Every finding on record at Carillon Nursing and Rehabilitation Center

Based on record review and interviews during the Recertification initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. This was identified for three (Unit 1, Unit 6, and Unit 7) of six nursing units reviewed for the Sufficient Staffing Task. Specifically, the facility was triggered for excessively low weekend staffing on the Payroll-Based Journal Staffing Data Report for the Fiscal Year Quarter 1 2025 (October 1-December 31). A review of the daily staffing sheets indicated that Unit 1, Unit 6, and Unit 7 did not have sufficient nursing staff available to care for residents during the weekends in October 2024, November 2024, December 2024, and 5/18/2025. The finding is: The facility policy titled Sufficient Staffing, dated 2/2025 documented it is the policy of the facility to utilize an electronic staffing system for scheduling and a paper breakdown sheet for daily staffing for the nursing department. The facility is required to provide licensed nursing staff, including certified nursing assistants, 24 hours a day, seven days a week, The facility also designates a licensed nurse to serve as a charge nurse on each tour of duty. The purpose of the policy was to ensure that sufficient qualified nursing staff are always available to provide nursing and related services. Staffing for each shift is evaluated and adjusted as necessary to ensure safe and effective nursing care. Staffing levels are determined based on resident assessments, individual care plans, and the number, acuity, and diagnoses of the facility's resident population, in accordance with the Facility Assessment to meet resident needs. Relief personnel are scheduled as needed to maintain coverage during vacations, holidays, emergencies, and leaves of absence. A review of the Payroll-Based Journal Staffing Data Report for the Fiscal Year Quarter 1 2025 (October 1-December 31) documented the facility was triggered for excessively low weekend staffing for the Fiscal Year Quarter 1 2025 (October 1-December 31). The Facility Assessment Policy, last reviewed on 1/24/2025, documented to complete a facility-wide assessment to determine what resources are necessary to care for residents competently during daily operations and during emergencies. The Facility assessment dated [DATE] documented that Unit 1 had a capacity of 44 residents and required the following number of nursing staff based on a full census: -For the 11:00 PM to 7:00 AM shift there should be one Nurse and two Certified Nursing Assistants. A review of the Daily Census Report on 10/6/2024 revealed that Unit 1 had a census of 38 residents. The Daily Staffing sheet dated 10/6/2024 indicated there was no nurse assigned to work during the 11:00 PM to 7:00 AM shift on Unit 1; however, the Facility Assessment documented a need for one Nurse. The Facility assessment dated [DATE] documented Unit 6 had a capacity of 51 residents and required the following number of nursing staff based on a full census: -For the 3:00 PM to 11:00 PM shift there should be one and a half Nurses (one nurse to work part of the shift) and five Certified Nursing Assistants, A review of the Daily Census Report revealed Unit 6 had a census of 48 residents on 10/05/2024. A review of the daily staffing sheets from 10/05/2024 to 10/31/2024 for Unit 6 during the 3:00 PM to 11:00 PM shift revealed the following: -One Nurse and four Certified Nursing Assistants were assigned to work on 10/05/2024; however, the Facility Assessment documented a need for one and a half Nurses and five Certified Nursing Assistants. The Facility assessment dated [DATE] documented Unit 7 had a capacity of 54 residents and required the following number of nursing staff based on a full census: - For the 3:00 PM to 11:00 PM shift there should be one and a half Nurses and five Certified Nursing Assistants, A review of the daily Census reports from 10/13/2024 to 10/27/2024 revealed Unit 7 had a census of 50-51 residents. A review of the daily staffing sheets from 10/13/2024 to 10/27/2024 for Unit 7 during the 3:00 PM to 11:00 PM shift revealed the following: -Three and a half Certified Nursing Assistants were assigned to work on 10/13/2024, during the 3:00 PM to 11:00 PM shift; however, the Facility Assessment documented a need for Five Certified Nursing Assistants. -Four Certified Nursing Assistants were assigned to work on 10/19/2024,10/20/2024 and 10/27/2024 during the 3:00 PM to 11:00 PM shift; however, the Facility Assessment documented a need for Five Certified Nursing Assistants. A review of the Daily Census Reports dated 5/18/2025 revealed Unit 7 had a census of 51 residents. A review of the daily staffing sheet dated 5/18/2025 revealed Unit 7 had four Certified Nursing Assistants assigned to work during the 7:00 AM to 3:00 PM shift; however, the Facility Assessment documented a need for five Certified Nursing Assistants. During an interview on 5/18/2025 at 5:15 PM, Registered Nurse #6 stated there are one and a half nurses on Unit 6 during the 3:00 PM -11:00 PM shift which means a second nurse would stay on the unit until 7:00 PM and after 7:00 PM Registered Nurse #6 would be responsible for all 45 residents. Registered Nurse #6 stated sometimes they are late administering medications because of understaffing. Registered Nurse #6 stated the facility administration knows the weekends are short-staffed including nurses and Certified Nursing Assistants. Registered Nurse #6 stated understaffing causes the residents to receive delayed assistance for the Activity of Daily Living and medication administration. During an interview on 5/18/2025 at 5:26 PM, Certified Nursing Assistant #2 stated they are usually assigned to work on Unit 6. When they were short-staffed they were not able to complete the incontinence care for their assigned residents. Certified Nursing Assistant #2 stated they were only able to toilet the residents who were alert and oriented and asked to use the bathroom. Certified Nursing Assistant #2 stated the residents did not receive incontinence care every two to four hours or turning and positioning every two hours. During an interview on 5/18/2025 at 5:40 PM, Registered Nurse #7 stated they were the only assigned nurse on Unit 7 until 7:15 PM today for 51 residents. During an interview on 5/18/2025 at 5:44 PM, Certified Nursing Assistant #4 stated today they have 13 residents on their assignment. Certified Nursing Assistant #4 stated they did not complete incontinent care for four residents, and these residents will not get assistance with incontinence care until 7:00 PM because of the dinner meal service. During an interview on 5/18/2025 at 6:08 PM, Certified Nursing Assistant #5 stated the facility is short of nursing staff on the weekends. The residents are not showered, toileted, or ambulated as per the plan of care. During an interview on 5/18/2025 at 6:10 PM, Registered Nurse #9 stated the facility is short of nurses and Certified Nursing Assistants on the weekends which causes the residents to get their medications late. When there are just two Certified Nursing Assistants, the residents do not get toileted on time. During an interview on 5/19/2025 at 10:27 AM, the Staffing Coordinator stated the facility administration is aware that the facility is understaffed on the weekends. The Staffing Coordinator stated in October, November, and December 2024 a lot of staff was out on leave for different reasons. The Staffing Coordinator stated the facility utilizes a staffing agency to fulfill the staffing needs for Nurses and Certified Nursing Assistants; however, even with agency employees, the facility continues to be understaffed on the weekends. During an interview on 5/19/2025 at 10:48 AM, the Director of Nursing Services stated they were aware the facility is understaffed especially on weekends due to staff call-outs and leave of absence for various reasons. The Director of Nursing Services stated when the facility is understaffed with Certified Nursing Assistants, the nurses are supposed to assist with resident care; the residents' showers may be rescheduled, or residents may experience delays in receiving care and medications. During an interview on 5/19/2025 at 11:14 AM, the Administrator stated they were aware that they were short of staff on the weekends, and they were working on hiring more staff. 10 NYCRR 415.13(a)(1) (i-iii)

Based on record review and interviews during the Recertification Survey initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Center for Medicare and Medicaid Services within 14 days of the resident assessment completion date. This was identified for one (Resident #240) of one resident reviewed for the Resident Assessment Task. Specifically, Resident #240's five-day Minimum Data Set Assessment was not transmitted within 14 days of the resident assessment completion date. Additionally, the resident was discharged from the facility in December 2024; however, the Minimum Data Set discharge assessment was not completed and transmitted until May 2025. The finding is: The facility policy and procedure titled Minimum Data Set Assessment Version 3.0, effective 10/2020, documented the facility will conduct initial and periodic comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity. The Resident Assessment Instrument must be completed within 14 days of admission. The Minimum Data Set department will generate a weekly/monthly Minimum Data Set Assessment schedule. They will input the completed Minimum Data Set Assessment into the data systems daily and submit records at least weekly in the New York State database within 14 days of the care plan date for comprehensive assessments and sign-off date for Quarterly and Prospective Payment System assessments. A review of the electronic medical record revealed Resident #240 was admitted to the facility on [DATE]. Resident #240's Five-Day Minimum Data Set assessment with an assessment reference date of 12/20/2024 was completed on 1/3/2025. A review of the Minimum Data Set Assessment 3.0 Nursing Home Validation Report dated 5/14/2025 revealed the Five-Day Minimum Data Set assessment dated [DATE] was transmitted to the Center for Medicare and Medicaid Services and accepted on 3/20/2025. Resident #240's minimum data set assessment was transmitted 62 days after the due date, 1/17/2025. A review of the Minimum Data Set Assessment 3.0 Nursing Home Validation Report dated 3/20/2025 revealed that the Discharge-Return anticipated Minimum Data Set assessment dated [DATE] was completed on 3/20/2025. The transmission was rejected due to data entry errors for sections B0100 through B1300. The validation report documented a warning that the Discharge-Return anticipated Minimum Data Set assessment was submitted late and was more than 14 days overdue. Resident #240's discharge-return anticipated Minimum Data Set assessment with an assessment reference date of 12/20/2024 was completed on 5/14/2025, 131 days after the due date, 1/3/2025. A review of the Minimum Data Set Assessment 3.0 Nursing Home Validation Report dated 5/14/2025 revealed that the Discharge-Return anticipated Minimum Data Set assessment dated [DATE] was completed on 5/14/2025, and the transmission was accepted. The validation report documented a warning that the Discharge-Return anticipated Minimum Data Set assessment was completed late and was more than 14 days after the assessment reference date. During an interview on 5/15/2025 at 9:57 AM, Minimum Data Set Coordinator #1 stated the Five-Day Minimum Data Set assessment should have been transmitted within 14 days of the completion date. Minimum Data Set Coordinator #1 stated the delay might have been a technical error; the Discharge assessment was initially submitted on 3/20/2025, rejected on 3/20/2025, and resubmitted and accepted on 5/14/2025. During an interview on 5/15/2025 at 2:25 PM, the Director of Nursing Services stated that the Minimum Data Set Coordinators should check the validation reports to ensure that Minimum Data Set assessments are completed and transmitted on time. The Director of Nursing Services stated the Five-Day assessment was not submitted due to a human error. 10 NYCRR 415.11

