Every finding on record at Blossom Health Care Center Inc.

Based on interview and record review, the facility did not ensure allegations of abuse were responded to timely and in response to allegations of abuse, residents were protected from further potential abuse for one (1) of three (3) residents reviewed (Resident #1). Specifically, on 03/12/2026, Physical Therapy Assistant #1 witnessed an alleged incident involving Resident #1 and Certified Nursing Assistant #1; however, the allegation was not immediately escalated to administration, Certified Nursing Assistant #1 continued to provide resident care across multiple shifts, and the facility did not ensure immediate protective measures were implemented upon initial staff awareness of the allegation.The findings include:The facility policy Prevention, Investigation and Reporting Resident Abuse and Mistreatment dated July 2024 documented all employees were responsible for monitoring residents. Any employee who witnessed abuse must immediately intervene to stop the abuse to protect the resident and must report the incident immediately to their supervisor or House Charge Nurse who would investigate the matter and, if warranted, immediately report to the Administrator, Director of Nursing, and/or Social Worker. The person responsible for completing the investigation should proceed to the incident scene promptly, ensure the resident was protected from the alleged abuser, and remove any accused staff from resident care pending the outcome of the investigation.Resident #1 had diagnoses including muscle weakness, cerebral infarction (loss of blood supply to part(s) of the brain), and diabetes. The Minimum Data Set (a resident assessment tool) dated 02/09/2026 documented the resident had moderately impaired cognition and required staff assistance for bed mobility and transfers.The facility investigation dated 03/16/2026 documented there was no evidence to support any alleged resident abuse had occurred. The investigation included a written statement from Physical Therapy Assistant #1 describing the alleged interaction, a statement from Certified Nursing Assistant #1, documentation Resident #1 could not recall the incident, and a statement from Resident #4 (roommate) indicating the interaction appeared abrupt. The facility investigation did not include documented statements from Licensed Practical Nurse #1 or the Human Resources Director, despite both being identified as having knowledge of the allegation.Review of the facility staff punches report revealed on 03/12/2026 Certified Nursing Assistant #1 punched in at 6:52 AM and punched out at 11:02 PM. On 03/13/2026 Certified Nursing Assistant #1 punched in at 6:48 AM and punched out at 11:00 AM.Review of the facility staff assignment sheets dated 03/12/2026 for the day and evening shifts and 03/13/2026 for the day shift revealed Certified Nursing Assistant #1 was assigned to Resident #1.In a progress note dated 03/13/2026, Registered Nurse #1 documented Resident #1 denied concerns with care and had no adverse findings on a full skin assessment.In a progress note dated 03/17/2026, the Regional Social Worker documented they spoke with Resident #1 regarding a possible incident, and the resident did not recall any issues.During an interview on 03/23/2026 at 11:48 AM, Resident #4 stated they recalled an interaction between Certified Nursing Assistant #1 and Resident #1 and stated Certified Nursing Assistant #1 seemed abrupt and rough but could not provide additional details.During an interview on 03/23/2026 at 12:23 PM, Resident #1 stated they did not believe they were ever abused by staff and did not know if staff yelled or swore due to their poor memory.During an interview on 03/23/2026 at 12:37 PM, Physical Therapy Assistant #1 stated on 03/12/2026 at approximately 11:15 AM they entered Resident #1's room to provide therapy. Physical Therapy Assistant #1 stated Resident #1 could sit up with cues and no additional assistance was required. Physical Therapy Assistant #1 stated while speaking with Resident #1, Certified Nursing Assistant #1 entered the room, stated who the hell told you to get back in bed, you need to be in the wheelchair for lunch, removed the blanket with force, threw it on the dresser, pulled Resident #1's leg, and yanked the resident up by the wrist, then stood the resident and placed them into the wheelchair before leaving the room. Physical Therapy Assistant #1 stated they did not intervene as the incident occurred quickly, and they froze. Physical Therapy Assistant #1 stated Resident #1 appeared fearful. Physical Therapy Assistant #1 stated Resident #1 indicated Certified Nursing Assistant #1 did that all the time. Physical Therapy Assistant #1 stated they reported the concern to Licensed Practical Nurse #1 sometime after lunch.During an interview on 03/23/2026 at 1:15 PM, Licensed Practical Nurse #1 stated on 03/12/2026 in the afternoon Physical Therapy Assistant #1 reported concerns regarding Certified Nursing Assistant #1 and Resident #1. Licensed Practical Nurse #1 stated immediately after the conversation they reported the concern to the Human Resources Director.During an interview on 03/23/2026 at 1:38 PM, the Human Resources Director stated when staff report abuse concerns, they bring the concern to the Director of Nursing immediately. The Human Resources Director stated they were aware of the incident involving Resident #1 and reported it to the Director of Nursing and Social Worker the same day but could not recall the exact date.During a telephone interview on 03/23/2026 at 2:05 PM, Certified Nursing Assistant #1 stated they provided care to Resident #1 and denied any inappropriate conduct. Certified Nursing Assistant #1 stated they did not use profanity toward Resident #1 and did not pull the resident by the wrist. Certified Nursing Assistant #1 stated they asked Resident #1 why they were in bed and told the resident they should be up for meals. Certified Nursing Assistant #1 stated they assisted the resident to a sitting position using their arm and indicated Physical Therapy Assistant #1 was present and assisted with positioning the wheelchair. Certified Nursing Assistant #1 stated Physical Therapy Assistant #1's account was not accurate and denied the allegations.During an interview on 03/23/2026 at 3:42 PM, the Regional Social Worker stated they became aware of the allegation on 03/13/2026, the day after the incident occurred.During an interview on 03/24/2026 at 11:44 AM, the Director of Nursing stated staff should report abuse concerns to their supervisor and then to the Assistant Director of Nursing or Director of Nursing. The Director of Nursing stated they were not aware of the incident until 03/13/2026 when informed by the Director of Therapy. The Director of Nursing stated Certified Nursing Assistant #1 should have been removed from resident care immediately and the investigation should have started on 03/12/2026.During an interview on 03/24/2026 at 11:59 AM, the Administrator stated staff should report abuse concerns to the Assistant Director of Nursing, Director of Nursing, or Administrator. The Administrator stated Physical Therapy Assistant #1 should have reported the concern the day of the incident and Certified Nursing Assistant #1 should not have continued providing care. The Administrator stated the investigation should have been initiated on 03/12/2026.During an interview on 03/24/2026 at 12:13 PM, the Director of Nursing stated if notified timely they would have obtained statements from Human Resources Director and Licensed Practical Nurse #1 and interviewed additional residents. The Director of Nursing stated there was a breakdown in communication related to this incident.10 New York Code of Rules and Regulations 415.4(b)(1)(i), (2), (3)

Based on observations and interviews conducted during a Recertification Survey from 09/25/2024 to 10/01/2024, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for two of four narcotic (controlled medications) cabinets reviewed. Specifically, numerous controlled medications (drugs that are regulated by law due to their potential for abuse or addiction), including narcotics and opioids (pain relievers), were secured with one lock rather than double-locked per the regulations. This is evidenced by the following: The facility policy Storage of Medications, dated January 2024, included that controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. The policy did not include that controlled substances were required to be double-locked behind two separate doors with two separate locks per the regulation. During observations on 09/25/2024 at 1:08 PM, the first door of the controlled medication cabinet (Third Floor Medication Room) labeled even was unlocked and open. During an interview at this time, Registered Nurse #1 stated they were not sure why the door was unlocked. They knew there were problems with it in the past and it did not lock easily. Registered Nurse #1 was unable to lock the cabinet door with the key when requested. During observations on 09/27/2024 at 8:53 AM, the first door of the controlled medication cabinet (Second Floor Medication Room) was unlocked and open. The first door of the cabinet had a hole where the lock should have been. The cabinet contained several blister packs of controlled substances including pain medications, narcotics, opioids, anti-seizure, and anti-anxiety medications. During an interview at this time, Licensed Practical Nurse #1 stated the first door of the cabinet had been broken for a long time. During an interview on 10/01/2024 at 9:18 AM, Licensed Practical Nurse Manager #1 stated controlled substances should be double locked in a cabinet and should have two different keys to open it. They were not aware a controlled cabinet lock was broken. During observations at this time, the first door of the controlled cabinet (Second Floor Medication Room) was unlocked and open. Licensed Practical Nurse #1 verified there had not been a lock on the door the previous week and maintenance had fixed the lock, but they forgot to lock the door. Licensed Practical Nurse #1 had difficulty turning the lock with the key. Licensed Practical Nurse Manager #1 stated they were aware the cabinet door did not have a lock a few months ago, but thought maintenance had fixed it. Licensed Practical Nurse Manager #1 stated the cabinet needed a new door and lock. During an interview on 10/01/2024 at 9:47 AM, the Director of Maintenance stated they were notified late last week that the second-floor controlled medication cabinet needed a new lock, but they did not have the correct size barrel and it was too long for that lock. The Director of Maintenance was not aware the third-floor medication room also had a controlled medication cabinet that did not lock properly. During an interview on 10/01/2024 at 9:49 AM, the Director of Nursing stated they were not aware there were controlled medication cabinets that were not double-locked. They were made aware of concerns with the cabinet locks in the past but thought they had been repaired. The Director of Nursing stated all controlled medications should be stored in the double lock cabinets. 10 NYCRR 415.18(e)(1-4)

Based on observations, interviews, and record review during the Recertification Survey from 09/25/2024 to 10/01/2024, the facility did not ensure there was a policy and procedure regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, staff were not aware or educated on facility policies and procedures to label, date, and measure temperatures of resident food brought in from outside the facility, and items were not properly labeled and dated. The findings are: The facility policy Foods Brought by Families/Visitors, dated January 2024, documented that food brought by family/visitors that is left with the resident to be consumed later will be labeled and stored in a manner that is clearly distinguished from facility-prepared food. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential food borne danger (for example mold growth, foul odor, past due package expiration dates). During obseravations on 09/25/2024 at 10:34 AM, there was no policy and procedure for how to store, label, and reheat food for resident consumption within the 3rd floor kitchenette. Additionally, there were no thermometers present for staff use to measure reheated food temperatures for resident consumption. During observations on 09/25/2024 and 09/26/2024 between 11:00 AM and 4:00 PM, there were undated and improperly labeled resident food items within the refrigerator of the 2nd floor kitchenette. There were three plastic containers of resident food items, two of which were containers displaying a resident name and room number with no date, and one container with no labeling at all. In addition, there were two reusable shopping bags with unidentified food items in them with no dates on the foods or containers. There was no policy and procedure for how to store, label, and reheat food for resident consumption within the 2nd floor kitchenette. Additionally, there were no thermometers present for staff use to measure reheated food temperatures for resident consumption. During an interview on 09/26/2024 at 12:32 PM, the Food Service Director stated nursing staff was responsible for the labeling and dating resident of food in the kitchenettes. The Food Service Director also stated that they were not sure if nursing staff was trained on how to reheat food for residents or if there was a procedure or thermometer available for nursing staff to use to reheat food. The Food Service Director further stated there was no microwave available on the nursing units so staff might have to come down to the first-floor breakroom to use the microwave. During an interview on 09/27/2024 at 11:35 AM, Licensed Practical Nurse #1 (3rd floor) stated nursing staff should be labeling food items for residents that are brought into the facility with name, room, and date. Licensed Practical Nurse #1 also stated that if food was not dated, they would discard it, and reheating of resident food would be the responsibility of nursing staff. Licensed Practical Nurse #1 further stated there was no training they received on how to reheat food for residents and they did not have microwaves or thermometers to reheat food. During an interview on 09/27/2024 at 11:50 AM, Certified Nursing Aide #5 (2nd floor) stated nursing staff was responsible for labelling and dating resident food from outside the facility with room number and name. Certified Nursing Aide #1 also stated they were not allowed to reheat food and had no way to do so as there was no microwave on the unit. Certified Nursing Aide #1 further stated they were not trained on how to reheat food and would take in ready to eat food, so they did not have to reheat anything. 10 NYCRR: 415.1(b)(1), 415.14(d), (h)

