressure ulcers in the following areas: - coccyx, starting on 6/2/2015; the pressure ulcer was monitored; it was documented as healed on 9/10/2015. The pressure ulcer re-opened; it was documented as healed again on 11/10/2015. - left buttock, starting on 8/26/2015. The pressure ulcer was monitored; it was documented as healed on 11/10/2015. - right buttock, starting on 11/10/2015. The September 2015 Turning and Positioning records documented the resident was not consistently turned/repositioned for at least 8 hours on 10 days that month: 9/4, 9/6, 9/7, 9/13, 9/14, 9/16, 9/19, 9/25, 9/26, and 9/30/2015. The Weekly Wound Rounds Record for September 2015 documented the resident had a left buttock pressure ulcer, as follows: - on 9/10/2015: Stage II (partial thickness skin loss), in-house (signifying it developed in the facility), measurements 1.2 centimeters (cm) x 1.0 cm. - on 9/15/2015: Stage II, 1.0 cm x 1.0 cm. A note documented there was an order dated 8/25/15 for Hydrogel (gel wound dressing) to left buttock wound base, cover with [MEDICATION NAME] (foam wound dressing) and change every other day. - on 9/22/2015: 3.0 cm x 1.0 cm x less than 0.1 cm depth. A notation on the record documented the length of wound was divided by a 1.5 cm healed area in the center. - on 9/29/2015: the left buttock pressure ulcer was healed. The October 2015 Turning and Positioning records documented the resident was not consistently turned/repositioned for at least 8 hours on 7 days that month, on 10/8, 10/12, 10/13, 10/15, 10/17, 10/18, and 10/20/2015. For an additional 3 days that month, on 10/24, 10/25, and 10/31/2015, there was no documentation for 16 hours each day that the resident was turned/repositioned (from 6 AM to 10 PM). The Weekly Wound Rounds Record for October 2015 documented the resident had skin issues on the right and left buttocks, as follows: - on 10/6/2015: moisture associated skin damage (MASD), in-house. - on 10/14/2015: MASD, in-house. - on 10/21/2015: MASD, in-house. It was noted the two areas were nearly healed. The resident was to be returned to bed after meals. There were no further wound round notes for October 2015. The November 2015 Turning and Positioning Records documented the resident was not consistently turned/repositioned for between 6 and 16 hours on 7 days that month: 11/1, 11/2, 11/15, 11/19, 11/22, 11/26, and 11/27/2015. The Weekly Wound Rounds Record for November 2015 documented the resident had 3 areas of skin impairment; the right buttock had skin impairment as follows: - on 11/3/2015: MASD, in-house. - on 11/10/2015: MASD, in-house. - on 11/17/2015: Stage II pressure ulcer, in-house, 1.2 cm x 1.2 cm x 0.1 cm. New order for Duoderm to right buttock. Change every 3 days and as needed. - on 11/25/2015: Stage II, in-house, no measurements were documented. The Weekly Wound Rounds Record for November 2015 documented the resident had 3 areas of skin impairment; the left buttock had skin impairment as follows: - on 11/3/2015: MASD, in-house. - on 11/10/2015: MASD, in-house. - on 11/17/2015: MASD now resolved. - on 11/25/2015: slight MASD; the wound was filling in; no depth. Continue with treatment in place. The Weekly Wound Rounds Record for November 2015 documented the resident had 3 areas of skin impairment; the coccyx had skin impairment as follows: - on 11/3/2015: MASD, in-house. - on 11/10/2015: MASD, in-house. - on 11/17/2015: MASD now resolved. The December 2015 Turning and Positioning Records documented the resident was not consistently turned/repositioned on 10 days that month, on 12/1, 12/4, 12/10, 12/11, 12/12, 12/13, 12/16, 12/20, 12/30, and 12/31/2015. For 12/14/2015, there was no documentation the resident was repositioned for a 16 hour period from 6 AM to 10 PM. The Weekly Wound Rounds Record for December 2015 documented the resident had 2 pressure ulcers; the right buttock had a pressure ulcer as follows: - on 12/2/2015: 1.8 cm x 2.0 cm. The pressure ulcer was documented as not improving. The wound nurse documented that the air mattress was found to be malfunctioning and maintenance was contacted. - on 12/8/2015: Stage II, 1.8 cm x 2.0 cm. - on 12/15/2015: Stage II, 1.0 x 1.0 cm. The Weekly Wound Rounds Record for December 2015 documented the resident had 2 pressure ulcers; the left buttock had a pressure ulcer as follows: - on 12/2/2015: 0.8 cm x 1.0 cm. The intervention was listed as resident to be returned to bed between meals. - on 12/8/2015: Stage II, 0.8 cm x 1.0 cm. - on 12/15/2015: Stage II, 0.4 cm x 1.0 cm. The January 2016 Turning and Positioning Records documented the resident was turned and positioned every 2 hours from 1/1/2016 - 1/22/2016. The record documented the resident was at the hospital from 1/23/16 through the rest of the month. The Weekly Wound Rounds Record for January 2016 documented the resident had 2 pressure ulcers; the left buttock had a pressure ulcer as follows: - on 1/5/2016: the wound care nurse documented the resident's left buttock pressure ulcer was covering most of the buttock, was unstageable and was significantly worse, and turning/positioning was not being done consistently. - on 1/14/2016: 3 cm x 2 cm x 3.4 cm, and was an unstageable area covered with eschar (dead tissue). A referral to the wound clinic was made. The Weekly Wound Rounds Record for January 2016 documented the resident had 2 pressure ulcers; the coccyx had a pressure ulcer as follows: - on 1/5/2016: the coccyx pressure ulcer was unstageable, 3.0 cm x 2.0 cm x 1.0 cm depth with 100% tan stringy necrotic slough (stringy dead tissue). - on 1/14/2016: unstageable, 13 cm x 2 cm x 3.2 cm depth, with tan stringy necrotic slough, and tunneling of 3 cm