Based on observation, record review, and interviews during the Recertification Survey initiated on 5/13/2025 and completed on, 5/20/2025 the facility did not ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (Resident #230) of one resident reviewed for Activities of Daily Living. Specifically, Resident #230's care plan included the use of a right-resting hand splint for positioning and a left-hand palm grip to be worn at all times; however, the resident refused the right arm splint and left palm grip. There was no documented evidence that the resident's care plan was revised to reflect the resident's preferences or refusals. The finding is: The facility's policy titled Care Planning Process, last reviewed on 7/2022, documented the facility shall have a care planning process that is person-centered, which includes integrating assessment findings in the care planning, developing an interdisciplinary care plan, and regularly reviewing and revising the care plan. The Nursing Care Profile will serve as the primary communication for the Certified Nursing Assistant to dictate their care. The care plan shall describe the services that are being provided and any services or treatments that would otherwise be required but are not provided due to the resident's exercise of the right to refuse treatment. The care plan is reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The care plan is revised by the members of the interdisciplinary team based on changing goals, preferences, and needs of the resident and in response to current interventions. Resident #230 was admitted with diagnoses including Cerebral Infarction, Hemiplegia, and Hemiparesis affecting the left non-dominant side. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 7, indicating the resident had severe cognitive impairment. The Activities of Daily Living care plan, dated 3/12/2025, documented the resident had a self-care performance deficit. The interventions included applying a right resting hand splint for positioning and a left-hand palm grip to be worn at all times and to be removed for hygiene/grooming and skin checks. An Occupational Therapy note dated 6/27/2024 documented that an assistive device was provided to the resident for their left hand to prevent contracture, which must be worn at all times and removed for hygiene/grooming, and skin checks. An Occupational Therapy note dated 7/2/2024 documented that a right resting hand splint for positioning was provided to the resident. An Occupational Therapy note dated 8/27/2024 documented that the resident preferred not to utilize the splint anymore despite education. An Occupational Therapy Evaluation dated 12/6/2024 documented that a left-hand splint was provided to the resident in the past, but the resident complained that the splint was uncomfortable. A Rehabilitation-Nursing Recommendation form dated 12/6/2024 documented that a left arm tray adaptive device was provided to the resident. A review of the Physician's orders revealed no order for the right-resting hand splint or the left-hand palm grip. A review of the Certified Nursing Assistant Accountability Record for March, April, and May 2025 revealed no documentation for using the right resting hand splint or the left-hand palm grip. During an observation and interview on 5/19/2025 at 9:22 AM, Resident #230 was sitting in bed. The resident did not have a hand splint on the right hand and did not have a left palm grip. The resident stated they did not use any splint. During an interview on 5/19/2025 at 12:15 PM, Registered Nurse #3 stated they were responsible for updating care plans and completing the Minimum Data Set assessments. Registered Nurse #3 stated they believe the resident refused the hand splint and left-hand palm grip. Registered Nurse #3 stated the care plan should have been revised to reflect the discontinued use of the hand splint and palm grip. During a re-interview on 05/19/25 at 12:31 PM, Registered Nurse #3 stated the resident came back from the hospital on 12/6/2024 and was re-evaluated by the rehabilitation department. The rehabilitation department did not recommend the hand splint or palm roll. Registered Nurse #3 stated that the care plan needed to be updated after the resident was re-evaluated by the rehabilitation department, and the use of the devices was no longer advised. During an interview on 5/19/2025 at 12:59 PM, the Rehabilitation Director stated the resident was assessed by the rehabilitation staff when the resident returned from the hospital on 12/6/2024. The right-hand splint and the left palm grip devices were no longer required and were not appropriate interventions. The Rehabilitation Therapist who made the determination should have filled out a nursing communication form for the nurses to update the care plan. During an interview on 5/19/2025 at 2:05 PM, the Director of Nursing Services stated Resident #230's care plans should have been updated to reflect changes to the devices based on the Rehabilitation Department's evaluation. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure that each resident received care consistent with professional standards of practice to promote healing, prevent infections, and prevent new ulcers from developing. This was identified for one (Resident #44) of four residents reviewed for Pressure Ulcers. Specifically, Resident #44 with a history of a pressure ulcer to the sacrum utilized an air mattress for pressure relief. During two separate observations, the weight setting for the air mattress was not calibrated to the resident's actual weight. The finding is: The facility's policy titled Pressure Injury/Pressure Ulcer Assessment, Prevention and Management, last revised on 3/2023, documented that the facility shall provide care and services consistent with professional standards of practice to prevent pressure injury/ulcer development and promote the healing of existing pressure injury/ulcer (including prevention of infection to the extent possible) as specified in the facilities Pressure Injury/Ulcer Assessment, prevention, and Management Program. Resident #44 was admitted with diagnoses including Venous Insufficiency (poor blood circulation to the lower extremities), Dysphagia (difficulty swallowing), and Heart Disease. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. The Minimum Data Set documented that the resident was at risk for Pressure Ulcers and utilized a pressure-reducing device for the bed. The operation manual for the Air Mattress included instructions to adjust the internal pressure according to the patient's weight by using the weight button on the control panel of the power unit. A Braden Scale Assessment (a standardized assessment tool used to predict the risk of developing pressure injuries) dated 4/3/2025 documented a score of 12 indicating the resident was at high risk for developing a pressure ulcer. A Comprehensive Care Plan entitled The resident has potential for skin breakdown, dated 12/17/2024, documented a history of sacral pressure ulcer, chronic wounds, and impaired mobility. The intervention included the use of an air mattress. A Physician Progress Note dated 4/28/2025 documented Resident #44 was bedridden with chronic skin changes to their right lower leg. The resident had a history of sacral ulcers and was followed on wound rounds due to a vascular wound to the right lower extremity. A Physician's order dated 5/2/2025 documented an order to check the air mattress function and weight setting at 250. A review of the electronic medical record indicated that Resident #44's most recent weight was 279.2 pounds on 5/01/2025. During an observation on 5/14/2025 at 10:29 AM, Resident #44 was in bed sleeping on an air mattress. The weight setting for the air mattress was set at 100 pounds. During an observation on 5/14/2025 at 3:36 PM, Resident #44 was seen in their bed sleeping on an air mattress. The weight setting for the air mattress was set at 200 pounds. During an interview on 5/14/2025 at 3:36 PM, the Unit Manager, Licensed Practical Nurse #1 verified the air mattress setting which was set at 200 pounds, and stated the air mattress weight setting sometimes changes by itself and they were responsible for making sure the setting is according to the resident's weight and the physician's orders. During an interview on 5/16/2025 at 9:40 AM, Wound Care Registered Nurse #1 stated they were responsible for obtaining an order for the air mattress and providing the air mattress to the residents who have pressure ulcers and residents who are at high risk for developing ulcers. The unit nurses are responsible to monitor and ensure the weight setting for the air mattress is set according to the resident's weight and according to the doctor's orders. Resident # 44's weight setting should have been set at 250 pounds as per the physician's orders. 10 NYCRR 415.12(c)(1)

Based on observations, record review, and interviews during the Recertification Survey initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure that pain management was provided to each resident who requires such services, consistent with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (Resident #335) of four residents reviewed for Pressure Ulcers. Specifically, Resident #335 complained of discomfort during the wound care treatment of their Coccyx (tailbone) Stage 2 pressure ulcer. Registered Nurse #4 (the nurse administering the wound treatment) continued the treatment without assessing and addressing the resident's pain. The finding is: The facility's policy titled Pain Management, dated 1/22/2025, documented the facility is committed to providing optimal pain management to the residents. Each resident has the right to have his/her pain issues addressed. If the resident reports pain, the registered professional nurse will rate the resident's pain using one of the following rating scales according to the resident's ability to communicate. The monitoring of pain before and after every nursing intervention for pain is also documented on the Medication Administration Record before and after the intervention to determine the effect of the intervention. The facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 1/22/2025, documented when assessing the resident with a pressure injury- assess residents for pain related to pressure injury or its treatment. Manage pain by eliminating or controlling the source of pain (i.e., cover wounds, adjust support surfaces, reposition). Provide analgesia (pain relief) as needed and appropriate. Resident #335 was admitted with diagnoses including Multiple Fracture of Ribs and Pneumonia. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. The resident had a stage 1 pressure ulcer, occasionally had moderate pain, and had received scheduled and as-needed pain medications. The resident was dependent on staff for bed mobility and transfers. A Comprehensive Care Plan titled Pain/discomfort, effective 3/19/2025, documented interventions including to assess/monitor for pain or change in condition with potential for pain, anticipate the resident's need for pain intervention, pre-medicate as needed, adjust daily schedule/routine for comfort as needed, and monitor the effectiveness of plan and response to interventions. A physician's order dated 5/13/2025 documented to administer Acetaminophen 325 milligrams, give 2 tablets by mouth every 6 hours as needed for Pain. The physician's orders also documented to cleanse the Coccyx wound with Derma Klenz (wound cleansing agent), apply Skin Barrier around the wound, allow the barrier to dry, and apply Dermafilm Hydrocolloid (wound dressing to cover the wound) every 3 days for the [stage 2]wound. The Wound care notes dated 5/14/2025 documented the resident had a Coccyx Stage 2 pressure ulcer that was acquired in the facility on 4/27/2025. During an observation of Resident #335's pressure ulcer treatment on 5/16/2025 at 10:15 AM, Registered Nurse #4 was observed performing treatment to the Coccyx area with the assistance of Certified Nursing Assistant #6. The resident was turned to the right side towards Certified Nursing Assistant #6. Registered Nurse #4 removed and discarded the dressing from the Coccyx area, and cleansed the wound with DermaKlenz sprayed onto a 4x4 dressing. Resident #335 complained of discomfort and stated, ouch, ouch. Registered Nurse #4 heard and acknowledged the resident's discomfort and continued with the treatment. Registered Nurse #4 stated, I know, the dressing is cold, and continued to wipe the area. Registered Nurse #4 did not question the resident about the pain or discomfort. Registered Nurse #4 was immediately interviewed and stated they did not assess the resident for pain because the resident was not in any pain before the treatment and did not want any pain medication. Registered Nurse #4 then stated they should have assessed the resident's pain level when the resident complained of discomfort and was saying ouch-ouch. During an interview on 5/19/2025 at 11:28 AM, Registered Nurse Unit Manager #5 stated Registered Nurse #4 should have stopped the treatment, assessed the resident's pain level, and notified the Physician to obtain an order for the pain medication. During an interview on 5/19/2025 at 2:19 PM, Wound Care Registered Nurse #1 stated Registered Nurse #4 should have stopped, assessed, and medicated the resident for pain. Wound Care Registered Nurse #1 stated the Physician should have been called if the current pain medication was not effective for the resident. Wound Care Registered Nurse #1 stated the stage 2 pressure ulcer treatment was recently changed from normal saline to Derma Klenz on 5/13/2025 which may have caused the discomfort on 5/16/2025 and the treatment order was changed back to cleansing the coccyx wound with normal saline on 5/16/2025. During an interview on 5/19/2025 at 2:17 PM, the Director of Nursing Services stated Registered Nurse #4 should have stopped the wound care treatment, assessed the resident's pain level, and medicated the resident. The Director of Nursing Services stated the resident's pain should be reported to the Physician for additional pain medication orders if needed. 10 NYCRR 415.12

Based on observation, record review, and staff interviews during the Recertification Survey, initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure that an infection prevention and control program was implemented to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Unit 2) of six nursing units reviewed during the Medication Administration Task. Specifically, during a medication pass observation for Resident #188, who was on Enhanced Barrier Precautions, Registered Nurse #8 handled Resident #188's used meal tray after administering medications to the resident. Registered Nurse #8 did not perform hand hygiene. Registered Nurse #8 then proceeded down the hall, pushing the medication cart and a blood pressure machine, entered Resident #248's room, and opened the resident's meal tray items. The finding is: The facility Infection Control Hand Hygiene Protocol policy, dated 11/2017, documented to follow a hand hygiene protocol to prevent the spread of potential pathogens. The guidelines for hand hygiene included before and after each resident/patient contact, before, during, and after food preparation, and before handling the resident/patient's food. Resident #188 was admitted with diagnoses that included Acute Kidney Failure, Type II Diabetes Mellitus, and Hemodialysis. The Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 9, which indicated the resident's cognition was moderately impaired. The resident was dependent and required maximal assistance from staff for all areas of activities of daily living, except for eating, which only required set-up help. A Physician's order dated 3/25/25 documented Enhanced Barrier Precautions during high contact activities related to Status Post Perma-catheter (a catheter inserted into a large vein, often in the neck or chest for dialysis treatments) every shift. Resident #248 was admitted with diagnoses that included Hypertension, Diabetes Mellitus, and Traumatic Brain Injury. The Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 9, which indicated the resident's cognition was moderately impaired. During a medication pass observation on 5/16/2025 at 9:00 AM on Unit 2, Registered Nurse #8 was observed administering medications for Resident #188. An Enhanced Barrier Precaution signage and a Personal Protective Equipment cart were observed outside the door of Resident #188's room. After the medication administration was completed, Registered Nurse #8 was observed removing the resident's used breakfast meal tray from the overbed table. Registered Nurse #8 did not perform hand hygiene. Registered Nurse #8 then proceeded down the hall, pushing the medication cart and a blood pressure machine, entered Resident #248's room, and opened the resident's meal tray items. During an interview on 5/16/2025 at 9:25 AM, Registered Nurse #8 stated they should have performed hand hygiene prior to leaving a resident's room. Registered Nurse #8 acknowledged that they did not perform hand hygiene when they left Resident #188's room and prior to entering Resident #248's room and assisting the resident with their meal tray setup. During an interview on 5/19/2025 at 12:48 PM, the In-service Coordinator stated after leaving a resident's room, staff must perform hand hygiene regardless of the task they have completed for the resident. The In-service Coordinator stated hand washing is the basic intervention to prevent the spread of infection. Registered Nurse #8 should have washed their hand before exiting Resident #188's room and before touching Resident #248's tray. During an interview on 5/19/2025 at 1:10 PM, the Director of Nursing Services stated Registered Nurse #8 should have performed hand hygiene prior to exiting Resident #188's room. The Director of Nursing Services stated that Registered Nurse #8 should not have handled the meal tray before washing their hands. 10 NYCRR 415.19(a)(1-3)