Based on observations and interview during the Recertification Survey from 09/25/2024 to 10/01/2024, for three (first, second, and third floors) of three resident-use floors, the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection and testing in a building that has fuel-burning appliances. The findings are: During observations on 09/25/2024 between 9:00 AM and 4:00 PM, battery operated carbon monoxide detectors were affixed to the walls on the first, second, and third floors. A battery-operated carbon monoxide detector was observed within the generator room that contained a natural gas generator, and another battery-operated carbon monoxide detector was observed within the main mechanical room on the first floor that contained fuel burning furnaces and boilers. During an interview on 09/25/2024 at 11:45 AM, the Director of Maintenance stated they were not aware the carbon monoxide detectors needed to be tested and did not know how often they should be tested . The Director of Maintenance further stated there was no documentation as they had never tested the detectors throughout the building. The 2015 edition of the International Fire Code, requires carbon monoxide detection to be provided in an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance. Additionally, carbon monoxide alarms shall be maintained in accordance with National Fire Protection Agency (NFPA) 720. The 2012 Edition of NFPA 720, Standard for the Installation of Carbon Monoxide Detection and Warning Equipment, requires that single-station carbon monoxide alarms shall be inspected and tested in accordance with the manufacturer's published instructions at least monthly. 10 NYCRR: 415.29(a)(2), 711.2(a)(1); 42 CFR: 483.70(b), 2015 IFC: Section 915, 915.1, 915.1.4, 915.6, Section 1103.9, 2012 NFPA 720: 8.7.1

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 09/25/2024 to 10/01/2024, for one (Resident #3) of one resident reviewed, the facility did not ensure that residents with limited mobility received the appropriate services, equipment, and assistance to maintain mobility and prevent complications. Specifically, Resident #3 did not consistently receive a hand device (rolled washcloth or gauze pad) for a hand contracture (a shortening of muscles, tendons, and skin) to prevent complications per Occupational Therapy's recommendations and as ordered by the physician. This is evidenced by the following: Resident #3 had diagnoses including cerebral infarction (stroke) with hemiplegia (paralysis on one side of the body) and aphasia (absence or difficulty with speech). The Minimum Data Set Resident Assessment, dated 07/18/2024, included the resident was severely impaired of cognitive function, had rejected care on one to three days in the previous seven days, and required substantial/maximal assistance for upper body dressing and personal hygiene. Review of Resident #3's Comprehensive Care Plan and Kardex (used by the Certified Nursing Assistant to direct care) revealed Resident #3 required a rolled washcloth or gauze pad to be applied to their right hand in the morning and removed at bedtime, to monitor the skin daily during care, and to notify the Registered Nurse for any redness or open areas to the hand. Physician's orders, dated 02/26/2024, included to place a rolled washcloth or gauze pad in the right hand in the morning, remove it at bedtime, and to notify the Registered Nurse for any redness or open areas to hand. In an Occupational Therapy Discharge Summary, dated 02/23/2024, Occupational Therapist #1 documented that Resident #3 received Occupational Therapy skilled interventions for a right-hand contracture to manually stretch (right hand) and increase palm guard tolerance. Discharge recommendations included to continue wearing a palm guard or rolled washcloth in their right hand to increase tolerance and reduce tone. During observations on 09/27/2024 at 11:21 AM, Resident #3 did not have a rolled washcloth or gauze pad in their right hand and the inside palm was reddened with dry and scaly skin that was peeling. During observations on 9/30/2024 at 9:43 AM and on 10/01/2024 at 10:11 AM and 12:32 PM, Resident #3 did not have a rolled washcloth or gauze pad in their right hand. Resident #3's skin integrity was unable to be observed due to the tightness of the contracture. During an interview on 10/01/2024 at 12:56 PM, Registered Nurse Manager #1 stated that at one time Resident #3 had a palm guard and sometimes they have a rolled washcloth in their palm. During an interview on 10/01/2024 at 1:00 PM, Certified Nursing Assistant #6 stated Resident #3's Kardex included to put a rolled washcloth or gauze pad in their right hand in the morning and off at bedtime. Certified Nursing Assistant #6 stated they did not know Resident #3 required a rolled washcloth only lotion (to the right hand). During an interview on 10/01/2024 at 1:07 PM, Physical Therapist #1 stated that Resident #3 needed the rolled washcloth or gauze pad for their right-hand contracture and if Resident #3 did not have the rolled washcloth or gauze pad in place, the resident could get skin breakdown. Physical Therapist #1 said the hand device would help to maintain their current range of motion and skin integrity of their hand. During an interview on 10/01/2024 at 2:51 PM, the Director of Nursing stated the Certified Nursing Assistants should follow and provide care to the residents using their care cards (Kardex). 10 NYCRR 415.12(e)(2)

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 09/25/2024 to 10/01/2024, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for one (Resident #29) of four residents reviewed. Specifically, the facility did not thoroughly investigate the resident's witnessed fall that resulted in a major injury and a care plan violation. This is evidenced by the following: The facility policy Investigating Resident Injuries, reviewed January 2024, included that all resident injuries are investigated, the director of nursing services or a designee will assess all resident injuries and document findings in the medical record, and descriptions in the medical record must be objective and sufficiently detailed. The facility policy Abuse-Prohibition Protocol, Types of Abuse, Response/Reporting, reviewed January 2024, documented all reports of alleged mistreatment, neglect, or abuse will be responded to immediately and an intervention shall be initiated. Events to be investigated may include, but not limited to, allegation of mistreatment, abuse, or neglect. Resident interviews are conducted to identify issues relating to mistreatment, neglect, or abuse. Investigations shall include, but not limited to re-enactments and written statements from the applicable staff members and residents. Statements must be dated and signed clearly indicating the name of the person giving the statement, their title, must be specific to the investigation, and must be a complete and accurate account of the incident. Resident #29 had diagnoses including Parkinson's disease, respiratory failure, and asthma. The Minimum Data Set Resident Assessment, dated 08/14/2024, included the resident was cognitively intact, has upper (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) impairment on both sides, was dependent for toileting hygiene and transfers, and requires maximum assistance for rolling left and right. Review of the Comprehensive Care Plan and Kardex (used by the Certified Nursing Assistant to direct care) revealed Resident #29 required assistance with self-care and mobility and was at risk for falls related to immobility, fatigue, impaired balance, history of falls, and neurologic disorder. Interventions included, but were not limited to, to provide the resident with two persons assist for transfers, rolling left and right (bed mobility), and toileting hygiene. Review of the document titled '#245 Fall' (identified by the facility as an Incident and Accident form in the electronic medical record), dated 09/11/2024, revealed Resident #29 had a witnessed fall in their room. Injuries observed at the time of incident were bruising to the face and a skin tear on the left elbow. Resident #29's mental status was oriented to place, time, person, and situation. Resident #29 was sent to the hospital and returned with a fracture to the left wrist. The form included that Certified Nursing Assistant #4 was educated on proper positioning when checking for incontinence and the resident's care plan was updated to ensure proper positioning in bed when checking for incontinence. Review of statements/description of the incident, dated 09/11/2024, obtained by the facility and documented in the electronic medical record included the following: 1. In a statement, dated 09/11/2024 obtained from Certified Nursing Assistant #4 by the Director of Nursing during an in-person interview, Certified Nursing Assistant #4 stated they went into the room, Resident #29 was lying on their side, and that they were checking for incontinence when the resident made a sudden move and fell off the opposite side of the bed. Certified Nursing Assistant #4 stated they tried to stop the resident from falling but were unable to. 2. In a statement, dated 09/11/2024, and written in a progress note in Resident #29's electronic medical record, Licensed Practical Nurse #2 stated they were notified by Certified Nursing Assistant #4 that Resident #29 was on the floor. Licensed Practical Nurse #2 entered room and observed the resident on the floor next to the bed face down, they were assisted back into the bed, first aid was administered, and the resident was sent to the emergency department. 3. Under 'resident description' on the electronic form, it included that the resident stated they fell off the bed. There was no further information regarding Resident #29's account of the fall. The Incident/Accident form did not include any information related to any potential care plan violation related to one staff assist for bed mobility. During observations on 09/25/2024 at 1:25 PM, Resident #29 had facial bruising on the corner of their right eye, left side of the neck, and left cheek, and their left wrist was in a cast. During an interview at this time, Resident #29 stated the bruises were from the fall and their left wrist was broken in the fall. When asked about the fall, Resident #29 said they were in bed with their face towards the right side of the bed and Certified Nursing Assistant #4 was trying to change their sheets by themselves. As Certified Nursing Assistant #4 was tucking the sheet up under them, they fell off the bed. During an interview on 09/30/2024 at approximately 12:20 PM, Registered Nurse Manager stated they opened the Accident and Incident report in the electronic health records risk management module and instructed the nurse they needed to document the fall. The Director of Nursing conducted the investigation and spoke to Certified Nursing Assistant #4 and Resident #29. During an interview on 09/30/2024 at 1:08 PM, the Director of Nursing stated the facility recently switched to using the electronic health record module for completing Incident and Accident reports and that there were different questions to answer than the previous forms such as abuse, neglect, or mistreatment, and additional questions to prompt the investigation. The Director of Nursing said that they ruled out abuse during morning report while gathering the Certified Nurse Assistant's statement and did not believe there was a break in the care plan as the Certified Nursing Assistant was not actually providing care while checking the brief. The Director of Nursing stated that if the Certified Nurse Assistant had been making the bed they would consider that providing care. During an interview on 09/30/2024 at 3:07 PM, the Administrator stated they felt the incident was thoroughly investigated since the report contained a resident statement, a nurses' statement, a Certified Nursing Assistant statement, and the provider had been made aware and the Resident #29 had been sent out for further evaluation. The Administrator stated the person who conducted the investigation should have been more specific when asking Certified Nursing Assistant #4 questions regarding checking the resident for incontinence, specifically how they performed that task. The facility was unable to provide any additional information such as the resident's detailed statement, a thorough statement from Certified Nursing Assistant #4 regarding following the care plan, or any conclusion including if abuse, neglect, and/or mistreatment had been ruled out related to Resident #29's fall with major injury. 10 NYCRR 415.4(b)(3)

Based on observations, interviews, and record review conducted during a Recertification Survey and complaint investigation (ACTS Reference number: NY00337359), for one (Resident #53) of two resident's reviewed for pressure ulcers, the facility did not ensure that the resident received the necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. Specifically, Resident #53 did not receive treatment for multiple wounds as prescribed by the Physician. This was evidenced by the following: Resident #53 had diagnoses including multiple stage three (full thickness tissue loss involving damage of the subcutaneous tissue) pressure ulcers (left buttock, right buttock, and sacrum), diabetes, and congestive heart failure. The Minimum Data Set Resident Assessment, dated 06/21/2024, documented that the resident was severely impaired cognitively, was at risk for developing pressure ulcers, and had no pressure ulcers at that time. Physician's orders, dated 09/19/2024, included for sacral wound care, staff were to cleanse the open sites on the buttocks with normal saline, pat dry, and apply Critic-Aid clear cream to all aspects of sacrum and buttocks thoroughly. The orders also included to apply Triad Hydrophilic cream once daily to the open wound sites only and to leave the wound sites open to air to prevent further moisture damage. The September 2024 Treatment Administration Record, dated 09/20/2024, documented that nursing staff signed off the wound care as not completed as ordered on 09/20/2024 to 09/27/2024 due to other-see nurses note and on 09/28/2024-09/30/2024 as on hold by the Physician. Review of interdisciplinary team progress notes, dated 09/20/2024 to 09/30/2024, did not include any information related to why the Triad Hydrophilic cream had not been administered or was on hold. In a wound progress note, dated 09/23/2024, Physician #1 documented to change the orders for the right buttock, left buttock, and sacral area wounds to cleanse the wounds with sterile water, apply xeroform gauze to wound bed, and cover with a border gauze (a wound dressing) once daily and as needed. The facility was unable to provide documentation that this order had ever been placed in their electronic health record or administered to the resident from 09/23/2024 to 09/30/2024. During an observation and interview on 09/27/2024 at 1:08 PM, Registered Nurse #2 stated the facility did not have the ordered Triad Hydrophilic cream and they would need to call the Physician to obtain a one-time order for the wound care. Registered Nurse #2 applied the new one-time order to the wounds using zinc oxide. Registered Nurse #2 stated that they were unable to find any Triad Hydrophilic cream for Resident #53 and was unsure as to why the cream was not available. During an interview on 09/30/2024 at 9:00 AM, Registered Nurse Manager #1 stated that when a resident returns from the hospital, the Physician should be notified, the medications reviewed, and entered in the electronic health system, and the orders sent to pharmacy to be filled. They stated that if there were any issues with the pharmacy not being able to fill prescriptions, then the pharmacy will notify the facility via phone. Registered Nurse Manager #1 stated they were not aware that the Triad Hydrophilic cream had never been filled or that Resident #53 had not been receiving the treatments as ordered. During an interview on 09/30/2024 at 9:44 AM, Pharmacist #1 stated that they do not provide Triad Hydrophilic cream and they have it noted that the facility has it as a stock cream. Pharmacist #1 stated that insurance is not an issue since the resident is all inclusive. They stated that they have not sent any of the Triad Hydrophilic cream to the facility except for the one time courtesy last Friday (09/272024 following the observation of wound care by the surveyor). During an interview on 09/30/2024 at 1:07 PM, Physician #1 revealed that their expectation was that when there are changes in orders or new orders are given that they are carried out in a timely manner. Physician #1 stated that they examined Resident #53's wounds on 09/23/2024 and gave new orders for the wounds. Physician #1 stated that they were just notified that Resident #53 had not been receiving the treatments ordered on 09/23/2024 due an error that the new orders had not been entered into the electronic medical record. During an interview on 09/30/2024 at 12:55 PM, Registered Nurse #3 stated they perform weekly wound rounds with the wound care Physician on all residents that have wounds and they accompany the wound care Physician when they assess the wounds. Registered Nurse #3 stated that they did perform wound care on Resident #53 recently but was unable to recall if Triad Hydrophilic cream was available. They stated that if the resident did not have the ordered wound supplies, then staff should contact the medical provider and get a different order. During an interview on 09/20/2024 at 2:37 PM, the Director of Nursing stated the nurse should contact the provider and inform them that the ordered wound care supplies were not available and request a new order. The Director of Nursing stated that the Triad Hydrophilic cream has not been ordered on a regular basis, is not a stock cream, and must come from the pharmacy. The Director of Nursing stated that when the wound care Physician does their weekly rounds with the nurse, any changes or new orders should be checked with pharmacy and if it is not something that they provide then someone in Administration should be notified. They stated that they were not aware Resident #53 did not have the Triad Hydrophilic cream to complete the ordered wound care. 10 NYCRR 415.12(c)(2)

