Every finding on record at Central Park Rehabilitation and Nursing Center

Based on record review and interviews, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made for one (1) of three (3) residents (Resident #1). Specifically, on 05/16/2026 during the 7:00 AM to 3:00 PM shift, Licensed Practical Nurse #3 alleged they witnessed Certified Nurse Aide #15 to have been verbally abusive and pushed Resident #1 toward a dining room chair. The incident was not reported as required and Certified Nurse Aide #15 continued to have access to residents. On 05/20/2026, the Director of Nursing discovered a written statement in their mailbox from Licensed Practical Nurse #3 that described the incident on 05/16/2026. Resident #1 was not assessed until 05/18/2026 at approximately 8:30 AM. Findings include: The 04/2026 revised facility policy, Abuse Prevention, documented in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect or mistreatment, including injuries of unknown source or misappropriation of resident property, are reported immediately, but not more than two hours after the allegation is made if the events that cause the allegation involve abuse. Resident #1 had diagnoses of Alzheimer's Disease and Unspecified dementia, severe with agitation. The 02/24/2026 Minimum Data Set assessment documented Resident #1 had severely impaired cognition, wandered daily, had no behaviors, and no rejection of care. The Comprehensive Care Plan reviewed 03/03/2026 documented the resident had potential for behavior problems, socially inappropriate behaviors related to Alzheimer's Disease, new environment, and new routines. Interventions included: reapproach, medications as ordered , wander alert device, redirection, provide safe quiet environment, approach in calm, positive manner, allow to express in appropriate ways, observe for signs of intent to harm self or others, divert attention, take to another location, assist with clothing when seen removing, and 1:1 supervision every day and evening shift (02/17/2026). The 05/17/2026 at 2:23 AM nursing progress note by Licensed Practical Nurse #21 documented Resident #1 was self-ambulating on the unit, as needed Ativan (an anti-anxiety medication) given with zero changes noted, and was difficult to redirect. No pain noted. The 05/17/2026 at 7:02 AM nursing progress note by Registered Nurse Supervisor #11 documented Resident #1 had not slept throughout the night. The resident was ambulating around the unit, and they were difficult to redirect. As needed medication given with no effect. Resident #1 pulled the fire alarm on the unit, which necessitated a 1:1 supervision for the remainder of the shift as attempts to redirect the resident were unsuccessful. The attending physician was notified for a requested medication review and medical will follow-up. Nursing will continue to monitor. The resident has no pain. The 05/18/2026 at 3:00 AM nursing progress note documented Resident #1 was in bed resting, 1:1 supervision continued, zero changes noted this shift, and the resident did not have pain. The 05/18/2026 at 9:45 AM nursing progress note by Registered Nurse Supervisor #10 documented a bruise was noted on Resident #1's left inner buttock to their left hip. There was no swelling or signs/symptoms of pain and is unaware of how area occurred. Per documentation, the resident had episodes of increased agitation and behaviors over the weekend. The resident has a history of poor safety awareness related to poor cognition. Nurse Practitioner #13 was made aware, the resident was assessed, and no new orders were provided at this time. The resident's representative was updated and the resident continues on 1:1 monitoring at this time. Resident #1 appears to be calm and cooperative currently. The 05/18/2026 at 8:30 AM Accident/Incident report completed by Licensed Practical Nurse Manager #7 documented Licensed Practical Nurse #16 reported Resident #1 had a bruise on their left buttock and left hip, was dark purple in color and measured 36 centimeters x 12 centimeters. Staff were interviewed and witness statements were obtained. The 05/18/2026 Facility Investigation Summary documented on the morning of 05/18/2026, the Director of Nursing found a written statement from Licensed Practical Nurse #3 dated 05/16/2026. The statement alleged abuse by Certified Nurse Aide #15 toward Resident #1. The Director of Nursing was not notified of the allegation at the time. Immediate action was taken to investigate; Certified Nurse Aide #15 was placed on administrative leave, and an investigation was started. The facility investigation summary documented abuse allegations could not be verified based on staff interviews, no witnesses, and Licensed Practical Nurse #3 recanted their allegations in a second statement. The Director of Nursing did not find a correlation between the allegation involving Certified Nurse Aide #15 and Resident #1's bruise. There was no documented evidence the alleged witnessed incident that occurred on 05/16/2026 during the 7:00 AM to 3:00 PM shift was reported to a Nursing Supervisor or Administrator immediately following the alleged incident.During an interview on 05/28/2026 at 1:57 PM, Licensed Practical Nurse #3 stated they wrote a statement on 05/16/2026 stating that Certified Nurse Aide #15 yelled at Resident #1 and handled them roughly by redirecting them to have a seat into a dining room chair. They stated they reprimanded Certified Nurse Aide #15 for cursing around the residents and family members. Certified Nurse Aide #15 became 'mouthy' after they were reprimanded. Licensed Practical Nurse #3 wrote them up and placed the paperwork into the Director of Nursing's mailbox. During a follow-up interview on 05/29/2026 at 10:18 AM, Licensed Practical Nurse #3 stated they wrote a second statement regarding the incident on 05/16/2026 and recanted what they initially documented. They stated they misinterpreted what they witnessed with Certified Nurse Aide #15, it was not abuse, they were both angry with each other and 'worked up' and felt it was just a personal issue. Licensed Practical Nurse #3 stated they did not report the incident to a Supervisor, the Director of Nursing or the Administrator. They wrote up Certified Nurse Aide #15 for cursing and placed the paperwork in the Director of Nursing's mailbox prior to leaving the facility. They did not learn Resident #1 had a bruise until 05/18/2026. During an interview on 05/29/2026 at 12:30 PM, the Director of Nursing stated they were not aware of an incident with Certified Nurse Aide #15 and Resident #1 until the morning of 05/18/2026 when they received a written statement from Licensed Practical Nurse #3 in their mailbox. They immediately started an investigation. Certified Nurse Aide #15 was placed on administrative leave. The Director of Nursing spoke to Licensed Practical Nurse #3 about the allegation and questioned the reason for not reporting it on 05/16/2026. Licensed Practical Nurse #3 stated it was not abuse, they felt the aide was angry for being reprimanded and their statement was not accurate due to the licensed practical nurse being frustrated with Certified Nurse Aide #15 at the time. The Director of Nursing asked Licensed Practical Nurse #3 to demonstrate how the Certified Nurse Aide #15 guided Resident #15 to sit. Licensed Practical Nurse #3 stated it was not forceful and could not have contributed to the bruise on the resident's buttock/hip area. Staff who cared for the resident 05/16/2026-05/17/2026 reported there were no signs of bruising. The area was first noticed on the morning of 05/18/2026. The Director of Nursing stated Licensed Practical Nurse #3 should have notified a supervisor of any suspicion of abuse based on their initial statement. Staff had educational training on Abuse prevention and reporting and were expected to notify a Supervisor, Director of Nursing, and Administrator. During an interview on 06/01/2026 at 1:32 PM with the Administrator, they stated they were not aware of the allegation related to Certified Nurse Aide #15 and Resident #1 until the morning of 05/18/2026. They expected all staff to report any suspicions of abuse, and their priority was to keep the residents safe. Staff had multiple training sessions throughout the year on abuse prevention and reporting. It was not facility protocol to leave a notice (of an abuse allegation) in the mailboxes.New York Codes, Rules and Regulations 415.4 (b)(2)(3).

Based on observations, record review, and interviews during the recertification and partial extended surveys conducted 4/28/2025 - 5/5/2025, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen walk-in cooler was not maintained in appropriate operating condition and had an air temperature of 50 degrees Fahrenheit. Milk stored in the walk-in cooler was measured at 47.8 degrees Fahrenheit. Potentially hazardous foods (food that requires time/temperature control for safety to limit the growth of pathogens) were in the stand-up unit refrigerators on four (4) of four (4) units (1st, 2nd, 3rd, and 4th floor) and originated from the main kitchen walk-in cooler. The potentially hazardous foods included tuna salad sandwiches, egg salad sandwiches, turkey sandwiches, and cottage cheese. The facility's failure to properly maintain the temperature of the main kitchen walk-in cooler placed all 153 residents at risk for food borne illness from consuming potentially hazardous food with the potential to cause serious harm, serious impairment, or death resulting in Immediate Jeopardy to resident health and safety. Findings include: The United States Food and Drug Administration Food Code (current as of 1/8/2025) Section 3-501.12 Time/Temperature Control documented temperature control for food under refrigeration would maintain the food temperature at 41 degrees Fahrenheit or less. The National Food Safety Information Network Gateway to Government Food Safety Information Guidelines documented cold food storage for eggs, luncheon meat, egg salad, tuna salad should be refrigerated at 40 degrees Fahrenheit or below. The undated facility policy Food Storage - Refrigerators & Freezers, documented the refrigerator would be maintained at 41 degrees Fahrenheit or lower. The hanging thermometer was placed in the warmest part of the refrigerator. The temperatures would be checked twice daily. The undated facility policy Food Safety and Sanitation Plan, documented to refrigerate meat and other potentially hazardous foods so an internal temperature was less than or equal to 41 degrees Fahrenheit. The 4/2025 Temperature Record for the main kitchen walk-in cooler documented the temperature was measured at 54 degrees Fahrenheit on 4/29/2025 at 8:00 PM. The column documenting the staff who checked the temperature was blank. Initial Cooling Concern: During an observation with the Food Service Director on 4/30/2025 at 11:00 AM, the main kitchen walk-in cooler had a digital thermometer on the compressor unit and an analog thermometer hanging inside the cooler. Both thermometers read 50 degrees Fahrenheit. Food items in the cooler were measured using the New York State issued thermometer and included chocolate milk at 47.8 degrees Fahrenheit, deli ham at 47.5 degrees Fahrenheit, and yogurt at 48 degrees Fahrenheit using the New York State issued thermometer. The facility thermometer verified the measured food temperatures, and all were within one (1) degree. During an interview on 4/30/2025 at 11:50 AM, [NAME] #4 stated they measured the walk-in cooler temperature on 4/29/2025 at 8:00 PM and it read 54 degrees Fahrenheit. Cold food was required to be maintained between 35-40 degrees Fahrenheit. They stated the Corporate [NAME] President told them at 4:00 PM on 4/29/2025 to watch the temperature of the walk-in cooler as staff had been going in and out of the cooler for food preparation (opening and closing the door). [NAME] #4 stated the walk-in cooler was 49 degrees Fahrenheit at 7:15 PM on 4/29/2025 but was not documented and they should have contacted the supervisor or the Director of Food Service to inform them the air temperature of the walk-in was out of range. During an observation and interview on 4/30/2025 at 12:25 PM, the Director of Food Service stated the walk-in cooler compressor unit was stuck in defrost mode. Food items in the walk-in cooler were measured using the New York State issued thermometer and included raw chicken measured at 47.8 degrees Fahrenheit, deli turkey meat at 48 degrees Fahrenheit, and sausage at 50 degrees Fahrenheit. The facility thermometer verified the food temperatures and was within one (1) degree difference. The Director of Food Service voluntarily discarded the contents of the walk-in cooler. They stated they were not told of any temperature issues regarding the walk-in cooler. Cold food items were required to be maintained between 35-40 degrees Fahrenheit. Staff that observed the air temperature out of range in the walk-in cooler should have reported it to the supervisor or to them, and a work order should have been placed. During a follow-up interview at 1:55 PM, the Director of Food Service stated the main walk-in cooler contained milk, cheese, produce, yogurt, cream, thawed meats, cottage cheese, and thawed meals. If the walk-in cooler was out of temperature, they expected dietary staff to contact maintenance or them, and they were not notified of the elevated temperatures on 4/29/2025. They contacted maintenance on 4/30/2025 at 11:00 AM after entering the walk-in cooler with a survey team member. During an interview on 4/30/2025 at 1:35 PM, the Corporate [NAME] President stated they told [NAME] #4 on 4/29/2025 to check the temperatures of the walk-in cooler as people were going in and out. [NAME] #4 was told to check on this situation after dinner to see if the air temperatures in the walk-in cooler had cooled back down below 40 degrees Fahrenheit, and if there were any issues to contact a supervisor, the Director of Food Service, or the Maintenance Director. They stated the walk-in cooler temperature log had a section on the bottom of the form that documented the approved cold food temperature range. During a follow up interview on 5/1/2025 at 2:41 PM, the Corporate [NAME] President stated they walked into the walk-in cooler on 4/29/2025 at approximately 5:00 PM and noticed it was warm. The digital thermometer measured 54 degrees Fahrenheit, and the analog hanging thermometer measured 44 degrees Fahrenheit. They told [NAME] #4 to measure the temperature again at 6:00 PM. During an interview on 4/30/2025 at 4:35 PM, the Corporate Maintenance Director stated during the morning of 4/30/2025 they discovered a broken wire in the walk-in cooler compressor causing the compressor to not fully function and provide the full amount of cold air. They were not told of the 4/29/2025 walk-in cooler air temperature issue. All kitchen staff knew how to submit work orders, and they should be completed via the computer. Prepared Sandwiches timeline: During an interview on 5/1/2025 at 9:34 AM, Dietary Aide #37 stated they worked the 2nd floor kitchenette. The milk was stocked on the unit on 4/29/2025 in the evening. The 2nd floor kitchenette's refrigerator contained one (1) egg salad sandwich dated 4/29/2025. During an observation and interview on 5/1/2025 at 9:35 AM, Food Service Aide #42 stated they were responsible for stocking the 1st floor kitchenette. There was an issue with the walk-in cooler in the main kitchen on 4/29/2025, so someone in the kitchen divided up the sandwiches by unit and brought them up to the unit's refrigerator from the walk-in cooler. The refrigerator in the 1st floor kitchenette contained three (3) tuna salad sandwiches, two (2) egg salad sandwiches, and one (1) turkey sandwich. During an observation and interview on 5/1/2025 at 9:35 AM, Food Service Aide #6 stated they were responsible for stocking the unit kitchenette refrigerators and had stocked the 4th floor refrigerator the morning of 4/30/2025 with milk and Health Shakes from the main kitchen walk-in cooler and these were served for breakfast on 5/1/2025 and the Mighty Shakes were served to residents by the licensed practical nurses that morning as well. The refrigerator was measured with the facility thermometer at 52 degrees Fahrenheit. The refrigerator contained one (1) egg salad sandwich dated 4/29/2025, three (3) bowls of creamer, and cottage cheese. Dietary Aide #6 stated the refrigerator was 50 degrees Fahrenheit which was an appropriate temperature. During an observation and interview on 5/1/2025 at 9:39 AM, Food Server #38 stated they floated to all the units, but was assigned to the 3rd floor. They gathered items needed from the walk-in cooler in the main kitchen for the meals they were serving. The clear door refrigerator contained two (2) egg salad sandwiches dated 4/29/2025, and more than 20 cottage cheese cups. During an observation and interview on 5/1/2025 at 10:35 AM, the white refrigerator on the 4th floor was measured at 45 degrees Fahrenheit and the thickened milk was 48.3 degrees Fahrenheit. Food Service Aide #6 stated they brought yogurt, cottage cheese, and a few other items to the unit that morning. The yogurt measured 52.5 degrees Fahrenheit, and the cottage cheese was 48.3 degrees Fahrenheit. There were nine (9) containers of cottage cheese, five (5) yogurts, and two (2) containers of yogurt. During a follow up interview on 5/1/2025 at 12:27 PM, the Director of Food Service stated the food service aides stocked milk, yogurt, and Health Shakes on the units the morning of 4/30/2025, but when the walk-in main kitchen cooler was discovered to be under temperature, they had them discard all items brought from the walk-in cooler on 4/30/2025. Sandwiches dated 4/29/2025, which were made between 3:00 and 4:00 PM and brought to the units at approximately 5:00 PM, were also discarded on 4/30/2025. If a resident was served food that needed to be refrigerated and was not properly refrigerated, they could get sick. The white refrigerator on the units were not meant for this type of setting, they were home style refrigerators. During an interview on 5/1/2025 at 12:35 PM, Food Service Aide #7 stated they made approximately 45 egg salad, tuna salad, and turkey sandwiches on 4/29/2025 between 12:30 PM and1:00 PM. The sandwiches were dated with the date they were made and stored in the walk-in cooler on trays for each floor. When they stored the sandwiches, the walk-in cooler felt warm, and they observed the temperature at 55 degrees Fahrenheit and they told [NAME] #4. During a telephone interview on 5/1/2025 at 1:55 PM, Food Service Aide #41 stated they worked in the main kitchen and the 4th floor for the evening shift on 4/29/2025. They saw the rack of sandwiches in the walk-in cooler before they went to the 4th floor to serve dinner, at approximately 5:30 PM. During a telephone interview on 5/1/2025 at 1:55 PM, Food Service Aide #40 stated they worked the evening of 4/29/2025 and the walk-in cooler was warmer than normal at 5:00 PM. They could not recall who they told but the person's response was they already knew about it. They stocked the refrigerator on the units with chocolate milk, regular milk, and sandwiches from the walk-in cooler. They stated the items felt cool to the touch, but not nearly as cold as usual. During a telephone interview on 5/1/2025 at 1:56 PM, Food Service Aide #39 stated they brought tuna salad sandwiches, egg salad sandwiches, turkey sandwiches, yogurt, and cottage cheese up from the walk-in cooler in the main kitchen to the 2nd floor kitchenette on 4/29/2025 at 5:00 PM. After dinner, they checked the dates of the items, discarded old items, and stocked again. The walk-in cooler was a bit warmer than usual on 4/29/2025, but they did not report it to anyone. During an interview on 5/5/2025 at 2:28 PM, the Director of Nursing stated if the main refrigerator was out of temperature, that food should not be brought to the unit, as it could cause a resident to get sick. During an interview on 5/5/2025 at 3:16 PM, the Administrator stated food storage temperatures should be accurate. The appropriate storage temperature for cold food was 41 degrees Fahrenheit and below. It was important to monitor refrigerator temperatures because they needed to make sure they were in the appropriate range. If the main refrigerator was out of temperature, that food should not be brought to the units. If a resident was served food that did not maintain proper temperature it could cause gastro-intestinal illness and food borne illness. During a telephone interview on 5/5/2025 at 3:45 PM, the Medical Director stated it was important to monitor refrigerator temperatures because temperatures were set to keep food from spoiling. If a resident was served food that did not maintain proper temperature, there could be a concern for food poisoning. 10 NYCRR 415.14(h) ______________________________________________________________________________ The facility was notified of the Immediate Jeopardy on 5/1/2025 at 6:35 PM. The Immediate Jeopardy was removed on 5/2/2025 at 12:00 PM prior to the completion of the survey. The facility implemented the following to remove the immediacy: - The facility discarded all items in the walk-in cooler on 4/30/2025 at 12:00 PM. Facility vendor arrived onsite at 1:45 PM for repairs to the walk-in cooler. Walk-in cooler was in working order per facility on 4/30/2025 at 5:00 PM. - All perishable foods in the unit kitchenettes were observed as discarded on 5/1/2025 at 7:44 PM. - Residents were monitored by 24-hour reporting system for 72 hours for signs and symptoms of foodborne illness. - The facility monitored temperatures twice per day, logs documented all temperatures were in appropriate temperature range. - The facility provided in-service education to over 85% of all staff as of 5/1/2025 at 8:00 PM, with plans for ongoing education of staff prior to the start of their next shift for those not currently on the schedule. - The survey team interviewed 13 staff members from various disciplines during an onsite visit(s) on 5/2/2024. All staff demonstrated knowledge of the education provided.

Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/6/2025, the facility did not ensure a process was in place for residents to have their grievances addressed appropriately for 153 of 153 residents residing in the facility. Specifically, information on how to file a grievance and grievance forms were not available to the residents and the facility did not have a process for residents to file an anonymous grievance. Additionally, 14 of 14 anonymous residents present at the resident group meeting stated they did not know where to obtain grievances forms from or of their right to file anonymously; some residents present did not know who the grievance officer was. Findings include: The undated facility policy Grievance Policy and Procedure, documented residents, family members, resident advocates or any other individuals had the right to voice grievances regarding such things as resident care and treatment which was provided or was not provided, the behavior of staff and other residents, and other concerns regarding their stay at the facility, without discrimination, reprisal, or the fear of discrimination or reprisal. The facility notified residents upon admission and through postings in prominent locations within the facility who the facility Grievance Official was and their rights related to grievances. The Grievance Official was responsible for overseeing the grievance process, receiving, and tracking grievances through to their conclusions. Grievances and/or complaints may be submitted orally or in writing and any facility staff member may assist any such individual in filing/reporting a grievance or complaint. Grievance forms were available on each nursing unit and through the social work department and may be filed anonymously. There were no documented grievances or grievance logs from April 2024-December 2024. January 2025 documented three grievances. There were no grievances documented in February of 2025. An email received on 4/30/2025 at 11:51 AM from the Administrator documented there was a lapse in time for the grievance logs. When the facility transitioned from one Director of Social Work to another, the new Director did not complete the process for the grievance program, and it was not identified until March of 2025. During a resident group meeting on 4/29/2025 at 10:08 AM, 14 of 14 anonymous residents stated they did not know how to obtain grievance forms or file a grievance anonymously. They felt it was hard to file grievances about staff to other staff. Some residents did not know who the grievance officer was. During observations on 4/29/2025 at 2:26 PM and 3:20 PM; 4/30/2025 at 10:53 AM; and 5/2/2025 at 11:19 AM ,11:38 AM, and 1:07 PM there were no postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; and the contact information of the grievance official with whom a grievance could be filed. During an interview on 5/5/2025 at 10:37 AM, the Director of Activities stated the Director of Social Work was responsible for the overall grievance process. Residents filed grievances by discussing their concerns with any staff member they chose. The Director of Activities stated the residents used to be able to get grievance forms on the unit from a folder behind the nurses' station. A resident could file an anonymous grievance via the form. They stated they were unsure where the resident could turn in the form and remain anonymous. It was important to have an anonymous grievance process as it was a resident's right to voice their concerns without fear of retaliation or being identified. During an interview on 5/5/2025 at 1:41 PM, Certified Nurse Aide #52 stated a resident could file a grievance by voicing their concern to a staff member. The staff member should inform the social worker or the Unit Manager. Grievance forms were available on the unit in a binder on a shelf behind the nurses' station. Residents had to ask staff for the grievance forms. During an interview on 5/5/2025 at 1:49 PM, Licensed Practical Nurse #53 stated they did not know how to file a grievance. At 1:51 PM, they went to the Unit Manager to inquire how a resident filed a grievance. At 1:55 PM, they stated if a resident wanted to file a grievance, staff should get the form from social work or the concierge, fill it out and give the form to the responsible department. The responsible department let the Administrator know. There was a 7-day investigation and by day 10, the resident was informed of the outcome. They stated residents did not have to ask for the grievance forms as they were kept at the nurses' station. Licensed Practical Nurse #53 could not locate a grievance form at the nurses' station and stated if a resident wanted to file a grievance anonymously, they could get a form from the front desk. During an interview on 5/5/2025 at 2:20 PM, the Director of Security stated they kept grievances at the front desk in a green folder labeled resident grievance forms. Residents had to ask for the grievance forms. If they wanted to file anonymously, they could pull the Director of Security aside or go to the social worker and they would make it confidential. Once the form was filled out it went into a locked box outside the Administrator, Director of Nursing, or Human Resource offices. The residents had to hand them to staff for the forms to be put inside the boxes as the offices were behind a locked door. It was important for a resident to be able to file a grievance anonymously as it prevented any retaliation, and they should be able to express how they feel without their name being mentioned. During an interview on 5/5/2025 at 2:40 PM, Social Worker #30 stated they weekly grievance meetings for follow up and to review any new grievances. If a resident or visitor needed to fill out a grievance, the front desk and the nurses' station had the forms. The form then went to the Director of Social Work. They stated the residents would have to ask for the grievance form since they were in a folder behind the nurses' station the residents did not have access to. They did not know how a resident filed a grievance anonymously because the resident had to ask for the form and where to turn it in. When the Director of Social Work was not available the Administrator was responsible for the grievance process. It was a resident's right to file a grievance and have their issues followed up on, and they had the fight to file anonymously to avoid fear of retaliation. During an interview on 5/5/2025 at 4:12 PM, the Administrator stated if the Director of Social Work was not available, the Administrator and Social Worker #30 were responsible for the grievance process. There were grievance forms at the front desk or on the units. The staff assisted as needed with filling out grievance forms. They stated residents filed anonymous grievances by obtaining the grievances from the nurses' station, but they had to ask the staff for the forms. They stated for the grievance to be filed anonymously, the resident would still have to hand the grievance form to a staff member for them to be put in the lock boxes outside the Administrator, Director of Nursing, and Human Resources' offices. They did not have a lock box in the lobby for residents to file anonymously. They stated it was important for residents to have a grievance process and be able to file anonymously so they could speak freely. 10NYCRR 415.3(C)(1)(ii)

Based on interviews and record review during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure that views, grievances, or recommendations voiced by residents during Resident Council group meetings were considered or acted upon and responded to with a rationale for 14 of 14 anonymous residents present at the resident group meeting. Specifically, 14 of 14 anonymous residents present at the resident group meeting stated they did not receive responses to topics or concerns addressed in prior Resident Council meetings. Additionally, there was no documented evidence residents' voiced concerns were investigated, and rationales or responses were provided to the residents. Findings include: The undated facility policy Resident Council, documented the facility would listen to the views of the council and respond to and/or act upon the grievances and recommendations of the council concerning proposed policy and operational decisions affecting resident care and life in the facility. Any grievances/suggestions voiced during the resident council that was specific to only one resident would be documented on a resident grievance form. Prior concerns or suggestions would be discussed each month. Concerns that had not been resolved would be documented on the Resident Council Grievance Form. New concerns or suggestions would be reviewed and documented on the Resident Council Grievance Form. The Resident Council Grievance Forms would be reviewed at the daily Inter-disciplinary team meeting. The facility's response to each grievance/suggestion would be reviewed at the next Resident Council Meeting. Reasonable attempts would be made to accommodate those recommendations/ grievances to the extent practicable and those decisions would be communicated to the Resident Council. During a resident group meeting on 4/29/2025 at 10:08 AM, 14 anonymous residents stated the facility did not always follow up, address, or resolve their concerns. They did not receive any feedback about their concerns regarding housekeeping, missing items from laundry, long call bell wait times, staff cell phone usage, toileting, and activities. Resident Council meeting minutes documented: - on 4/10/2024, new concerns noted housekeeping, missing items from laundry, linen, call bell times, and staff phone usage. - on 5/8/2024, new concerns noted housekeeping, missing items from laundry, linen, call bell times, and staff cell phone usage. - on 6/20/2024, new concerns noted housekeeping, missing items from laundry, linen, staff cell phone usage, and showers. - on 7/10/2024, new concerns noted housekeeping, missing items laundry, linen, staff cell phone usage, and new board games. - on 8/14/2024, new concerns noted housekeeping, missing items from laundry, linen, call bell times, staff cell phone usage, and different types of activities. - on 9/11/2024, new concerns noted housekeeping, missing items from laundry, and call bell times. - on 10/9/2024, new concerns noted housekeeping, missing items from laundry, linen, call bell times, and staff cell phone usage. - on 11/14/2024, new concerns noted housekeeping, missing items from laundry, staff cell phone usage, and call bell times. - on 12/11/2024, new concerns noted housekeeping, missing items from laundry, and staff cell phone usage. - on 1/8/2025, new concerns noted housekeeping, missing items from laundry, linen, staff cell phone usage, and more trivia activities. - on 2/12/2025, new concerns noted housekeeping, missing items from laundry, call bell times, staff cell phone usage, toileting, and more karaoke. - on 3/12/2025, new concerns noted housekeeping, missing items from laundry, linen, staff cell phone usage, call bell times, toileting, and types of activities. - on 4/9/2025 new concerns noted housekeeping, missing items from laundry, linen, staff cell phone usage, call bell times, toileting, and types of activities. There was no documented evidence the new concerns were investigated, or the rationales and responses were provided to the Resident Council during subsequent meetings. During an interview on 5/5/2025 at 10:37 AM the Director of Activities stated social work did the grievances for resident council and the concierge did missing items/personal issues. They provided housekeeping with a copy of the minutes as well, so they knew there were recurrent issues with the environment. The grievance forms prior to March 2025, did not have a place to put what the follow up was from the grievance. They stated some of the issues that were recurrent were being worked on but the staff members responsible for that department did not always come to Resident Council meetings when requested for follow up. They stated for every Resident Council meeting they reviewed the minutes from the month prior and all the issues discussed. The residents did not speak up and say issues were not resolved until they discussed new issues, and the old issues were brought up as still being a problem. During an interview on 5/5/2025 at 2:40 PM Social Worker #30 stated they recently began being invited to attend the Resident Council meetings. They were informed by the residents there were a lot of recurrent issues. They stated they had only been to two meetings so far and agreed there were recurrent issues without follow up. The reason behind not having resolutions was situational but they could not give an overall reason During an interview on 5/5/2025 at 4:12 PM, the Administrator stated they were notified of issues brought up during Resident Council and there were a lot of audits regarding linen, call bell times, and staff cell phone usage occurring. It was important for the issues brought up in Resident Council to be addressed as that was the purpose of the Resident Council. Resident issues should be addressed timely. 10NYCRR 415.5(c)(6)

Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for two (2) of four (4) resident units (First and Fourth Floors) and the main kitchen. Specifically, the first floor, the fourth floor, and the main kitchen had unclean surfaces including stained and sticky floors, unclean walls, and unclean shelving. Findings include: 1.Unclean Surfaces Resident Units On 4/28/2025 the following observations were made in the Fourth Floor dining room: - at 12:35 PM, there was food debris and stains on the floor under six of nine tables. - at 12:37 PM, the section of floor on the side area to the right of the kitchenette was sticky and shoes stuck to the floor. - at 12:42 PM, the dining room wall had a black/grey line running along the entire length of the wall. On 4/29/2025 the following observations were made in the Fourth Floor dining room: - at 3:16 PM, there were stuck on food stains on the floor under seven of nine tables. - at 3:17 PM, there was food debris and stains on a section of floor next to the window on the kitchenette side of the dining room and the floor was sticky. During an observation on 4/30/2025 at 9:46 AM, the floors in the common area of the First Floor next to room [ROOM NUMBER] were sticky and shoes stuck to the floor. On 5/2/2025 the following observations were made in the Fourth Floor dining room: - at 12:14 PM, there was food debris and stains on the floor under and near the table near the dining room half wall. - at 12:16 PM, there was food debris and other marks on the floor in the front of the kitchenette serving window. - at 12:16 PM, shoes stuck to the floor in multiple areas of the dining room. - at 12:17 PM, there was food debris and dried spill marks under a table on the kitchenette side of the dining room. - at 12:28 PM, there were visible footprints and marks on the floor in the eating area across from the kitchenette. There was food debris and dried spill marks on the floor around one of the tables and the dining room walking area. During an interview on 5/5/2025 at 1:41 PM, Certified Nurse Aide #52 stated the housekeeping department was responsible for the cleanliness of the dining room floor, and the housekeepers should mop and sweep the floors. They stated they had never noticed there was food debris on the dining room floor under the tables or the dining room floors were sticky. Certified Nurse Aide #52 stated if they observed unclean or sticky floors they would tell a housekeeper. During an interview on 5/5/2025 at 2:55 PM, Certified Nurse Aide #49 stated the housekeeping department was responsible for cleaning the dining room floors and they helped housekeeping pick up the bigger pieces of food debris from the floor after meals. They stated most housekeeping staff worked until 3:00 PM, and there was one employee who worked 3:00 PM to 11:00 PM who cleaned the dining room after dinner. Certified Nurse Aide #49 stated they did not see a housekeeper on the fourth floor after the 5/5/2025 lunch meal. During an interview on 5/5/2025 at 3:07 PM, Licensed Practical Nurse #44 stated they did not see a housekeeper on the Fourth Floor unit until after lunch. They stated the housekeeper they saw today was not normally on this unit. Licensed Practical Nurse #44 stated a spill should not be left on the floor. Sticky floors could be caused by the cleaning chemicals and visibly soiled food debris. During an interview on 5/5/2025 at 3:19 PM, the Director of Housekeeping stated cleaning the dining rooms were part of the housekeeping staff daily tasks. After every meal housekeepers should sweep and mop the floors. They recently changed over the whole housekeeping roster, and it was difficult to train new employees. They stated the housekeeper usually assigned to the Fourth Floor was sick this day so two of the housekeepers had to go together to the Second Floor and the other housekeepers worked their assigned floor. The Director of Housekeeping stated they had just been on the fourth floor and stated it was difficult to maintain the floor as it could be cleaned and two minutes later the floor was sticky. Nursing staff was supposed to clean up a preliminary stains or spills, but nursing staff did not do this and did not inform the housekeeping department there was a spill. They stated the Fourth Floor dining room floor was last stripped on 3/3/2025, and a top scrub had been completed twice since that date. 2. Main Kitchen During an observation on 4/28/2025 at 9:20 AM, the main kitchen pots and pan area had unclean shelving with multiple pots and pans on top. The shelves were wet and covered with standing water. During an observation on 4/29/2025 the following observations were made in the main kitchen: - at 12:15 PM, near the clean area of the dish machine there was 1 ceiling tile stained with food debris and the metal ceiling grids were rusty. - at 12:20 PM, the wall behind the three bay sink was sticky and unclean. During an interview on 5/2/2025 at 10:43 AM, the Director of Food Service stated they were aware of the unclean surfaces and told staff to clean all components of the main kitchen before the next federal survey. They stated the porter was responsible for cleaning the pots and pans area shelving and wall behind the three-bay sink. The Director of Food Service stated staff who completed this task signed off every day at the end of the shift. The Director of Food Service verified this form was not completed. They stated maintenance staff was responsible for stained ceiling tiles and rusty metal grids, and a work order should have been made. The Director of Food Service stated it was important the main kitchen environment was maintained for the safety of residents and staff. 10 NYCRR 415.29(j)(1)