Based on observation, record review, and interview the facility failed to prevent abuse for one of three residents reviewed for physical abuse. Specifically, on 12/27/2023 at approximately 5:00 AM, Resident #1 reported to Registered Nurse #1 that Certified Nursing Assistant #1 physically assaulted them. The same day at approximately 7:00 AM, Resident #1 again reported to Registered Nurse Manager #2 that Certified Nursing Assistant #1 physically assaulted Resident #1. Subsequently, the Facility's Accident and Incident investigation determined that Resident #1 sustained bruising and pain from the encounter and there was reasonable conclusion that Certified Nursing Assistant #1 physically assaulted Resident #1. This resulted in actual harm to Resident #1 that is not immediate jeopardy. The findings are: The facility's policy titled Resident Rights and Organizational Ethics effective 10/2022, documented Abuse (Federal)-Willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish . Abuse (New York State)-Inappropriate physical contact with a resident which harms or is likely to harm the resident. Inappropriate physical contact includes, but is not limited to striking, pinching, kicking, shoving, bumping . The facility shall not use or permit verbal, mental, sexual, or physical abuse including corporal punishment and involuntary seclusion of residents, or other mistreatment or neglect. This prohibition extends to abuse by anyone, including but not limited to, other residents, staff, consultants, volunteers, and staff of other agencies serving the residents, family members, legal guardians, friends, or other individuals. Resident #1 was re-admitted with a medical diagnosis which included Dementia, Psychotic disturbance, Mood disturbance, and Anxiety. According to the Quarterly Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 out of fifteen indicating severe cognitive impairment. Resident #1 did not reject care during this assessment. Resident #1 required supervision with eating, oral hygiene, upper body dressing, lower body dressing, putting on and taking off footwear, and with personal hygiene. Resident #1 required partial/moderate assistance with toileting, hygiene and with shower/bathing. A review of Resident #1's care plan dated 07/01/2022 documented that Resident #1 was at risk to be a victim of abuse, neglect, and/or mistreatment. The care plan documented that Resident #1 was vulnerable due to cognitive deficits and physical disabilities. A review of the facility's Accident Incident report dated 12/27/2023 revealed the facility documented that Resident #1 told Registered Nurse Manager #2 they were hit on the chest by a Certified Nursing Assistant (the report did not identify the aide in question). The Accident Incident report further documented that Registered Nurse Manager #2 interviewed Resident #1 who stated that a staff member (did not identify) entered Resident #1's room during the night shift while Resident #1 was asleep and insisted that Resident #1 got out of bed so that Resident #1's bed sheets could be changed due to Resident #1's bed being wet with urine . According to the Accident Incident report, Resident #1 stated, they did not want to get up and then demonstrated with their hands that the staff member hit Resident #1 on the chest. The Accident Incident report further documented that the facility's physical assessment of Resident #1 revealed bruising to Resident #1's chest and left upper arm. The Accident Incident report documented that Resident #1's safety was ensured and maintained by immediate removal of Certified Nursing Assistant #1 from schedule pending investigation and the incident was reported to the New York State Department of Health as well as the Suffolk County Police department. In addition, the Accident Incident report also documented that Resident #1's family as well as the Medical Director were notified. The Accident Incident report further documented that the Medical Director examined Resident #1 and ordered an X-ray of Resident #1's left arm which was negative for fractures. The Accident Incident report concluded that based upon the facility's collection and review of Resident #1's and facility's staff interviews and statements, the facility could not rule out an act of abuse had taken place. The Accident Incident report further documented that the facility would continue to monitor and in-service staff on abuse, neglect, or mistreatment annually and as needed. The Accident Incident report documented that Resident #1 would continue to be monitored for any sequalae resulting from Resident #1's injury from the incident. A review of Resident #1's medical record revealed a change of condition assessment was completed by Registered Nurse Manager #2 on 12/27/2023 at 3:47 PM. Assessment documented an area of ecchymosis (discoloration) to Resident #1's left breast and left upper extremity which was not present prior. Resident #1 reported new onset of pain and tenderness to the areas. Resident #1 did not exhibit any changes in behavioral, and/or functional status. The health status note charted by Registered Nurse #2 on 12/28/2023 at 1:17 PM documented that areas of ecchymosis (discoloration) persist to Resident #1's left breast left upper extremity. The health status notes further documented that bruising also visible on Resident #1's right breast. In addition, the health status note documented that an X-ray of Resident #1's left humerus (bone of the upper arm) was ordered and pending completion. A review of Resident #1's vital signs record dated 08/27/2023 at 7:56 PM recorded Resident #1 rated their pain at 3 on a numerical pain scale (A scale which rated pain from zero [0] to 10 with zero indicative of no pain and 10 demonstrating the worst pain possible). A review of the Medical Director's progress note dated 12/28/2023 at 1:47 PM documented that Resident #1 complained of tenderness to the left arm and breast area, and Resident reported to the Medical Director that an aid hit them in the breast and grabbed their arm. The progress note documented that on examination, Resident #1's breast was noted with linear ecchymosis (bruising that took a straight shape or pattern) and left arm that were tender (painful) to touch. The Medical Director's progress note further documented that Resident #1 was on acetylsalicylic acid (ASA) [an anti-inflammation and blood thinning medication] and Plavix (blood thinning medication). The progress note documented that the Medical Director ordered an X-ray of Resident #1's left arm and discussed their finding with the facility's administration and were advised that an investigation was underway. Further review of Resident #1's medical record revealed Resident #1 was assessed by a psychologist and the facility's Director of Social work on 12/28/2023. While the assessment conducted by the identified parties made no findings that Resident #1 suffered any form of psychosocial harm from Resident #1's encounter with Certified Nursing Assistant #1, their assessments determined that Resident #1's narrative about being physically assaulted by Certified Nursing Assistant #1 was consistent, and that Resident #1 suffered bodily injury which resulted in pain for Resident #1. Certified Nursing Assistant #1's employee file was reviewed on 02/08/2024 at 8:25 AM, and it contained evidence of Certified Nursing Assistant #1's Termination form dated 01/08/2024 documented the reason for termination as Unsatisfactory Work Performance. Certified Nursing Assistant #1 was unavailable for an interview despite multiple attempts. During an interview on 02/08/2024 at 8:00 AM, Resident #1 stated they recalled being in their bed the day Certified Nursing Assistant #1 delivered several punches to Resident #1's chest (breast area) and other parts of Resident #1's body. Resident #1 stated they were shocked that Certified Nursing Assistant #1 hit them. Resident #1 stated they were in pain from the encounter but could not rate the pain. Resident #1 stated that the punches left a purple-like discoloration on Resident #1's left breast and left upper arm. Resident #1 stated they felt safe after they learned from the facility administration Certified Nursing Assistant #1 was no longer employed at the facility. Registered Nurse #1 was not available for interview despite multiple attempts. During an interview on 02/08/2024 at 8:15 AM, Registered Nurse Manager #2 stated they were the Unit Manager on the dementia unit (the unit which housed cognitively impaired residents) during the 7:00 AM through 3:00 PM shift on 12/27/2023. Registered Nurse Manager #2 stated that Resident #1 approached Registered Nurse Manager #2 to report they were hit by Certified Nursing Assistant #1. Registered Nurse Manager #2 stated that they immediately re-directed Resident #1 back to Resident #1's room and then conducted a full body assessment on Resident #1. Registered Nurse Manager #2 reiterated that their assessment of Resident #1 identified bruising and pain to Resident #1's left breast. Registered Nurse Manager #2 stated that Resident #1 did not have prior history of fabricating malicious allegations against their peers or facility staff. Registered Nurse Manager #2 stated that the Medical Director evaluate d Resident #1 for additional findings and ordered an X-ray for Resident #1's complaint of pain . Registered Nurse Manager #2 also stated that they immediately reported Resident #1's allegation to the facility administration as the facility abuse policy dictated. Registered Nurse Manager #2 stated the facility immediately suspended Certified Nursing Assistant #1 pending a full investigation and subsequently terminated Certified Nursing Assistant #1. During an interview on 02/08/2024 at 8:29 AM, the Director of Social Work stated the social worker who handled the investigation advised the Director of Social Work that Resident #1's recollection was consistent in their description that they were punched in the chest area. The Director of Social Work stated that Resident #1 reported they were experiencing soreness to their chest area. The Director of Social Work stated that based on Resident #1's consistent statement identifying the area of their body where the resident alleged that Certified Nursing Assistant #1 delivered several punches, the facility's review of the video footage which corroborated that Certified Nursing Assistant #1 was in contact with the resident at the time proximate to when Resident #1 first complained about the alleged physical abuse to Registered Nurse #1 and the lack of any explanation from Certified Nursing Assistant #1 about how Resident #1 sustained the identified discoloration, the facility concluded that Resident #1 was physically abused and that Certified Nursing Assistant #1 perpetrated the abuse. During an interview on 02/08/2024 at 8:42 AM, the Assistant Director of Nursing stated that Registered Nurse #2 reported the allegation of physical assault made against Certified Nursing Assistant #1 by Resident #1 . The Assistant Director of Nursing stated that they immediately suspended Certified Nursing Assistant #1 while the facility investigated the allegation. The Assistant Director of Nursing reiterated that the facility investigation determined that there was sufficient evidence to believe that Resident #1 was physically abused by Certified Nursing Assistant #1. The Assistant Director of Nursing stated that the facility went through a great deal of measure to ensure they do not hire anyone with history of abuse by conducting thorough pre-hire background checks on all prospective employees. The Assistant Director of Nursing added that the facility also trained all employees on abuse, neglect, and mistreatment as well as managing behaviors among the population of residents the facility cared for as a measure to curtail any form of abuse. During an interview on 02/08/2024 at 8:57 AM, the Nursing Home Administrator stated the facility's abuse prevention strategy was to hire employee without history of abuse. The Nursing Home Administrator stated that Resident #1 had history of using profanity against staff as well as physically assaulting staff. The Nursing Home Administrator acknowledged that residents of the facility should be free from any sort of punishment including those driven by the resident's known behavior. The Nursing Home Administrator stated the facility's investigation reasonably believed that Resident #1 was physically assaulted by Certified Nursing Assistant #1. The Nursing Home Administrator stated that Resident #1 sustained bodily injury (bruising to the resident's left breast and left upper arm) and pain resulting from the physical abuse. The Nursing Home Administrator stated that the facility terminated Certified Nursing Assistant #1 because the facility reasonably believed Certified Nursing Assistant #1 abused Resident #1. During an interview on 02/8/2024 at 9:18 AM, the facility's Medical Director stated that the facility requested that the Medical Director evaluate Resident #1 following a physical abuse allegation. The Medical Director stated that their evaluation of Resident #1 ruled out the resident's use of blood thinner as the cause of the bruising noted to Resident #1's left breast and left upper arm. The Medical Director stated that Resident #1 complained about new onset of pain due to the physical abuse by Certified Nursing Assistant #1. The Medical Director stated that Resident #1 did not express feeling unsafe at the facility following the physical abuse encounter with Certified Nursing Assistant #1. The Medical Director stated the facility was expected to have zero tolerance for abuse. 10 NYCRR 415.4(b)(1)(i)