Based on observations, interviews, and record reviews conducted during the Recertification Survey 09/25/2024 to 10/01/2024, for one (Resident #29) of three residents reviewed, the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standard of practice, and the resident's care plan, goals, and preferences. Specifically, Resident #29 was observed wearing oxygen via nasal cannula (a device that delivers oxygen through a person's nose). There was not a physician's order in place for oxygen use or documentation in the Medication Administration and Treatment Administration Records that reflected the use and care of the oxygen. Additionally, the facility did not develop a comprehensive person-centered care plan related to Resident #29's respiratory needs. This is evidenced by the following: The facility policy Oxygen Administration, reviewed January 2024, documented for staff to verify that there is a physician's order for this procedure and review the residents' care plan to assess for any special needs for the resident. Resident #29 had diagnoses that included respiratory failure, asthma, and obstructive sleep apnea (disorder in which breathing stops and starts repeatedly during sleep). The Minimum Data Set Resident Assessment, dated 08/14/2024, included the resident was cognitively intact, had shortness of breath when lying flat, and was not receiving oxygen therapy. Review of the Resident #29's Comprehensive Care Plan did not include that the resident had a compromised respiratory diagnosis requiring continuous oxygen via nasal cannula, person-centered interventions, or desired outcomes. Review of the current physician's orders did not include the use of oxygen. Review of the Medication Administration and Treatment Administration Records from 08/01/2024 to 08/31/2024 and 09/01/2024 to 09/30/2024 did not include documentation reflecting Resident #29's continuous use of oxygen via nasal cannula. During several observations on 09/25/2024 at 1:37 PM, 09/27/2024 at 11:36 AM, and 09/30/2024 at 12:14 PM, Resident #29 was in their room, wearing a nasal cannula with oxygen set at 2.5 liters per minute administered through an oxygen concentrator. During an interview on 09/30/204 at 12:17 PM, Licensed Practical Nurse #2 stated Resident #29 was on continuous oxygen and last they knew it was at 3 liters. Licensed Practical Nurse #2 reviewed Resident #29's current orders for oxygen administration at this time and stated they could not see any. During an interview on 09/30/2024 at approximately 12:20 PM, the Registered Nurse Manager #1 stated Resident #29 used oxygen continuously via nasal cannula at a rate fluctuating between 2-3 liters, but usually kept at 2 liters, through an oxygen concentrator. Registered Nurse Manager #1 reviewed Resident #29's current orders for oxygen at this time and stated there was no order and there should be. Registered Nurse Manager #1 stated there was nothing in the resident's care plan for oxygen use and there should be along with a supporting diagnosis for the need for the oxygen. During an interview on 10/01/2024 at 2:51 PM, when asked if oxygen should be administered without a physician's order, the Director of Nursing stated it should not and that there should be a person-centered comprehensive care plan for the oxygen, including the respiratory diagnoses (associated with the need for oxygen). 10 NYCRR 415.12(k)(6)

Based on observations and interview during the Recertification Survey from 09/25/2024 to 10/01/2024, for two (second and third floors) of three resident-use floors, the facility did not ensure essential equipment was properly maintained in operating condition. Specifically, handwash sinks in soiled utility rooms did not function and were not operational when tested . The findings are: Durinb observations in the presence of the Director of Maintenance on 09/25/2024 at 10:40 AM, the handwashing sink in the 3rd floor soiled utility room was not functional and did not discharge water when the hot- and cold-water handles were turned. During an interview at this time, the Director of Maintenance stated the faucet had not been operational for some time, at least a year. During observations in the presence of the Director of Maintenance on 09/25/2024 at 10:57 AM, the handwashing sink in the 2nd floor soiled utility room was not functional and did not discharge water when the hot and cold-water handles were turned. 10NYCRR: 415.29, 415.29(b), 415.29(d)

Based on observations, interviews and record reviews conducted during the Recertification Survey 09/25/2024 to 10/01/2024, for one (Resident #29) of four residents reviewed, the facility did not ensure that all alleged violations involving potential abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health in accordance with state law. Specifically, the facility did not report an incident to the state agency regarding a care plan violation where Resident #29 fell out of bed while getting care by a staff member sustaining a major injury. This is evidenced by the following: The facility policy Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating, reviewed January 2024, documented all reports of resident abuse and neglect are reported to local, state, and federal agencies and thoroughly investigated by facility management. Resident #29 had diagnoses including Parkinson's disease, respiratory failure, and asthma. The Minimum Data Set Resident Assessment, dated 08/14/2024, included the resident was cognitively intact, has upper (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) impairment on both sides, was dependent for toileting hygiene and transfers, and required maximal assistance for rolling left and right. Review of the Comprehensive Care Plan and Kardex (used by the Certified Nursing Assistant to direct care) revealed Resident #29 required assistance with self-care and mobility and was at risk for falls related to immobility, fatigue, and impaired balance, a history of falls, and a neurologic disorder. Interventions included, but were not limited to, to provide the resident with two persons assist for rolling left and right (bed mobility), transfers, and toileting hygiene. Review of the document titled '#245 Fall' (identified by the facility as an Incident and Accident form), dated 09/11/2024 and signed by Registered Nurse Manager #1, revealed Resident #29 had a witnessed fall in their room. Injuries observed at the time of incident were bruising to the face and a skin tear on the left elbow. Resident #29's mental status was oriented to place, time, person, and situation, and Resident #29 was sent to the hospital and returned with a fracture of the left wrist. The form included that Certified Nursing Assistant #4 was educated on proper positioning when checking for incontinence and the resident's care plan was updated to ensure proper positioning in bed when checking for incontinence. Review of statements/description, dated 09/11/2024, obtained by the facility included the following: 1. In a statement, dated 09/11/2024, Licensed Practical Nurse #2 stated they were notified by Certified Nursing Assistant #4 that Resident #29 was on the floor. Licensed Practical Nurse #2 entered room and observed the resident on the floor next to the bed face down, was assisted back into the bed, first aid was administered to open areas, and the resident was sent to the emergency department. Licensed Practical Nurse #2's statement was a written progress note taken from the electronic health record. 2. In a statement, dated 09/11/2024, obtained from Certified Nursing Assistant #4 by the Director of Nursing in an in-person interview, Certified Nursing Assistant #4 stated they went into the room, Resident #29 was lying on their side, Certified Nursing Assistant #4 was checking for incontinence when the resident made a sudden move and fell off the opposite side of the bed. Certified Nursing Assistant #4 stated they tried to stop the resident from falling but were unable to. 3. Under resident description, the form included that the resident stated they fell off the bed. During observations on 09/25/2024 at 1:25 PM, Resident #29 had facial bruising on the corner of their right eye, left side of the neck, and left cheek, and their left wrist was in a cast. Resident #29 stated the bruises were from the fall and their left wrist was broken in the fall. When asked about the fall at this time, Resident #29 said they were in bed with their face towards the right side of the bed and Certified Nursing Assistant #4 was trying to change their sheets by themselves. As Certified Nursing Assistant #4 was tucking the sheet up under them, they fell off the bed. During an interview on 09/30/2024 at 1:08 PM, the Director of Nursing stated a fall with major injury and a break in care plan would be considered a state reportable incident to the New York State Department of Health. The Director of Nursing stated abuse and neglect were ruled out after gathering Certified Nursing Assistant #4's statement. The Director of Nursing said that Certified Nursing Assistant #4 was not actually providing care at the time of Resident #29's fall and that abuse, neglect, or mistreatment did not occur. The Director of Nursing said checking for incontinence was not providing care as they were only moving the brief not the person, and that was why they did not report it to the Department of Health. The Director of Nursing stated if Certified Nursing Assistant #4 had been making the bed, then they would consider that providing care to the resident. During an interview on 09/30/2024 at 1:36 PM, Certified Nursing Assistant #5 (Resident #29's primary Certified Nursing Assistant for this day) stated Resident #29 was a two assist and they wait for another staff member before going into the room even if it was to check the resident for incontinence care. Certified Nursing Assistant #5 stated Resident #29 stays in bed during linen changes and required two staff assistance while checking for incontinence. Additionally, Certified Nursing Assistant #5 stated Resident #29 was factual in their stories and they would believe them. During an interview on 09/30/2024 at 3:07 PM, the Administrator stated to their understanding Certified Nursing Assistant #4 was not providing care to Resident #29 because they do not consider checking for incontinence as providing care. The Administrator said they were not aware that Resident #29 had a different recollection of the fall in which Resident #29 stated their linen was being changed on their bed or that the resident required two staff assistance (with bed mobility). Certified Nursing Assistant #4 was not available for interview. The facility was unable to provide any additional information such as Resident #29's detailed statement or if abuse, neglect, and mistreatment had been ruled out related to Resident #29's fall with major injury. 10 NYCRR 415.4