Based on observations, record review, and interview during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) meals reviewed (Lunch meals on 4/30/2025 and 5/2/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 4/30/2025 and 5/2/2025. Additionally, Resident #5 complained the food was cold. Findings include: The undated facility Food Safety and Sanitation Plan documented hot foods were required to be held at 135 degrees Fahrenheit or greater. During an interview with Resident #5 on 4/28/2025 at 1:47 PM, they stated the food was usually cold and the meat was tough. Test Tray #1: During an observation on 4/30/2025 at 1:15 PM, after all the residents had been served on the Third floor, a portion of meatloaf was requested from the Third floor steam table. The meatloaf's temperature was 118 degrees Fahrenheit and tasted lukewarm. Food Service worker #14 verified the measured temperature of the meatloaf. During an interview on 4/30/2025 at 1:15 PM, Food Service Worker #14 stated food should be held in the steam table at 140 degrees Fahrenheit or higher. They stated the meatloaf should have been warmer. Test Tray #2: During an observation on 5/2/2025 at 1:08 PM, after all residents were served on the First floor, there were three resident tickets not plated and the steam table was still on. Resident #142's food items were requested for a test tray in addition to a serving of the ground stroganoff. Resident #142 was provided a replacement meal. At 1:13 PM, the temperature of the ground stroganoff was 117 degrees Fahrenheit, noodles were 88 degrees Fahrenheit, and broccoli was 120 degrees Fahrenheit. During an interview on 5/2/2025 at 2:20 PM, the Food Service Director stated hot food items should be maintained at 135 Fahrenheit, or above. They stated that it was not acceptable the noodles were 88 degrees Fahrenheit, the ground stroganoff was 117 degrees Fahrenheit, and the broccoli was 120 degrees Fahrenheit. The Food Service Director stated noodles alone would not stay warm, and the temperature of the ground stroganoff in a pan would not be maintained if the bottom of the pan was not immersed in the hot water of the steam table. They stated it was important hot food items were maintained at palatable temperatures, so the residents were happy with the food served, and to ensure the food was safe for the residents to consume. During an interview on 5/5/2025 at 11:34 AM, the Food Service Director stated the meatloaf temperature of 118 degrees Fahrenheit was not acceptable and was required to be served at 135 degree Fahrenheit or above. 10NYCRR 415.14(d)(1)(2) 48052 48895

Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for one (1) of four (4) residents (Resident #56) reviewed. Specifically, Resident #56 had significant weight loss, weekly weights were not competed as ordered, reweighs were not obtained per policy, nutritional needs were not reassessed following the significant weight loss, and they did not receive assistance at meals as planned. Findings include: The undated facility policy Registered Dietitian Intervention and Documentation on Resident's Nutritional Status, documented the Registered Dietitian would assess and evaluate residents with significant weight loss or gain per the Minimum Data Set assessment guidelines and would develop care plans with the interdisciplinary team. All residents considered to be high nutritional risk were to have nutritional assessments completed monthly until nutritional status had improved (weight loss had at least stabilized with body mass index (BMI) greater than 19, pressure ulcers had resolved, meal intakes were greater than 75% estimated energy and fluid needs). Residents clinically assessed to be high risk were to have weekly weights obtained. Residents who exhibited recent unplanned weight loss of five (5) % over 1 month, seven and half (7.5) % over three (3) months or ten (10) % over six (6) months were considered high risk: The facility's revised 3/2025 Resident Weights policy documented each resident would have a weight on admission and at least monthly unless otherwise indicated by Physician, Nurse Practitioner, or Dietitian. It was the responsibility of the Nursing Department to provide accurate weights on residents monthly. The re-weights would be done within 72 hours of the weight discrepancy. A five (5) pound gain or loss required that a re-weight be obtained, unless specifically contraindicated by a Physician or Nurse Practitioner. The Unit Manager or Dietitian would document weights in the resident's clinical record. The Dietitian would document weight problems, reassess if needed, and discuss with the interdisciplinary team. Resident #56 had diagnosis including dementia, Parkinson's disease (a progressive neurological disorder), and dysphagia (difficulty swallowing). The 2/26/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, required partial/ moderate assistance with eating, and was 62 inches tall. There was no documented weight and had no known significant weight changes at one (1) or six (6) months. The Comprehensive Care Plan initiated 6/2022 documented the resident required partial/moderate assistance with eating, provide finger foods, encourage fluids, set-up, open containers, cut up meat, butter bread, monitor/ document meal consumption, offer alternatives, and encourage the resident to be out of bed for meals. The resident had potential for nutrition problems. Interventions included provide diet as order, monitor weights, Ensure Plus (oral nutrition supplement) three times daily, and high calorie dairy items. The 7/22/2024 physician order documented 7.5 milligrams of Remeron (appetite stimulant) once daily. The resident's record documented the following weights: - on 10/2/2024 128.9 pounds. - on 11/22/2024 114 pounds (14.9 pound/ 11.56 % loss x 30 days). There was no documented evidence a re-weight was obtained. The 11/25/2024, Dietetic Intern/ Diet Technician #20 progress note documented the resident triggered for a weight loss. Intakes at meals were 51-100%, they continued to receive eight ounces of Ensure Plus three times daily, family continued to bring in outside foods, they received additional snack items on their meal tray, and high calorie dairy items. They discussed the weight loss with Registered Dietitian #21 and the Registered Nurse Unit Manager and would follow up with the Registered Nurse Manager regarding notification of weight decline. There was no documented evidence the resident's nutritional needs were reassessed or nutritional interventions were updated. The 11/29/2024 physician order documented weekly weights. The 12/5/2025 Physician #27 progress note documented the resident's recent weights had trended downward, and the resident appeared to be eating and drinking without signs of worsening trouble swallowing or aspiration. They would continue Remeron for appetite stimulant and continue to encourage oral intakes and monitor weights. There was no documented evidence weekly weights were obtained as ordered from 11/29/2024-12/13/2024. On 12/13/2024, the resident's record documented they weighed 105 pounds (9 pound/ 7.89% loss x 23 days). There was no documented evidence a re-weight was obtained. The12/17/2024, Dietetic Intern/ Diet Technician #20 progress note documented the resident triggered for a weight loss. Intakes were documented 76-100% at meals, they continued to receive eight ounces of Ensure Plus three times daily, family continued to bring in outside foods, and the resident received high caloric dairy items on their tray. The plan was to increase Ensure Plus to four times daily and follow up with the Unit Manager about family preferences regarding weight decline. There was no documented evidence the resident's nutritional needs were reassessed after the significant weight loss. The resident's record documented the following weights: - on 12/17/2024, 108 pounds. - on 12/31/2024, 107 pounds. There was no documented evidence weekly weights were obtained 12/17/2024-12/31/2024. The 1/8/2025 Nurse Practitioner #11 progress note documented the resident's weight was 107 pounds and their body mass index was 19.6. The 1/14/2025 Registered Dietitian #21 progress note documented they spoke with the Unit Manager and Speech Language Pathologist about the resident's weight decline and family bringing in foods for additional calories. There was no documented evidence the resident's nutritional needs were reassessed. The 1/14/2025 Physician #27 progress note documented Remeron was discontinued, and the resident appeared to be tolerating their modified diet appropriately. The 1/27/2025 physician orders documented to upgrade diet to regular consistency. There was no documented evidence the resident was weighed in 1/2025. The 2/4/2025, Dietetic Intern/ Diet Technician #20 quarterly nutrition assessment documented the resident was on a regular diet with thin liquids, required set-up help at meals, received eight ounces of Ensure Plus four times daily, intakes were good with occasional refusals, they received juice, water, coffee, and pudding at all meals, and diet soda and ice cream at lunch and dinner. The resident weighed 107 pounds, their body mass index was 19.5, had a significant weight loss at 90 days of 16.99% and at 180 days of 17.82%. Weight gain was goal, and estimated nutritional needs still applied from since last assessment. There was no documented evidence the resident's nutritional needs were reassessed for their current weight. The resident was weight once in 2/2025. On 2/13/2025 the resident's weighed 109.2 pounds (18.8 pound/ 15.2% loss x 90 days). There was no documented evidence weekly weights were obtained as ordered in 2/2025. On 3/13/2025, the resident's record documented they weighed 102.6 pounds (6% loss x 30 days). There was no documented reweight, the resident's nutritional needs were not reassessed, and there was no documented evidence their nutritional interventions were updated. The 3/14/2025 Physician orders documented to discontinue weekly weights. The 3/17/2025, Registered Dietitian #21 progress note documented the resident triggered for a significant weight loss at 30 and 180 days and the resident continued to receive eight ounces of Ensure Plus four times daily. The plan was to add ice cream to the lunch meal and pudding to the dinner meal to aid with providing additional calories. The 3/17/2025, Nurse Practitioner #11 progress note documented the resident's weight was 102.6 pounds, and their body mass index was 18.2. On 4/2/2025, the resident's record documented they weighed 104.2 pounds (24.7 pounds/ 19.16% loss x 180 days). On 4/10/2025, Registered Dietitian #21's progress note documented the resident triggered for a significant weight loss at 180 days. The resident's diet was heavily supplemented with eight (8) ounces of Ensure Plus four (4) times daily, weights had stabilized, mealtime intakes were 76-100% at most meals, pudding, and ice cream had been added to the meal pattern for additional calories. On 4/14/2025, Physician #3 documented the resident was seen for 60-day follow up visit. The resident weighed 104 pounds, their body mass index (BMI) was 19, appeared thin and frail, had weight loss, and received Ensure Plus. The following observations were made of Resident #56: - on 4/28/2025 at 1:30 PM, residents were eating lunch in the main dining room. The resident was in their bed sleeping, appeared thin, and there was no meal in their room. - on 4/29/2025 at 1:29 PM, seated at a table in the dining room. The resident consumed 100% of their ice cream, 100% of one pudding, and 25%-50% of the second pudding, 0-25% milk, 0-25% fruit cup, 25-50% of their coffee, and 0-25% of meatloaf, carrots, and potatoes. Staff did not help the resident during the meal. - on 5/2/2025 at 1:09 PM seated at a table in the dining room. The resident asked the surveyor to remove the lid from their ice cream. Another resident at the table assisted the resident with removing the lids. At 1:12 PM, the resident was eating their ice cream with a fork. The resident continued to eat their meal without staff assistance. At 1:30 PM, they resident closed their eyes. They consumed 100% ice cream, 75% turkey stroganoff, 50% of broccoli and cauliflower mix, 0-25% of milk and ginger ale. During an interview on 5/5/25 at 12:17 PM Registered Nurse Unit Manger #22 stated nursing was responsible for obtaining resident's weights and they were weighed monthly unless there was a physician order for weekly weights. The aides obtained the weights, and the Nurse Manager entered the weights into the computer. If there was a weight discrepancy of five pounds staff should obtain a reweight. It was the Nurse Manager's responsibility to ensure all weights were obtained as ordered. They stated Resident #56 had an order for weekly weights and had weight loss in the past. They stated the resident was supposed to receive partial to moderate assistance at meals and staff should be opening items for them. It was important for staff to provide the correct level of assistance to aid with promoting intakes. During an interview on 5/5/2025 at 12:48 PM Certified Nurse Aide #25 stated the Nurse Manager let the aides know which residents needed to be weighed, the aides obtained the weights, and the nurse entered them into the computer. If there was a five pound change from the previous weight a reweight should be obtained. They stated Resident #56 was on weekly weights and had weight loss. The resident had variable intakes depending on their mood, but typically ate their sweets. They stated it was the responsibility of the person passing the meal tray to ensure all items were opened and items were cut up if needed. The resident did not always require assistance at meals and could eat without assistance most of the time. During an interview on 5/5/2025 at 1:30 PM Registered Dietitian #21stated weights should be completed as ordered. It was the responsibility of nursing to obtain weights. If there was a weight discrepancy of five pounds a reweight should be obtained within 72 hours. They alerted the Nurse Managers, Director of Nursing, and Administrator of any missing weights. Significant weight changes were 5% change at 30 days, 7.5% at 90 days, and 10% at 180 days. Significant weight changes were discussed weekly during the weight and skin meeting with the Nurse Managers and the wound care nurse, and a copy of the weight changes were provided to the Director of Nursing and Administrator. Once a resident had a significant weight change, they reviewed the resident's record to see what had changed. If needed they added or removed any supplements and reviewed menu preferences. They stated Resident #56 was on weekly weights, the resident's weight was not always obtained as ordered, and they had a significant weight loss and reweights were not obtained per policy. It was a struggle to get the weights at the facility. They reassessed the resident's nutritional needs on admission, annually, or for significant changes. They were unaware the resident was no longer receiving an appetite stimulant, and they did not complete meal rounds on the unit. They stated the resident liked sweets and their meal pattern reflected preferred food items. The resident was provided with eight ounces of Ensure Plus four times daily. Nursing staff should ensure all items were opened to aid with promoting optimal intakes. 10NYCRR 415.12(i)1

Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences for one (1) of one (1) resident (Resident #95) reviewed. Specifically, Resident #95 did not receive double portions per their preference. Additionally, during the facility's April 2025 Food Committee Meeting 20 residents voiced concerns regarding double portions. Findings include: The facility policy Fine Dining- Meal Captain, revised 4/2024 documented the facility would provide a Meal Captain for each meal to coordinate the efficient process of the meal and to ensure that all residents have an enjoyable meal experience. The Meal Captain would give the dietary staff the residents' meal tickets, and the food would be prepared as directed on the ticket and served to the resident. Resident #95 had diagnoses including depressive disorder, anxiety, and heart failure. The 4/18/2025 Minimum Data Set assessment documented the resident had intact cognition, required setup or clean-up assistance with meals, and received a therapeutic diet order. The 2/16/2024 physician orders documented the resident received a regular consistency two gram sodium diet with thin liquids. The revised 2/4/2025 Comprehensive Care Plan for nutrition documented the resident received a regular two gram sodium diet and double portions per their request. The 4/27/2025 Dietetic Intern/ Diet Technician #20 Nutrition Assessment documented the resident continued a two gram sodium regular consistency diet and their meal pattern provided coffee, juice, and water three times daily along with double portions per their preference. The 4/2025 care instructions documented the resident received a regular consistency two gram sodium diet and required set-up/ clean-up assistance at meals and to offer alternatives if needed. The following meal observations of Resident #95 were made: - on 4/28/2025 at 1:33 PM, the resident was seated in the dining room and their meal ticket documented a two gram sodium diet with double portions. The meal ticket documented six ounces of herb baked chicken, eight ounces of vegetarian baked beans, eight ounces capri vegetables, eight ounces mandarin oranges, sixteen ounces of ice water, and eight ounces of juice. The resident had a double portion of the herb baked chicken, but only had four ounces of vegetarian baked beans, capri vegetables, and fruit. - on 5/2/2035 at 1:15 PM, the resident was seated in the dining room and their meal ticket documented a two gram sodium diet with double portions. The meal ticket documented eight ounces of Tukey stroganoff with mushroom cream sauce, eight ounces egg noodles, eight ounces broccoli and cauliflower, and eight ounces watermelon cup. The resident had a double portion of turkey stroganoff and noodles, but only had four ounces of broccoli and cauliflower, and watermelon. During an interview on 5/2/2025 at 2:04 PM Certified Nurse Aide #29 stated Resident #95 received double portions. They stated the food service aide plated the hot foods, and nursing staff placed the cold items on the meal trays. During an interview on 5/2/2025 at 2:12 PM Food Service Aide #14 stated they plated the hot foods and nursing staff placed the cold items on the meal trays. All staff should read the meal tickets to ensure the right items and correct portion sizes were plated. They stated they would place two scoops of vegetables into the dishes if a resident was on double portions and would not provide two separate dishes. A normal portion size for most vegetables and fruits was four ounces and a double portion would be eight ounces. During an interview on 5/5/2025 at 11:34 AM the Food Service Director stated food service aides plated the hot food items according to the meal ticket and nursing staff provided the cold items per the meal ticket. The dishes used for the vegetables either held four or six ounces. If a resident's meal ticket indicated they received double portions they should receive two bowls because eight ounces would not fit into either bowl used for side dishes/ or vegetables. The fruits and most desserts were pre-portioned out four ounces so they should receive two of them if their meal ticket documented double portions. During an interview on 5/5/2025 at 12:48 PM Certified Nurse Aide #25 stated the food service aides plated the hot items according to the meal ticket and nursing placed the cold items on the tray. All staff should review the tickets to ensure the resident received the correct portion sizes. Resident #95 should receive double portions, and their preferences should be honored. During an interview on 5/5/2025 at 1:30 PM Registered Dietitian #21 stated resident meal preferences were added to their meal pattern and printed on the ticket. Nursing staff and the food service aides should review the tickets to ensure the residents received the correct portions and items. Resident #95 requested double portions, and it was listed on their meal ticket. It was important to honor resident food preferences. 10NYCRR 415.14(d)(3)(4) 48895

49448 Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not provide ongoing programs to support each resident in their choice of activities, for two (2) of three (3) Residents (Residents #74 and #156) reviewed. Specifically, Residents #74 and #156 were not offered meaningful activities that included their interests and preferences. Findings include: An activities policy was requested on 5/1/2025 at 8:36 AM. At 9:35 AM, the Administrator sent an electronic communication the facility did not have an activities policy. 1) Resident #156 had diagnoses including depressive disorder and stroke. The 3/24/2025 Minimum Data Set assessment documented the resident was cognitively intact, was dependent for mobility with use of a manual wheelchair, and felt it was very important to do their favorite activities; somewhat important they had books, newspapers, and magazines to read, to go outside; and to participate in religious services; and very important to listen to music they liked. The activities Comprehensive Care Plan initiated 3/19/2025 documented an activities focus. Interventions included encourage to attend group programs on and off the unit, place a calendar in the resident's room, provide tools for independent activities, and transport the resident to programs that met their interests. The 3/18/2025 Director of Activities initial activities assessment documented the resident's activity program included trivia games, musical entertainment, small groups for reminiscing, and outings. Independent programs included library cart, radio, family outings, and television watching. The 4/2025 Activity Calendar present in Resident #156's room posted on the bulletin board outside the nursing station documented the following daily activities: - on 4/28/2025 at 7:00 AM coffee cart, 9:30 AM garden club, and 10:00 flower crafts. At 2:00 PM, Unit 1 had BINGO, Unit 3 had coloring [NAME], and Unit 4 had manicures. Unit 2 (short term rehabilitation unit) did not have any unit specific activities listed at 2:00 PM. - on 4/29/2025 at 10:00 AM trivia games and at 11:00 AM word games. At 2:00 PM, Unit 1 had an ice cream social, Unit 3 had social hour, and Unit 4 had BINGO. Unit 2 did not have a unit specific activity at 2:00 PM. - on 4/30/2025 at 7:00 AM coffee cart, 10:00 AM sing-fit, 1:00 PM- 3:3:30 PM walking taco fundraiser, and Unit 4 had music hour at an unspecified time. During an interview and observation on 4/28/2025 at 3:09 PM, Resident #156 was lying in bed. Their television was off, and they stated their remote control did not work. They liked to watch television and go to therapy, otherwise there was nothing to do at the facility. They knew there were activities because there was an activity room on the first floor. They were never invited to an activity. They stated they liked to draw. There were no drawing supplies observed in their room. Resident #156's activity log documented they had 1:1 time with Activities Leader #18 daily from 4/28/2025 through 5/1/2025. During a follow up observation and interview on 4/29/2025 at 4:40 PM, Resident #156 stated nobody from the facility had ever sat down and talked with them except for the psychiatrist. They did not know who Activities Leader #18 was and they never met anyone in the activities department. One of the occupational therapists told them about a religious bible study that took place every Thursday and they wanted to attend. The resident had a bible, and a book titled Jesus Calling on their nightstand. During an observation on 4/29/2025 at 4:45 PM, there was a flyer approximately 6 feet from the floor on the wall in the hallway across from the resident's room that advertised spiritual group at 2:00 PM on Thursdays. During a telephone interview on 5/2/2025 at 1:56 PM, Certified Nurse Aide #17 stated the second floor was their usual unit and there were no activities on the second floor. They had never seen any 1:1 visits conducted on the floor. Occasionally, someone from activities would take a few of the residents from the second floor to activities on other floors. Residents could get bored and aggravated, and activities kept them going, gave them excitement and joy, and gave them something to do to keep busy. They were told the activities department was short staffed and there was nobody to cover the second floor. During an interview on 5/2/2025 at 2:51 PM, Activities Leader #18 stated the former Director of Activities was responsible for the second floor, but the current Director of Activities told them the floor was to be split. There were three activities leaders, all assigned a different floor. They were supposed to split up the second floor between them. They stated they were responsible for rooms 201-208. They were not sure who Resident #156 was but was sure they invited them to activities before, and they never completed a 1:1 visit with Resident #156. During a telephone interview on 5/5/2025 at 12:51 PM, Licensed Practical Nurse #16 stated there were no activities on the second floor. They advocated for their residents and if they saw an activity in the first-floor activity room, they called down and asked if activities would come get some of the residents from the second floor and they would. There was nobody from activities assigned to the second floor. It was important for the residents to have activities to give them something to do and keep their cognition going. During an interview on 5/5/2025 at 11:20 AM, The Director of Activities stated activities were important because they kept the residents active, entertained, and kept them thinking. The calendar showed large activities for the entire facility in the morning and then unit specific activities in the afternoon. The second floor was split between the activity's leaders. The expectation was when the daily chronicle was passed out, they should speak with each resident and review the activities for the day and see if the resident wanted to attend. Activities Leader #18 documented they completed 1:1 visits with Resident #156 and they expected they were completed if documented. 2) Resident #74 had diagnoses including Parkinson's disease (a progressive neurological disorder), neurocognitive disorder with Lewy bodies (a progressive brain disorder), and depression. The 2/14/2025 Minimum Date Set documented the resident had moderate cognitive impairment and required supervision to moderate assistance with most activities of daily living. The 8/30/2024 Minimum Data Set for Preferences for Customary Routine was not completed with the resident due to the resident rarely/never being understood. The staff assessment of Customary Routine and Activities documented the resident preferred reading books, newspapers, or magazines; listening to music; and participating in favorite activities The resident's Comprehensive Care Plan documented the following: - 8/16/2022 and last reviewed 3/3/2025, the resident had depression with goals to not exhibit signs or symptoms of depression and continue to participate in their plan of care. Interventions included invite the resident to activities of choice, encourage adequate rest periods, and increase daytime activities. - 4/4/2024 the resident had a mental health issue with a goal to have emotional, social, and psychiatric needs met with no need for acute inpatient psychiatric hospitalization . Interventions included encourage and assist the resident to attend therapeutic group activities to address emotional, cognitive, and behavioral symptoms of their mental illness. The resident enjoyed fishing, watching television, and talking with their family. -12/2/2024 last revised 2/24/2025, the resident did not wish to attend activities with other residents, had low motivation or interest, and had cognitive deficits. The goal was for the resident to attend small group activities, participate more actively within the activity program, respond positively to one-to-one activity visits, and socialize with staff during one-to-one visits. Interventions included to place a calendar in the resident's room, provide activity tools for independent activities, transport to programs that met the resident's interest, encourage activities where the resident could gain independence, encourage the resident to watch the activity a few minutes before deciding on participation, and allow the resident to choose programs to attend. The resident's activity log documented the resident participated in the following activities: - three music performer activities on 4/2/2025, 4/16/2025, and 4/30/2025; - one one-to-one time on 3/24/2025; - one social hour and a music entertainer on 2/19/2025; There was no documented evidence of activity attendance for 1/2025 or invitations to activities the resident declined. The April Activities calendar documented: - on Monday 4/28/2025 coffee cart at 7:00 AM, Garden Club at 9:30 AM, Flower Crafts at 10:00 AM, and Manicures at 2:00 PM on Unit 4. - on Tuesday 4/29/2025 10:00 AM Trivia time, 11:00 AM World Games, and Bingo at 2:00 PM on Unit 4. - on Wednesday 4/30/2025 coffee cart at 7:00 AM, 10:00 AM Sing-fit, and 4:00 PM Music Hour. The resident was observed on: - 4/30/2025 at 10:14 AM in their wheelchair in front of a TV playing a movie in the alcove area across form the nurses' station. The resident's head was down, and they appeared asleep. At 10:34 AM, Activities Leader #48 came onto the unit with a cart of Bingo supplies and other activity items. The resident was not invited to the activity. - 4/29/2025 2:58 PM Activities Leader #48 escorted two residents off the unit to the ice cream social. Resident #74 was not one of the residents invited. - 5/2/2025 at 11:29 AM, the resident was at a table in the dining room. At 11:30 AM, an unidentified nurse aide brought the resident to the area across from the nurses' station and placed them in front of the TV. The resident was alert and looking around. During an interview on 5/05/2025 at 10:37 AM, the Activities Director stated there was an activities leader assigned to the fourth floor. The activities leader's job was to transport residents to the large group activities, return the residents to the unit in a timely manner, organize their own activities on the unit, do one-to-one visits, and do the activities assessments for the Fourth floor. Every other Wednesday there was a happy hour entertainer on the Fourth floor. The one-to-one activities were documented in the electronic medical record. There was no set schedule for one-to-one visits, but they were fit in throughout the day when they had a break in activities. At least twice a week a resident should be a part of a group activity or a one-to-one visit. The after-breakfast movie staff put on for the resident did not count as one of the activities. The activity department should make sure residents from all floors participated in the large activities that mixed all the floors together. During an interview on 5/05/2025 at 11:15 AM, Activities Leader #48 stated they tracked the activity attendance via an activities sheet and entered it into the electronic medical record. The one-to-one activities were documented in the electronic medical record. They stated they tried to do an activity every day but for residents who did not come to the large group activities, they had to make sure there were at least two activities throughout the week to include one-to-one visits. Resident #74 did not come to activities a lot and liked to be independent. The resident enjoyed the happy hour and sitting with the music. They tried to do more one-to-ones with the resident as the resident liked to socialize. They stated the resident enjoyed food activities as well and seeing their sibling who was also in the facility on another unit. During an interview on 5/05/2025 at 2:55 PM, Certified Nurse Aide #49 stated Resident #74 did not attend activities so the certified nurse aides on the unit tried to get the resident to watch movies. They stated the resident liked to watch sports and their favorite thing to watch was a drag race show. The resident also liked to socialize and talk to people one-on-one. They stated the only people who did one-on-one with the resident was therapy. Activities sometimes socialized with the resident, but they could not remember when they last saw that occur. 10NYCRR 415.5(f)(1)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00375619, NY00359259, and NY00351358) surveys conducted 4/28/2025-5/5/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two (2) of eight (8) residents (Residents #60 and #158) reviewed. Specifically, Residents #60 was not provided showers as planned; and Resident #158 was not provided incontinence care as planned. Findings include: The facility policy Activities of Daily Living, revised 3/2025, documented activities of daily living would be documented by staff after completion; the resident's care plan and profile care card provided information on the level of assistance required by each individual to complete activities of daily living; and the nurse was notified of any resists/refusals and document in the progress notes. The facility policy ADL (activities of daily living) Support, revised 3/2025, documented residents who were unable to carry out activities of daily living independently received the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The facility policy Quality of Life-Dignity, revised 3/2025, documented residents shall be groomed as they wish to be groomed. 1) Resident #60 had diagnoses including left and right above the knee amputations and need for assistance with personal care. The 5/31/2024 Minimum Data Set assessment documented the resident felt it was very important to decide their type of bath. The 2/14/2025 Minimum Data Set assessment documented the resident had intact cognition and required moderate assistance for showering/bathing. The Comprehensive Care Plan, revised 1/13/2025, documented the resident had an activities of daily living/mobility problem. Interventions included partial/moderate assistance for shower/bathing, and dependence for transfers in and out of tub/shower. Comments documented sponge bath. The 4/2025 care card (care instructions) documented the resident was to receive showers on Sundays and Wednesdays during the 7:00 AM -3:00 PM shift. The 4/2025 certified nurse aide assignment sheets documented the resident was planned to receive a shower on Tuesday and Friday evenings on the 3:00 PM-11:00 PM shift. The resident's Care Log report documented the resident received one shower the weeks of 1/12/2025, 1/19/2025, 3/2/2025, 3/9/2025, 3/23/2025, 4/13/2025, and 4/27/2025 and no shower the weeks of 2/10/2025, 3/30/2025, 4/6/2025, 4/20/2025. Nursing progress notes 1/1/2025-4/30/2025 did not document refusals of showers. During interviews on 4/29/2025 at 9:39 AM and 3:07 PM, Resident #60 stated they were supposed to receive showers twice a week but only received a shower once a week. They stated if they did not receive a shower, they felt gross. They did not receive a shower in two weeks, but felt they would get into trouble if they complained. During an interview on 4/30/2025 at 10:00 AM, Resident #60 stated they got a shower, but staff told them they would not get one if they complained. During an interview on 5/2/2025 at 1:57 PM, Certified Nurse Aide #29 stated shower days and shifts were on the assignment sheets and the aides documented showers in the computer. If a resident refused, they reported that to the nurse and re-approached the resident. They stated on 4/29/2025, the resident requested a partial bed bath and not a regular shower. The resident complained to them about lack of showers yesterday. The resident had never refused their shower since they had been taking care of them. During an interview on 5/5/2025 at 12:00 PM, Licensed Practical Nurse #24 stated scheduled showers were on the assignment sheet. If a resident refused their shower they were reapproached, a bed bath was offered, and the refusal would be documented. They thought Resident #60's shower was scheduled during the day shift. The resident liked their shower and would not refuse one. During an interview on 5/5/2025 at 12:17 PM, Registered Nurse Unit Manager #22 stated the resident's scheduled shower days were listed in the computer and on the assignment sheet and the two should match. Resident #60's shower schedule in the computer did not match the assignment sheet. Showers were scheduled based on room number not resident preference. Resident #60 transferred from another unit in 3/2025 and was getting their showers on evenings. They did not talk to the resident about changing the day of their shower. The resident was supposed to get a shower twice a week, but the care log documentation did not document they were receiving showers as planned. They were not aware the resident was not getting their shower, and the resident did not complain to them recently about not receiving showers. They were responsible for making sure the assignment sheet and care instructions in the computer matched and was in the process of updating things. They stated they were aware the resident was not getting their showers twice weekly in the past and spoke to the evening staff about the importance of providing showers per the schedule. During an interview on 5/5/2025 at 12:48 PM, Certified Nurse Aide #31 stated showers were given twice a week and were listed on the assignment sheet. If the assignment sheet did not match the computer, they asked the nurse to determine when to give the shower. Resident #60 was an evening shower and required assistance of two. If a resident refused, they re-approached and documented the refusal. They would also tell the nurse and suggest a bed bath. If they gave a bed bath, they would document a bed bath was provided. During an interview on 5/5/2025 at 3:03 PM, Social Worker #30 stated Resident #60 approached them in 3/2025 and said they were told they would only get one shower a week. Social Worker #30 spoke with the Ombudsman, the Director of Nursing, and Registered Unit Manager #22 about the resident's concerns. They thought the issue was resolved. During the 4/2025 Resident Council Meeting the resident brought up their concern again and they passed the information along to the Nurse Manager. They had not heard anything since the meeting and was hoping the issue was resolved. It was important for everyone to get a shower twice a week and if not, it could impact the resident emotionally. 2) Resident #158 had diagnoses including Alzheimer's disease and need for assistance with personal care. The 2/17/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment, required partial/ moderate assistance with toileting, was frequently incontinent of bowel and bladder, and did not reject care. The Comprehensive Care Plan initiated 2/3/2025 and revised 2/11/2025 documented the resident had an elimination problem related to the need for assistance with personal care and difficulty walking. Interventions included an individualized toileting schedule and was to be checked and changed every 2 hours and as needed. The following observations of Resident #158 were made: - on 4/28/2025 at 1:30 PM, self-propelling in their wheelchair into their room. There was a strong odor of urine. There was a sign on the wall from the resident's family member documenting One outfit a day please. If going through more than 1 outfit, change brief more often. After 1st outfit of the day, use gown, brief, socks and sweater (over gown). Should not be going through 2 and 3 outfits a day. At 3:02 PM, self-propelling in their wheelchair through the hallway with a strong odor of urine. - on 4/29/2025 at 3:00 PM self-propelling in the hallway. There was a strong odor of urine, and their sweatpants were wet from the groin to just above the knees on both legs. At 3:08 PM, there were two visitors conversing with the resident in their room. Their navy-blue sweatpants were wet. The visitor stated the resident often smelled of urine and last week had a puddle under their wheelchair. The electronic care log for 4/29/2025, included Certified Nurse Aide #32's documentation the resident was incontinent of bladder at 10:00 AM. Certified Nurse Aide #33 documented the resident was incontinent of bowel and bladder at 4:00 PM. There was no documented evidence incontinence care was provided between 10:00 AM and 4:00 PM on 4/29/2025. During a telephone interview on 4/30/2025 at 9:11 AM, the resident's representative stated they asked the facility to toilet the resident every two hours because when they came to visit the resident was often wet. They did the resident's laundry and visited every evening around 5:30 PM. They typically took home three pairs of soiled pants every day. They stated they felt they had to come every day because the resident might be toileted less frequently if they were not there. Last week the resident was eating dinner in the dining room with a puddle of urine under their wheelchair. They stated the resident was wet approximately 4 out of 7 days when they visited. The resident always had an odor of urine, and they brought their own cleaning supplies because they could not stand the smell in their room. They stated when the resident was always very modest and clean. During an interview on 5/2/2025 at 12:08 PM, Certified Nurse Aide #32 stated Resident #158 was incontinent. They attempted to toilet the resident every two hours because they were a heavy wetter. It was important to toilet the resident to prevent skin breakdown. The resident's family complained about the resident being wet. They stated every time the resident was provided toileting assistance it was documented. On 4/29/2025 they toileted the resident in the morning and again in the afternoon. Usually, if they toileted the resident by 4:00 PM, they were dry, if they waited until 5:00 PM, they were soaking wet. During a telephone interview on 5/5/2025 at 1:02 PM, Licensed Practical Nurse #16 stated if Resident #158 was toileted every two hours as planned, they would not be wet to their knees. The resident often smelled of urine. Frequent incontinence care was important for dignity and prevented skin issues. During an interview on 5/5/2025 at 1:20 PM, Registered Nurse Unit Manager #31 stated Resident #158 was provided with incontinence care every two hours and as needed. The resident was a heavy wetter, and they had seen urine puddles under their wheelchair before. They had several conversations with family regarding incontinence care and explained the resident was often wet again a half hour after being changed. 10NYCRR 415.12(a)(3) 49448