Based on observations, interviews, record review during the Recertification Survey initiated on 10/19/2023 and completed on 10/25/2023 the facility did not ensure an infection prevention and control program was established to help prevent the development and transmission of communicable diseases and infections. This was identified for 1) one (Resident #141) of five of residents reviewed during a medication administration task; and 2) for one (unit 3) of six units observed on 10/23/2023. Specifically, 1) Resident #141 was on contact and droplet precautions for COVID-19 exposure and contact precautions for Vancomycin-Resistant Enterococci (VRE) infection. During the medication pass observation 1 a) the medication nurse did not follow instructions for proper Personal Protective Equipment (PPE) use as indicated on the signage outside the resident's room; 1 b) during the same medication pass observation, a maintenance worker entered Resident #141's room without donning (putting on) proper PPE; and 2) Resident #617 was on contact and droplet precautions for COVID-19 exposure. On 10/23/2023, a Certified Occupational Therapy Assistant (COTA) was observed providing treatment to Resident #617 in their room without the use of proper PPE. The findings are: 1a) The facility's policy titled Transmission-Based Precautions (Isolation), effective 4/2020, documented appropriate PPE will be donned upon entry into the environment of a resident on transmission-based precautions (for example, contact precautions, droplet precautions) since the nature of the interaction with the resident cannot be predicted with certainty and contaminated environmental surfaces are important sources for transmission of pathogens. The facility will educate its employees on transmission-based and standard precautions at the time of orientation and repeated as necessary to maintain competency. Resident #141 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia, Cerebrovascular Accident, and Hypertension. The 9/29/2023 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severe cognitive impairment. The Physician's order dated 10/16/2023 documented to place the resident on Contact Precautions for positive VRE of the urine. A Physician's order dated 10/18/2023 documented to implement Contact and Droplet Precautions for COVID-19 exposure for 10 days. A medication administration task observation for Resident #141 was performed by Registered Nurse (RN #2) on 10/20/2023 at 8:25 AM. Resident #141 was observed in their bed located by the window. The bed by the door was empty and was previously occupied by a resident who tested positive for COVID-19 infection on 10/19/2023. Outside Resident #141's door was a contact precautions sign and a droplet precautions sign. The contact precaution sign documented, everyone must put on gloves before room entry and discard gloves before room exit; put on a gown before room entry and discard the gown before room exit; and clean hands before entering and when leaving the room. The droplet precaution sign documented everyone must make sure their eyes, nose, and mouth are fully covered before room entry; remove face protection before room exit; and clean hands before entering and when leaving the room. RN #2 donned gloves, a gown, and wore a surgical mask; however, RN #2 did not wear eye protection. RN #2 then entered the room to take the resident's blood pressure. RN #2 returned to the medication cart, which was outside the room, after taking the resident's blood pressure. RN #2 removed their (RN #2) gloves and sanitized their (RN #2) hands but did not remove the gown. The gown was observed coming in contact with the medication cart as the nurse prepared the medications to be administered. The nurse then put on gloves and re-entered the room and administered the medications. After the medications were administered, the nurse again returned to the cart and removed the gloves and sanitized their hands but did not remove the gown. RN #2 stated the resident refused three medications and the nurse brought the refused medications to the medication cart. RN #2 opened the medication cart drawer and reviewed the resident's blister packs to determine which medications were refused. RN #2 was observed wearing the same gown. RN #2 stated she did not wear eye protection because Resident #141 was tested for COVID-19 infection yesterday and was negative. RN #2 stated if the resident was COVID-19 positive, they (RN #2) would wear eye protection. RN #2 stated they should have removed the gown before exiting the room and will now have to sanitize the medication cart. The Infection Preventionist/Assistant Director of Nursing Services (RN #3) was interviewed on 10/20/2023 at 9:36 AM. RN #3 stated RN #2 should have taken the gown off before exiting the room. RN #3 stated the nurses are taught to prepare for medication administrations prior to going into the resident's room so they do not have to go back and forth and alleviate the need to put on and take off the PPE. The Director of Nursing Services (DNS) was interviewed on 10/25/2023 at 11:50 AM and stated RN #2 should have removed the gown before exiting the resident's room. The DNS further stated that the nurses are instructed to keep the medication cart outside the resident's room and that all PPE must be removed when leaving the room. 1 b) A medication administration task observation for Resident #141 was performed by Registered Nurse (RN #2) on 10/20/2023 at 8:25 AM. Resident #141 was observed in their bed located by the window. The bed by the door was empty and was previously occupied by a resident who tested positive for COVID-19 infection on 10/19/2023. Outside Resident #141's door was a contact precautions sign and a droplet precautions sign. The contact precaution sign documented, everyone must put on gloves before room entry and discard gloves before room exit; put on a gown before room entry and discard the gown before room exit; and clean hands before entering and when leaving the room. The droplet precaution sign documented everyone must make sure their eyes, nose, and mouth are fully covered before room entry; remove face protection before room exit; and clean hands before entering and when leaving the room. While RN #2 was preparing the medications for Resident #141 at the medication cart, Maintenance Worker #1 entered Resident #141's room carrying tools. The maintenance worker did not put on a gown, gloves, mask, or eye protection. Maintenance Worker #1 placed the tools on the overbed table belonging to the unoccupied bed near the door and then walked over to Resident #141's bed area to check some wires. Maintenance Worker #1 then collected the tools and exited the room without sanitizing their hands. Maintenance Worker #1 was interviewed on 10/20/2023 at 9:07 AM and stated they did not realize there were contact and droplet signs present outside the resident's room door. Maintenance Worker #1 stated they just went into the room to check something because last night they were moving beds around due to the COVID-19 outbreak in the facility. The Infection Preventionist/Assistant Director of Nursing Services (RN #3) was interviewed on 10/20/2023 at 9:36 AM. RN #3 stated the maintenance worker should have put on appropriate PPE, including a gown, gloves, and a mask, before entering the resident's room. The Director of Nursing Services (DNS) was interviewed on 10/25/2023 at 11:50 AM and stated Maintenance Worker #1 should have put on appropriate PPE as per the signage before entering the resident's room. The DNS stated the education for maintenance staff is provided by nursing staff and is re-iterated by Maintenance Director. 28670 2) Resident #617 was admitted with diagnoses that include Hypertension, Left Femur Fracture, and Anxiety Disorder. The Minimum Data Set (MDS) assessment was not available due to the resident being newly admitted to the facility. The Nursing Admission assessment dated [DATE] documented the resident was oriented to person, place, and time. During an observation on 10/23/2023 between 11:40 AM to 11:55 AM. There was a sign for droplet and contact precautions posted on the door frame of the resident's room. Certified Occupational Therapist Assistant (COTA) #2 was observed in Resident #617's room providing a therapy session. COTA #2 was observed within three feet of the resident and was not wearing a gown or gloves. COTA #2 had a mask and a face shield in place. COTA #2 was interviewed on 10/23/2023 at 11:55 AM and stated they were aware that Resident #617 was on Transmission Based Precautions (TBP) and they were supposed to be wearing full Personal Protective Equipment (PPE) including a gown and gloves. COTA #2 stated they made a mistake by entering the resident's room without wearing a gown and gloves. Registered Nurse (RN) #10 was interviewed on 10/23/2023 at 11:58 AM and stated that Resident #617 was on TBP due to COVID-19 exposure. RN #10 stated full PPE should be worn upon entering a resident's room who is on TBP. Full PPE includes an N95 mask, eye protection, a gown, and gloves. RN #10 stated that COTA #2 should have donned full PPE, including a gown and gloves prior to entering Resident #617's room. The Infection Control Preventionist (ICP) was interviewed on 10/23/2023 at 12:05 PM and stated that COTA #2 should have donned full PPE including a gown and gloves prior to entering the room of a resident who was on TBP. The ICP stated full PPE includes an N95 mask, eye protection, a gown, and gloves. A Physician's order dated 10/25/2023 documented to implement contact and droplet precaution for 10 days starting from 10/19/2023 for COVID-19 exposure until 10/29/2023. The Director of Nursing Services (DNS) was interviewed on 10/25/2023 at 11:50 AM. The DNS stated that all staff were inserviced regarding using appropriate PPE when entering a resident's room who is on TBP. The DNS stated that COTA #2 should have put on a gown and gloves when they entered Resident #617's room. 10 NYCRR 415.19(a)(1-3)