Based on observations, record review and interviews conducted during the Abbreviated Survey (# NY00310033, NY00310062, NY00310414, NY00309529, NY00309103), completed on 2/16/23 it was determined that the facility did not ensure sufficient staffing to provide nursing services to all residents to attain or maintain the highest practical physical, mental and psychosocial well-being. Specifically, there was insufficient nursing staff on two of two resident units, to ensure residents remained free of significant medication errors and received all activities of daily living. The findings include the following: For additional information see Centers for Medicare/Medicaid Services (CMS) Form 2567: F760-Residents are Free of Significant Medication Errors and F727-lack of Registered Nurse coverage 8 hours/7 days/week that were also cited during this survey. The facility Staffing Policy, dated January 2022, documented the facility budgeted staffing plan included for the two 40-bed units each unit would have for day shift- one Licensed Practical Nurse (LPN) and three Certified Nursing Assistants (CNAs), Evening shift- one LPN and three CNAs, and night shift- one LPN and 2 CNAs. The Facility Emergency Staffing Plan did not include emergency nursing staffing policies and procedures. During an observation on 2/6/23 at 6:00 a.m., there was one LPN and three CNAs for the whole facility (approximately 73 residents with 35-40 on each unit). During observations on 2/11/23 at 6:00 a.m. there was one LPN and three CNAs for the whole facility. The staffing sheets for the past 2 weeks from 1/5/23 through 2/6/23 for the facility with approximately 73 residents included, but not limited, to the following: 1/5/23 one LPN 7:00 a.m.- 5:00 p.m. 1/21/23 one LPN from 4:00 p.m. to 12:00 a.m. 1/22/23 no LPNs 12:00 a.m.-7:00 a.m. 1/29/23 one LPN 4:00 p.m.-7:00 a.m. 1/31/23 one LPN 6:00 p.m.-7:00a.m. During an interview on 2/6/23 at 9:30 a.m. Resident #1 stated they have not been getting their medications consistently because there are often no nurses working on the evening shift and that it is happening more and more frequently. Resident #1 stated their neighbor fell out of bed and had to lay there for a while because there was no nurse to come help and they went up to the 3rd floor unit to alert staff that the resident fallen out of bed. During an interview on 2/6/23 at 9:50 a.m. Resident #3 stated they have not been getting their medications for heart failure or their blood thinners or their eye drops that were prescribed after cataract surgery regularly because there are never enough nurses on staff. Resident #3 stated they are worried that not getting their eye drops are going to mess up their eye. During an interview on 2/6/23 at 10:00 a.m., Resident #5 stated they haven't been getting their heart medications and are concerned there will be no one to call if something happens. Resident #5 stated they have told the Director of Nursing (DON) and the Administrator that there were no nurses at night, but nothing has been done. During an interview on 2/7/23 at 10:30 a.m., the LPN/Nurse Manager (NM) stated they typically have 2 nurses to give out medications but the day prior (2/6/23) they did not, and they could not get the medications passed in the allowable time frame despite asking the DON and the scheduler for help. The LPN/NM stated the Nurse Practitioner came in around 3:30 p.m. to approve all the late medication administrations, especially the insulins and heart medications. The LPN/NM stated their nursing staffing is horrible and that they are not informed when staff calls off and no nurses on the unit until the next morning when they come in and see the report that there were no medications given or when residents come to the desk to say that they didn't get their medications the night before. During an interview on 2/7/23 at 11:47 a.m., LPN #1 stated when they came on shift yesterday at 2:00 p.m. they were the only nurse as the previous nurse had to leave early. LPN #1 stated many residents told them that they had gotten their medications. During an interview on 2/7/23 at 2:50 p.m. the DON stated they are responsible for staffing and that they did receive phone calls on 1/20/23 and 2/5/23 about lack of coverage with only one nurse in the facility and they reached out to the scheduler and other nurses to fill in and finally did find someone later in the day. During an interview on 2/11/23 at 6:06 a.m. LPN #2 stated stated they were the only nurse in the building (approximately 75 residents) as the other nurse was sick and they did not have keys to the 3rd floor medications. During an interview on 2/11/23 at 6:25 a.m., Resident # 7 stated they have been in pain all night and did not receive any pain medications due to only one nurse in the facility and they did not have keys to their unit's medications. Resident #8 (Resident #7's roommate) stated at this time they had been incontinent at 11:00 p.m. and did not get changed until 5:00 a.m. During an interview on 2/6/23 at 10:03 a.m. and again on 2/7/23 at 11:25 a.m., the Administrator stated that if fully staffed there should be 2 LPNs per unit but at a minimum staffing on the day and evening shifts should be one nurse with three CNAs for each 40-bed unit and one nurse with two CNAs on the night shift. The Administrator stated they should be notified if the facility is at minimum staffing, and they were notified on 1/21/23, 2/4/23 and 2/5/23 because of lack of nurses. The Administrator stated that their recruitment procedures were on-going, and that they are working with QAPI to address recruitment, current staffing and need for accountability for staff who do not show up. The Administrator stated they were aware of nurses working 20 hours and are aware of residents not receiving their medications due to lack of nurse coverage. 415.13(a)(1)(i-iii)

Based on record review and interviews conducted during the Abbreviated Survey (# NY00310033, NY00310062, NY00310414, NY00309529, NY00309103), it was determined for 6 (Residents #1, 2, 3, 4, 5, 6) of 6 residents reviewed for medication administration, the facility did not ensure residents were free of significant medication errors. Specifically, the residents were not administered their medications consistently as ordered. This is evidenced by but not limited to the following: The facility policy Administering Medications dated January 2023 documented medications must be administered in accordance with physician orders, including any required time frame. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1.Resident # 1 was admitted to the facility on [DATE] with diagnosis that included pain in the right hip, heart failure, thrombocytopenia (blood disorder), anemia, and acute embolism (blood clot) of the left lower extremity. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was cognitively intact. Review of physician (MD) orders dated 5/4/22 included: a. Aldactone 12.5 milligrams (mg) daily in the morning for heart failure. b. Atorvastatin Calcium 80 mg daily in the evening for heart failure. c. Carvedilol 3.125 mg twice daily for heart failure. d. Entresto 24-26 mg give .5 tablet twice daily for heart failure. e. Lasix 40 mg in the morning for heart failure. Review of the Medication Administration Audit Report for missed documentation for 1/15/23 through 2/6/23 revealed the following: a. Aldactone was not signed off as administered on 2 of 23 opportunities. b. Atorvastatin Calcium was not signed off as administered on 7 of 23 opportunities. c. Carvedilol was not signed off as administered on 5 of 46 opportunities. d. Entresto was not signed off as administered on 5 of 46 opportunities. e. Lasix was not signed off as administered on 2 of 23 opportunities. In an interview on 2/6/23 at 9:30 a.m., Resident #1 stated they had not been getting their medications consistently because there are no nurses working the evening shift and that it has happened more frequently lately. Resident #1 stated they were scared that something could happen at night and there would not be anyone there to help. 2.Resident #3 was admitted to the facility on [DATE] with diagnosis that include lupus (an inflammatory disease of the immune system), schizophrenia, chronic obstructive pulmonary disease (COPD), diabetes and recent cataract surgery. The MDS assessment dated [DATE] documented the resident was cognitively intact. Review of MD orders dated 1/19/23 to 2/9/23 included: a. Ketorolac Tromethamine Ophthalmic Solution 5% 1 drop in right eye four times a day for right eye surgery. b. Prednisolone Acetate Ophthalmic suspension 1% 1 drop in right eye four times a day for right eye surgery. c. Ofloxacin ophthalmic solution .3% 1 drop in right eye four times a day for right eye surgery. d. Novolog (insulin) injection 24 unit subcutaneously before meals for diabetes. Hold and notify the MD for a blood glucose less than 70 or greater than 400. e. Levemir (insulin) inject 60 unit subcutaneously at bedtime for diabetes. f. Ativan tablet .5 mg at bedtime for anxiety. g. Eliquis tablet 5 mg twice daily for blood clot prevention. h. Olanzapine 10 mg at bedtime for schizophrenia. i. Gabapentin 200 mg twice daily for right hip pain. Review of the Medication Administration Audit Report for missed documentation for 1/15/23 through 2/6/23 revealed the following: a. Ketorolac Tromethamine Ophthalmic Solution was not signed off as administered on 12 of 92 opportunities. b. Prednisolone Acetate Ophthalmic suspension was not signed off as administered on 16 of 92 opportunities. c. Ofloxacin ophthalmic eye drops were not signed off as administered on 16 of 92 opportunities. d. Novolog insulin was not signed off as administered on 14 f 69 opportunities. e. Levemir insulin was not signed off as administered on 4 times of 23 opportunities. f. Ativan was not signed off as administered on 4 of 23 opportunities. g. Eliquis was not signed off as administered on 4 of 46 opportunities. h. Olanzapine was not signed off as administered 2 times 23 opportunities. i. Gabapentin was not off signed off as administered on 2 of 46 opportunities. In an interview on 2/6/23 at 9:50 a.m., Resident #3 stated they have not been regularly getting their eye drops after their cataract surgery or many of their other medications. Resident #3 stated there are never enough nurses on staff and that they are worried that lack of medication is going to 'mess up their eye' or cause problems with their heart. 3. Resident #6 was admitted to the facility on [DATE] with diagnosis that include congestive heart failure (CHF), cardiogenic shock, cardiomyopathy (disease of the heart muscle), diabetes, asthma, and depression. The MDS assessment dated [DATE] documented that the resident was cognitively intact. Resident #6 was discharged to the hospital on 2/8/23 where they remained at the time of the survey. Review of MD orders dated 1/19/23 to 2/9/223 included: a. Torsemide (water pill) 100 mg daily for fluid retention. b. Amiodarone (heart medication) 200 mg daily for cardiomyopathy c. Metoprolol ER 75 mg daily for high blood pressure. Hold if pulse is less than 60, or systolic blood pressure is less than 100 and notify the MD d. Atorvastatin calcium 80 mg daily for CHF heart failure e. Apixaban Tablet 2.5 mg twice daily for anticoagulation (to prevent blood clots) f. Trazodone (antidepressant) 25 mg at bedtime for insomnia/agitation g. Symbicort Aerosol 160-4.5 mcg/act-2 puffs inhalation twice daily for shortness of breath or wheezing. Review of the Medication Administration Audit Report for missed documentation for 1/15/23 through 2/6/23 revealed following: a. Torsemide, amiodarone, metoprolol ER, trazodone and atorvastatin were not signed off as administered on 2 of 23 opportunities. b. Apixaban was not signed off as administered on 2 of 46 opportunities. c. Symbicort inhaler was not signed off as administered on 4 of 46 opportunities. In an interview on 2/7/23 at 10:30 a.m., the Licensed Practical Nurse (LPN)/Nurse Manager (NM) stated are only responsible to pass medications for the medication cart that they count out (count medications and receive the keys from previous shift) at the beginning of the shift (half the unit). The LPN/NM stated medications had not been passed to the whole unit on 2/6/23 because they only had one nurse to pass the medications. The LPN/NM stated they did inform the Director of Nursing (DON) via a text (verified sent on 2/6/23 at 9:04 a.m.) that there were not enough nurses to pass medications for the whole floor and informed the nurse scheduler that they only had one nurse on the floor (for approximately 35 residents). In an interview on 2/7/23 at 11:02 a.m., Registered Nurse (RN)/Nurse Educator they were told that the facility was short staffed but that they had not been instructed to pass medications. In an interview on 2/7/23 at 11:25 a.m., the Administrator stated they were aware that they were not enough nurses and that some medications had been missed due to lack of nursing staff. The Administrator stated they were not aware of how many medications had been missed and that they had not informed the medical director. In an interview on 2/7/23 at 11:47 a.m., Licensed Practical Nurse #1 stated that when they came to work on 2/6/23, most residents on one side of the unit informed them that they had not received their medications the evening before. LPN #1 stated if they are the only nurse on the unit (approximately 35 residents) they would administer medications for the whole unit and prioritize the medications and blood glucoses for both sides. LPN #1 stated that they had been told by higher than them (supervisors) that if they do not count for both sides of the unit, they are not responsible for both sides. In an interview on 2/7/23 at 1:00 p.m. RN/Regional Clinical Director stated they should be notified if there were staffing issues such as no nurse coverage in the building to pass medications. The RN/Regional Clinical Director stated they were aware of missed medications and that they made the DON aware that they needed to notify the physician, write up medication errors and ensure no harm had come to any residents. The RN/Regional Clinical Director stated they had not informed the nurses that they were responsible for only half of the unit regardless of who counted medications from the previous shift. In an interview on 2/7/23 at 2:50 p.m., the DON stated they had received the missed medication report from the RN/Regional Clinical Director but had not reviewed yet. The DON stated they pull that report daily and review it in their morning meeting where they ask staff to investigate whether the medications were not administered or just not signed as administered but had not followed up on the issue. The DON stated they were unaware of why a nurse would only pass medications on half of the unit. In an interview on 2/9/23 at 12:16 p.m. the Medical Director stated their expectation was for staff to notify the provider (medical) group if medications were not given as prescribed as is their protocol and to provide the medications as soon as staff are available. The Medical Director stated that they were made aware of the missed medications by the RN/Regional Clinical Director due to lack of staff and stated it has been an ongoing issue for the last several weeks. The Medical Director stated they was a policy that should be followed on missed medications. Regarding Resident #6's Medication Administration Audit Report recent discharge to the hospital, the Medical Director stated they had not been aware of the resident missed medications and that it could have possibly contributed to their discharge to the hospital. 10NYCRR 415.12(m)(2)

Based on record review and interviews conducted during the Abbreviated Survey (#NY00309103, NY00310033, NY00310062, NY00310414, NY00309529) completed on 2/16/23 the facility did not use the services of a Registered Nurse (RN) for at least 8 hours/7 days/week. Specifically, two of two resident care units reviewed for staffing revealed an RN was not present and available for 8 hours/7 days/week on nine days between 1/15/23 through 2/13/23. The finding is: Review of the facility nurse Daily Staffing forms dated 1/15/23 through 2/13/23 revealed no documented evidence that an RN was present and available for eight consecutive hours on 9 of the 30 days reviewed. During an interview on 2/6/23 at 9:36 a.m., the Director of Nursing (DON) stated there should be RN coverage eight hours a day, seven days a week. The DON stated they work at least eight hours per day, Monday through Friday and occasionally on the weekends if there is no other RN coverage. At 4:45 p.m., the DON stated they were not aware that they were supposed to ensure RN coverage and thought the Administrator was taking care of it. During an interview on 2/6/23 at 10:03 a.m., the Administrator stated it is the staffing coordinator's responsibility to ensure there is proper RN coverage at a minimum of eight hours a day, weekends included. The Administrator stated they were aware of the days the facility had no RN coverage. Review of phone call logs from the Administrator to the DON on 1/21/23 revealed the Administrator had attempted to reach the DON nine times with no return calls. During an interview on 2/7/23 at 12:30 p.m. the Staffing Coordinator stated it is their responsibility to staff the facility to the best of their ability. The Staffing Coordinator stated their work hours are 8:00 a.m. to 4:30 p.m. and if there are staffing issues after they leave the nurse on duty is to call the DON and the Administrator. The Staffing Coordinator stated they are not always made aware of staffing issues in the evening and that only themselves, the DON and the Administrator are allowed to use the online system to attain agency staff. In an interview on 2/6/23 the RN/Regional Clinical Director stated it is their expectation that staff notify them if they have no RN coverage and that they had not been aware of no RN in the facility on several of those days and on one of those days (2/5/23) they were not informed that the nurse did not show. 415.13 (b)(1)