x 2 cm x 3.4 cm depth. The resident's CCP for impaired skin, updated on 1/15/2016, documented interventions as: air mattress and check function/settings every shift; wheel chair cushion; PT/OT consults as needed; wound clinic referral; frequent small changes in between turning and positioning; heel protectors; turn and position every 1 hour and as needed; and incontinence care every 1 hour and as needed. There was no documentation in the medical record after that point that the resident was turned and positioned every hour as planned. There was no documentation in the resident's medical record a physical therapy evaluation was completed. On 1/21/2016, the nurse practitioner (NP) ordered a wound clinic evaluation for the resident. The Wound Care Clinic visit note, dated 1/21/16, documented the resident's sacral/coccyx pressure ulcer was Stage IV (full thickness skin loss with extensive damage to underlying muscle, bone, or supporting structures), measuring 14 cm x 5 cm x 6 cm depth. There was fat and fascia (connective tissue) exposed, with a large amount of serosanguinous (bloody yellow) drainage noted, and a medium amount of necrotic tissue within the wound bed, including eschar and adherent slough. Recommendations were to apply [MEDICATION NAME] (wound treatment) to coccyx wound bed, apply gauze, cover with abdominal pad, and change dressing every day and as needed for excessive drainage. Review of Interdisciplinary Progress Notes revealed the resident was sent to the hospital on [DATE] for surgical wound debridement of the sacral pressure ulcer. He returned to the facility on [DATE] with a wound vac (negative pressure dressing) in place over the sacral wound, sized 14 cm x 5.5 cm x 6 cm. When the Director of Nursing (DON) was interviewed on 2/4/2016 at 10:45 AM, she stated the resident had moisture associated skin damage that quickly developed into a Stage III (full thickness skin loss) area, and was then unstageable due to necrotic slough. The DON said the resident was referred to the wound clinic on 1/21/2016, and that was when the resident's bariatric bed arrived at the facility. The DON stated the bariatric bed was first used on 2/2/2016, as it was too large to fit through the room door when it arrived. The DON stated the team believed the bigger bed would help keep the resident off his back a little better because there was very little room to turn him in the regular bed. On 2/4/2016 at 1:00 PM, the surveyor observed the resident being transferred into the bed. Two certified nurse aides (CNAs) transferred the resident into a bariatric bed with an air mattress in place. The wound care registered nurse (RN) #3 was interviewed on 2/4/2016 at 1:00 PM. RN #3 stated she made a verbal request for a PT/OT evaluation at the morning meeting on 8/2/2015. The RN said she did not submit a formal written request for the PT/OT evaluation, or ask PT/OT to write an order for [REDACTED].#3 stated the T&P records had many blanks for November and December 2015. The RN said the aides were told at a meeting a few weeks prior (was unable to provide an exact date) that the T&P records had to be reviewed by the charge nurse, or nurse supervisor, at the end of each shift. The RN stated that monitoring of the T&P records was started on 2/1/2016. CNA #1 was interviewed on 2/4/2016 at 2:45 PM. CNA #1 stated the resident was on a 2 hour T&P/incontinence schedule. The CNA stated it could be difficult at times to turn and position the resident as the resident was heavy, and required a two-person assist with a mechanical lift for transferring. The CNA said it could be hard to find a second person to help, especially on weekends when people called in. The CNA stated the T&P records had to be checked by the charge nurse before leaving for the shift. CNA #1 stated the aides did the best they could to turn and position and change the residents in a timely manner, but sometimes there was just too much to do. A physician visit note, dated 2/10/2016, documented that the resident was bed bound and developed a sacral lesion. On 1/22/2016, the physician sent the resident to the emergency department for evaluation. The resident was admitted for treatment of [REDACTED]. The resident was treated with intravenous (IV) antibiotics and given a wound vac. The NP was interviewed on 2/23/2016 at 9:30 AM. The NP stated the resident was a large man and he had trouble with moisture/pressure areas on his sacrum/buttocks, off and on for quite a while. The NP stated he vaguely remembered the wound nurse had asked for a PT/OT evaluation due to the continued pressure on the buttocks, but he could not say when the evaluation was requested. The NP stated he did not recall signing an order for [REDACTED]. The NP stated there was a consult to the wound clinic. The NP stated the wound clinic did not really do anything besides recommend the resident receive consultation with a specialist who was three hours away. The NP stated the resident was then sent to the hospital instead, and the wound was debrided and the resident was given a wound vac. The NP stated he was not sure of the progression of the wound, but believed there were no signs/symptoms [MEDICAL CONDITION] when the resident was sent out. The NP said if the wound was covered with necrotic eschar or significant amount of slough, the area could have been debrided at that time to aid in healing. The NP stated he was aware the bariatric bed did not fit through the door and had to be taken apart and rebuilt in the room. The NP said he was not sure when the bed arrived or when the resident actually started to use it. The NP stated the team believed the bariatric bed would provide more comfort and possibly better pressure relief. 10 NYCRR 415.12(c)(1-2)