Based on record review and staff interviews during the Recertification Survey initiated on 10/19/2023 and completed on 10/25/2023 the facility did not ensure that all alleged violations of resident abuse, neglect, exploitation, or mistreatment were thoroughly investigated. This was identified for one (Resident #113) of four residents reviewed for accidents. Specifically, on 9/7/2023 Resident #113 was observed by Certified Nursing Assistant (CNA) #3 sitting on the toilet in their (Resident #113) room. The resident required extensive assistance of one staff member for toileting; however, CNA #3 did not stay with the resident. The resident subsequently was found on the floor in their room and complained of left hip pain upon assessment. Resident #113 was transferred to the hospital and was diagnosed with a hip fracture. The facility investigation did not include a statement from CNA #3 or any indication that Resident #113 was left on the toilet. The finding is: The facility's policy titled Resident Accident Reporting and Investigation, dated 7/2020, documented the report is a summary of the circumstances surrounding an episode, including statements from staff on duty and all witnesses at the time of the occurrence and any related treatment or investigations to be documented and submitted by the nursing supervisor to the Director of Nursing Services (DNS) no later than 24 hours following the occurrence. The nursing supervisor will obtain relevant statements from all staff, and witnesses, including the resident. Statements will be attached, summarized, and documented in the accident report and investigation form. The DNS reviews all accident reports to ensure accurate and complete documentation of the incident and to determine if there is credible evidence to substantiate an allegation of abuse. Resident #113 was admitted with diagnoses including Non-Alzheimer's Dementia, Traumatic Brain Injury, and Depression. The 8/13/2023 Significant Change Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The resident had short and long term memory problems, required extensive assistance of one staff member for transfers, toilet use, and personal hygiene; and was not steady moving on and off the toilet and for walking. The resident was only able to stabilize with staff assistance. The Nursing Care Profile (instructions provided to CNAs regarding resident care needs) for Resident #113, dated 8/6/2023, documented that the resident was unsteady, had impaired judgment, and was impulsive and confused. The resident needed Help A Lot with assistance of one staff member for toileting and hygiene. For walking and transfers the resident required Support Hold. The care profile documented that the resident had a clip alarm (alarm clipped to the resident and the wheelchair to alert staff if the resident rises unattended) for the wheelchair and a pressure-sensitive alarm for the bed. A Situation Background Assessment Recommendation (SBAR) note dated 9/7/2023 documented Resident #113 fell and complained of left hip/buttock pain on 9/7/2023 at 9:45 AM. The summary of observations documented the resident was observed lying on their right side and complaining of pain to the left hip/buttock. The resident stated they were unable to move the left lower extremity. The Physician was notified, and the resident was sent to the emergency room . The SBAR note documented this was an unwitnessed fall. The Accident Report dated 9/7/2023 documented Resident #113 was observed lying on their right side next to their bed. The resident stated, I slipped. The resident complained of pain to the left hip/buttock area during the range of motion. The Physician was contacted, and the resident was transferred to the emergency room for further evaluation. A written statement from Registered Nurse (RN) #4, who was the charge nurse, dated 9/7/2023 documented the resident was observed lying on the right side and was complaining of left hip/buttock pain. The clip alarm was sounding, and the alarm string was found in the garbage. Certified Nursing Assistant (CNA) #2, who was the assigned CNA for Resident #113, dated 9/7/2023 documented in their written statement that they were on their break and did not witness the incident. CNA #2 documented they provided morning care to the resident and last saw the resident at 9:30 AM. A written statement from RN #5 dated 9/7/2023 documented that Resident #113's roommate called for help. RN #5 found Resident #113 on the floor by the bed on the right side. The alarm was sounding. A written statement from RN #6, the RN Supervisor, dated 9/7/2023 documented the resident was walking without assistance and slipped. The incident was unwitnessed, and the only person listed as involved with the resident was CNA #2. The investigation summary completed by the Director of Nursing Services (DNS) dated 9/8/2023 documented the resident had a history of falling secondary to gait disturbance and memory impairment. The resident frequently gets up unassisted and attempts to ambulate unassisted. The resident resides on a secure unit due to his wandering and risk for elopement. The resident's cognition prevents them from requesting assistance or using appropriate devices to increase safety. Resident #113 was last seen by the assigned CNA at 9:30 AM. At 9:45 AM, the resident's chair alarm was sounding and when staff responded, the resident was observed on the floor on their right side. The Clip alarm string was detached and was found in the garbage. The resident was admitted to the hospital with a left hip fracture. The resident received all appropriate care per their care plan and was last taken care of 15 minutes prior to the fall. No evidence of abuse, neglect, or mistreatment was noted. The summary added an addendum on 9/14/2023 that documented resident was noted with new-onset atrial fibrillation (an irregular and often very rapid heart rhythm) and started on medication. The facility concluded that it is reasonable and likely that the abnormal heart rhythm may have contributed to the resident falling which would not have been able to be avoided due to this acute medical event. CNA #2 was assigned to Resident #113 during the 7:00 AM to 3:00 PM shift. During an interview on 10/24/2023 at 10:21 AM, CNA #2 stated they were on their break when Resident #113 fell . CNA #2 stated before they went on their break, they placed the Resident in their wheelchair in their room. The wheelchair had a chair alarm. CNA #2 stated the resident self-propels their wheelchair all over the place and can be left safely in their room in the wheelchair. RN #4 charge nurse was interviewed on 10/24/2023 at 10:29 AM and stated the resident might have attempted to go to the bathroom and fell . RN #4 stated the resident removed the string that was attached from the chair alarm to the resident and put the string in the garbage. RN #4 stated staff responded, and the resident was already on the floor. RN #4 stated the resident was non-compliant and would get up on their own but would be safe to be left alone in their room for short periods. RN #2 stated they thought the resident was found by CNA #3. CNA #3 was interviewed on 10/24/2023 at 2:20 PM and stated they were covering for CNA #2's assignment while CNA #2 was on their break on 9/7/2023. CNA #3 stated they heard the chair alarm sounding and went into Resident #113's room. The resident was sitting on the toilet at the time. CNA #3 stated that RN #5 also came into the room, and they told RN #5 that the resident was on the toilet. CNA #3 stated the resident seemed stable on the toilet, so CNA #3 left the room. CNA #3 stated RN #5 did not stay in the room either. CNA #3 stated they wanted to give the resident privacy. When CNA #3 went back to see if the resident was done toileting, RN #4 told them Resident #113 was on the floor. CNA #3 stated they had to write a statement regarding Resident #113's fall that day. CNA #3 further stated they did not know Resident #113 was a fall risk. The Accident Report dated 9/7/2023 did not include a written statement from CNA #3. RN #4 was re-interviewed on 10/24/2023 at 2:49 PM and stated they thought about Resident #113's fall on 9/7/2023 and now recalled that the resident was on the toilet. RN #4 stated they were not sure if the resident put themselves on the toilet or if CNA #3 put the resident on the toilet. RN #4 stated Help A Lot in the Nursing Care Profile means the resident needs extensive assistance with toileting. RN #4 stated the CNA did not have to stay in the bathroom. The CNA had to stay in the resident's room because the resident requires extensive assistance to complete the toileting process. The written statement provided by RN #4 for the Accident Report dated 9/7/2023 did not include the resident being found sitting on the toilet by CNA #3. CNA #2 was re-interviewed on 10/25/2023 at 8:34 AM and stated they had notified CNA #3 that they were going on their break. CNA #2 stated when they returned, CNA #3 told them the chair alarm for Resident #113 had sounded, and CNA #3 had turned the alarm off. CNA #3 told CNA #2 that Resident #113 was in the bathroom sitting on the toilet, CNA #3 left the resident in the bathroom and told RN #5 that the resident was sitting on the toilet. CNA #2 stated that when they took Resident #113 to the bathroom, they always stayed outside the bathroom door because the resident required extensive assistance to complete toileting. RN #6, assessed Resident #113 on 9/7/2023 after the fall. RN #6 was interviewed on 10/25/2023 at 10:26 AM and stated CNA #3 responded to Resident #113's chair alarm and reported that the resident was sitting on the toilet. CNA #3 left the resident's room because they thought the resident would be okay. RN #6 stated they obtained CNA #3's statement. RN #6 then wrote up CNA #3 because if the CNA was not sure of the resident's toileting needs, they should not have left the resident alone. RN #6 stated the DNS was aware that CNA #3 left Resident #113 alone in the bathroom and that CNA #3 was written up. RN #6 stated they left CNA#3's counseling record and their written statement in the DNS's mailbox. The written statement provided by RN #6 for the Accident Report dated 9/7/2023 did not include the resident being found sitting on the toilet by CNA #3. A review of the 9/7/2023 accident report revealed that there was no statement included from CNA #3, there was no documentation regarding the CNA being written up, and there was no indication in the report that the resident was first identified on the toilet by a staff member and that the staff member did not stay with the resident. The DNS was interviewed on 10/25/2023 at 11:50 AM. After reviewing the accident report the DNS stated they were not aware that CNA #3 had responded to Resident #113's chair alarm and had found the resident sitting on the toilet prior to the incident. The DNS stated that if the Nursing Care Profile indicated Help a Lot for resident care needs then the resident should not have been left alone in the bathroom. The DNS stated if there was a statement from CNA #3, then that statement should have been included in the accident report. The DNS stated that all write-ups are submitted to them (DNS). The DNS stated there were not any write-ups for CNA #3 related to the 9/7/2023 incident. The DNS stated the accident report is supposed to be completed when the report is submitted to them. 10 NYCRR 415.4(b)(1)(ii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/19/2023 and completed on 10/25/2023 the facility did not ensure each resident received adequate supervision to prevent avoidable accidents. This was identified for two (Resident #113 and Resident 31) of four residents reviewed for accidents. Specifically, 1) Resident #113, who required extensive assistance of one staff member for toileting, was left unattended in the bathroom. Subsequently Resident #113 was found on the floor in their room, was transferred to the hospital and diagnosed with a hip fracture. 2) Resident #31 required extensive assistance with personal hygiene, including shaving. A used disposable razor was observed in the resident's room with no staff in the vicinity. The findings are: 1) The facility's policy titled Fall Prevention Program, dated 11/2017, documented to identify the fall risk of all residents and outline interdisciplinary interventions to prevent falls. A care plan for the prevention of falls will reflect interventions for fall prevention and injury reduction. The policy documented residents will be assessed for fall risk using the Morse Fall Scale (assessment tool to identify fall risk) with high risk 45 and over, moderate risk 25-44, and low risk 0-24. The policy included a care plan intervention to not leave residents unattended in the bathroom and to ensure toileting needs are care planned. Resident #113 was admitted with diagnoses including Non-Alzheimer's Dementia, Traumatic Brain Injury, and Depression. The 8/13/2023 Significant Change Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The resident had short and long term memory problems, required extensive assistance of one staff member for transfers, toilet use, and personal hygiene; and was not steady moving on and off the toilet and for walking. The resident was only able to stabilize with staff assistance. A Comprehensive Care Plan (CCP) dated 6/29/2021 and last updated 9/7/2023, for Falls/Injury documented that the resident was at Risk for Falls/Injury related to medication use, wandering/elopement, balance impairment, cognitive impairment, and gait/balance problems. The interventions included to toilet the resident with appropriate staff assistance every 2-4 hours and as needed and that the resident uses a chair alarm and a pressure-sensitive bed alarm. The Morse Fall Risk Assessment from the 8/6/2023 nursing admission assessment documented a fall risk score of 80, indicating Resident #113 was at high risk for falls. The Nursing Care Profile (instructions provided to CNAs regarding resident care needs) for Resident #113, dated 8/6/2023, documented that the resident was unsteady, had impaired judgment, and was impulsive and confused. The resident needed Help A Lot with assistance of one staff member for toileting and hygiene. For walking and transfers the resident required Support Hold. The care profile documented that the resident had a clip alarm (alarm clipped to the resident and the wheelchair to alert staff if the resident rises unattended) for the wheelchair and a pressure-sensitive alarm for the bed. There was no documented evidence in the Nursing Care Profile with a description for Help A Lot and Support Hold to guide nursing staff on how much assistance was required for the resident. A Situation Background Assessment Recommendation (SBAR) note dated 9/7/2023 documented Resident #113 fell and complained of left hip/buttock pain on 9/7/2023 at 9:45 AM. The summary of observations documented the resident was observed lying on their right side and complaining of pain to the left hip/buttock. The resident stated they were unable to move the left lower extremity. The Physician was notified, and the resident was sent to the emergency room . The SBAR note documented this was an unwitnessed fall. The Accident Report dated 9/7/2023 documented Resident #113 was observed lying on their right side next to their bed. The resident stated, I slipped. The resident complained of pain to the left hip/buttock area during the range of motion. The Physician was contacted, and the resident was transferred to the emergency room for further evaluation. A written statement from Registered Nurse (RN) #4, who was the charge nurse, dated 9/7/2023 documented the resident was observed lying on the right side and was complaining of left hip/buttock pain. The clip alarm was sounding, and the alarm string was found in the garbage. Certified Nursing Assistant (CNA) #2, who was the assigned CNA for Resident #113, dated 9/7/2023 documented in their written statement that they were on their break and did not witness the incident. CNA #2 documented they provided morning care to the resident and last saw the resident at 9:30 AM. A written statement from RN #5 dated 9/7/2023 documented that Resident #113's roommate called for help. RN #5 found Resident #113 on the floor by the bed on the right side. The alarm was sounding. A written statement from RN #6, the RN Supervisor, dated 9/7/2023 documented the resident was walking without assistance and slipped. The incident was unwitnessed, and the only person listed as involved with the resident was CNA #2. The investigation summary completed by the Director of Nursing Services (DNS) dated 9/8/2023 documented the resident had a history of falling secondary to gait disturbance and memory impairment. The resident frequently gets up unassisted and attempts to ambulate unassisted. The resident resides on a secure unit due to his wandering and risk for elopement. The resident's cognition prevents them from requesting assistance or using appropriate devices to increase safety. Resident #113 was last seen by the assigned CNA at 9:30 AM. At 9:45 AM, the resident's chair alarm was sounding and when staff responded, the resident was observed on the floor on their right side. The Clip alarm string was detached and was found in the garbage. The resident was admitted to the hospital with a left hip fracture. The resident received all appropriate care per their care plan and was last taken care of 15 minutes prior to the fall. No evidence of abuse, neglect, or mistreatment was noted. The summary added an addendum on 9/14/2023 that documented resident was noted with new-onset atrial fibrillation (an irregular and often very rapid heart rhythm) and started on medication. The facility concluded that it is reasonable and likely that the abnormal heart rhythm may have contributed to the resident falling which would not have been able to be avoided due to this acute medical event. The hospital consult note Adult-Nephrology Attending dated 9/10/2023 documented under the assessment section that Resident #113 was with history of Hypertension, Hyperlipidemia (high cholesterol level), and Dementia presented with fall and subsequent fracture, left hip repair on 9/8/2023; since then, the creatinine is rising and new onset Atrial Fibrillation with low-grade fevers. On 10/24/2023 at 10:17 AM Resident #113 was observed in the dayroom sitting in their wheelchair. The resident had a chair alarm and was utilizing an abduction wedge cushion separating the knees. The resident was observed with a wander guard on the left wrist. The resident was observed self-propelling out of the day room. CNA #2 was assigned to Resident #113 during the 7:00 AM to 3:00 PM shift. During an interview on 10/24/2023 at 10:21 AM, CNA #2 stated they were on their break when Resident #113 fell . CNA #2 stated before they went on their break, they placed the Resident in their wheelchair in their room. The wheelchair had a chair alarm. CNA #2 stated the resident self-propels their wheelchair all over the place and can be left safely in their room in the wheelchair. RN #4 charge nurse was interviewed on 10/24/2023 at 10:29 AM and stated the resident might have attempted to go to the bathroom and fell . RN #4 stated the resident removed the string that was attached from the chair alarm to the resident and put the string in the garbage. RN #4 stated staff responded, and the resident was already on the floor. RN #4 stated the resident was non-compliant and would get up on their own but would be safe to be left alone in their room for short periods. RN #2 stated they thought the resident was found by CNA #3. CNA #3 was interviewed on 10/24/2023 at 2:20 PM and stated they were covering for CNA #2's assignment while CNA #2 was on their break on 9/7/2023. CNA #3 stated they heard the chair alarm sounding and went into Resident #113's room. The resident was sitting on the toilet at the time. CNA #3 stated that RN #5 also came into the room, and they told RN #5 that the resident was on the toilet. CNA #3 stated the resident seemed stable on the toilet, so CNA #3 left the room. CNA #3 stated RN #5 did not stay in the room either. CNA #3 stated they wanted to give the resident privacy. When CNA #3 went back to see if the resident was done toileting, RN #4 told them Resident #113 was on the floor. CNA #3 stated they had to write a statement regarding Resident #113's fall that day. CNA #3 further stated they did not know Resident #113 was a fall risk. The Accident Report dated 9/7/2023 did not include a written statement from CNA #3. RN #4 was re-interviewed on 10/24/2023 at 2:49 PM and stated they thought about Resident #113's fall on 9/7/2023 and now recalled that the resident was on the toilet. RN #4 stated they were not sure if the resident put themselves on the toilet or if CNA #3 put the resident on the toilet. RN #4 stated Help A Lot in the Nursing Care Profile means the resident needs extensive assistance with toileting. RN #4 stated the CNA did not have to stay in the bathroom. The CNA had to stay in the resident's room because the resident requires extensive assistance to complete the toileting process. The written statement provided by RN #4 for the Accident Report dated 9/7/2023 did not include the resident being found sitting on the toilet by CNA #3. CNA #2 was re-interviewed on 10/25/2023 at 8:34 AM and stated they had notified CNA #3 that they were going on their break. CNA #2 stated when they returned, CNA #3 told them the chair alarm for Resident #113 had sounded, and CNA #3 had turned the alarm off. CNA #3 told CNA #2 that Resident #113 was in the bathroom sitting on the toilet, CNA #3 left the resident in the bathroom and told RN #5 that the resident was sitting on the toilet. CNA #2 stated that when they took Resident #113 to the bathroom, they always stayed outside the bathroom door because the resident required extensive assistance to complete toileting. Multiple calls were made to RN #5 and voice messages were left with no return call. Review of the hospital discharge instructions with a hospital admitted [DATE] documented Resident #113 sustained a left hip fracture which required surgical repair. RN #6, assessed Resident #113 on 9/7/2023 after the fall. RN #6 was interviewed on 10/25/2023 at 10:26 AM and stated CNA #3 responded to Resident #113's chair alarm and reported that the resident was sitting on the toilet. CNA #3 left the resident's room because they thought the resident would be okay. RN #6 stated they obtained CNA #3's statement. RN #6 then wrote up CNA #3 because if the CNA was not sure of the resident's toileting needs, they should not have left the resident alone. RN #6 stated the DNS was aware that CNA #3 left Resident #113 alone in the bathroom and that CNA #3 was written up. RN #6 stated they left CNA#3's counseling record and their written statement in the DNS's mailbox. The written statement provided by RN #6 for the Accident Report dated 9/7/2023 did not include the resident being found sitting on the toilet by CNA #3. The DNS was interviewed on 10/25/2023 at 11:50 AM and stated that Help A Lot means the resident needs a lot of help from one staff member to assist with hygiene and getting the resident on and off the toilet and that the resident cannot be left alone during toileting. The DNS stated when a CNA goes on break, the Nursing Care Profile information is available on the unit for the covering CNAs to review. The DNS stated even if the CNA is a floater and not familiar with the resident, the Nursing Care Profile information is on the unit. The DNS stated if the CNA comes into a situation like this and they do not know the resident, the CNA should call for help and stay with the resident if they do not know the resident. The DNS further stated that knowing that Resident #113 is so high risk of falling, the staff should have stayed with the resident and should have anticipated a potential fall being that the chair alarm was ringing. The Primary Care Physician was interviewed on 10/25/2023 at 12:47 PM and stated it is not their call to determine if a CNA should have stayed with the resident in the bathroom; CNAs cannot just stand there and wait. The Primary Care Physician stated they do not see how an aide could just stand there; all the residents on that unit are at risk for falls and 9:45 AM is a peak time. 41051 2) The facility's Safety/Hazard in the Environment policy dated 11/2017 documented to ensure each resident has a safe, clean, comfortable, and homelike environment. The Certified Nursing Assistant (CNA) is responsible for ensuring that all wastes, including grooming items that can present any harm, are removed frequently. The Nurse Supervisor/charge nurse shall conduct environmental rounds daily. Rounds will include observations, inspection and follow-up of findings requiring correction within the resident and unit environment. The facility's Shaving with Disposable Razor policy dated 4/2023 documented disposable razors should be discarded in the red sharps container after use. If a resident wishes to utilize their own supply of razors, razors should be stored in the resident's drawer with personal hygiene items. Resident #31 was admitted with diagnoses of [NAME]-Sachs Disease (a genetic neurological disorder), Epilepsy, and Muscle Wasting. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #31 had intact cognition. The MDS also documented that Resident #31 required extensive assistance of one person for personal hygiene, including shaving. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL) Self-Care, dated 10/4/2023 documented Resident #31 required substantial/maximal assistance with personal hygiene, including shaving related to limited Range of Motion (ROM), Musculoskeletal impairment, limited mobility, disease process, impaired balance, [NAME]-Sachs Disease, Quadriparesis (muscle weakness in all four limbs) and Paraplegia (paralysis of the lower body). The CCP was updated on 10/16/2023 to include an intervention that Resident #31 received a new electric razor and would like to have it used as needed when they need to be shaved. During an initial tour on 10/19/2023 at 10:46 AM a disposable razor was observed on the sink in Resident #31's room. The door to Resident #31's room was open, and the disposable razor was visible from the doorway. Resident #31 was not in the room at the time of observation. CNA #4 was interviewed on 10/19/2023 at 10:49 AM and stated that Resident #31 is shaky and cannot use an electric or disposable razor by themselves. CNA #4 stated another CNA usually assisted Resident #31 with shaving and they (CNA #4) never saw the disposable razor being used for Resident #31. Licensed Practical Nurse (LPN) #2 was interviewed on 10/19/2023 at 10:51 AM and stated Resident #31 cannot use a razor by themselves because they (Resident #31) were right hand dominant and as a result of [NAME]-Sachs Disease Resident #31 lost use of their right hand. During a second observation on 10/19/2023 at 10:56 AM the disposable razor was again observed in the sink area in Resident #31's room after both CNA #4 and LPN #2 were interviewed regarding the presence of a disposable razor in Resident #31's room. Resident #31 was interviewed on 10/20/2023 at 12:05 PM. Resident #31 was sitting in an electric wheelchair. The resident was maneuvering the electric wheelchair with their left hand. Resident #31 stated they no longer had use of their right hand and had limited use of the left hand. Resident #31 stated the disposable razor was used within the last week but could not remember on which day and which staff person shaved their (Resident #31) head and face. Resident #31 stated they were not able to shave themselves. Resident #31 stated they did not know why the disposable razor was by the sink. Resident #31 then stated that the disposable razor was usually placed in the blue basket behind the faucet of the sink. Resident #31 located the razor in the top drawer of their dresser, and it was observed in the drawer with a protective plastic cover. CNA #7 was interviewed on 10/24/2023 at 1:19 PM and stated they work during the 7:00 AM to 3:00 PM shift and were regularly assigned to Resident #31. CNA #7 stated they assisted Resident #31 with morning care because Resident #31 cannot use their (Resident #31's) hands for all ADLS and required total assistance with shaving. CNA #7 stated they use an electric razor to shave Resident #31's head and face and have never used the disposable razor. CNA #7 stated they (CNA #7) saw a resident from another unit wandering into a resident's room. Registered Nurse (RN) #9 was interviewed on 10/24/2023 at 3:23 PM and stated personal hygiene items should be stored in a locked drawer in the resident's room. RN #9 stated Resident #31's disposable razor should have been stored in a drawer so that no other resident could access it and hurt themselves. RN #9 stated they do not have any wandering residents on the unit but two residents from the adjacent unit do wander down the hallway onto this unit. RN #9 stated Resident #31 is not able to use their (Resident #31) hands to complete self-care skills and would not be able to use a disposable razor safely. RN #9 stated the disposable razor should have been put in a drawer by LPN #2 or CNA #4 as soon as it was brought to their attention on 10/19/2023. The Rehabilitation Director was interviewed on 10/25/2023 at 11:32 AM and stated Resident #31 receives Physical Therapy (PT) and Occupational Therapy (OT) services for fine and gross motor skills. Certified Occupational Therapy Assistant (COTA) #1 and Physical Therapy Assistant (PTA) #1 were interviewed concurrently on 10/25/2023 at 11:52 AM. COTA #1 stated Resident #31's fine motor skill tasks include manipulating small puzzle pieces and gross motor skills tasks include using the whole hand such as holding and grasping a cup. COTA #1 stated that Resident #31 would likely hurt themselves if they tried to use a disposable razor. PTA #1 stated the resident is not capable of using a disposable razor safely. The Director of Nursing Services (DNS) was interviewed on 10/25/2023 at 2:25 PM. The DNS stated a razor with a blade should not be left out and accessible to residents for safety reasons. The DNS stated the disposable razor should have been put in a drawer as soon as it was brought to the attention of LPN #2 and CNA #4. 10 NYCRR, 415.12 (h) (2); 415.12 (h)(1)