Based on observations and interviews conducted during the Recertification Survey completed on 12/5/22, it was determined that for three (first, second, and third floors) of three resident use floors, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically: an exhaust ventilation system was not working, walls were in disrepair or dirty, floors were stained and dirty, resident handwash sinks were stained, privacy curtains were in disrepair or dirty, resident furniture was in disrepair, medical supplies were stored on the floor, a toilet seat was in disrepair, dead insects were present in a light fixture, a resident bed was not functioning properly, and kitchen equipment was not clean. The findings are: On 12/1/22 at 11:46 a.m. the administrator provided the surveyor with the facility policy 'Physical Homelike Environment, effective 1/2022', which included that it is the policy of the facility to have defined procedures to provide a safe, clean, comfortable, and homelike environment for their residents. The Maintenance/Housekeeping team will ensure: a. Privacy curtains will be changed between room changes, discharges, and new admissions. b. All resident area floors will be cleaned in corner and next to wall on an as needed basis. c. All scrape marks and holes in walls will be repaired on a as needed basis; and d. All resident furniture is in good repair. 1. Observations and interviews on 11/28/22 from 8:40 a.m. to 2:16 p.m. included the following: a. Several floor tiles near the foot of the B-bed in resident room [ROOM NUMBER] had brown circular stains. b. The privacy curtain in resident room [ROOM NUMBER] was coming off the ceiling tract and the middle drawer of the dresser was missing the cover. During an interview at this time, Resident #48 stated that they should not have to live with furniture falling apart. c. There were black stains and chipping paint on the wall behind the A-bed in resident room [ROOM NUMBER]. Additionally, the middle drawer of the dresser was missing the front cover. During an interview at this time, Resident #45 stated it's disgusting and they don't like it. d. The handwash sink in the soiled utility room across from room [ROOM NUMBER] did not work. During an interview at this time, a licensed Practical Nurse (LPN) stated that they were unsure how anyone does hand hygiene in the soiled utility room. e.There were 3 green chairs in the 2nd floor dining room that were wobbly when touched (not sturdy). f. In the 2nd floor clean utility room there were Jevity nutrition drinks and an open box of nasal cannulas stored on the floor. g. In the 1st floor clean linen room there were 3 stacks of briefs stored on the floor. h. The bed controls for the A-bed in resident room [ROOM NUMBER] did not work properly. When the button for 'head up' was pressed the foot of the bed raised, and when the 'foot up' button was pressed nothing happened. When interviewed at this time, Resident #63 stated that it has been like this for weeks and no one has fixed it. Resident #63 stated that they told the CNA's who said they told maintenance. 2. On 11/29/22 at 2:45 p.m. it was observed that wall next to the bed in resident room [ROOM NUMBER] was damaged and there were brown stains on the floor near the foot of the bed. 3. Observations and interviews on 11/30/22 from 8:03 a.m. to 11:43 a.m. included the following: a. The toilet seat in the women's lobby restroom had 3 sections of approximately one- inch by 1/2-inch sections peeling off. b. The sinks in resident rooms [ROOM NUMBERS] had brown stains. c. The ceiling light fixture in the shared bathroom between resident rooms #208 and #206 had dozens of dead insects within. Additionally in this room were several holes in the wall. During an interview at this time, Resident #10 stated that the holes were from a toilet paper holder that fell off the wall approximately 3-4 months ago. Resident #10 also stated that they told staff about it but nothing has been done and it was inconvenient to reach around to the back of the toilet so they keep the toilet paper on their wheelchair. d.The privacy curtain in resident room [ROOM NUMBER] had two brown stains that were approximately 12-inches long by 1-inch wide, with multiple other smaller brown stains. 4. During an interview on 12/1/22 at 8:13 a.m., a housekeeper stated that the black circles on the floors in resident rooms are from fluids that come from the resident beds and they can only get the stains out if they strip the floors. 5. During an interview on 12/1/22 at 8:32 a.m. the Corporate Engineering Coordinator (CEC) stated that they looked at the exhaust ventilation on the roof and discovered two or three of the 7 roof exhausts were not working. 6. On 12/1/22 from 8:53 a.m. to 8:59 a.m. it was observed that the exhaust ventilation was not working (drawing air out) at the following locations: shared bathroom between resident rooms #309 and #307, shared bathroom between resident rooms #206 and #208, the bathing suite across from resident room [ROOM NUMBER], the bathing suite across from resident room [ROOM NUMBER], the 3rd floor dirty utility room, the 2nd floor dirty utility room across from resident room [ROOM NUMBER], and the 1st floor women's restroom. When a piece of paper was placed against the exhaust grates in each of the aforementioned rooms, there was insufficient air draw to keep the paper in place. 7. The undated facility policy, 'Sanitation Procedures', included equipment would be cleaned and sanitized as often as necessary. Observations during a follow-up visit to the main kitchen on 12/1/22 from 12:15 p.m. to 1:15 p.m. included the following: a. The bottom of the ice machine and sides were covered in dried white and brown drips. b. The commercial floor mixer was covered with a black bag and had a large, dried, multicolored food piece in bottom. The cook stated they did not know what it was. c. The oven, grill top, exposed piping and adjacent side of this equipment was covered in thick, dark brown residue. d. A stainless-steel shelving unit holding a plastic tub of onions and steamer machine was covered with a thick layer of tan and white dried debris and brown dust. During an interview on 12/1/22 at 1:00 p.m., the Director of Food Service (DFS) stated that there was a weekly equipment cleaning schedule and they try to stick to it. The DFS stated that the company who cleans the kitchen hoods, offered to clean the exposed piping, however because there was extra charge, the facility has declined thus far. The DFS also stated that they stored the onions in the plastic tub because the shelving was dirty. 10NYCRR: 415.29, 415.29(b), 415.29(d), 415.29(h)(1)(2), 415.29(i)(1), 415.29 (j)(1), 10NYCRR: Subpart 14-1.110(b)(c)(d)

Based on observations and interviews conducted during the Standard Recertification Survey completed on 12/1/22 and complaint investigation (#NY00287526), it was determined that for two (second and third floors) of two resident sleeping floors the facility did not properly maintain the resident nurse call system. Specifically, elements of the nurse call system were not functioning. The findings are: 1. Observations and interviews on 11/28/22 from 8:40 a.m. to 2:10 p.m. included the following: a) The nurse call system including wall mounted stations in resident rooms marked as 'Executone' and a corresponding console with lights and room numbers at the nurse stations. b) Two nurse call stations at the bed sides in resident room [ROOM NUMBER] did not illuminate above the door or at the nurse station when pressed. During an interview at this time, resident #25 stated that they were given a tap bell about 5-6 weeks ago and doesn't like it because staff do not come. c) The nurse call station in resident room [ROOM NUMBER] did not illuminate above the door or at the nurse station when pressed. d) the nurse call station behind the A-bed in resident room [ROOM NUMBER] was marked as 'bad station' in marker, and the call light did not illuminate above the door when pressed. During an interview at this time, a Licensed Practical Nurse stated that the call bell in room [ROOM NUMBER] has been broken for a while. e) The nurse call station for the B-bed in resident room [ROOM NUMBER] did not illuminate above the door or at the nurse station when pressed. 2. Observations and interviews on 11/29/22 from 2:42 p.m. to 3:06 p.m. included the following: a) The nurse call station in resident room [ROOM NUMBER] did not illuminate above the door when pressed. During an interview at this time a Certified Nursing Assistant (CNA #1) stated that they know some call bells are not working on both floors and they put it in the maintenance book. b) The nurse call station in resident room [ROOM NUMBER] did not activate at the console at the 3rd floor nurse station when pressed. c) The nurse call station in resident room [ROOM NUMBER] (window bed) did not activate the light above the door or at the nurse station when pressed. d) The nurse call station in resident room [ROOM NUMBER] (door side bed) did not activate the light above the door or at the nurse station when pressed. e) The nurse call station in resident room [ROOM NUMBER] did not activate the light above the door. 3. During an interview on 11/30/22 at 9:44 a.m. CNA #2 stated that they know a lot of the call bells are not working and it has been reported to maintenance, and some have been that way for about a year. 4. During and interview on 11/30/22 at 1:10 p.m. the Corporate Engineering Coordinator (CEC) stated that they can't find anything on the nurse call system including maintenance or repairs. 10NYCRR: 415.29, 415.29(b), 415.29(j)(1)

Based on observations, record review, and interview conducted during the Standard Recertification Survey completed on 12/1/22, it was determined that for one (Elevator 1) of two elevators, and two of three laundry dryers the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, an elevator serving resident sleeping floors and two resident laundry dryers were out of service, and repairs had not been made. The findings are: 1. On 11/28/22 at 8:30 a.m., it was observed that the right elevator in the lobby was marked with a sign that indicated out of order. During an interview on 11/28/22 at 10:25 a.m. the Director of Maintenance stated that about 2 weeks ago the elevator service company was called in and they took the whole motherboard to try and swap out, but they were waiting on a transistor for the elevator which is on back order. 2. On 11/28/22 at 2:18 p.m. it was observed that there were 3 dryers in the first- floor laundry room. Additionally, the 'Electrolux and 'Wasomat' dryers were observed to be out of order. When interviewed at this time, a member of the housekeeping staff stated that the dryers have not been working for about 4-5 months. 3. On 11/30/22 at 11:10 a.m. the Corporate Engineering Coordinator (CEC) provided the surveyor with email correspondence regarding elevator repairs. The email from the vendor dated 8/3/22 included that they were waiting on a new motor. During an interview at this time the CEC stated that was all they had. 4. Record review on 11/30/22 at 12:47 p.m. revealed the elevator recall testing log included that elevator one has been 'out of order' from July 2022 through present date. 10NYCRR: 415.29, 415.29(b), 415.29(j)(1)

Based on record reviews and interviews conducted during the Recertification survey, completed 12/5/22, it was determined that for two of (Resident #5 and #28) of 18 residents reviewed, the facility did not ensure that each resident was screened for a mental illness (MI) or intellectual disability (ID) prior to admission to the facility and that individuals identified with MI or ID were evaluated and received care and services in the most integrated setting to meet their needs. Specifically, for Resident #28, there was no evidence that a Pre-Admission Screening and Resident Review (PASARR) was completed and for Resident #5, the PASARR was incomplete. Both resident had been admitted to the facility with a significant MI diagnosis. This is evidenced by the following: 1. Resident #28 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses of schizophrenia and anxiety. The Minimum Data Set (MDS) Assessment, dated 10/1/22, documented that Resident #28 rarely or never understood others, had short-term and long-term memory problems, and received antipsychotic medications on a routine basis. The facility could not provide documented evidence that a Preadmission Screening and Resident Review (PASARR) was performed for Resident #28 prior to or on admission to the facility. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia and major depression. The MDS Assessment, dated 9/17/22, documented that the resident was cognitively intact. Review of the Resident's Electronic Medical Record and their paper chart included an incomplete PASARR that was missing the information related to the resident's MI and potential need for further screening and possible need for services related to their MI. During an interview on 12/1/22 at 9:23 a.m., the Director of Admission stated that they were new to the facility but were aware that a PASARR was a required document that should be received prior to admission of the resident. During an interview on 12/2/22 1:20 p.m., the Director of Social Work (DSW) stated they did not currently play a role in the PASARR but had discovered they should be part of the process. The DSW stated they were new to the facility and still training. 10NYCRR 415.11(e) 45355

Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigations (#NY00291558 and #NY00291712), completed on 12/5/22, it was determined that for two (Resident #8 and Resident #26) of three residents reviewed for pressure ulcers, the facility did not ensure the services provided or arranged by the facility as outlined in the Comprehensive Care Plan (CCP) met professional standards of quality. Specifically, there was incomplete documentation that the residents wound care treatments were administered as ordered by the medical team. This is evidenced by the following: 1. Resident #8 had diagnoses that included paraplegia, osteomyelitis (infection in the bones), and mild protein calorie malnutrition. The Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #8 was cognitively intact, had skin and ulcer/injury treatments, application of nonsurgical dressings, ointments and/or medications, and was at risk for developing pressure ulcers. Review of the current CCP revealed that Resident #8 had alteration in skin integrity from a non-healing abscesses of the left ischium (hip/buttock area), impaired mobility, and paraplegia. Interventions included weekly wound assessments, monitoring of daily dressings, and reporting any changes in the skin to the provider. The CCP also included that Resident #8 bathed independently. Review of active physician orders for October 2022 and November 2022 included multiple order changes to Resident #8 upper and lower buttock/hip abscesses, all to be changed daily and as needed. Review of the Treatment Administration Record for October 2022 and November 2022 revealed for the two wounds: no documentation the wound treatments to the lower buttocks abscess were completed on 12 of 61 opportunities and no documentation the wound treatments to the upper buttocks abscess were completed on 10 of 61 opportunities. During an observation on 11/29/22 at 9:00 a.m., and 9:15 a.m., Resident #8 was lying in bed on their left side with both wounds being open to air. Resident #8 stated that staff did not change their buttock dressings yesterday and motioned to multiple dressing supplies on the bedside tray table (despite the wound treatments being signed off as completed). Resident #8 stated that they shower daily and that the dressing changes are usually done after their shower. During an interview on 11/29/22 at 1:24 p.m., Licensed Practical Nurse (LPN) #1 stated that they were familiar with Resident #8, and that the resident had two wounds. LPN #1 stated Resident #8 showered daily on day shift, would remove the dressings and would tell the staff when he removed it. LPN #1 stated that Resident #8 did not get their dressings changed yesterday because the resident had said they were not ready so they reported this to the next shift. 2. Resident #26 had diagnoses including a stroke and sepsis (serious infection of the blood stream). The MDS assessment dated [DATE], documented that Resident #26 was moderately impaired cognitively, required extensive assistance with all activities of daily living, and had a stage three (full thickness tissue loss involving damage to subcutaneous tissue) pressure ulcer and two arterial and venous ulcers. Review of the resident's CCP, dated 9/14/22, revealed Resident #26 had impaired skin integrity with interventions that included to monitor and document skin integrity, and apply treatments as ordered by provider. Review of current physician orders included, but not limited to dressing changes to the left hip once daily and to a left ankle wound twice daily. Review of the October 2022 TAR revealed no documentation that the prescribed wound treatments for the left hip and a left ankle ulcers were completed on 18 of 93 opportunities. During an interview on 12/2/22 at 2:09 p.m., the Director of Nursing (DON) and the Corporate Clinical Registered Nurse (CCRN), the CCRN stated that no documentation on the TAR indicated that the treatment had not been signed for or had not been done. The CCRN stated that all medications and treatments should be administered and documented. If a treatment cannot be completed, then the provider (medical team) should be notified, it should be documented on the 24-hour report and the interdisciplinary care team notified during the daily meetings. 10 NYCRR 415.11(c)(3)(i)

Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY00291558, #NY00297274, #NY00287526), completed on 12/5/22, it was determined that for one (Resident #53) of eleven residents reviewed the facility did not ensure that Activities of Daily Living (ADLs) care was provided for dependent residents. Specifically, the resident was not provided incontinence care in a timely manner. Resident #53 had diagnoses including a stroke, chronic pulmonary obstructive disease (COPD) and anxiety. The Minimum Data Set assessment dated [DATE], documented that the resident was moderately impaired cognitively, was always incontinent of bladder (urine) and bowel (stool) and required extensive assistance with personal hygiene. Review of the current Comprehensive Care Plan (CCP) revealed that Resident #53 required assistance with ADLs. Interventions included encouragement of the resident to use the call bell for assistance, extensive assist of two staff members for personal hygiene, and total dependence of two staff members for toileting. The CCP documented that Resident #53 was at risk for pressure ulcer development related to incontinence. Interventions included minimizing extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing and sheets as needed. The CCP documented that Resident #53 did not want to be woken up between 11:30 p.m. and breakfast for care and would use the call bell if the resident needed assistance. Observations and interviews on 11/30/22 included the following: a. At 10:13 a.m., Resident #53's call bell light was on, and the resident verbalized needing to be changed (incontinent of urine or stool). b. At 10:17 a.m., Certified Nursing Aide (CNA) #1 responded to Resident #53's room leaving within two minutes. c. At 10:19 a.m., Resident #53 stated that CNA #1 told them they would get additional staff to help and return. d. At 11:12 a.m., Resident #53 stated that they had not yet been changed and no one had returned. e. At 11:13 a.m., CNA #1 stated that they had not been able to find a second staff member to assist. f. At 11:26 a.m., Resident #53 was assisted with incontinence care by CNA #1 and CNA #2. When observed the resident's brief and both bed sheets under them were saturated with urine. Resident #53's buttocks were reddened but without skin breakdown. During an interview on 12/2/22 at 11:00 a.m., Licensed Practical Nurse (LPN) #1 stated that staff are expected to respond to call bells within five minutes and if additional assistance is needed, they should ask another CNA or nurse for help. LPN #1 stated that with recent staffing challenges, they could see where it would take an hour to provide incontinence care to a resident. During an interview on 12/2/22 at 1:30 p.m., the Administrator stated that an incontinent resident waiting one hour for care to be provided is a problem. The Administrator stated that they would encourage staff to leave the resident's call light on if more help was needed. The Administrator stated that they had talked to staff about how all staff should answer a call bell. During an interview on 12/2/22 at 3:50 p.m., the Director of Nursing (DON) stated Resident #53 was a two person-assist, and the CNA could not help the resident because they could not find a second staff member to assist. The DON stated that they would expect the nurses to assist when necessary. 10NYCRR 415.12 (a)(3)

Based on observation, interview and record review conducted during the Recertification Survey, completed on 12/5/22, it was determined that for one (Resident #13) of eleven residents reviewed for Activities of Daily Living (ADLs), the facility did not ensure that residents received services with reasonable accommodation of resident's needs. Specifically, the resident was not provided a call bell based on the resident's functional needs and preferences. Additionally, the call bell was observed out of the resident's reach on multiple occasions. This is evidenced by the following: The facility policy Answering the Call Light, dated last reviewed and revised January 2022, documented that when the resident is in bed or is confined to a chair be sure the call light is within easy reach of the resident. The policy included that staff are to ask the resident to return demonstration of use of the call bell, so they will be sure that the resident can operate it. Resident #13 was admitted to the facility on [DATE], with diagnoses including a stroke, arthrogryposis multiplex congentia (limited movement of two or more joints), and fibromyalgia (widespread muscle pain). The Minimum Data Set Assessment, dated 8/14/22, documented that Resident #13 was cognitively intact, was frequently incontinent of bladder and bowel and required assist of staff for toileting. The facility Admission Evaluation dated 3/15/22, documented Resident #13 had contractures or restricted range of motion to both upper extremities, and hand grasps were Not Applicable with a comment unable due to birth defect. Review of the current Comprehensive Care Plan documented that Resident #13 required assistance with ADLs. Interventions included, but not limited to, encouraging the resident to use the bell to call for assistance. Review of a physician progress note dated 11/21/22, documented that on physical exam, under musculoskeletal, that Resident #13 had decreased ability with ADLs due to right-sided weakness. During an observation and interview on 11/28/22 at 9:57 a.m., Resident #13 had a push call button (joystick-looking device with red button in the center, connected by a cord to the wall). Resident #13 stated that the provided call bell was difficult to use and they had asked for a touch pad call bell that they had used during previous hospitalization s. During an observation and interview on 11/30/22 at 9:05 a.m., Resident #13 was sitting up on the side of the bed. The push call bell rested behind the resident on the bed. When asked if they could reach the call bell, Resident #13 said they could not reach it and that it was supposed to be next to them. Resident #13 stated that they had asked the facility for a touch pad call bell a while ago. Resident #13 stated that when they need help, they yell out. During an observation on 11/30/22 at 10:15 a.m., Resident #13 was sitting in bed, with the call bell clipped to the fitted sheet at the resident's shoulder level. Resident #13 attempted to change position and move closer but was unable to reach the call bell. When interviewed on 11/30/22 at 10:32 a.m., Certified Nursing Assistant (CNA) #1 stated that Resident #13 would just yell out when they needed help. CNA #1 stated that Resident #13 had a different type of call button when they were in another room. CNA #1 stated that they had never seen Resident #13's call button ring as the resident just yells for help. CNA #1 stated they did not think that Resident #13 could use the call bell in their room. During observations on 12/1/22 at 8:27 a.m., and at 8:33 a.m., Resident #13 was heard yelling out for help and saying they were in bad pain. During an interview with Resident #13 and CNA #1 on 12/2/22 at 1:58 p.m., Resident #13 stated they would use a flat (touch pad) call button if they had one, instead of yelling out for help. During an interview on 12/2/22 at 2:13 p.m., Licensed Practical Nurse (LPN) #1 stated that Resident #13 does not use the call button and yells out for help. During an interview on 12/2/22 at 3:50 p.m., the Director of Nursing (DON) stated that they were familiar with Resident #13 and that the resident had contractures to the hands. The DON stated that they have heard Resident #13 calling out and that staff reported that the resident does this instead of using the call bell. The DON stated that they have two call bell options and will look into the other option for Resident #13. 10 NYCRR 415.5(e)(1)