Based on record review and interviews during the recertification and abbreviated (NY00355209) survey conducted 4/28/2025-5/6/2025, the facility did not ensure all alleged violations were thoroughly investigated and a plan was implemented to prevent further potential abuse for one (1) of two (2) residents (Resident #121) reviewed. Specifically, Resident #121 sustained an injury of unknown origin, a human bite mark, and it was not reported to the New York State Department of Health within 24 hours as required. Findings include: The facility policy Accident/Incident Reporting, revised 3/2025 documented all accidents or incidents that involved residents, employees, visitors or vendors that occurred at the facility had to be investigated and reported to the Administrator. Injuries of unknown source must be reported to the department supervisor as soon as such accident/incident was discovered or when information of such accident/incident was learned. The Nurse Supervisor/Charge Nurse must be immediately informed of accidents or incidents so that medical attention can be provided. The Nurse Supervisor/Charge Nurse Complete was to complete an Accident/ Incident Report and submit it to the Director of Nursing Services. The policy did not include procedures for reporting to the New York State Department of Health. The New York State Department of Health Nursing Home Incident Reporting Manual dated 8/2016 documented the following two elements must be present for an incident to be reportable to the New York State Department of Health: - Injury without known incident - the facility was unable to rule out abuse or care plan violations. Incidents resulting in serious bodily injury must be reported within two hours after forming a suspicion; all other incidents must be reported within 24 hours. Resident #121 had diagnoses including dementia with agitation, delirium, and violent behavior. The 7/3/2024 Minimum Data Set documented the resident was severely cognitively impaired, had physical behaviors 1 to 3 days that interfered with the resident's care and social interactions, had no wandering behaviors, and required supervision for transfers and ambulation. The 4/17/2023 Comprehensive Care Plan documented the resident was a potential victim of abuse due to their cognitive disabilities and having previously abused other residents. Interventions included redirect the resident away from persons of concern, encourage attendance at supervised activities, encourage the resident to spend leisure time in supervised areas, monitor socialization, observe and intervene with residents removing clothing, observe whereabouts of resident, intervene as needed to redirect, assess for behaviors used as communication for symptoms of pain, and offer diversional activities. The unsigned 9/20/2024 facility Investigative Summary documented: - on 9/20/2024 at approximately 8:20 PM, Licensed Practical Nurse #50 was informed by Licensed Practical Nurse #51 the resident had a possible bite mark on their left forearm. The incident was unwitnessed, and the resident was unable to state what happened. - the corrective actions taken by staff were frequent checks by staff, monitor the resident for changes in behavior and baseline mental state, the resident was up to date on their tetanus shot having last received it in 2018, the resident was assessed by a registered nurse, the provider was notified, and a dressing order for the wound was obtained. - based upon record review, interviews and internal investigation, the facts in this investigation do not support the allegation of abuse as defined by the New York State Department of Health regulations. - the report was signed by Licensed Practical Nurse #50 and the Director of Nursing. There was no documented evidence the incident was reported to the New York State Department of Health within 24 hours as required. The untimed 9/20/2024 Director of Nursing progress note documented they were notified by the licensed practical nurse the resident had an open crescent shaped area of concern to their left elbow. There was no determination on how or when the wound happened. The impression appeared to be teeth marks with 3 small open areas with purple/maroon discoloration and slight swelling. There was no documented evidence the incident was reported to the New York State Department of Health. The 9/23/2024 facility Investigative Summary documented: - on 9/20/2024 at approximately 8:20 PM Certified Nurse Aide #26 entered the resident's room to provide care during their last rounds. Certified Nurse Aide #26 discovered a bite mark on the resident's arm. The bite mark was reported to Licensed Practical Nurse #51 and Licensed Practical Nurse #50 informed the Nurse Supervisor. - there were no other residents observed in the area or in the resident's room. The resident was unable to say what occurred, but they did not appear fearful of anyone on the unit. - A registered nurse (not identified) completed an assessment which noted a crescent shaped laceration to the left elbow midline. The impression appeared to be teeth marks and there were three small open areas with purple/maroon discoloration and swelling was noted. - The resident was followed up with by the Director of Nursing and Nurse Practitioner #11 on 9/23/2024. There were no signs or symptoms of infection. - Per the staff interviews, the resident was last seen at 7:45 PM by Licensed Practical Nurse #51 prior to the care provided by Certified Nurse Aide #26. - The conclusion documented based on record review, interviews, and investigation, this event was reportable to the New York State Department of Health related to an injury of unknown origin with no clear understanding of where the injury came from. The 9/23/2024 Director of Nursing progress note documented they followed up on the resident's left elbow injury. The resident was unable to report what happened. The incident was reported to the Department of Health due to injury of unknown origin. During an interview on 5/5/2025 at 4:28 PM, Licensed Practical Nurse #50 stated it was reported to them Resident #121 had a bite mark on their elbow. They went to look at the mark then notified the Director of Nursing since it was a state reportable incident. The Director of Nursing or the Administrator made the decision if something was reported to the state. During an interview on 5/5/2025 at 4:00 PM, the Director of Nursing stated they were notified of injuries of unknown origin. If they were in the building staff called them to come to the floor. If they were not in the building the Registered Nurse Supervisor called them to inform them of the incident. It was determined if the injury of unknown origin was reportable to the State by the assessment of the resident, the resident's history, and the statements from the resident and staff. They assessed if there was the possibility of abuse or neglectful injury. Resident #121's bite mark was sustained on their elbow, and they were not able to determine a cause. The incident was reportable. They stated the incident occurred on 9/20/2024 but was not reported to the New York State Department of Health until 9/23/2024 because they received the notification of the incident late and was not notified until 9/23/2024. They stated they assessed the resident on 9/20/2024 due to the bite mark and did not know why they did not report it on 9/20/2024. 10 NYCRR 415.4

Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for four (4) of seven (7) residents (Residents #30, #97, #121, and #123) reviewed. Specifically, Residents #97, #121, and #123 were provided unplanned plastic silverware and plastic cups during meals; and Resident #30 wore soiled shorts because they did not get their personal laundry items returned to them timely. Findings include: The facility policy Quality of Life-Dignity, revised 3/2025, documented staff would address the resident by their name and not label them or refer to them by the care needs. 1) Resident #30 had diagnoses including need for assistance with personal care. The 1/23/2025 Minimum Data Set assessment documented the resident was cognitively intact, felt it was somewhat important to take care of personal belongings or things, required partial/ moderate assistance with dressing and toileting, was always continent of bowel and bladder, and was on a diuretic (causes frequent urination). The undated care instructions documented the resident was independent with toileting, continent of bowel and bladder, and used size 2XL (extra-large) incontinence products. The 3/12/2025 Resident Council Meeting Minutes documented residents had concerns with laundry not returning clothing timely. Observations and interviews with Resident #30 included: - on 4/28/2025 at 2:24 PM, they stated laundry was a two-week process. They only had two pairs of shorts left because laundry did not return their other clothing. They had to recycle their clothing, including shorts soiled with urine and they hung up their shorts to dry. There was a pair of shorts hanging from the windowsill and a pair hanging in the bathroom. The resident was seated on their bed wearing a purple shirt and a gown over their lap. The resident stated when they asked why laundry took so long to get back, they were told there were four floors of laundry to do. They stated they were incontinent and took themself to the bathroom. Today they gave one pair of pants to laundry they wore for the past 2 weeks. - on 4/29/2025 at 2:43 PM, there was a pair of shorts hanging in the bathroom. The resident was wearing the same purple shirt as 4/28/2025. The resident was seated on their bed wearing an incontinence brief and no pants/shorts. They stated they were never a person to wear the same thing twice without washing it and never imagined recycling dirty clothes. It made them feel old. - on 4/302025 at 11:58 AM, self-propelling their wheelchair to lunch wearing red shorts. At 4:17 PM, the red shorts were hanging in the bathroom. The resident was sitting up in bed wearing a purple nightgown. During an interview on 5/2/2025 at 12:15 PM Certified Nurse Aide #32 stated housekeeping came every night and collected residents' personal laundry from the bucket in the dirty utility room. Laundry Personnel #46 was the only person that returned the laundry for the entire facility. The residents complained that it often took a week or two to get their laundry items back. Laundry Personnel #46 was up to their head with the laundry in the laundry room. It was important the resident had clean clothes. They stated they complained to the Director of Housekeeping. During an interview on 5/2/2025 at 12:25 PM, Laundry Personnel #46 stated they were behind with laundry and tried to catch up the next day, but the laundry just kept coming. It was important residents had clean clothing for appointments and family visits. It was a health issue to wear dirty clothes. Resident #30 did not have very many personal clothing items. During an observation with Laundry Personnel #46 on 5/2/2025 at 12:30 PM the laundry room had laundry piled from floor to ceiling with a small workspace in the middle of the room. During an interview on 5/2/2025 at 12:34 PM, Laundry Personnel #47 stated they washed personal items first thing in the morning. There were usually five to six loads daily and after the items were dried, they went to the laundry room for Laundry Personnel #46 to fold/ hang and return the clothing to the residents. During a telephone interview on 5/5/2025 at 12:55 PM, Licensed Practical Nurse #16 stated the residents complained laundry took forever. There was only one person that returned laundry for the entire facility. Some of the residents complained it had been weeks since their items were returned. It was inappropriate Resident #30 had to dry their urine-soaked clothes and re-wear them. The residents were at the facility because they needed help with care, and they should all have clean clothes to wear. During an interview on 5/5/2025 at 1:12 PM, Registered Nurse Unit Manager #31 stated Resident #30 was frequently incontinent of urine. They were not aware the resident was holding onto and re-wearing soiled laundry. The resident should not wear soiled clothing and fear their items would not be returned timely. This was a dignity issue, and the resident had a right to have their belongings returned timely. During an interview on 5/5/2025 at 3:54 PM, the Director of Housekeeping stated they were responsible for overseeing the laundry process. Laundry should be returned in one to two days. Laundry should never take two weeks to be returned, and they were not aware it was taking that long. Residents should have clean clothes, this was their home, and everyone deserved to have clean clothes. 2) Resident #97 had diagnoses including dementia with behavioral disturbances, restlessness and agitation, and anxiety. Resident #97's Comprehensive Care Plan dated 2/25/2025 documented the resident used psychotropic medications for behavioral impairment. The resident's antipsychotic was discontinued due to resident remaining calm and cooperative without exhibited behaviors. There was no documentation the resident required plastic/paper dinnerware. Resident #97's meal tickets did not include the use of plastic/paper dinnerware. Resident #121 had diagnoses including dementia with agitation and violent behavior. Resident #121s Comprehensive Care Plan dated 4/17/2023 documented the resident used psychotropic medications for behavioral impairment. The resident had increased agitated behaviors, aggression, and combative behaviors when redirection was provided. There was no documentation the resident required plastic/paper dinnerware. Resident #123 had diagnoses including dementia with behavioral disturbances and anxiety. Resident #123's Comprehensive Care Plan dated 2/14/2024 documented the resident had potential for behavioral problems and disruptive behaviors related to dementia. The resident became increasingly agitated and aggressive. There was no documentation the resident required plastic/paper dinnerware. During an observation on 4/30/2025 at 12:56 PM, Residents # 97, #121, and #123 were assisted with their meals by nursing staff at a table in the middle of the dining room. The residents were provided with plastic silverware. During an observation on 5/2/2025 at 1:00 PM, Residents #97 and #121 were assisted with their meal by staff. The residents were provided with plastic silverware. At 1:03 PM, there were regular plates and regular several knives, forks, and spoons in the kitchenette silverware holder. During an interview on 5/02/2025 at 2:26 PM, Certified Nurse Aide #26 stated some residents in the dining room used plastic silverware if they had behaviors and were care planned for it. However, not every resident at the table where residents received assistance from staff had behaviors which required plastic silverware. They stated they may have run out of regular silverware. They stated it was not dignified for residents to use plastic dinnerware if they were not care planned to use it. During an interview on 5/2/2025 at 2:43 PM, Licensed Practical Nurse #43 stated residents who required feeding were assisted by staff and received plastic silverware. There were days the residents received plastic silverware or plates because the kitchen staff did not bring up enough plates and silverware. They stated by the time staff get to the residents who required feeding they often ran out of cups and silverware. It was not dignified for residents to receive plastic silverware if there was not a reason why. Acceptable reasons could be for safety. During an interview on 5/05/2025 at 12:41 PM, Licensed Practical Nurse #19 stated It was not dignified for residents who received total assistance with their meals to be assisted using plastic silverware. During an interview on 5/5/2025 at 1:23 PM, Licensed Practical Nurse Unit Manager #44 stated the residents assisted with dining received plastic cups and silverware on 5/2/2025 because they did not have enough by the time they got to that table. It was not dignified for residents who did not require plastic silverware, plates, or cups to be served those items. 10 NYCRR 415.5(d)(1)(i) 49448