Based on observations, interviews, and record review during the COVID-19 Focused Infection Control Survey conducted on 03/10/2021, the facility failed to ensure facility staff, including individuals providing services under arrangement and volunteers, were tested for COVID-19 that is consistent with current infection control measures for staff testing. Specifically, one of two vendors (Vendor #1) did not have documented evidence of COVID-19 testing upon entering the facility. The Finding is: The Centers for Medicare and Medicaid Services (CMS) QSO-20-14-NH Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Nursing Homes dated 03/13/2020 and updated on 9/28/2020 documented: Facilities should review and revise how they interact with vendors . and other non-health care providers (e.g., food delivery, etc.), and take necessary actions to prevent any potential transmission. For example, do not have supply vendors transport supplies inside the facility. Have the supplies dropped off at a dedicated location (e.g., loading dock). Facilities can allow entry of these visitors if needed, as long as they are following the appropriate CDC [Centers for Disease Control and Prevention] guidelines for Transmission-Based Precautions. The Department of Health guidance, Health Advisory: Revised Skilled Nursing Facility Visitation, dated 09/17/2020, documented that if a facility meets metrics to reopen for visitation: Visitors, including long-term care ombudsman, are screened for signs and symptoms of COVID-19 prior to resident access. Additionally, the visitor must present a verified negative test result within the last week (7 days) and visitation must be refused if the individual(s) fails to present such negative test result, exhibits any COVID-19 symptoms, or does not pass screening questions. The facility Policy and Procedure titled COVID-19 Prevention, dated 4/2020 documented that the Facility should have posted signs to alert vendors of warnings prior to making deliveries; Vendors are required to complete a screening upon arrival to facility; Any vendor identified to be at risk should be denied access to the facility. When feasible, facility should arrange for curbside or loading dock only deliveries. On 3/10/2021 at 3:15 PM Vendor #1 was observed wearing a surgical mask, face shield, gown, and gloves when delivering an air mattress to a resident room (316) located on the COVID-19 positive unit. Vendor #1 was interviewed on 3/10/2021 at 3:16 PM and stated he thought he was last tested for COVID-19 about 4 weeks ago. He stated he was screened at the front desk and was provided PPE; however, no one asked him to provide evidence of a recent COVID-19 test results. The Administrator and the Director of Nursing Services (DNS) were interviewed concurrently on 3/10/2020 at 3:45 PM. The Administrator stated the vendors are expected to be swabbed for COVID-19 at least weekly. She stated the facility required the contractors and vendors to complete the nursing home required testing for each vendor before entering the facility. In a subsequent concurrent interview with the Administrator and the DNS on 3/12/2021 at 12:42 PM the Administrator stated that she could not confirm the last date of the COVID-19 testing for Vendor #1. The receptionist should have requested Vendor #1's COVID-19 test results. If Vendor #1 did not have documented evidence of the COVID-19 test results the receptionist should have contacted the Administrator for further guidance. The receptionist did not contact the Administrator or the DNS. The Administrator further stated if she was aware of the issue, she would have asked Vendor #1 to leave the mattress outside the facility. Additionally, the Administrator stated that the Vendor could have received a rapid COVID-19 test and waited outside until the results were obtained for him to be able to enter the facility. 415.19(a)(1-2), 400.2