Based on record review and staff interview conducted during the extended survey, the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents who were victims of Resident #15's sexually aggressive behaviors, including 3 of 26 sampled residents, Residents #16, 25 and 26). Specifically, the QA committee failed to identify concerns of resident to resident abuse and failed to implement corrective measures. In addition, QA failed to recognize the facility did not have a plan to prevent further abuse and protect other resident's from aggressive behaviors; failed to fully investigate the incidents; failed to recognize the facility did not have adequate supervision for the residents with behaviors; and failed to recognize the facility's abuse prohibition protocols were not applied to incidents of resident to resident abuse. This resulted in no actual harm with potential for serious harm that was Immediate Jeopardy to the health and safety of residents, including Residents #15, 16, 25 and 26. Refer to F223, F226, and F323. Findings include: The Administrator, who stated he was responsible for quality assurance (QA) was interviewed at 11:30 AM on August 17, 2012 and stated he became aware of the concern when surveyors began asking questions of the staff related to resident to resident behaviors. He stated that he should have been aware of the problem and that he attended morning report daily and attended the monthly behavior meetings. He stated these concerns were not discussed directly by the QA committee and had not been tracked. The Director of Nursing (DON) was interviewed on August 17, 2012 at 11:45 AM and stated there were monthly behavior committee meetings attended by the DON, Nurse Managers, social worker, the Administrator, pharmacy and the psychologist. The concerns were not discussed directly by the QA committee. -------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed on August 21, 2012 based on the following corrective actions taken by the facility: - The Incident/Accident Report form was updated to include resident to resident incidents of physical or verbal abuse, and the Incident/Accident reporting investigation policy was revised to reflect the revisions in the form; - The Behavior Monitoring Procedure was revised; - The resident (Resident #15) who exhibited inappropriate sexual behavior was placed on 1:1 supervision until reevaluated by the geriatric psychiatrist and an appropriate plan was in place to effectively monitor the resident; and - all staff in house were inserviced on the revised policies and procedures and the specific plan for Resident #15. 10 NYCRR 415.27(a-c)

Based on record review and staff interview conducted during the extended survey, the Administrator and Director of Nursing (DON) failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable mental and physical well-being of each resident. Specifically, the Administrator failed to ensure the facility immediately addressed incidents of sexually aggressive behaviors affecting 4 of 26 sampled residents (Resident #15, 16, 25 and 26). In addition, the Administrator failed to prevent resident to resident abuse; failed to ensure resident abuse incidents were thoroughly investigated; failed to implement the facility's abuse protocols, and failed to implement measures to prevent abuse. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to the health and safety of residents, including Residents #15, 16, 25, and 26. Refer to F223, F226, and F323. Findings include: The Administrator was interviewed on August 17, 2012 at 11:30 AM and stated he became aware of the concern when surveyors began asking questions of the staff related to resident to resident behaviors. The Administrator was not aware of any incidents with Resident #15 and other residents. He stated that he should have been aware of the problem and that he attended morning report daily and the monthly behavior meetings. He stated there was a communication breakdown when these behaviors occurred. The Director of Nursing (DON) was interviewed on August 17, 2012 at 11:45 AM and stated she was not aware of any resident to resident inappropriate sexual behaviors in the facility. Prior to survey, there had been no formal investigation of inappropriate sexual behavior and there was no policy in place related to inappropriate sexual behaviors by residents. The DON stated there are monthly behavior committee meetings attended by the DON, Nurse Managers, social worker, the Administrator, pharmacy and the psychologist. -------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed on August 21, 2012 based on the following corrective actions taken by the facility: - The Incident/Accident Report form was updated to include resident to resident incidents of physical or verbal abuse, and the Incident/Accident reporting investigation policy was revised to reflect the revisions in the form; - The Behavior Monitoring Procedure was revised; - The resident (Resident #15) who exhibited inappropriate sexual behavior was placed on 1:1 supervision until reevaluated by the geriatric psychiatrist and an appropriate plan was in place to effectively monitor the resident; and - all staff in house were inserviced on the revised policies and procedures and the specific plan for Resident #15. 10 NYCRR 415.26