Based on observations, interviews, and records reviews conducted during an Abbreviated Survey (complaint #NY 726) completed on 2/17/17, it was determined that for one (Resident #3) of three residents reviewed for pressure ulcers, the facility failed to provide timely and necessary care and treatment to prevent the development and promote healing of pressure ulcers. Specifically, a lack of a thorough skin assessment on admission, lack of weekly skin checks, and the development of two additional pressure ulcers. This is evidenced by the following: Resident #3 is a [AGE] year old resident admitted to the facility from the hospital on [DATE] for functional rehabilitation with [DIAGNOSES REDACTED]. The resident has been wheelchair bound since 2008 and has a suprapubic catheter (tube from the bladder through the stomach to drain urine) and a [MEDICAL CONDITION]. Review of a hospital discharge summary, dated 1/6/17, does not include any documentation regarding skin breakdown. A Nursing Admission Assessment, dated as completed on 1/6/17 and signed by the Director of Nursing (DON), includes under skin assessment that the skin is intact and that the Braden Scale (scale for predicting pressure ulcer risk) score is 15 indicating mild risk for developing pressure ulcers. It also includes that the resident is alert and oriented to person, place, time, and situation. The Certified Nursing Assistant (CNA) assignment summary, dated 1/6/17, includes that the resident is a total assist for bathing, transfers, and toileting, and requires extensive assist for bed mobility, dressing, and turn and positioning every two hours. Review of Interdisciplinary Progress Notes, from 1/6/17 through 1/13/17, do not include any documentation regarding any skin issues. A progress note signed by the Licensed Practical Nurse (LPN), dated 1/8/17, includes that the resident is totally dependent on staff for [MEDICAL CONDITION] and urine catheter care. Review of the Medical Admission Assessment Note, dated 1/9/17 as date of service and signed by the Nurse Practitioner (NP), and a progress note, dated and signed by the physician on 1/11/17, documented that the skin is pale, warm, and dry. There is no mention of any skin breakdown. The Comprehensive Nursing Care Plan (CCP), dated as effective 1/11/17, does not include any mention of skin care, actual or potential skin issues. There is no documented evidence that an interim care plan was done. Physician orders, dated 1/12/17 and signed by the NP, include to apply [MEDICATION NAME] to sacrum and midback after cleansing with normal saline every shift. Review of a Wound Healing Solutions evaluation, dated 1/13/17, revealed that the consultation was for evaluation and management of wounds which include: a. Pressure ulcer of sacral region (full thickness and unstageable) measuring 4.2 centimeters (cm) x 1.5 cm x 0 depth with suspected deep tissue injury. b. Pressure ulcer of the right buttock (Stage II or partial thickness injury) measuring 2 cm x 2.2 cm x 0 depth and presents as a ruptured blister. c. Midline [MEDICATION NAME] spine (Stage II or partial thickness injury) measuring 2.5 cm x 2 cm x 0 depth. The consult recommended twice daily cleansing with saline, treat with [MEDICATION NAME] cream (a topical antibiotic used in partial and full thickness wounds [MEDICAL CONDITION] prevent infection) and border gauze and to off-load pressure on the areas. Interviews conducted on 1/20/17 included the following: a. At 8:45 a.m. and again on 2/16/17 at 8:50 a.m., the LPN Manager stated that she was called into the resident's room on 1/12/17 by a CNA who showed her a dressing on the resident's sacrum that was dated 12/27/16 (from hospital stay). She said that skin sheets are to be done weekly, and this resident was due on her shower day (1/10/17). She said the resident's skin sheet had not been completed since admission. The LPN Manager said that the nursing admission assessment was done by the DON. She said the day they found the dressing, dated 12/27/16, she notified the DON. She said that there was no interim care plan for this resident but one should have been initiated on the day of admission. b. At 9:50 a.m., the DON stated that she did the admission and does not remember seeing the wounds on admission or if she turned the resident over. She said that she also does not remember the LPN Manager showing her the dressing, dated 12/27/16 on 1/12/17. The DON said that she would have completed an Incident Report if she had known, but one was not done. She said there are not enough Registered Nurses (RN) to do all the assessments. c. At 10:40 a.m., the resident stated that she has very sensitive skin and has had a lot of skin issues in the past. She said she was aware of the area on her bottom as it was starting to break down before the hospital stay. She said she remembers her home health aide watching it for her but she forgot about it. The resident said that no one turned her over or checked her skin on admission to the facility. She said it is hard to reposition her due to a cracked rib. She stated that she thought the dressing was put on in the hospital. Interviews conducted on 2/16/17 included the following: a. At 8:20 a.m., the LPN stated that she was not here the first week that this resident was admitted , but the protocol is that the LPNs complete some of the admission and skin assessments are completed by the RNs. She said the CNAs should have repositioned the resident every two hours and should have seen the dressing from the hospital. The LPN said that a full head to toe skin assessment should be done on shower days by the LPNs. She said the Nurse Manager (NM) should be notified of any skin issues. b. At 8:30 a.m., the resident's primary CNA stated that she was not here the day the resident was admitted , but provided care for her several times that first week. She said she found the old dressing one day when she turned the resident over. The CNA stated she has no idea how the dressing was missed all week, but on some days, therapy did her morning care. She added that the resident does not refuse to turn, but only likes to be turned one way due to pain. The CNA said that the wound on the resident's bottom is difficult to see unless the resident is turned the other way. She said that when a resident is turned, the skin should be looked at each time. c. At 10:15 a.m., the NP stated that she expects an RN to do full skin assessment on admission, to let her know of any skin issues, and apparently this was not completed. She added that she herself did not look at the resident's sacrum or back. She said she would expect that the resident be turned and positioned daily as she was sick and at high risk for skin breakdown. She added that her skin breakdown could have been avoided if the skin was addressed properly on admission. She said they really do not know what the resident's skin was like on admission. When interviewed on 2/17/17 at 11:35 a.m. by telephone, the LPN Manager said she signed for a skin check on 1/10/17 and she does not remember if she completed the skin check. She said she was working as charge nurse and passing medications. Review of the current facility policy, Skin Assessment, includes that the RN/LPN will do a complete head to toe skin assessment on each resident on admission and weekly with shower. It also includes that the nurse will notify the skin team, dietary, and therapy, and place the resident on the 24 hour report sheet for continuous monitoring. (10 NYCRR 415.12(c)(1))

Based on observations, interviews and record reviews, it was determined that for one of one Main Kitchen and 55 of 67 residents residing in the facility, facility staff failed to prepare food in a safe and sanitary manner. Concerns rising to the level of immediate risk to resident health and safety included the provider's failure to adequately monitor the cooling of a 10 to 16-pound corned beef roast, a Time/Temperature Control for Safety (TCS) food, potentially exposing residents to the spread of a foodborne illness outbreak. This resulted in Immediate Jeopardy to resident health or safety, which has the potential for serious injury, harm, impairment, or death to residents receiving meals in the facility. This is evidenced by the following: During the initial tour of the Main Kitchen on 5/25/16, in the presence of the Dietary Supervisor, the following interviews and observations were made: a) At 8:30 a.m., the surveyor asked the Morning Cook if they had any food items that had been cooked and cooled. The Morning Cook stated that they cooked and cooled a corned beef roast the previous day (5/24/16), and it was currently in the walk-in cooler. b) At 8:35 a.m., the surveyor began the process to check the accuracy of his Taylor Model #9845 digital thermometer and the facility's thermometers using the ice-point method. During this process, the ice water temperature was holding at approximately 40 degrees Fahrenheit (°F). The surveyor requested facility staff to add additional ice to the cup and to replace the water. After adding ice, the surveyor's and facility's thermometers all measured 32°F. c) At 8:45 a.m., the Morning Cook was asked by the surveyor to measure the temperature of the corned beef roast. When the Morning Cook removed the pan with the corned beef roast from the walk-in cooler, the corned beef roast was covered tightly with foil that was not vented. When uncovered, the surveyor observed a single large piece of meat within the foil. The surveyor and the Morning Cook both took the temperature of the corned beef roast in the thickest portion of the meat, and it was 47°F. In an interview at that time, the Dietary Supervisor stated that she did not know what the time and temperature goals for cooling of TCS foods were. She said she knew the temperature had to get down to a certain temperature, and she thought that it should be 38°F to 40°F. The Morning Cook then retrieved a copy of a cooling log, and he stated that foods that need to be cooled have to get down to 120°F in two hours and 70°F within four hours after that. When asked for a cooling log for the corned beef roast, the Dietary Supervisor stated that she did not know where the cooling log was located. d) At 9:07 a.m., the Dietary Supervisor stated that the temperature of the corned beef roast would be all right by the time they sliced the meat that afternoon. She then provided a food vendor order sheet, which showed that corned beef roasts are delivered uncooked and weigh between 10 to 16 pounds. e) At 12:23 p.m., the Supervising Administrator reported that he spoke to the Dietary Supervisor and informed her that the corned beef roast should have been cut in half if it was larger than 8 pounds. It should have been placed in a shallow pan, on top of a pan of ice, and then put into the cooler. f) At 2:35 p.m., there was a pan of sliced corned beef and a pan of ground corned beef sitting on the counter where the Evening Cook was working. At that time, the Evening Cook stated that she was done slicing the corned beef and was just processing the purees. The Evening Cook then stated that the Day Cook started cooking the corned beef roast at 12:00 p.m. the previous day (5/24/16) and that she (the Evening Cook) took the corned beef roast out of the oven at 3:00 p.m. and placed it next to the stove to cool at room temperature. At that time, the temperature was 175°F to 180°F. The Evening Cook then stated that she monitored the temperature of the corned beef roast to ensure that it did not get below 70°F. The temperature of the corned beef roast was 78°F when it was placed in the cooler at approximately 7:30 p.m. on 5/24/16. The Evening Cook stated that she did not take a temperature of the corned beef roast that day (5/25/16) before beginning to slice it. The Evening Cook reported that 55 residents were going to receive the corned beef for the dinner meal. g) At 2:51 p.m., the surveyor informed the Dietary Supervisor that the corned beef roast, a TCS food product, had not been cooled according to regulatory requirements and could not be served. h) At 2:59 p.m., the Registered Dietitian (RD) stated that she has no involvement in training staff regarding cooling of foods. When asked what the cooling requirements were, the RD stated that she would have to look them up. A review of the facility's undated written policy and procedure, Cooling Potentially Hazardous Foods, provided by the Supervising Administrator on 5/25/16, revealed the statements to chill cooked, hot foods from 135°F to 70°F within two hours. Take corrective action immediately if food is not chilled from 135°F to 70°F within two hours or 70°F to 41°F or below in remaining time. The total cooling process from 135°F to 41°F may not exceed six hours. Take corrective action immediately if food is not chilled from 135°F to 41°F within the six hour cooling process. The Corrective Action portion of the written procedures included the following: Retrain any food service employee found not following the procedures in this Standard of Practice; reheat cooked, hot food to 165°F for 15 seconds and start the cooling process again using a different cooling method when the food is above 70°F and two hours or less into the cooling process and above 41°F and six hours or less into the cooling process; discard cooked, hot food immediately when the food is above 70°F and more than two hours into the cooling process and above 41°F and more than six hours into the cooling process. The facility presented a letter alleging compliance to remove the Immediate Jeopardy on 5/27/16 at 2:55 p.m. Steps taken to establish compliance included the following: a) The corned beef roast was discarded on 5/25/16 at 4:10 p.m. b) The Dietary Supervisor, Morning Cook, Day Cook and Evening Cook (all staff responsible for this process) were in-serviced several times between 5/25/16 and 5/27/16 regarding appropriate cooling methods for TCS foods. This included the requirement that staff were able to recite the required time and temperature goals for cooling and appropriate corrective actions if proper cooling had not been achieved. c) In a telephone interview, the Administrator and owner stated that they were planning to use the New York State Sanitary Code as their reference for food cooling procedures. (14-1.40 Food protection, potentially hazardous food, temperature and refrigeration requirements. (a) Food is to be protected from contamination during storage, preparation, display, service and transportation. The temperature of potentially hazardous food is to be 45 degrees Fahrenheit (7.2 degrees Celsius) or below, or 140 degrees Fahrenheit (60 degrees Celsius) or above at all times, except during necessary times of preparation or during a limited period of time while being held for service which may not exceed two hours. Intact shell egg temperatures shall be considered acceptable if the ambient storage temperature is 45 degrees Fahrenheit (7.2 degrees Celsius) or less. (b) Potentially hazardous food requiring refrigeration is to be cooled by an adequate method so that every part of the product is reduced from 120 degrees Fahrenheit (48.9 degrees Celsius) to 70 degrees Fahrenheit (21.1 degrees Celsius) within two hours and to 45 degrees Fahrenheit (7.2 degrees Celsius) or below within four additional hours. (c) Intact shell eggs shall be stored at an ambient temperature of 45 degrees Fahrenheit (7.2 degrees Celsius) or below.) Facility staff responsible for managing the TCS food cooling process were interviewed by survey staff on 5/27/16 between 3:06 p.m. and 4:00 p.m. and were able to verbalize knowledge of the TCS food cooling methods and corrective actions. During an interview on 5/31/16 at approximately 10:25 a.m., the RD asked the surveyor what caused the immediacy related to cooling foods. At this time, the Diet Technician spoke up and explained that the corned beef was at 47°F the morning after it was cooked. It had not been cut up, was covered tight, and dietary staff had no documentation to show that it had been cooled properly. The dietary staff were not able to tell surveyors temperature guidelines for the cooling process. (10 NYCRR 415.14(h); 14-1.40, 14-1.83)

Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 403), it was determined that for one (Resident #79) of one resident reviewed for hydration, the facility did not provide each resident with sufficient fluid to maintain proper hydration. Specifically, the facility did not provide consistent assessment or monitoring of fluid intake and output resulting in the hospitalization of Resident #79 on two separate occasions with [DIAGNOSES REDACTED]. Resident #79 has [DIAGNOSES REDACTED]. The 4/15/14 Nutritional Assessment includes the resident's fluid needs are 1,980 cubic centimeter (cc)/day and 2,520 cc are provided. It also includes the resident is not at risk for dehydration. A 7/4/14 nursing note includes the resident's blood pressure was 88/51, the resident reported being dizzy, and fluids were encouraged. The blood pressure was later rechecked, reading 123/71. The physician was notified of the results, with orders to monitor. A 7/7/14 nursing note documented that the resident had a poor appetite for the past two days, and the physician was notified. A 7/8/14 nursing note included that the resident had increased lethargy and was assessed by the Nurse Practitioner (NP) with orders for lab work and to encourage the resident to drink fluids. An antibiotic was ordered for a possible Urinary Tract Infection [MEDICAL CONDITION]. The note also indicates to encourage fluids and monitor urinary output, but this is not included on the Medication Administration Record [REDACTED] A NP note, dated 7/9/14 includes the resident has a UTI, a low sodium level of 117 (normal range 133-145), and dehydration based on laboratory results. The note includes to consult dietary for meal and fluid adjustments, and staff to push oral fluid intake and monitor output by diaper moisture. A 7/9/14 (evening shift) nursing note includes the resident drank 240 cc fluid with dinner. A 7/10/14 (night shift) nursing note includes the resident's intake was 300 cc and voided twice. A 7/10/14 evening shift and 7/11/14 night shift note indicated fluids were encouraged. No specific amounts for the intake are noted, and no mention of diaper moisture is documented. A 7/11/14 dietary note includes that dietary is aware that "No Added Salt" was discontinued from the resident's diet due to abnormal lab values, and sodium intake will be encouraged. No documentation of fluid adjustments (that were mentioned in the 7/9/14 NP note) are documented. A 7/11/14 nursing note includes the resident's family requested the resident be sent to the hospital. The physician was notified and gave an order for [REDACTED]. Review of the daily intake and output monitoring sheets, dated 7/1/14 through 7/11/14, revealed only five days that had complete entries for the resident's fluid consumption. None of the 11 days had any fluid intake totals. The average fluid intake for the complete entries for this resident was 1,080 cc/day. From 7/8/14 (when the NP noted to encourage the resident to drink) through 7/11/14 only two of the four days had complete entries. The resident's average fluid intake for the two completed days (7/10/14 and 7/11/14) was 1,050 cc/day. The resident was hospitalized from [DATE] through 7/15/14. The hospitization summary, dated 7/15/14, included the resident was treated with a normal Saline infusion as dehydration was the cause of [MEDICAL CONDITION] (a low sodium level of 110 on 7/11/14). A nursing readmission note, dated 7/15/14, included [DIAGNOSES REDACTED]. A NP readmission note, dated 7/16/14, included the resident had [MEDICAL CONDITION]/dehydration and to monitor her intake. The resident gets dehydrated, and staff state she is not drinking well. A nursing note, dated 7/16/14, includes the resident's output and to encourage fluids per the NP. A 7/16/14 evening shift nursing note includes the resident's output of 200 cc and intake 560 cc. A Dietary Readmission nutritional assessment, dated 7/17/14, included the resident's fluid needs to be 2,316 cc/day. A dietary note, dated 7/17/14, included the resident on a high salt diet. It also included that nursing reported the resident was eating well at breakfast and lunch, and oral intake seems to be good at that time. Dietary plan is to add 4 ounces of a supplement (Glucerna) at each meal to increase caloric intake. Dietary will continue to monitor and make changes. The dietary nutritional quarterly review, dated 7/18/14, included the above information. A nursing note for 7/17/14 day shift includes an intake of 240 cc. The resident is noted to be incontinent. A 7/22/14 NP note included the resident is lethargic and they are awaiting laboratory work. A NP note, dated 7/23/14, includes the resident has poor intakes and is lethargic. The laboratory work was reviewed with the family, showing dehydration and failure to thrive. The NP and family agreed the resident did not require hospitalization at that point. A nursing note, dated 7/24/14, includes the resident was sent to the hospital. Review of the daily intake and output monitoring sheets for 7/15/14 through 7/23/14 revealed 6/8 sheets to be incomplete. The one date (7/19/14) that was complete, was not totaled by the facility. The total daily intake was 920 cc for this resident. One of the sheets (7/22/14) was missing altogether. hospitalization sheets, dated 7/26/14, include the resident with acute [MEDICAL CONDITION] from dehydration. Interviews conducted on 7/31/14 included the following: a. At 1:00 p.m., the Certified Nursing Assistant said they are supposed to record the resident's intakes for solids and liquids on the Intake/Output board, for breakfast, lunch, and supper. If the resident is not eating/drinking well, she would report this to the charge nurse. She also said she did remember this resident, who was eating approximately 50 percent of her food and did not drink water, but did like coffee. She reported that the nurses did know about this. b. At 1:18 p.m., the Licensed Practical Nurse (LPN) Manager said dietary monitors the residents' intakes that are on the daily intake and output monitoring board. She believes that they do this weekly. She also said that no one looks at it on a daily basis or totals the amounts; dietary does all of that. Interviews on 8/1/14 included the following: a. At 8:30 a.m., the Dietary Technician (DT) said the daily intake and output monitoring sheets stay at the nursing station, and that is something that the nurses are to monitor. She reported that as long as she had been there, she had not looked at any of the intake and output monitoring sheets. She also said that prior to the resident being hosptalized on [DATE], she was not made aware of any problems the resident was having nutritionally, such as eating or drinking. Following the resident's hospitalization and readmission on 7/15/14, the DT said they did not do anything different in regards to monitoring the resident and did not do an intake study. She was aware the resident had lost some weight. She said she was planning to initiate an intake study on 7/22/14, however, the resident was hospitalized the next day, and she did not document this. The DT reported she did not monitor the resident's fluid intakes after her readmission on 7/15/14, and the I/O sheets are specifically for nursing to monitor. b. At 9:04 a.m., the LPN Manager said when there are blanks on the daily intake and output monitoring sheets, it could mean they refused. She also said the unit clerk files these sheets in the drawer in the nursing station. c. At 9:06 a.m., the unit clerk said she files the daily intake and output monitoring sheets after they show up in her "to file" bin. She did not know who put them in there. d. At 10:17 a.m., the Registered Dietician (RD) said the nursing staff is responsible for reviewing and totaling the daily intake and output monitoring sheets. She reports they are to record all the meals, solids, and fluids, and the nurses are to review them at least weekly. She said she was not aware that they are frequently not completely filled out. The RD also said she comes to the facility weekly and was aware that the resident was readmitted on [DATE]. The DT did a reassessment, which she did review and sign. The next time she was going to review the resident, she was already in the hospital. e. At 10:50 a.m., the Director of Nursing said nursing is to look at the daily intake and output monitoring sheets on a daily basis to determine what the resident's intakes really are. She also said something needs to be put into place to make sure this is happening. f. At 11:20 a.m., the LPN Manager said she was not aware that dietary was not looking at the I/O sheets or that nursing was to total them. She said they told the NP verbally that the resident was not eating well, and the CNAs did report this to them. The facility policy for intake and output monitoring, dated 10/9/13, includes the purpose is to accurately record the intake and output of each resident. The CNA is to record the amounts of meals and intakes including nourishments. The total intake is to be done by the night nurse at the end of each day. A fluid intake goal is established for each resident, and if the goal is not met, the night nurse will notify the Nurse Manager and the physician when the resident does not meet the goal after three days. (10 NYCRR 415.12(j))

Based on observations, family, resident, and staff interviews, and record reviews, it was determined that for four of six residents reviewed for abuse, the facility did not ensure that residents were free of mental anguish. The issues involved lack of timely toileting for Residents #15, #53, and #64, and possible abuse for Residents #64 and "A." This resulted in actual harm for Resident #15, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #53, #64, and "A." This is evidenced by the following: 1. Resident #15 has [DIAGNOSES REDACTED]. A 10/15/10 entry on the Care Plan revealed a recent change in self-image with a plan to encourage the resident to share feelings, worries, or concerns. The Minimum Data Set (MDS) Assessment, dated 1/7/11, revealed that the resident is cognitively intact. The 1/11/11 Care Plan addresses the resident's inability to independently perform activities of daily living because of decreased strength and endurance, and a plan to provide a one person assist with toileting every 3 hours to maintain the resident's physical functioning at the highest level of independence possible. Review of a 2/2/11 Physician's Assistant (PA) note revealed that the resident receives an antidepressant but continues to be depressed. The PA attributed the continued depressive symptoms to the resident's concerns with staff. When interviewed on 3/7/11 at 10:28 a.m., the resident said by the time staff take her to the bathroom, "It's in the diaper. I was told they are supposed to check every 3 or 4 hours to see if I have to go to the bathroom, sometimes they do, sometimes they don't." Interviews and observations on 3/10/11 are as follows: a) At 1:35 p.m., the resident was seated in a wheelchair in front of the nurses' station and told the surveyor she had to go to the bathroom. The assigned Certified Nursing Assistant (CNA) took the resident to her room and transferred her to the toilet. The resident's brief was visibly wet with urine. The CNA stated she believed the resident is afraid to ask to go to the bathroom because at times some of the aides will not take her. The CNA said that on 3/9/10, an activities staff member had witnessed an incident where the resident requested assistance with toileting and was ignored. b) At 1:40 p.m., the resident said, "Yes, that did happen." She not only asked the assigned CNA but another aide, and both of them ignored her. The resident became visibly upset and started to cry, said she could not hold it, and wet all through her clothes. The resident added that this happens often and is really embarrassing. c) At 2:23 p.m., the activities aide said that on 3/9/10 at 1:45 p.m. the resident told her that she wanted to go to the bathroom and had already asked a couple of people for assistance and they said no. The activities aide said that she found the primary CNA, who was caring for another resident, and told her the resident needed to go to the bathroom. The primary CNA responded that she needed to finish the care she was providing and assist another resident before she could get to Resident #15. The activity aide stated that she saw the resident at Bingo at 2:15 p.m. and she had not moved. d) At 3:00 p.m., the activities aide asked the resident if she had been taken to the bathroom. The resident became upset, crying, and said that she had gone in her pants. The activities aide described the resident as soft-spoken and timid. The resident was so upset about the toileting problems that it made the activities aide want to cry. Interviews on 3/11/11 are as follows: a) At 9:35 a.m., the PA said that the resident expressed concerns regarding a specific night shift CNA who gave her attitude when she put her call light on for assistance with toileting. This CNA also refused the resident's requests for water and told her she did not need any more water. When in her presence, the CNA talked over her to other staff. The PA said he told the Licensed Practical Nurse/Nurse Manager (LPN/NM) about this, and he believes they let the aide go. b) At 9:44 a.m., the LPN/NM stated that she reported these concerns to the Director of Nursing (DON), and the CNA was terminated. The LPN/NM also said that she was not aware that any other staff member followed up with the resident about her concerns but had not heard her complain about anything else. c) At 1:01 p.m., the Social Worker (SW) said she was not aware of the concerns the resident told the PA on 2/2/11 about the staff and would have seen the resident immediately if she had been made aware. The SW said she would not assume that the resident was ok. In an interview on 3/15/11 at 1:06 p.m., the LPN/NM said that she was not aware of the resident's concerns and did not understand why the resident had not told them to her. 2. Resident #53 has [DIAGNOSES REDACTED]. When interviewed on 3/7/11 at 12:06 p.m., the resident's family said they visit every evening. The biggest complaint is that when the resident puts on his call light that he has to go to the bathroom, they all say that he needs to wait for his CNA. The family said sometimes it takes 45 minutes to an hour and this is when the family is with the resident. Resident #53 has gone in his pants because he has to wait. They also said they no longer attend care plan meetings because when they bring up any issue, the Nurse Manager tells them, "My staff would never do that." In an interview on 3/11/11 at 11:13 a.m., the resident said that in the last few days staff have been better about assistance with toileting. He said that before this, he often had accidents in his pants and had to wait up to 40 minutes for assistance. He added, "I have a clock on the wall." When interviewed on 3/15/11 at 1:06 p.m., the LPN/NM said that she was not aware of the resident's concern regarding toileting assistance and did not understand why the resident and family had not come and told her about any issues. 3. Resident #64 has [DIAGNOSES REDACTED]. When interviewed on 3/7/11 at 1:22 p.m., the resident said she had been verbally abused by staff last week but did not tell anyone about it. She was unsure who she should tell. The resident said she knew who the Nurse Manager was but, although nice, thought she was too busy to talk with her. In addition, the resident and daughter when interviewed on 3/14/11 at 11:49 a.m. said the resident had to wait that morning for someone to take her to the bathroom. She asked a CNA, who said she was not her aide. By the time her aide came, the resident had already gone in her pants. When interviewed on 3/16/11 at 9:30 a.m., the LPN/NM said she was unaware there was any complaint from the resident, and it is not good if the residents do not know who to tell about things like this. 4. Resident "A," who was afraid to be identified, was interviewed on 3/7/11 at 9:16 a.m. The resident said that staff can be rough when they put you into bed. Resident "A" reported being afraid at times but has not reported this due to concerns that staff will retaliate and make life miserable. The staff have that attitude that they can do that and that is why you do not tell anybody because you do not want them to think you snitched on them. The facility's policy entitled, "Prevention, Investigation and Reporting of Resident Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property," dated May 2007, described mental abuse as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Neglect was defined as failure to provide timely, consistent, safe, adequate, and appropriate services, treatment, and/or care to a resident of the facility while such resident is under the supervision of the facility, including activities of daily living. The policy directs that all employees are responsible for monitoring residents and reporting abuse, signs and symptoms of potential abuse, trends suggesting abuse, and actual reports of abuse by residents, families, or resident's representatives. The employee must report the incident immediately to the supervisor, who will investigate the matter. The 2010 mandatory staff in-service for abuse and neglect includes: Abuse includes depriving of goods and services necessary for physical, mental, and psychosocial wellbeing. It also includes neglect as failing to provide services necessary to avoid harm, anguish, or mental illness. These services would include cares for bowel and bladder management. (10 NYCRR 415.4(b)(1)(i))