Based on interviews and record review during an abbreviated survey (Complaint # NY 507), the facility did not ensure resident rights to be free from abuse for one (Resident #1) of three residents reviewed for Abuse. Specifically, a Certified Nurse's Aide (CNA) pushed Resident #1 in her bed using his hand over her head/face three times when the resident was trying to get out of bed. Resident #1 was cognitively intact and provided a consistent account of the incident. The finding was: The facility's policy titled Reporting and Investigation of Resident Abuse/Neglect, or Mistreatment dated 11/2016 documented all alleged violations and results of investigations shall be reported immediately to the Administrator/DNS. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish. Willful is defined as the individual must have acted deliberately not that individual must have intended to inflict injury or harm. Physical Abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. The facility's policy further documented, all staff members have an obligation to report any reasonable suspicion of a crime to the police and State Survey Agency. The employee must make the report to the police within 2 hours if the suspected crime involves serious bodily injury to the individual, or within 24 hours if there is no serious bodily injury involved. The facility will determine the necessity of involving law enforcement. Resident #1 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 6/15/19 documented the resident's cognitive status as intact. She required extensive assistance of 2 persons with bed mobility, transfer and toilet use and extensive assistance of one person for personal hygiene and dressing. The CNA Accountability Record dated 6/8/19 documented, the resident was alert and oriented, impulsive, and anxious. The resident had verbal outbursts and needed tender loving care (TLC). The Comprehensive Care Plan (CCP) titled Activity of Daily Living (ADL) dated 6/10/19 documented self-care performance deficit related to decreased mobility. Interventions included providing extensive assistance of two persons for bed mobility, extensive assist of one person for transfer, dressing, and personal hygiene. The CCP titled Behavior dated 6/13/19 documented the resident frequently called out during the night. Interventions included providing a calm environment, adjust temperature, noise, lighting or stimulation for the resident's comfort. Approach the resident calmly and use a friendly tone of voice, slow, careful gestures. Monitor and evaluate signs and symptoms of confusion. The Accident/Incident Report and facility's investigation dated 7/28/19 documented, the resident was heard calling out stop hurting me. The resident was interviewed by the Registered Nursing Supervisor (RNS), Charge nurse, Director of Nursing (DNS), and the Administrator. The resident provided a consistent account of the incident. The resident alleged that CNA #1 pushed her down on the bed three times, using his hand over her forehead. The Resident stated the CNA was angry, he used foul language and berated her for calling out. The resident was assessed and had no injuries. The resident provided a consistent account of this alleged incident several times. The facility concluded that there was probable cause to believe abuse, neglect or mistreatment occurred. CNA #1 was terminated from the facility. The Medical Progress Note (MPN) dated 7/29/19 documented, according to the patient, the CNA was verbally abusive and placed his hand over her face and pushed her head to the pillow three times asking her to shut up. She denied any head or neck pain and had the usual range of motion of her cervical spine. She felt shocked by CNA's attitude and aggression. No physical injuries were sustained post altercation with CN[NAME] The Psychology consult dated 7/29/19 documented, the resident was very upset about a traumatic incident that took place between herself and an aide during the night shift. The resident reported the aide began to become loud and yelled at her when she asked to get her up out of her bed. She asked the aide for ice water. After having a few sips, the aide took the water away from her and threw it in the sink. Then the aide pushed her down into her bed by pressing his hand on her face and repeatedly pushed her face down at least two more times. The Social Worker (SW) note dated 7/30/19 documented the resident stated she was doing fine but shaken up about the incident. The CNA #1's personnel file documented he received in-service on Resident Abuse, Mistreatment, Neglect Prevention and Reporting on 5/3/18 and 2/11/19. CNA #1 had been counseled in the past for removing a resident's call bell. CNA #1 was terminated from the facility on 7/29/19. Resident #1 was observed on 8/23/19 at 1:45 PM lying in her bed. She was alert and oriented x 3. She stated a couple of weeks ago she asked the night aide for a can of ginger ale and he snapped at her and stated they did not have a ginger ale. She asked for ice water and the aide gave her ice water. After she had a sip, the CNA grabbed the ice water from her hand and threw the water in the sink. She told him that she did not finish drinking. The resident asked for more ice water. CNA #1 gave her the ice water and again grabbed the cup away from the resident and threw the water in the sink after she had one sip. CNA #1 told the resident that he (CNA #1) was sick of her yelling at night. She was waking other residents up and she did not have regards for other residents. CNA #1 continued badgering her. Then he put his hand on her face and pushed her to the bed/pillow and told her to stop talking. Resident #1 stated she thought of the legal term tort (a wrongful act or an infringement of a right (other than under contract) leading to civil legal liability). She stated CNA #1 was assaulting her and he had no right to touch her violently. Resident #1 stated she felt scared at that time but now, she is fine. Resident #1 stated she reported the incident to the nurse and the RNS that same night. The 3:00 PM-11:00 PM CNA #1 was interviewed via telephone on 8/23/19 2:54 PM and stated he was assigned to Resident #1 during the 11-7 shift on 7/28/19. The resident rang her call bell multiple times asking for ginger ale and water. CNA #1 provided the resident with ice water twice. He did not snatch the cup from the resident, she placed the cup on the table and then he threw the water in the sink. The resident rang again and asked to sit up in bed. The resident was constantly calling out for help. CNA #1 asked the resident not to yell as she may wake her roommate. CNA #1 told the resident that she could not sit up in bed as she was a fall risk. He offered to take her out of bed to a wheelchair, but she wanted to sit up in bed. CNA #1 told the resident to lay down. While the resident was trying to lay down in bed and he was placing the call bell on her, the RN came asked him to attend to another call bell that was going off. CNA #1 left the resident room. CNA #1 denied pushing the resident, snatching the cup from the resident or using foul language. CNA #1 stated that he received in-service on abuse, neglect, and mistreatment. He was terminated from the facility due to the complaint made by the resident. The 11:00 PM-7:00 AM Registered Nurse (RN) was interviewed on 8/23/19 at 12:32 PM and stated that Resident #1 was a fall risk. She had assigned CNA #1 to sit in front of the resident's room to watch her. The RN heard Resident #1 yelling you are hurting me, why are you doing that. The RN ran to the resident's room and saw CNA #1 standing over Resident #1's bed, and the resident was in bed and she looked fearful. CNA #1 looked angry and said: This is ridiculous, she continued to get out of bed several times and she does not listen. The RN sent CNA #1 out of the resident's room immediately. Resident #1 started crying. The resident told the RN that CNA #1 pushed her 3 times onto her bed. He used the palm of his hand on her forehead to push her down. RN stated Resident #1 was alert and oriented x3 and all her statements were credible. RN stated she did not witness the incident. The Director of Nursing (DON) was interviewed on 8/23/19 at 3:23 PM and stated that Resident #1 was credible and told the same story multiple times. Based on the investigation, there was a strong possibility that abuse occurred. CNA #1 was terminated. The incident was not reported to the police because there was no injury to the resident. The 11:00 PM- 7:00 AM RNS was interviewed on 8/26/19 at 2:30 PM and stated, Resident #1 told her that CNA #1 berated her and used foul language. CNA #1 was complaining she was waking other residents with her calling out. Resident #1 was moving around in her bed and the alarm sounded, CNA #1 pushed her head down 3 times. Resident #1 yelled out and said she was afraid of CNA #1. The RN heard the resident calling for help and went to the room. CNA #1 did not want to tell the RNS what happened. He stated he did not feel well and wanted to go home. Resident #1 had no history of fabricating a story and her statement was credible. Resident #1 stated to the RNS that she could file assault charges. The RNS did not ask Resident #1 if she wanted to call the police. Resident #1 was satisfied that the facility was investigating. 415.4(b)(1)(i)

Based on observation, record review, and interviews during the Recertification survey the facility did not ensure that each resident who is unable to carry out activities of daily living receives the necessary services in a timely manner. This was identified for one (Resident #136 ) of 1 resident reviewed for Activities of Daily Living (ADLs). Specifically, Resident #136 was requesting assistance to use the bathroom and did not receive the assistance in a timely manner. The finding is: Resident # 136 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident required extensive assistance of one person to transfer, ambulate, and for toilet use and personal hygiene. The resident was always incontinent of urine and was continent of bowel. The Comprehensive Care Plan (CCP) for Activities of Daily Living, dated 6/10/16 and last updated 1/27/19, for Toileting and Elimination due to Bladder & Bowel Management/Incontinence included goals that the resident will maintain/increase continence and/or Toileting skills and the resident will be free of signs/symptoms of Urinary/ Bowel complications through the review period. Interventions included but were not limited to: provide extensive assist of one staff, toilet per plan, check and change the resident, tell staff of need for toileting and respond promptly to call bell, toilet to help with normal elimination pattern and identify routine schedule. The CCP for falls/ injury related to Balance Impairment, Fall History, Medication Use, Psychoactive drug use dated 6/10/16, and last updated 1/27/19, had interventions including to: anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The CCP documented that the resident needs prompt response to all requests for assistance and to toilet with appropriate staff assistance every 2-4 hours and as needed. On 5/14/19 at 10:00 AM, the resident's call bell light was illuminating. The resident stated she has been waiting over 1 hour to go to the bathroom. The Registered Nurse (RN) was made aware by the surveyor and stated the resident required a two person assist to take care of her and she will find the Certified Nursing Assistant (CNA) to assist. The resident was observed at 10:30 AM, and stated she still has not been taken to the bathroom. The resident stated she has been waiting more than 1.5 hours as of 10:30 AM to receive assistance. The resident stated this was not the first time she had to wait. The resident further stated there have been many times she had to wait close to an hour to receive care. On 5/14/19 at 10:33 AM, the Resident's CNA (#1) was interviewed and stated she was busy taking care of another resident. CNA#1 stated that each resident takes about 20 minutes to take care of. She stated she did not know that the resident was waiting more than an hour. She was told by the RN, that the resident required care while she (the CNA) was caring for another resident. She stated she could not leave to take care of Resident # 136 at that time. A review of the physician orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. On 5/16/19 at 12 PM, there was no audible sound of the call bell light at the Nursing Station. The call bell light outside the resident's room was on. CNA # 2 was in the hallway near the nursing station and was asked if she could hear the call bell alarm. CNA#2 stated that she could not hear the alarm. The Director of Maintenance was made aware of the low audible level of the call bell panel on 5/16/19 at 12:00 PM and stated a new call bell system is planned for the unit. He further stated he will repair the audible level of the call bell system. On 5/16/19 at 2:30 PM the Director of Maintenance confirmed the system was repaired and provided a copy of the work order. The RN was interviewed on 5/17/19 at 9:36 AM and stated when she went to assist the resident, the resident asked for the CNA to assist her to go to the bathroom. She went and told CNA #1. The RN stated she did not monitor to see if the CNA went immediately to the resident because the RN had to care for other residents who required assistance. She stated she was not aware that the resident's call bell light was on for 1 hour and was not aware that the resident waited an additional half hour to receive care by the CNA. 415.12(a)(2)

Based on observations, record review and interviews during the Recertification survey, the facility did not ensure the resident's environment remains as free of accident hazards as is possible; and each resident receives adequate supervision to prevent accidents. This was noted for two of two residents ( Resident #222 and #261) reviewed for accidents. Specifically, two Nurses who administered medication were observed to leave the medications with the residents without ensuring the medications were taken under their observation. The findings are: A facility Medication Administration Policy effective 6/2017 documented, that Medications are not to be left with the resident; the medication nurse must observe ingestion of the drug. 1) Resident # 261 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Resident's Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) Score of 12 indicating moderately impaired cognition. The MDS documented the resident required extensive assistance of 1 person for transfers, and extensive assist of 2 persons for bed mobility. Resident # 261 was observed on 5/14/19 at 9:30 AM with approximately 7 pills in a small plastic cup on her bedside table. The resident was interviewed on 5/14/19 at 9:30 AM and stated the Nurse just left the medications with her a few minutes ago and she has to take them. She stated when the Nurse gave her the medicines she had a cough from drinking soda and was going to take the pills when her throat felt better and that the Nurse had someone else he had to go see. The resident was observed taking the pills and stated I am done. The 7:00 AM to 3:00 PM Licensed Practical Nurse (LPN) was interviewed on 05/14/19 at 9:40 AM and stated that this morning he had given the resident 9 pills including: Aspirin for [MEDICAL CONDITION] for pain, Senna (two pills) for constipation, [MEDICATION NAME] (two pills) and [MEDICATION NAME] for Depression, [MEDICATION NAME] for gastro intestinal [MEDICATION NAME] and a Multivitamin tablet. The LPN stated he assumed the resident had taken the pills because he thought he saw the resident with the pill cup in her hand and saw her taking the cup to her mouth. 2) Resident #222 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Resident's MDS dated [DATE] documented the resident had a BIMS Score of 15 indicating the resident was cognitively intact. The MDS also documented that the resident required extensive assistance of 1 person for transfers and extensive assist of 2 persons for bed mobility. Resident #222 was observed being wheeled from the Shower room to her room by a Certified Nursing Assistant (CNA) on 05/17/19 at 10:05 AM. A small plastic the cup was observed on the resident's bedside table with white [MEDICATION NAME] material. The resident stated that the white material in the cup was the crushed Potassium pill from this morning. The resident further stated that this morning she took a few pills with the Nurse and told her to leave the crushed Potassium so that she could mix it in a little water and drink it later. The medication Registered Nurse (RN) was observed to walk into the resident's room at 10:08 AM. The medication RN was observed to pour some water in the cup with crushed Potassium and administered it to the resident. The Medication RN was interviewed on 05/17/19 at 10:10 AM and stated she gave the resident her medications at 9:00 AM and then went to give medications to two other residents. The RN further stated that she always gave the resident her medications together but today the resident wanted to take the Potassium separately, mixed in water, so she just opened the Potassium capsule and left it for the resident to take it with water. She stated she came back twice to see if the resident had taken the medicine but she still had not. She also stated she never left the medicines with the resident and made a mistake today. The Director of Nursing Services was interviewed on 5/16/19 at 10:00 AM and stated that the nurses should not leave medications with the residents. 415.12(h)(2)