Based on observation, record review, and staff and resident interview conducted during the extended survey, the facility did not provide an environment free of accident hazards or provide adequate supervision to prevent accidents for 4 of 26 sampled residents (Residents #15, 16, 25 and 26). Specifically, the facility failed to provide adequate supervision to Resident #15 to protect other residents from abuse, including Residents #16, 25, and 26. This resulted in no actual harm with the potential for serious harm and is Immediate Jeopardy and Substandard Quality of Care for Residents #15, 16, 25, and 26. Additionally, the facility did not provide an environment free of accident hazards for Resident #30, and did not ensure devices were in place to prevent accidents. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #30. Findings include: 1) Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing progress notes, dated November 19, 2011 through February 1, 2012, documented Resident #15's behaviors included wandering into other residents' rooms and, on 2 separate occasions, Resident #15 was found in other residents' beds. The comprehensive care plan (CCP) documented Resident #15 was to be encouraged to stay in sight and out of other residents' rooms. On February 1, 2012, the CCP was updated to include the resident's inappropriate behaviors. The resident was noted to be verbally and physically sexually inappropriate. The CCP documented the resident "touched another resident's breasts", and "verbally talks about sex and body parts". The CCP documented, staff were to redirect the resident away from the others and "tell him his behavior is inappropriate and he needs to stop". There was no documented evidence increased supervision was provided for Resident #15. On February 3, 2012, a nursing progress note documented the resident was wandering into other rooms and needed to be redirected 20 times in a shift. On February 7, 2012, the "Behavior Monitoring Flow Sheet", documented the resident exhibited inappropriate sexual behavior described as "feeling female residents breasts". The resident was removed from the situation. A "15 Minute Location Monitor" form was initiated on February 7, 2012 and was completed for February 7 and 8, 2012. There was no documented evidence of the monitoring for February 9, 2012. Nursing progress notes between February 9 and 14, 2012 documented the resident wandered from room to room, went in to other residents' beds and on one occasion stated he wanted to go to his car "to get his condoms". There was no documentation the CCP was updated following the above episodes. The facility provided the surveyor with "15 Minute Location Monitor" forms (dated February 10, 11, 12, 15, 16, 17, 20, 21, 23, and 24, 2012). Review of these forms revealed documentation was incomplete on these dates. There was no documented evidence the resident was monitored daily. The physician's progress notes, dated February 21, 2012, documented the resident was started on paroxetine (an antidepressant) for sexually inappropriate behaviors. The physician did not identify the behaviors. A nursing progress note dated February 25, 2012 documented the resident was on 15 minute checks and there was no inappropriate behaviors. There was no documented explanation related to the reason for the 15 minute checks or when they were initiated. The "15 Minute Location Monitor" forms continued through March 9, 2012 and nursing continued to document the resident's wandering behavior during this time period. The resident was documented as wandering in the hallways, in the dayroom and on March 2, 2012, wandered "into other rooms". On March 19, 2012, the physician documented the resident was on medication for agitation and for sexually inappropriate behavior. The resident's behavior was described as "better with recent" medication adjustments "but still wanders". A nursing progress note dated April 6, 2012 documented the resident continued to wander into other rooms and intruded on the privacy of others. Review of nursing progress notes from April 12, 2012 through May 13, 2012, revealed the resident continued to wander in the hallway on the unit. On May 14, 2012 the "Behavior Monitoring Flow Sheet" and nursing progress note documented the resident made sexually inappropriate comments to a staff member. As a result, the flow sheet documented staff offered the resident food/drink, offered the bathroom and offered "rest". The outcome was documented as positive. The physician's progress note dated May 24, 2012 documented the resident was on the medication for sexually inappropriate behavior and the staff felt his behavior was "good" on the medications. Review of the nursing progress notes between May 14, 2012 and June 13, 2012 revealed the resident continued to wander on the unit. On June 5, 2012, the resident's wandering included wandering into other residents' rooms. On June 14, 2012 the Behavior Monitoring Flow Sheet documented at 7:00 AM, the resident was found with "his hand on a female resident's breast - brief opened too with nightgown pulled up". The resident was removed from the room. On June 14, 2012, a nursing progress note documented the resident was "kept on" 15 minute watch and although wandering the unit, "did not enter any res (resident) room". There was no further documentation related to the incident on the Behavior Monitoring Sheet of the same date. There was no documented evidence the care plan was updated at this time. On June 15, 2012, nursing documented the resident was seen attempting to go in another resident's room and was redirected. The 24-hour report dated June 15, 2012, documented the resident wandered into the rooms of other resident's. The report documented the resident was found holding the breast of Resident #26. On June 19, 2012, a nursing progress note documented the resident was found on the floor in his room and the resident's roommate (Resident #25) stated he "pushed him out of his bed". An Accident/Incident Report was completed for an occurrence of June 19, 2012 at 6:15 AM documented the resident had an unobserved fall when attempting to get in his roommate's bed. The two certified nurse aides (CNAs) who responded to the resident's fall, stated the resident said he was in bed with his roommate and the roommate pushed him on the floor. The plan of correction was to use floor mats and continued 15 minute checks. The 15 Minute Location Monitor for June 19, 2012 was blank from 5:45 AM to 6:15 AM when the resident was found on the floor. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition with short and long term memory impairment. The resident required limited assistance with locomotion and with dressing, and was described as wandering daily. There was no documentation of behavior problems on the MDS. On July 5, 2012, a nursing progress note documented the interdisciplinary team decided to discontinue the 15 minute checks as there had been "no incidents" since being placed on the checks. It was unclear what "incidents" the team was referring to as the documentation included inappropriate sexual behavior on 3 occasions during the time period of the 15 minute checks. The nursing progress note dated July 9, 2012 at 11 AM, documented the resident wandered the unit and went into the rooms of other residents, at times causing other residents' to become upset. At 11:30 AM, it was documented the resident was in the doorway of an unidentified resident and the unidentified resident was yelling to "get out". On July 11, 2012, the CCP documented the resident's behaviors were described as follows: verbal and sexual comments and actions toward others including talking of body parts and attempting to touch another resident's breasts. The interventions included "explain that his comments and actions are inappropriate and that he needs to stop", and medications as ordered. On July 14, 2012 the Behavior Monitoring Flow Sheet documented the resident was attempting to enter other resident rooms. There was no further documentation of this behavior at that time and nursing progress notes documented the resident did not exhibit any behaviors on this date. On August 6, 2012, 15 minute checks was added to the CCP with no explanation added to the care plan. On August 7, 2012 a psychology progress note documented the resident was referred for consultation "to devise the most reasonable behavior plan". The psychologist documented the goal was to eliminate the resident's "violating sexual behaviors" and that reasoning with the resident was not an option. The other residents needed to be kept safe, leading to "an impossible situation". The psychologist documented "temporarily providing 1:1 to protect other residents seemed to be warranted". There were no documented changes made to the CCP regarding increased supervision for Resident #15, following the psychologist's visit. The current (undated) "Person Centered Carecard" (used by the certified nurse aides (CNAs) to provide daily care) documented the resident's socially inappropriate behaviors and wandering behavior. There was no specific plan identified on the care card related to the resident's supervision. On August 15, 2012 Resident #15 was observed wandering on the unit at 3:30 PM. On August 16, 2012, Resident #16 was interviewed at 10:15 AM and reported to the surveyor she had an incident with Resident #15 "2 to 3 weeks ago." She stated he entered her room and observed her receiving incontinence care. The resident was crying and asked the surveyor how the staff could allow "that man' to come in my room and watch me. On August 16, 2012 at 10:15 AM, Resident #16 described a second time when the resident entered her room when she was in bed and said the resident "groped" her bed clothes. She stated when she informed the staff, they "laughed at her". There was no documentation related to either incident described by Resident #16. On August 16, 2012 RN #1 was interviewed at 3:20 PM regarding Resident #15's behaviors and if there were any interventions in place related to the behaviors. She stated the resident wandered in his wheelchair and was on "15 minute checks" due to the wandering behavior. The RN Unit Manager (RN#2) was interviewed on August 16, 2012 at 3:25 PM. She stated she was not aware of any recent inappropriate sexual behavior however, if there was any, she would expect the staff to remove the resident from the situation, document in the behavior book, and notify the nurse, social worker and the family. On August 17, 2012, at 7:15 AM, the CNA who was involved in the incident with Resident #16 (when Resident #15 observed care being provided), was interviewed. She stated Resident #15 was not removed from the situation until care was completed. She stated she reported the incident to the RN Manager (RN #2). On August 17, 2012 at 11:45 AM, the DON was interviewed and stated Resident #15 was moved from one unit to another due to wandering behaviors and safety. She heard that one time he was found in another resident's room. He was more verbal than physical; she spoke to the physician, and his medication was changed. ---------------------------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed on August 21, 2012 based on the following corrective actions taken by the facility: - The Behavior Monitoring Procedure was revised; - The resident (Resident #15) who exhibited inappropriate sexual behavior was placed on 1:1 supervision until reevaluated by the geriatric psychiatrist and an appropriate plan was in place to effectively monitor the resident; and - all staff in house were educated on the specific plan developed for Resident #15. 