Based on observation, record review and interview during the abbreviated survey (NY00341649), the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2's bedroom had food debris on the floor, there were no linens on the bed, the mattress had large tears, and the privacy curtain was stained. Findings include: The facility's Housekeeping Operations Manual, revised 3/2020, documented daily procedures for cleaning a resident room included dust mopping the floor, damp mopping the floors, and cleaning vertical and horizontal surfaces. Resident #2 had diagnoses including dementia and Parkinson's disease (a progressive neurological disorder). The 2/28/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required partial/moderate assistance with toileting, personal hygiene, and transfers, and did not have behavioral symptoms. The 3/21/2024 comprehensive care plan documented the resident was at risk for falling, needed assistance with activities of daily living, and was noncompliant with transfers, showers, medications, and threw drinks and food on the floor. Interventions included clear pathway, clutter free room, divert attention, avoid overstimulation, inquire as to reasoning for non-compliance and provide alternate options. The following observations were made of Resident #2's room: - On 7/17/2024 at 12:50 PM, the bedside tray table was tipped over on the floor with an empty plate next to it. A brown crumbled food substance was scattered on the floor near the bed and on the bedside mat. A half-eaten slice of pizza with dried hardened cheese was on a plate on the nightstand. The lunch meal with a meal ticket dated 7/17/2024 was on the nightstand uncovered and uneaten. A protective pad on the bed had dried yellow stains. - On 7/19/2024 at 8:36 AM, the floor near the resident's bed and bedside mat had scattered pieces of chocolate candy, a container of wipes, and a non-slip sock. The mattress had no sheets or blankets, and 2 pillows with pillowcases were on the bed. The mattress had a protective coating with multiple large open gouge marks near the head of the mattress. At 10:44 AM, the resident's room remained in the same condition as 8:36 AM. The privacy curtain had a large area of dried brown stains along the bottom of the curtain. The 7/17/2024 untimed Registered Nurse Manager #1 progress note documented the resident was highly agitated that morning. The aide had put the resident's hair in a ponytail and dressed them neatly when the resident proceeded to take out their ponytail and kept ripping their briefs off. Attempts at redirection were not successful. Additionally, the resident flipped over their bedside table with their breakfast tray and would not eat when given a replacement. During an interview on 7/19/2024 at 10:50 AM, Certified Nurse Aide #2 stated the aides typically changed bed linens and housekeeping cleaned resident rooms. If linens were not available on the unit, they were typically delivered by the end of the shift and they waited for delivery of linens before making up the beds. The resident had a lot of snacks in their room the resident's family brought in. The resident often had behaviors including throwing food on their floor. When they came on duty that morning, they found the resident's room with food on the floor and linens stripped from the bed and they reported it to the floor nurse and to Registered Nurse Manager #1. Housekeeping should have cleaned up the room and they were not sure why it had not been done yet. Certified Nurse Aide #2 stated they did not make the resident's bed yet because they did not have any linens available. The resident had a specialty mattress, the linen on the unit did not fit their mattress, and they were waiting for linen to be delivered from housekeeping. Towels, linens, and washcloths were typically in short supply at the facility. During an interview on 7/19/2024 at 11 AM, Registered Nurse Manager #1 stated housekeeping cleaned resident rooms daily and certified nurse aides changed bedding on shower days and more frequently if soiled. Certified nurse aides should be making beds and tidying resident rooms after resident's got up for the day. Resident #2 had behaviors and when agitated, the resident dumped snacks on the floor. When the resident was agitated and trashing their room, staff typically brought them out of the room to engage them in conversation. Certified Nurse Aide #2 did not make them aware the resident's room was not cleaned that day. Housekeeping should clean the resident's room daily and they were not sure if they had cleaned the resident's room yet. During a telephone interview on 7/23/2024 at 10:32 AM, Housekeeper #1 stated they were responsible for cleaning resident rooms and did tasks such as sweeping, mopping, dusting, and cleaning bathrooms. They typically started in one hallway of the unit and cleaned Resident #2's hallway last, getting there around 12:00 PM most days. Staff could always ask them to clean a resident room sooner if it was very dirty. They were familiar with Resident #2 and frequently cleaned up food and drink items from their floor. On 7/17/2024, they were running late to clean the resident's room. On 7/19/2024, they had not made it to the resident's hall to clean until around 12:00 PM. No staff on the unit asked them to clean the resident's room earlier on either 7/17/2024 or 7/19/2024. Laundry was responsible to care for the soiled privacy curtain. During a telephone interview on 7/23/2024 at 2:11 PM, Housekeeping Supervisor #4 stated there was no expectation for what time housekeeping staff should be finished cleaning resident rooms on the unit. Each unit had one housekeeper assigned during the day shift and they needed to do as much as they could get done in their 8-hour shift. If a resident had a spill in their room, including liquids or food, the process was for the aides or nurses to clean up the initial spill and then notify housekeeping for sanitizing. There was plenty of linens available on each unit and if linens were not available, they expected to be notified. Every day, 1 resident room on each unit, had a deep clean and that was when the privacy curtains were inspected and removed for cleaning if needed. If staff noticed a spill or an unclean curtain, they should notify the housekeeping staff. Nobody made them aware Resident #2's privacy curtain was stained and or there were no linens to make the resident's bed. If they had known, they would have addressed the issue. During a telephone interview on 7/24/2024 at 8:06 AM, Registered Nurse Manager #1 stated staff needed to let them know if there was an issue with a resident's mattress and they would complete an electronic work order for the Maintenance Department to address the issue. They stated no one notified them there was an issue with the resident's mattress. 10 NYCRR 415.29(j)(1)

Based on observation, interview, and record review during the recertification and abbreviated (NY00318580, NY00315254, NY00312648, NY00302926, NY00315085, and NY00314497) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 4 resident units (Units 1, 2, 3, and 4). Specifically, floors were unclean, windows were damaged or had missing components, and linen items were not available in sufficient quantities for resident use on all units. Finding include: The facility policy Work Orders dated 9/11/2023, documented the system was utilized to report issues requiring maintenance and/or housekeeping attention. The housekeeper job description documented daily resident room cleaning included proper techniques for all vertical and horizontal surface cleaning, sweeping, and mopping floors, sanitizing, and disinfecting restrooms. All housekeepers must report problems, concerns, and maintenance issues to the supervisor. The facility's resident Admission Agreement documented under services included under the daily basic rate was fresh bed linens. Monthly linen order for the past 9 months (1/28/2023, 2/25/2023, 3/26/2023, 4/29/2023, 5/28/2023, 6/24/2023, 7/29/2023, 8/26/2023, and 9/18/2023), documented wash cloths, towels, bed pads, pillowcases, fitted sheets, flat sheets and gowns were ordered each month. Each month 100-300 wash cloths, 25-50 dozen towels, 2.5-7 dozen bed pads, 5-10 dozen pillowcases, 5-20 dozen fitted sheets, 5-10 dozen flat sheets, and 5-10 dozen gowns were ordered each month. Unclean floors, walls, and equipment: The following observations were made on 9/5/2023: - at 10:21 AM, there were 11 total discolored white quarter size spots on the floor within resident room [ROOM NUMBER]. - at 10:43 AM, there was a cluster of brown spots on the floor outside the door to resident room [ROOM NUMBER] measuring 6 inches by 4 inches - at 11:20 AM, there was an unclean and soiled folding chair and commode in the 3rd floor shower room. - at 11:26 AM, there were 5 soiled and unclean ceiling tiles with food debris in the 3rd floor kitchenette. The wall adjacent to the soiled ceiling tiles was unclean and soiled with food debris. - at 1:00 PM, there was a stained post in the 1st floor activity room with debris on it and a 1 foot x 1 foot stained section on the flooring adjacent to it. - at 1:40 PM, the walls were unclean and stained with food debris within the 1st floor kitchenette. The floor behind and under equipment on the back wall was unclean and soiled with food debris. The following observations were made on 9/6/2023: - at 8:58 AM, there were approximately 10 discolored white spots on the wall within resident room [ROOM NUMBER]. - at 11:38 AM, there were unclean and stained sections of ceiling in multiple spots within the 4th floor dining room. During an observation on 9/7/2023 at 10:53 AM, the floors and walls in the 3rd floor kitchenette were unclean and soiled with food debris under and behind the food preparation table. The following observations were made on 9/8/2023: - at 10:38 AM, the wall mounted toilet in common shower room [ROOM NUMBER] was leaking from the wall and rear of the toilet onto the wall and floor when flushed. The floor under the toilet was discolored and black. - at 10:53 AM, the bed on the left side of resident room [ROOM NUMBER] was unmade with a bare mattress that had a large soiled, unclean section with black staining, and a strong urine odor. - at 11:25 AM, the floors were sticky throughout the dining room adjacent to resident room [ROOM NUMBER]. - at 11:35 AM, the bathroom floors in resident room [ROOM NUMBER] were hazy and unclean in appearance. During an interview on 9/8/2023 at 10:38 AM, the Regional Director of Housekeeping stated it seemed like the wax ring on the toilet in the shower room [ROOM NUMBER] might be leaking. They were not sure if maintenance knew about it. During an interview on 9/8/2023 at 10:53 AM, the Regional Director of Housekeeping stated the mattress in room [ROOM NUMBER] needed to be changed out. Nursing staff should not have left the mattress in place to be made and should have known it needed to be replaced. The mattress would not be able to be cleaned. During an interview on 9/8/2023 at 10:56 AM, certified nurse aide (CNA) #40 stated they cleaned mattresses with bleach wipes and then let them air dry. If a mattress needed to be replaced the Nurse Supervisor would be notified. They were not sure who was changing the resident's bed in room [ROOM NUMBER]. They did not know the mattress was soiled and needed to be changed. They stated the mattress should not have been used. CNA #17 stated the mattress was beyond cleanable and should have been replaced. They believed the supervisor should have been keeping a log to share with the maintenance department. During an interview on 9/8/2023 at 11:00 AM, registered nurse (RN) #19 stated they kept logs and let maintenance know of anything that had been brought to their attention that needed to be fixed or replaced. They did not know the mattress in room [ROOM NUMBER] needed to be replaced and was so badly soiled. They further stated the mattress should not have looked like that and was beyond cleanable and should be replaced. The nursing staff would enter a work order for maintenance and that can be done at any computer. During an interview on 9/8/2023 at 11:35 AM, the Regional Director of Housekeeping stated the bathroom floors that were replaced with sand color tile had looked that way for years due to a poor grouting job by the installers. The grout was not removed properly during installation and was now on top of the tiles and looked unclean even when it was clean. During an interview on 9/8/2023 at 2:00 PM, the Director of Maintenance stated they were not aware of the leaking toilet in the common shower room [ROOM NUMBER] and there was no work order. The toilet should not have been leaking. Laundry and linens: Observations made of linen carts on unit 1 on 9/5/2023 included: - at 12:36 PM, the red linen cart in front of resident room [ROOM NUMBER] was stocked with: 2 bath blankets, 1 gown, 1 flat sheet, 10 blue briefs, 2 yellow briefs, 1 package of wet wash clothes, and 1 pair of socks. - at 2:29 PM, the linen cart located outside the TV lounge #1 was stocked with: 18 incontinence briefs, 7 nightgowns, and 4 bath towels. Observations made of linen carts on unit 1 and 2 on 9/6/2023 included: - at 8:41 AM, the linen cart arrived on the 2nd floor and was stocked with incontinence briefs, 2 washcloths, 2 towels, 3 gowns, 2 blankets, 2 bottom fitted sheets, and 2 top sheets. - at 8:58 AM, there were three linen carts on unit 1 and one was stocked with: 5 gowns, one blanket, one sheet, one fitted sheet, and one wet towel. The second cart was stocked with 4 fitted sheets. The third cart was stocked with 4 blankets, 3 gowns, 6 pillowcases, 13 fitted sheets, and 1 soaker pad. - at 9:07 AM, the red linen cart in front of resident room [ROOM NUMBER] was stocked with: 5 blue briefs, 5 yellow briefs, 50 wash clothes, 2 bath blankets, 1 bed blanket, 1 box of gloves, and 1 fitted sheet. - at 9:24 AM, the red linen cart in front of resident room [ROOM NUMBER] was stocked with: personal clothing, 2 boxes of gloves, 1 blanket, 1 bag of large briefs, 1 fitted sheet, 1 towel, and 2 white briefs. Observations made of linen carts on unit 2 on 9/7/2023 included: - at 8:56 AM, the red linen cart in front of resident room [ROOM NUMBER] was stocked with: 2 gowns, 2 white briefs, 8 blue briefs, 4 yellows briefs, stack of soft dry wipes, packet of wet wipes, 1 boxes of gloves, 4 fitted sheets, 2 chux pads, 1 blanket, and 1 towel. - at 8:56 AM, the red linen cart in front of resident room [ROOM NUMBER] was stocked with: 10 yellow briefs, bins on tissues boxes, 2 blue briefs, 4 wash clothes, 1 gown, 1 fitted sheet, and 2 boxes of gloves. - at 9:35 AM, the linen cart outside resident room [ROOM NUMBER] was stocked with: 2 gowns, 2 blankets, 2 top sheets, and 5 fitted sheets. - at 9:37 AM, the linen cart outside resident room [ROOM NUMBER] was stocked with: 1 pillowcase, 11 fitted sheets, and 4 gowns. During an interview on 9/7/2023 at 10:17 AM, the Regional Director of Housekeeping stated nurses were responsible for changing beds and making beds. Laundry staff was responsible for delivery of linen carts to units each shift. During an interview on 9/07/2023 at 10:24 AM, Resident #45 stated they had been waiting over 2 weeks for their laundry to come back. Observations made of linen carts on units 1, 2, 3, and 4 on 9/8/2023 included: - at 8:14 AM, there were three linen carts for unit 2 outside resident room [ROOM NUMBER]: one cart had no linen. The second cart was stocked with one fitted sheet. The third cart was stocked with 5 washcloths, 1 pillowcase, 5 fitted sheets, 2 flat sheets, 3 soaker pads, 2 blankets, and 4 gowns. There was a linen cart outside resident room [ROOM NUMBER] was stocked with 1 pillowcase, 3 fitted sheets, 2 towels, 1 flat sheet, 4 washcloths, and 3 blankets. - at 10:20 AM, the blue linen cart on unit 4 was stocked with 3-4 towels and 8 wash clothes. - at 10:50 AM, the blue linen cart on unit 3 was stocked with 3 resident gowns, 5 towels and 8 wash clothes. - at 11:22 AM, the blue linen cart on unit 2 was stocked with 3 resident gowns, 6 towels, 8 wash clothes and 2 bed pads. - at 11:34 AM, the blue linen cart on unit 1 was stocked with 3 resident gowns, 4 towels, 8 wash clothes and 1 bed pad. During an interview on 9/8/2023 at 11:06 AM, CNA #40, stated they needed linens because resident rooms required fresh new linen for bed making. The laundry staff was responsible for bringing linens to the unit and putting them on the unit carts. During an interview on 9/8/2023 at 11:30 AM, the Laundry Supervisor stated each shift gets a blue cart with linens on it. More linen could be requested if needed. Staff could also come down to the laundry area to get more. There were plenty of new linen supplies in stock within the basement. Laundry staff only got back about half of what gets delivered to the units. Linen was thrown away in the garbage by unit staff, residents hoarded linens, and staff have taken linen home. During an observation on 9/8/2023 at 11:33 AM, there was a bundle of soiled linen on the floor within the right side of resident room [ROOM NUMBER]. The resident's bed was made, and linen was left on the floor. During an interview on 9/8/2023 at 11:35 AM, CNA #53 stated the linen should not have been left on the floor once the bed linens were changed out and needed to be put in the soiled linen room. They were not sure who changed the bed, but the soiled linens should not be left in the room on the floor. Observation made of linen supplies in the basement on 9/8/2023 included: - at 12:00 PM, the laundry supply room had new banded supplies that were stocked with 3,600 wash clothes, 600 towels, 120 fitted sheets, and 90 bed pads. - at 12:03 PM, the back storage room was stocked with 1,200 towels, 60 fitted sheets, 3,000 wash clothes, and 30 bed pads. During an interview on 9/8/2023 at 11:45 AM, the Laundry Supervisor stated they delivered linen each shift and each day on the floors. Missing linen on the floors was an issue for years now and they were not sure how to solve it. There were plenty of stocked supplies of linens of all kinds. Linen items were purchased often and held in the basement. New stock could be worked into the par level, but it happened way too often. The laundry staff only get back about half of what was sent out. During an interview on 9/8/2023 at 12:00 PM, the Regional Director of Housekeeping stated they believed staff were treating items like towels and washcloths as disposable items and throwing them away. They stated residents were also taking and hoarding the linens. During an interview on 9/8/2023 at 12:25 PM, housekeeper #55 stated nursing staff would throw linen out in the trash. They found linen in the garbage, and it seemed like the nursing staff treated linen as if they were disposable. During an interview on 9/8/2023 at 12:30 PM, laundry aide #56 stated they folded linen at the end of every shift and filled 4 blue linen carts, one for each unit. The carts were delivered on all three shifts and did not get back the stock of linen to wash they sent to the unit; they may get back half of the supply. There was plenty of linen in stock, but not sure what happened to it all on the floors and in rotation. They stated they get back less every day and shift. Linen was found in the garbage many times. Trying to get staff to not throw linen away especially washcloths and towels was difficult. If staff came down to ask for more linen, they would ask staff if they had any dirty linen that could be washed and replaced for them. If the staff stated there was no linen that could be washed, then they would open more new linen. Resident clothes were kept for 90 days and if not claimed with nursing staff help the clothes would go into donations. During an interview on 9/8/2023 at 1:00 PM, CNA #30 stated there was a big issue with no linen on the unit. They work overnights and would go to the basement to look for linen and sometimes there was not any available to use or gather for the resident. There were carts for each shift but sometimes evening shift takes the night shifts allotment and there will be no linen for night shift. During an interview on 9/08/2023 at 1:20 PM, LPN #46 stated there was not enough linen which made residents wait to get showered. During an interview on 9/08/2023 at 1:20 PM, LPN #46 stated there was not enough linen and this resulted in the residents waiting for showers. During an interview on 9/11/2023 at 10:12 AM, CNA #2 stated the unit was always low on linens and they had gone to the basement to find linen for the unit, but not all CNAs would do that. When they do not have linen, they used wet wipes. They could not shower residents without linen. During an interview on 9/12/2023 at 9:33 AM, licensed practical nurse (LPN) #7 stated there was only one person responsible for laundry at the facility. There was no linen when they needed it. There had been times when there were no blankets to provide to the residents. Residents could not receive showers, because there were no towels or washcloths available on the carts. Damaged or missing equipment and furnishings: The following observations were made on 9/5/2023: - at 10:05 AM, there was a section of the radiator falling off the wall and rusted within resident room [ROOM NUMBER]. - at 11:17 AM, the soap dispenser was off the wall and sitting on the sharp's container within shower room [ROOM NUMBER]. The following observations were made on 9/8/2023: - at 10:22 AM, the right side window screen frame was bent and not fitting flush with the window frame within resident room [ROOM NUMBER]. - at 10:23 AM, the right side window had a loose screen that was bent and not fitting flush to the window frame within resident room [ROOM NUMBER]. - at 10:30 AM, the baseboards were peeling and loose from the wall on the right side of resident room [ROOM NUMBER]. - at 10:42 AM, there was a missing window operation handle on the right side window within resident room [ROOM NUMBER]. - at 10:46 AM, the bathroom tiles were broken and missing at the threshold from the bathroom to the bedroom within resident room [ROOM NUMBER]. - at 11:08 AM, there was a window screen frame that was broken and rolled under itself within the dining room adjacent to resident room [ROOM NUMBER]. - at 11:15 AM, the right side window screen had a baseball sized hole through the screening within resident room [ROOM NUMBER]. - at 11:18 AM, the window screen was broken, and a linear rip was through the screen approximately 3-4 inches long within resident room [ROOM NUMBER]. - at 11:25 AM, the window frame was bent and had a quarter size hole in the screening within the dining room adjacent to resident room [ROOM NUMBER]. - at 11:55 AM, there was a damaged outlet cover with the left side sheared off within resident room [ROOM NUMBER] adjacent to the wall side resident bed. During an interview on 9/8/2023 at 10:30 AM, the Regional Housekeeping Director stated the baseboards should have been replaced. The Director of Maintenance stated they were not aware of a work order for the peeling or damaged base boards. They should not have been peeling and needed to be put up or replaced. Window screens should not be broken or have holes in them. During an interview on 9/8/2023 at 10:46 AM, the Director of Maintenance stated they did not the bathroom tiles in room [ROOM NUMBER] were broken and missing. They should not have been missing and broken. During an interview on 9/8/2023 at 11:55 AM, the Director of Maintenance stated there was no work order in place for the broken outlet covers and they did not know about them. They stated it was something that should have been fixed and not left. 10 NYCRR 415.29(j)(1) 48446 48895