Based on observations, record review and interviews during the Recertification survey, the facility did not ensure there was sufficient nursing staff to care for each residents needs as identified through resident assessments and plans of care on 1 of 7 nursing units (Unit 7) in a timely manner. Specifically, Resident # 136, who required assistance with transfers and toileting did not have staff provide care in a timely manner. The finding is: The Facility Census and Conditions form, dated 5/21/19, revealed that there was a total of 47 residents on Unit 7. Of the 47 residents, 14 residents were occasionally or frequently incontinent of bladder, 44 residents were in the chair all or most of the time, 3 residents were bedfast, 41 residents required the assistance of one or two staff for dressing, 44 residents required assistance for eating, 37 residents required assistance for toileting and 35 residents had Dementia. Resident # 136 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident required extensive assistance of one person to transfer, ambulate, and for toilet use and personal hygiene. The resident was always incontinent of urine and was continent of bowel. On 5/14/19 at 10:00 AM, the resident's call bell light was illuminating. The resident stated she has been waiting over 1 hour to go to the bathroom. The Registered Nurse (RN) was made aware by the surveyor and stated the resident required a two person assist to take care of her and she will find the CNA to assist. The resident was observed at 10:30 AM, and stated she still has not been taken to the bathroom. The resident stated she has been waiting more than 1.5 hours as of 10:30 AM to receive assistance. The resident stated this was not the first time she had to wait. The resident further stated there have been many times she had to wait close to an hour to receive care. On 5/14/19 at 10:33 AM, the Resident's CNA (#1) was interviewed and stated she was busy taking care of another resident. The CNA stated that each resident takes about 20 minutes to take care of. She stated she did not know that the resident was waiting more than an hour. She was told by the RN, the resident required care while she (the CNA) was caring for another resident. She stated she could not leave to take care of Resident # 136 at that time. The CNA further stated it was hard to get everyone toileted and out of bed in a timely manner. The RN was interviewed on 5/17/19 at 9:36 AM and stated when she went to assist the resident, the resident asked for the CNA to assist her to go to the bathroom. She went and told CNA #1. The RN stated she did not monitor to see if the CNA went immediately to the resident because the RN had to care for other residents who required assistance. She stated she was not aware that the resident's call bell light was on for 1 hour and was not aware that the resident waited an additional half hour to receive care by the CNA. A review of the staffing sheet revealed on 5/14/19, Unit 7 had 49 residents, 2 LPNs and 5 CNAs. The Facility Assessment documented during the 7 AM to 3 PM shift there should be 2 licensed nurses per unit and 4-5 unit CNAs per unit. The Director of Nursing Services (DNS) was interviewed on 5/21/19 at 11:25 AM and stated Unit 7 has 5 CNAs to get up 49 residents. Each resident requires at least 20 minutes of care in the AM leaving residents requesting to be toileted without receiving assistance in a timely manner at times. Per the Minimum Data Set (MDS) breakdown of Unit 7, 17 residents required 2 staff member assistance to transfer. The DNS stated 15 minutes is a reasonable amount of time to wait for care during this busy AM period. Anything past 15 minutes is excessive. The Administrator was interviewed on 5/21/19 at 11:37 AM and stated waiting 30 minutes is excessive and that Resident #136 is very particular about who provides her care. If Resident # 136 wanted her CNA and her CNA was busy, then we must evaluate how we can provide her with the help she needs. The Administrator was asked how are staffing levels determined and the Administrator stated each unit will have typically 5 CNAs and the acuity needs of the residents will be divided amongst the CNAs so that 1 CNA does not have a heavy assignment. 415.13(a)(1)(i-iii)

Based on observation, record review and staff interviews during the Recertification survey, the facility did not implement an ongoing Infection Prevention and Control Program (IPCP) to prevent, recognize, and control the onset and spread of infection. This was identified for one (Resident #92) of one resident reviewed for Infection control. Specifically Resident #92's, Suprapubic drainage bag was observed laying directly on the floor without a barrier. The finding is: Resident #92 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Physician orders [REDACTED]. A Comprehensive Care Plan (CCP) dated 3/22/19 for Suprapubic Catheter care included to cover the catheter bag for privacy. The resident was observed sleeping in bed on 5/14/19 at 9:20 AM. The Resident's Foley bag was observed laying partially on a floor mat and partially on floor. The Foley bag was not covered. The resident's 7:00 AM-3:00 PM Certified Nursing Assistant (CNA) was interviewed on 05/14/19 at 12:15 PM. The CNA stated that she made her rounds at 7:15 or 7:30 AM and saw the Foley bag on the floor mat and it was not in a covered with a privacy bag. She stated that she should have done something about it then. The CNA stated that the evening and night shifts should have hooked the Foley bag to the bed frame and also put the Foley bag in a Foley bag privacy cover. The Unit Registered Nurse (RN) Manager was interviewed on 5/14/19 at 12:20 PM and stated that the Foley bag is covered only when resident is out of bed and it should be hung on the bed rail when the resident is in bed. The Director of Nursing Services (DNS) was interviewed on 5/17/19 at 11:37 AM. The DNS stated that every resident using a Foley bag should have the Foley bag covered. 415.19(a)(1-3)

Based on record review and staff interview during the Recertification Survey, the facility did not ensure that an incidence of a communicable disease was reported to the NYS Department of Health as required. Specifically, 5 residents (Residents # 171, # 198, #112, #114, and # 303), residing on 1 of 7 units (unit 700), from a total sample of 31 Stage 2 residents, reviewed for infection control were being treated for [REDACTED]. The findings include but are not limited to: An undated policy for the facility Surveillance Program for Infection Control Program was reviewed. The policy included the protocol to monitor and investigate infections and the manner of their spread. There was no documented evidence in the policy that information for reporting a communicable disease to the NYS DOH was defined. The New York State Communicable Disease Reporting Requirements (form DOH 389) documents as follows: Reporting of suspected or confirmed communicable disease is mandated. While individual cases of some diseases (e.g., scabies . ) are not reportable, a cluster or outbreak of cases of any communicable disease is a reportable event. 1) Resident #171 had [DIAGNOSES REDACTED]. On 9/21/17 the Physician ordered [MEDICATION NAME] cream 5 % to be applied to the neck down for rash after being showered on 9/21/17 and 9/22/17. A physician's progress note dated 9/22/17 documented the resident continued with itching, was positive for scabies and being treated for [REDACTED]. 2) Resident # 198 had a [DIAGNOSES REDACTED]. The staff assessed the resident as modified independence (some difficulty in new situations only) for cognitive skills for daily decision making. A dermatology consult dated 8/31/17 documented the resident's forehead was noted with monomorphous crusts. The [DIAGNOSES REDACTED]. A Dermatology consult dated 9/6/17 documented the resident's forehead with monomorphous crust. The [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The September 2017 Medication Administration Record (MAR) documented that Resident # 198 was treated with Ivermectin three times during the month. 3) Resident # 112 had a [DIAGNOSES REDACTED]. A Physician's Progress Note dated 9/22/17 documented the resident was being treated [MEDICATION NAME] for scabies due to exposure of a roommate who was positive for scabies. The physician orders [REDACTED]. The Director of Nursing Services (DNS) was interviewed on 11/2/17 at 2:45 PM. She stated that she reports everything she is supposed to report. The DNS also stated that she did not report the incidence of scabies to the NYS DOH since it was not a cluster of cases. The Medical Director was interviewed on 11/03/2017 at 11:40 AM. He stated that he was aware of the NYS reporting requirements and that it had been discussed with the Administrative team. He also stated that scabies is a communicable disease and the DNS was responsible to report to NYS Dept of Health. The DNS was interviewed on 11/3/17 at 2:45 PM. The DNS stated the facility should have reported the concern to the Department of Health. 415.19(a)(1-3)

Based on observation, record review, resident and staff interviews, during a recertification survey the facility did not ensure, that each resident was treated with respectfully in regards to personal privacy. This was identified for one of 29 Stage 2 sampled residents. Specifically, Resident #223 had a concern that her Physician discussed her personal medical information in the Physical Therapy Gym with other staff and residents in close proximity. The finding is: Resident # 223 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the Resident's Brief Interview for Mental Status score is 15/15. (Cognitively intact). An interview with Resident # 233 was held on 9/19/16 at 1:00 PM. The Resident stated that while she was being treated in the Physical Therapy gym on 9/12/16 her Attending Physician came over to her and began speaking to her about her private medical information. The Resident stated that she had complained to the Social Worker but felt that he should have been spoken to. The Social Worker (SW) was interviewed on 9/20/16 at 10:00 AM. The SW stated that she was made aware of the resident's complaint about her Physician. The SW stated that she did not document the resident's complaint and did not report the complaint to the Administration. The Physician was interviewed on 9/20/16 at 11:00 AM. The Physician stated that he may have discussed the resident's care but did not realize it had bothered her. The Director of Nursing Services was interviewed on 9/20/16 at 11:30 AM. The DNS stated that the Physician should have met with the resident in a private area to speak to her about her care. 413.3(d)(1)(ii)

Based on observation, record review, resident and staff interviews during the recertification survey, the facility did not ensure that a resident's concern was documented in her medical record or that the information that was communicated to the Social Worker was passed on to Administration. This was identified for one of 29 Stage 2 sampled residents. Specifically, Resident #233 complained that her Physician discussed personal medical information in the Physical Therapy Gym area. There was no documented evidence that the Social Worker (SW) documented the complaint or that the SW passed the information to the administration. The finding is: Resident # 223 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score is 15/15 (cognition intact). An interview was held on 9/19/16 at 11:00 AM with Resident #233. The Resident stated that while she was receiving therapy on 9/12/16 in the Physical Therapy Gym her Attending Physician stopped in to discuss her personal medical information. Additionally, the resident stated that she had told her SW about this issue and was not sure if she relayed the information to the administration. The SW was interviewed on 9/20/16 at 1:00 PM. The SW stated that she did not document in the resident's medical record because she did not feel that the issue was a problem. The Director of Nursing Service (DNS) was interviewed on 9/20/16 at 1:15 PM. The DNS stated that the SW should have brought the information to administration so the administrative staff can address the issue. 415.5(g)(1)(i-xv)

Based on observations and staff interviews during the recertification survey, the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable environment were provided. Specifically, during the initial tour of the general environment on 4 of 7 resident units (Units 4, 5, 6 and 7), ceiling tiles were in disrepair throughout the hallways, bedside dressers were in disrepair, and walls were in need of painting. The finding is: During the Initial tour of the the facility on 9/14/16 during the hours of 8:30 AM and 10:30 AM, and throughout the survey process from 9/14/16 through 9/20/16 the following observations were made: Units 4, 5, 6, and 7: Ceiling tiles were noted to be stained, discolored and torn throughout the hallways. Unit 4: Room 423- wall under the sink and adjacent to the bed was in need of painting, with brown stains and scuff marks. Unit 7: Room 707-wall under the sink and adjacent to the bed was in need of painting, with brown stains and scuff marks. Room 710-wall adjacent to the bed was in need of painting. Room 713-the bedside dresser was in disrepair, with a broken drawer and the wall under the window was in disrepair. The Director of Environmental Services was interviewed on 9/20/16 at 1:00 PM and stated that he was aware of the condition of the ceiling tiles and renovations are taking place throughout the facility. The Director stated that the disrepair of the walls and dressers would be addressed immediately. 415.5(h)(2)