2) Resident #30 had [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired, transferred with 2 person assist, moved between locations with total dependence, used a wheelchair, and had a recent fall. An occupational therapy (OT) progress note dated June 12, 2012 documented the resident has a high back wheel chair that is able to be reclined, "with lateral supports and elevating leg rests for positioning when out of bed." An OT progress note dated June 19, 2012 documented the "resident's ability to maneuver himself on unit using his feet to propel his wheel chair is inconsistent from day to day. Resident has difficulty pushing wheel chair wheels with his arms...and inability to coordinate his upper extremities to push/propel his wheel chair." The resident's comprehensive care plan (CCP) updated on June 21, 2012 documented the resident: Had potential for falls related to decrease in mobility, incontinence and decreased cognition; Was observed on the floor or to fall or roll to the floor 15 times between June and August, 2012; Was on a walk to dine program, Attended physical therapy for strengthening, balance standing activities; Had anti-tippers for wheel chair; and Had impaired activities of daily living (ADL) mobility related to Parkinson's disease and to "assist with all ADLS" and to "keep resident safe." A physical therapy (PT) evaluation completed July 4, 2012 documented the resident's sitting balance is fair and standing balance is poor. PT documented the residents upper extremities strength as a 1 out of 5 and lower extremity strength as 3 out of 5 and that the resident was unable to ambulate, and needs a wheel chair. On August 16, 2012 at 3:09 PM a licensed practical nurse (LPN) was observed pushing the resident in a manual wheel chair to the dining area towards a dining table. The resident's feet had been forward (wearing socks with sneakers on both feet) and slowly came down and pulled back underneath the resident's wheel chair. The LPN continued to push the resident forward with his feet pulled under with the top of the toes to the floor, to the dining table. The LPN walked away from the resident. The resident was then observed to be able to pull his left foot forward on his own, the resident attempted to move the right foot forward and was unable to, he continued to try to use his hands to lift the right leg by the knee area and was unable to move his leg. Another LPN came at approximately 3:15 PM and moved the resident backwards to bring him to another location to provide treatment, at that time the nurse noticed the right leg and pulled the right foot forward. The nurse did not ask the resident if he was in pain. During an interview with the registered nurse (RN) Unit Manager on August 17, 2012 at 6:03 PM, she stated that "if a resident can not lift their feet, they should have leg rests." 10 NYCRR 415.12(h)(1)(2)

Based on record review and staff interview conducted during the extended survey, the facility failed to develop and implement written policies and procedures related to resident to resident sexual abuse, for 4 of 26 sampled residents (Residents #15, 16, 25 and 26). Specifically, the facility did not have a policy related to inappropriate sexual behaviors by residents, including when Resident #15 exhibited multiple incidents of resident to resident abuse toward Residents #16, 25, and 26. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. Findings include: Resident #15 was admitted to the facility in November of 2011 with [DIAGNOSES REDACTED].#15 wandered into other residents' rooms (including Residents # 16, 25 and 26) and exhibited inappropriate verbal and physical sexual behaviors. On August 17, 2012 at 11:45 AM, the surveyor interviewed the Director of Nursing (DON) who stated the facility did not have a policy related to inappropriate sexual behaviors by residents. The DON stated the facility's Accident/Incident report did not include "inappropriate sexual behavior" on the form. She said that after learning of this problem during the survey, the Accident/Incident Report form was revised and staff were educated on how to complete this form. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed on August 21, 2012 based on the following corrective actions taken by the facility: - The Incident/Accident Report form was updated to include resident to resident incidents of physical or verbal abuse, and the Incident/Accident reporting investigation policy was revised to reflect the revisions in the form; and - all staff in house were inserviced on the revised policies and procedures and the specific plan for Resident #15's inappropriate behaviors toward other residents, including Residents #16, 25 and 26. 10 NYCRR 415.4 (b)

Based on observation, record review, and staff and resident interview conducted during the extended survey, the facility failed to ensure 4 of 26 (Residents # 15, 16, 25 and 26) sampled residents had the right to be free from verbal and sexual abuse. Specifically, the facility: - failed to ensure residents, including Residents #16, 25, and 26, were protected from Resident #15's sexually aggressive behaviors; - failed to ensure staff immediately intervened when Resident #15 exhibited abusive behaviors towards residents; - failed to ensure all incidents involving Resident #15's abusive behaviors were thoroughly investigated; - failed to ensure the facility's abuse prohibition protocols were applied to incidents of resident to resident abuse; - failed to ensure there was documented evidence effective and timely interventions were implemented to protect other residents from sexual abuse. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care for residents in the facility. Findings include: The facility's policy titled "Prevention, Investigation & Reporting Resident Abuse, Mistreatment, Neglect and Misappropriation of Resident Property" last revised on May 5, 2012, documented the facility policy included the prevention of verbal, mental, sexual or physical abuse of residents. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The "RN (registered nurse) Assessment for Socially Inappropriate Behavior" dated November 18, 2011, documented the resident had socially inappropriate behavior. Staff provided diversion that was "partially ineffective." The plan included "new admission; monitor" and "intervene, if needed." The nursing progress notes documented: - On November 19, 2011, the resident was found ambulating unclothed in the hallway. - On November 24, 2011, the resident "put himself" in an unidentified resident's bed. - On December 4 and 12, 2012, the resident was found in female (unidentified) residents' bed(s). The physician's progress note dated December 19, 2011, documented the resident had occasional agitation "but no major change noted by staff." The nursing note dated January 15, "2011" (filed with January 2012 nursing progress notes), documented the resident was found on the floor in another resident's room with his brief (incontinent product) and pants around his ankles. There was no documented evidence an investigation was conducted concerning this incident. The comprehensive care plan (CCP) dated February 1, 2012, documented the resident had impaired cognition, wandered, was verbally/sexually inappropriate (touched a resident's breasts and talked about sex and body parts). Interventions included redirection, informing the resident his behavior was inappropriate, and telling him to stop. The nursing progress note dated February 3, 2012, documented the resident wandered the unit in his wheelchair and tried go into other residents' rooms. The "Behavior Monitoring Flow Sheet" documented on February 7, 2012, the resident felt the breasts of unidentified "female residents" in the dining room. Nursing progress notes dated February 3, 11 and 14, 2012 documented the resident wandered into other residents' rooms and was found in their beds. physician progress notes [REDACTED]. A nursing progress note dated April 6, 2012 and Social Service Review dated April 11, 2012, documented the resident wandered into the rooms of others, intruded "on the privacy of others" and had a history of [REDACTED]. The Behavior Monitoring Flow Sheets dated May 10 and 14, 2012 noted the resident was going into other rooms and documented the resident was verbally (sexually) inappropriate to staff. The physician's progress note dated May 24, 2012, documented staff felt his behavior was "good" on the present medications. The Behavior Monitoring Flow Sheet documented that on June 14, 2012, the resident was found with his hand on an unidentified resident's breast, and her brief (incontinence product) was open and the resident's nightgown was pulled up. The resident was removed from the unidentified resident's room. The June 15, 2012 twenty-four hour report documented the resident was found holding the breast of Resident #26. The "Accident/Incident Report" dated June 19, 2012, documented the resident attempted to get into another resident's bed. A staff witness statement documented the resident was found on the floor, and the resident stated he was in his roommate's bed (Resident #25) and the roommate pushed him out of bed. The second staff witness statement documented the resident's roommate reported he pushed Resident #15 out of his bed. The nursing progress note and 24 hour report dated June 24, 2012, documented the resident stated he could "really have some fun tonight" with an unidentified female resident and made sexual comments to a female CNA (certified nurse aide). The MDS assessment dated [DATE], documented the resident had moderate cognitive impairment and did not have behaviors directed towards others. A nursing progress note dated July 6, 2012, documented the resident was moved to a different room and he continued to wander into the rooms of other residents. The "Behavior Monitoring Flow Sheet" documented on July 6, 2012, the resident was "accused" of fondling his roommate (an unidentified resident). The social work progress note dated July 9, 2012, documented Resident #15 was offered a room change, as he had behaviors with his roommate. The nursing progress note dated July 9, 2012 at 11:30 AM, the resident sat in the doorway of an unidentified resident, and the unidentified resident "yelled to get out." The "Social Service Review" dated July 11, 2012, documented the resident did not have sexual comments or actions this quarter. The CCP dated July 11, 2012, documented the resident had verbal and sexual comments and actions towards others. An example was documented as touching residents' breasts. The psychology progress note dated August 7, 2012, documented: - the resident was referred as part of a complex problem solving effort to devise the most reasonable behavioral plan; - the goal for the resident was to eliminate his violating sexual behaviors towards other residents and staff; - reasoning with the resident was not an option; - the other residents need to be kept safe, as the resident could not be unnecessarily restrained; - "so this appears" to lead to an almost impossible situation; and - in the short-term the resident could be provided with 1:1 supervision. Resident #15's current (undated) "Person Centered Carecard" (used to provide care) documented the resident wandered and was socially inappropriate at