Based on observation, record review, and interview during the recertification and abbreviated surveys(NY00302926, NY00311496, NY00314497, NY00315085, NY00315254, NY00317770, NY00318580, and NY00321728) conducted 9/5/2023-9/12/2023, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain adequate nutrition, and personal care including grooming and oral hygiene for 7 of 9 residents (Residents #3, 27, 76, 95, 110, 133, and 417) reviewed. Specifically, Resident #3 was not dressed in clean clothes or shaved as they preferred; Resident #27 was not assisted with range of motion (ROM) as planned; Resident # 76 was not toileted every two hours as planned; Resident #95 was not turned and positioned, shaved, or provided with nail care as planned; Resident #110 was not changed when visibly incontinent in the dining area; and Residents #133 and 417 were not assisted with showering. The facility policy Activities of Daily Living (ADLs) revised 3/2023, documented residents should be provided assistance with daily living based on their care plans. ADLs included moving residents from side to side and positioning the body when in bed, dressing, eating, toileting, and personal hygiene. Residents who were unable to carry out ADLs independently received the necessary services to maintain good nutrition, grooming, personal, and oral hygiene. Residents were to be dressed, toileted, and provided assistance with personal hygiene including shaving according to the care plan. The facility policy Quality of Life-Dignity revised 3/2023, documented residents would be treated with dignity and respect at all times. Treated with dignity was defined as assisting with maintaining and enhancing their self-esteem and self-worth, and the residents were groomed as they wished. 1) Resident #95 was admitted to the facility with diagnoses including sepsis (widespread infection), dysphagia (difficulty swallowing), and muscle weakness with the need for assistance with ADLs. The 7/20/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required extensive assistance of 2 for bed mobility, transferring, toileting, and personal hygiene. The comprehensive care plan (CCP) initiated 7/17/2023, documented Resident #95 was at risk for skin tears due to aging frail skin and their nails were to be short. The resident had a self-care deficit and was dependent on staff for personal care, due to decreased ADL function. The resident required extensive assistance of 1 for bed mobility. The 11/28/2023 CCP documented the resident was at risk for skin impairment. Interventions included to teach weight shift as able every 20 minutes and use a lift pad/sheet for repositioning. The undated care instructions documented the resident required extensive assistance of 2 for bathing, bed mobility and transfers. The 7/14/2023 occupational therapist (OT) #63 progress note documented the resident required extensive assistance of 1 for bed mobility and turning and positioning and limited assistance of 1 for personal hygiene. Resident #95 was observed: - on 9/5/2023 at 1:55 PM, lying on their back in bed, leaning to the left, with their eyes closed. There was stubble on their face. Their fingernails were long with a brown substance under the nails. - on 9/6/2023 at 9:58 AM, lying on their back in bed, leaning to the left, with their feet over the end of the bed on the right side. There was stubble on their face. The resident stated they would like to be showered, shaved, have their nails clipped, and they were uncomfortable in their current position. - on 9/7/2023 at 8:22 AM, in bed with the head of the bed elevated, their feet were hitting the bottom of the bed board, and their upper body leaned to the left. They stated they were not comfortable and would like to be repositioned. Their fingernails were long with brown substance underneath. They stated they wanted their nails cut. At 1:22 PM, they were in bed covered with a sheet and blanket with the head of the bed slightly less than 90 degrees. Their feet and their ankles were approximately 2 inches over the end of the mattress and resting on the footboard. The resident stated their feet hurt and they wanted assistance with repositioning and wanted their nails clipped. They stated they wanted to get out of bed and had not been out of bed this week. - on 9/8/2023 at 8:36 AM, in bed on their back with the head of the bed up slightly less than 90 degrees and the foot slightly elevated. Their feet were hitting the foot of the bed and upper body was leaning to the left. At 9:36 AM, in bed on their back with their feet hitting the footboard and their upper body leaning to the left. At 9:47 AM, certified nurse aide (CNA) #35 entered and left the residents room and stated they just repositioned the resident. At 9:52 AM licensed practical nurse (LPN) # 44 went into the room and stated the resident needed to be repositioned and attempted to reposition the resident. CNA #35 documented they turned and position the resident on 9/5/2023, 9/7/2023, 9/8/2023 and the resident required assistance of 1. During an interview on 9/7/2023 at 2:32 PM, CNA #35 stated they provided Resident #95 care that morning. They stated AM care included a bed bath, oral care, and nail clipping. They stated they did not shave the resident. CNA #35 stated they turned the resident three times when they changed the resident's brief. They were not sure if the resident was care planned for one or two assistance for bed mobility and stated they turned and positioned then independently. They stated it was important to shave a resident for dignity purposes and it was important to have nails clipped and cleaned to prevent scratching of the skin and for infection control to prevent getting sick from dirty fingernails. They stated they should have shaved the resident and cleaned their nails. During an interview on 9/8/2023 at 1:20 PM, LPN # 46 stated if residents did not get washed, they could have skin issues and get infections. They stated turning and positioning was important to prevent skin breakdown from lack of blood flow and infections. They stated the night shift was not always able to get residents up and sometimes left them soiled because there was only one or two staff on the night shift. During an interview on 9/8/2023 at 1:30 PM, with registered nurse (RN) Unit Manager #10 stated CNAs were responsible for showering, turning, and positioning, shaving, and providing nail care to residents. They stated residents confined to bed required turning and positioning every two hours and this was put on the schedule by the nurse. If turning and positioning was not done it could lead to skin breakdown. 2) Resident #133 was admitted to the facility with diagnoses including cerebral infarction (stroke), morbid obesity, and diabetes. The Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact, did not display behaviors, did not reject care, and required extensive assistance of one or two people with activities of daily living including bathing, and required a mechanical lift for transfers. The comprehensive care plan (CCP) dated 8/1/2023 documented Resident #133 required assistance of 1 with bathing and dressing. The undated care card (care instructions) documented a shower was to be provided every Tuesday and Friday. The undated care log documented the last shower was provided 8/18/2023. Resident #133 was observed on 9/8/2023 at 10:16 AM, 9/11/2023 at 10:05 AM, and 9/12/2023 at 08:57 AM with greasy and matted hair. During an interview on 9/6/2023 at 9:46AM, Resident #133 stated they had not been showered in at least 2 weeks. The resident stated the last shower they received was on a Friday in the middle of August 2023, but they could not recall the exact date. The resident stated that their hair was greasy and matted and they felt they smelled bad. The resident stated staff had been spraying a detangler in their hair and the product caused their hair to look bad. During an on 9/11/2023 at 1:32PM, registered nurse (RN)/Unit Manager #3 stated they were not aware of the resident not receiving a shower on their scheduled shower day. RN/Unit Manager #3 stated the CNA assigned to the resident was responsible to provide a shower on the assigned day. RN/Unit Manager #3 stated if the CNA was unable to complete their assignment for any reason, they were expected to report that to the charge nurse or the RN/Unit Manager who would then ensure the resident received their shower on their assigned day. During an interview on 09/12/2023 at 12:41PM, the Director of Nursing (DON) stated it was normal facility procedure to provide showers to the residents two times per week on their assigned days. The DON stated the CNAs received an assignment sheet which included shower days. Resident shower day was also listed in the electronic care card. The CNA was required to document the shower was provided in the CNA assignment area of the electronic medical record. The DON stated if there was no documentation in the electronic medical record then the shower was not completed. The DON stated the only time a resident should not receive a shower on their assigned day was with a medical order for resident to not shower. The DON stated if a resident was not showered as scheduled, it was not a dignified experience for the resident. 3) Resident #27 was admitted to the facility with diagnoses including non-Alzheimer's dementia and contractures (tightening of muscles, tendons, or joints). The 7/12/2023 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance of 2 for hygiene, repositioning and transfers, and had limited range of motion (ROM) in both upper and lower extremities and a stage 4 pressure ulcer on the sacrum. Physician orders dated 8/8/2023 documented nursing apply and/or check placement of bilateral palm guards every shift and remove for hygiene only. The comprehensive care plan (CCP) initiated 8/14/2023 documented the resident required total assistance with ADLs, had contractures of their upper body, and required palm guards to both hands to prevent worsening condition. Interventions included to monitor and follow up with occupational therapy (OT) as needed, reposition every 2 hours and keep skin clean and dry. The undated care instructions documented: bilateral palm guards, a pillow between knees at all times, turn and position every 2 hours, and extensive assistance of 2 for hygiene, transfers, and repositioning. The following observations of Resident #27 were made: - on 9/5/2023 at 10:04 AM, seated in the common television area without palm guards in either hand or a cushion placed between their knees. At 1:09 PM, the resident had a bright white palm guard in their right hand only. There was no palm guard in the left hand and there was no pillow between their knees. -on 9/6/2023, 9/7/2023, 9/8/2023, 9/11/2023 and 9/12/2023, the resident was observed with a palm guard in their right hand. There was no palm guard in their left hand and there was no pillow between their knees. The September 2023 treatment administration record (TAR) documented the resident was checked to ensure they had bilateral (left and right) palm guards in place as ordered from 9/5/2023-9/12/2023, every shift. During an interview on 9/8/2023 at 1:53 PM, certified nurse aide (CNA) #34 stated the resident should have palm guards in each hand, but the left palm guard could not be found. They stated the resident should have something between their knees, but they did not have anything to use. They stated they knew that the resident required these items as they were listed in the care card instructions for the resident. During an interview on 9/11/2023 at 11:19 AM, licensed practical nurse (LPN)/Unit Manager #31 stated that staff could locate each resident's ADL instructions from their care card. During an interview on 9/12/2023 at 1:03 PM, LPN #33 stated that the resident should have a palm guard but could not recall for which hand. During an observation and interview on 9/12/2023 at 1:27 PM, LPN #33 entered the resident's room. The resident was lying in bed with a palm guard in their right hand and nothing in their left hand or between their knees. LPN #33 stated the resident should have palm guards in both hands and something between their knees. They stated if the palm guards and padding were not used as ordered, the areas of concern could become more contracted and cause skin breakdown or pain. During an interview on 9/12/2023 at 3:23 PM, physical therapist (PT) #32 stated they would provide a recommendation for palm guards and medical would order the item. The therapy department provided the item and would follow up with application and evaluate the resident's ability to tolerate the appliance. Resident #27 was last seen by PT on 8/17/2023, and PT recommended the resident to have bilateral palm guards. The palm guards were a soft cushion used to maintain, not improve, positioning of the hand. They stated if the resident did not have the palm guard, nursing would usually tell PT who would get them one. The facility stocked the palm guards used for Resident #27. During an interview on 9/12/2023 at 3:41 PM, LPN Unit Manager #31 stated that palm guards were ordered by medical after therapy evaluated the resident. Nursing staff updated the residents care card and care plan and would also verbally notify unit staff. Therapy provided the palm guards and instructed staff on the application and use. Resident #27 had palm guards ordered for both hands. They stated they saw them on the resident that morning. If the resident needed another palm guard because they were missing or soiled, nursing staff should call therapy. They stated without the palm guard the resident could have skin break down and/or their contractures could worsen. During an interview on 9/12/2023 at 5:22 PM, the DON stated they expected a palm guard to be worn by a resident when recommended by therapy and ordered by medical. Therapy provided all the palm guards, and they had a supply of many commonly used supplies and could order what they did not have. Resident #27 had an order for bilateral palm grips. The DON stated they expected the resident to have them. 10NYCRR 415.12(a)(3) 48511 48632