times. There was no description of the socially inappropriate behaviors and no interventions were identified related to the inappropriate behaviors. The resident was observed August 16, 2012 at 9:45 AM, in the dining room. His eyes were closed, 12 other resident's were in the dining room, and the floor was being mopped by a staff member. The resident was not observed to be on 1:1. During an interview with Resident #16 on August 16, 2012 at 10:15 AM, she asked the surveyor how the staff could let Resident #15 walk into her room and watch her. Resident #16 started to cry and stated he "groped my bed clothes". Resident #16 told the surveyor that Resident #15 said he had a right to do this, as she was his wife. She stated she told staff and "they laughed at me." During an interview with registered nurse (RN) #2, the Unit Manager, on August 16, 2012 at 11:10 AM, she stated the resident had an incident "one week ago" where he told Resident #16 she was his wife and he had a license to watch her. CNA (certified nurse aide) #1 stated in an interview on August 16, 2012 at 11:50 AM, the resident's behaviors included confusion and in the past he made sexual statements. She heard in morning report "maybe" 1 month ago the resident was in a resident's room and touched their breast. She stated she did not have any other information, as she did not see this behavior. RN #1 stated during an interview on August 16, 2012 at 3:20 PM, the resident had sexual behaviors during care. She stated she had heard a rumor the resident tried to climb into the bed of Resident #25. RN #2 stated in an interview on August 16, 2012, at 3:25 PM, that Resident #15 did not have any behaviors at this time. She described his prior behaviors as stating that he had to go buy condoms and telling residents he liked their breasts. She stated the resident had an incident "maybe 6 months ago" with Resident #26 where he touched her breasts and he also touched Resident #25. She stated she did not know where he touched Resident #25 and stated Resident #25 was very sensitive about it. RN #2 stated to her knowledge, the resident also had an incident in February 2012 where he touched a resident's breast. She did not know if investigations were completed for these incidents and referred the surveyor to Director of Nursing (DON). RN #2 was interviewed on August 16, 2012 at 4:10 PM, and stated she had not heard of incidents with Residents #15 and 16. She stated Resident #15 had gone into the rooms of other residents. RN #1 was interviewed on August 16, 2012 at 4:15 PM, and stated she was in orientation 2-3 weeks ago, and her preceptor (RN # 3) stated Resident #16 reported that Resident # 15 went into her room and saw her unclothed. During an interview with RN #3 on August 16, 2012 at 4:25 PM, she laughed, and stated she heard Resident #15 used to be a ladies man, tried to be suave, and was called Casanova. She stated when the resident changed rooms he was confused, and thought Resident #16 was his wife. She stated Resident #15 stood at the bathroom door of Resident #16 and watched her in the bathroom. She stated she would know if Resident #15 touched Resident #16 inappropriately as she asked her. She stated Resident #16 did not make any grievances when she was watched by Resident #15. RN #3 stated she wrote "something" up and gave it to RN #2 who wrote a progress note. She stated she thought the Supervisor was notified and did not remember who that was. During an interview with CNA #3 on August 17, 2012 at 7:50 AM, she stated Resident #15 had sexual behaviors including: - going into his former roommate's bed and touching the resident physically; - going into the room of Resident #16 a "couple of times." She stated Resident #16 yelled for him to leave the room and Resident #15 stated he did not want to hurt her, he wanted to make love to her; and - Resident #15 watched her and another CNA provide incontinence care to Resident #16 1-2 weeks ago and when they saw Resident #15 was watching, they did not remove him as Resident #16 needed the assistance of 2 people for care and they could not leave her to remove Resident #15. Resident #15's attending physician was interviewed on August 17, 2012 at 10:55 AM, and stated he had heard about some sexual behaviors and he was unsure of the resident's specific behaviors. The physician read his progress notes and stated the resident was started on [MEDICATION NAME] on February 20, 2012, and he did not specify in his progress note what the sexually inappropriate behaviors were. He stated he had not heard about any further behaviors, so he "assumed" the [MEDICATION NAME] was effective. On August 17, 2012 at 11:45 AM the DON was interviewed and stated that prior to the DOH survey there were no formal investigations of inappropriate sexual behaviors by any resident. Resident #15 was moved from one unit to another due to wandering behaviors and safety. She heard that one time he was found in another resident's room and to her knowledge, he was more verbal than physical, she spoke to the physician, and his medication was changed. ********************************************************************************************* The Immediate Jeopardy situation was removed on August 21, 2012 based on the following corrective actions taken by the facility: - The Incident/Accident Report form was updated to include resident to resident incidents of physical or verbal abuse, and the Incident/Accident reporting investigation policy was revised to reflect the revisions in the form; and - All staff in house were inserviced on the revised policies and procedures and the specific plan for Resident #15. 10 NYCRR 415.4(b)(1)(i)