Based on observation, record review, and interview during the recertification and abbreviated (NY00315085, NY00318580, NY00321728) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure residents were free from abuse for 1 of 2 residents (Resident #422) reviewed. Specifically, CNA #60 was witnessed verbally abusing Resident #422 and CNA #60 was not immediatley removed from the facility and returned to the unit after the abuse had occurred. Findings include: The facility policy Resident Rights revised 3/2023 documented the residents were to be treated with respect, kindness, and dignity. Each employee was given a copy of resident rights upon being hired and was responsible to read and learn them. Training related to resident rights was completed in orientation and annually. The facility policy Abuse Prevention revised 3/2023 documented residents were to be free from verbal, mental, sexual, and physical abuse, as well as corporal punishment, and involuntary seclusion. Staff was educated on techniques to protect all parties. Residents were protected from abuse, neglect, and harm, and abuse and harm of any kind was not tolerated. Resident #422 was admitted to the facility with a diagnosis of schizophrenia (a mental health condition), anxiety, and metabolic encephalopathy (a disease that alters brain function). The admission Minimum Data Set (MDS) assessment had not yet been completed. The comprehensive care plan (CCP) initiated 8/16/2023 documented the resident had the potential to be the victim of abuse related to diagnosis of metabolic encephalopathy with dementia and hallucinations. Interventions included providing a safe, quiet environment; approaching in a calm, positive manner; redirection and refocusing; and offering active listening. The care instructions dated 8/16/2023 documented the resident was alert and lacked information about how to intervene when behaviors occurred. The 9/6/2023 licensed practical nurse (LPN) #59's progress note documented the resident was up at 6:00 AM yelling and causing a commotion and was redirected without success. The day shift was notified of the incident. A 9/6/2023 investigation completed by the Director of Nursing (DON) documented on 9/6/2023 at approximately 7:00 AM there was a verbal altercation between a resident and a staff. Social worker (SW) #6 reported between 6:30 AM and 7:00 AM, they observed CNA #60 using profanity, was in the resident's personal space, putting their hands in the resident's face, and stated nobody wants you. The resident was severely cognitively impaired. CNA #60 was asked to leave the unit and not to engage further with the residents. Immediate actions taken included: removing CNA #60 from the unit and suspending them pending investigation. Statements were obtained from all parties. SW #6 interviewed all involved residents and residents in the surrounding area for safety concerns. On 9/7/2023 the Department of Health was notified, and the medical provider evaluated the resident for physical and emotional status. The 9/8/2023 investigation conclusion documented the termination of CNA #60 and licensed practical nurse (LPN) #59 who was supervising the CNA on the night shift and did not intervene. There were no documented staff statements included in the investigation report. During an interview on 9/6/2023 at 8:43 AM, Resident #406 stated CNA #60 approached them saying I will put my hands on you and slap the [explicative] out of you. CNA #60's timecard documented on 9/5/2023 they clocked in at 11:53 PM and clocked out at 7:46 AM on 9/6/2023. On 9/6/2023 at 9:18 AM, CNA #60 was observed on the second floor (the resident's unit) just outside the television area with a half wall, by the nursing station where residents were gathered watching television (approximately 2 1/2 hours after the witnessed incident). CNA #60 was walking and headed towards the elevator and stated, If that was the case you will have to fire everybody. Residents were in the television area and CNA #60 started yelling immediately outside that area as they walked toward the elevator. During an interview on 9/6/2023 at 9:20 AM, Resident #408 stated they were sleeping and awakened by yelling across the hall. They left their room and witnessed CNA #60 pointing their finger in Resident #422's face stating I will whip your [explicative]. Resident #408 stated they did not feel safe until SW #6 arrived. They felt anxious and fearful again after they saw and heard CNA #60 on the unit discussing the incident with the day staff later in the morning. They stated they requested and accepted medication for anxiety. During an interview on 9/6/2023 at 9:36 AM, SW #6 stated they observed CNA #60 yelling at Resident #422 with other residents in the area trying to intervene and protect Resident #422. They asked CNA #60 to leave the unit and notified the DON. The 9/8/2023 medical report completed by nurse practitioner (NP) #49 documented they were asked to evaluate Resident #422 after a verbal altercation a few days ago. The resident was alert and confused and in no acute distress. Recommendations included continuing to optimize a safe environment and follow closely. During an interview on 9/8/2023 at 12:05 PM, CNA #60 stated on 9/6/2023 Resident #422 was disrespectful to staff. They observed the resident throwing water on LPN #59 and attempted to redirect them to their room. CNA #60 stated they continued completing their morning rounds, ignoring Resident #422 who was following them from room to room. Resident #408 came out of their room, and they redirected them to their room to avoid an audience. At approximately 6:45 AM, they asked SW #6 to assist getting residents back to their rooms. CNA #60 stated they were not asked to leave the unit and continued working until their shift ended. They were waiting for a ride home from LPN #59 who had left for an appointment. The Assistant Director of Nursing (ADON) whom they had never met before stated they were suspended until the incident was investigated. They were asked to leave the unit and could not remember what time that occurred. During an interview on 9/8/2023 at 12:28 PM, LPN #59 stated on 9/6/2023 Resident #422 came out of their room when a dialysis driver arrived to pick up another resident. Resident #422 had previously stated they were attracted to the driver and did not like the way CNA #60 and LPN #59 were interacting with the driver. The resident spilled water on the floor and LPN #59 asked why they spilled the water and Resident #422 stated [explicative] I can do whatever I want. They ignored the resident's behavior and continued passing medications. Resident #408 came out of their room and started swearing at CNA #60 at approximately 7:00 AM, SW #6 arrived at the unit and was asked to redirect both residents back to their room. They stated they wrote a progress note and had to leave the facility before writing a statement because they had an obligation. When they returned to the facility after more than one hour, they wrote a statement and picked up CNA #60, as they were their ride. They did not hear any staff swear or make any gestures at the resident. They were not asked to leave the unit and was unsure if CNA #60 was asked to leave the unit. If they heard staff swearing or making inappropriate gestures they would intervene, redirect staff, and notify the supervisor. During an interview on 9/12/2023 at 10:22 AM, the Assistant Director of Nursing (ADON) stated they ruled out cases of abuse and neglect by taking a statement from the resident about their concern. After a report of abuse, residents were assessed for signs of physical or psychological abuse. The ADON stated they gathered statements from anyone involved. On 9/6/2023 around 7:00 AM they were notified by phone that CNA #60 was in a verbal altercation with a resident and was being disrespectful and using profanity. Staff were trained during orientation on appropriate ways to intervene and address behaviors. Some interventions in Resident #422's care plan included ignoring, verbal redirection, and diffusion which were not implemented per the report from SW #6. Resident #422 was evaluated by NP #49. CNAs that work overnight normally clocked out at 7:15 AM and LPNs at 7:30 AM and should not return to the unit after clocking out. CNA #60 was suspended around 8:00 AM and should have left the building. They were not sure how or why CNA #60 accessed the unit again. They were notified at least one hour later that CNA #60 was on the unit discussing the incident with day staff. CNA #60 was escorted to the first floor to leave the building by the ADON. During an interview on 9/12/23 at 12:11 PM, SW #6 stated on 9/6/23 around 7 AM, they arrived on the unit and heard CNA #60 swearing at Resident #422 and Resident #408 was intervening by redirecting Resident #408 to their room. They stated they also observed CNA #60 gesturing and putting their hands in the face of Resident #422. They asked CNA #60 to leave the unit and witnessed them leave the unit. They did not ask any other staff to leave the unit. They interviewed Resident #422 and recommended a psychiatric consultation and they also interviewed Resident #408. During an interview on 9/12/2023 at 12:01 PM, the Administrator stated if there was a report of staff being physically or verbally abusive with residents, the staff member would be immediately removed from the unit and interviewed by nursing administration. The staff member would be sent home pending an investigation. If they returned to the unit, they could possibly retaliate against residents and could be disruptive to resident care by distracting staff. They stated on 9/6/2023 around 6:30 AM to 7:00 AM, SW #6 reported a verbal altercation between a staff member and a resident. CNA #60 cursed at Resident #422. CNA #60 was sent to Human Resources where the ADON met with CNA #60 and obtained their statement of the incident. After obtaining the statement the CNA was asked to leave the building pending investigation of the incident. The CNA did not leave the building and returned to the unit where the incident occurred and discussed the incident with day staff. They stated that over an hour later, they were notified by SW #6 that CNA #60 had returned to the unit. They notified the ADON who escorted CNA #60 out of the building. Normally, the Safety Department was notified when staff or residents were restricted from getting on the units. The Safety Department was not notified and they should have been. 10NYCRR 415.4(b)(1)(i)

Based on record review and interview during the recertification survey conducted 9/5/2023-9/12/2023 the facility did not ensure that within 14 days after completion of a resident's assessment they electronically transmitted encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS (Centers for Medicare and Medicaid Services) System for 4 of 4 residents (Residents #24, 30, 81, and 100) reviewed. Specifically, the MDS assessments for Residents #24, 30, 81, and 100 were not transmitted within 14 days of completion. Findings include: The CMS Minimum Data Set (MDS) Resident Assessment Instrument Version 3.0 Manual documented that comprehensive assessments must be transmitted electronically to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system using the CMS wide area network within 14 days of the care plan completion date and all other MDS assessments must be submitted within 14 days of the MDS completion date. The facility's MDS Transmission Logs for 9/7/2023 documented: - Resident #100 had a significant change in status requiring an MDS assessment with the target date of 7/26/2023 and was signed as completed on 8/9/2023. The MDS was transmitted on 9/7/2023. - Resident #24 had an Annual MDS assessment due with the target date of 8/1/2023 and was signed as completed on 8/14/2023. The MDS was transmitted on 9/7/2023. - Resident #30 had a Quarterly MDS assessment due with the target date of 7/28/2023 and was signed as completed on 8/11/2023. The MDS was transmitted on 9/7/2023. The facility's MDS Transmission Log for 9/9/2023 documented: - Resident #81 had a Quarterly MDS assessment due with a target date of 7/28/2023 and was signed as completed on 8/11/2023. The MDS was transmitted on 9/9/2023. On 9/12/2023 at 2:51 PM, an electronic communication from the Administrator documented that the facility did not have a MDS policy, and they would refer to the RAI (Resident Assessment Instrument) manual located online. During an interview on 9/12/2023 at 3:29 PM, the MDS registered nurse (RN) #16 stated that assessment completed meant sections were completed by all the interdisciplinary team members but did not mean they were submitted. They stated the MDS assessment needed to be submitted within 14 days of completion, and that meant sending the file electronically to CMS. They stated they signed off on section Z (Assessment Administration, provides billing information and signatures of persons completing the assessment) indicating that the assessment was completed. Corporate MDS Consultant RN #50 would then be notified the MDS was completed and would submit the information to CMS. During a telephone interview on 9/12/2023 at 3:59 PM, Corporate MDS Consultant RN #50 stated their position was to guide staff that completed the MDS and update the facility on MDS rules and regulations to keep the facility in compliance. MDS assessments were completed by MDS RN #16. The ARD was the start date that drives the completion date which was 14 days afterwards. Once the MDS assessment was completed, the MDS needed to be transmitted to CMS within 14 days. They stated in the last 6 months, some MDS assessments had been completed late, and the facility had started to submit them. The facility had pulled in other staff to assist MDS RN #16 with getting up to date and in compliance. Corporate MDS RN #50 stated they had access to the electronic medical record (EMR) and reviewed specific resident records. They stated Resident #100's ARD was 7/26/2023 and was submitted on 9/7/2023; Resident #24's ARD was 8/1/2023 and was submitted on 9/7/2023; Resident #81's ARD date was 7/28/23 and was submitted on 9/9/23; and Resident #30's ARD was 7/28/23 and was submitted on 9/7/23. They stated those submissions were not completed timely. They stated they were aware the facility had several MDSs out of compliance. 10 NYCRR 415.11 (a)(5)

48632 48895 Based on observation, record review, and interview during the recertification survey conducted 9/5/2023-9/12/2023, the facility did not implement a person-centered care plan to meet the medical, mental, and psychosocial needs for 3 of 3 residents (Residents #119, 143, and 505) reviewed. Specifically, Resident #119 did not speak English and was not provided a communication board as planned; Resident #143 was addressed by a name not included in their care plan; and Resident #506 required glasses and was observed wearing broken glasses. Findings include: The undated facility policy Care Planning/Care Conference documented the comprehensive care plan (CCP) should describe the resident's medical, nursing, physical, mental, and psychosocial needs, and preferences and how the facility will assist in meeting these needs and preferences. Care plans should reflect person-centered care with resident specific interventions. 1) Resident #119 was admitted to the facility with a diagnosis of cerebral infarction (stroke). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, required extensive assistance of one for most activities of daily living (ADLs), had unclear speech, and was able to make self understood and understood others. The comprehensive care plan (CCP) initiated on 6/14/2023, documented the resident had a communication problem; was rarely/never understood, did not speak English, and sometimes understood others. Interventions included anticipating the resident's needs, understanding the resident's frustration, ask yes and no questions, reassure and praise all efforts, speak slowly, and enunciate distinctly, provide clues, point to items when discussing them, and provide and encourage communication board/picture board use. On 9/8/2023 at 9:54 AM, the Administrator documented in an electronic communication (email) the facility utilized two internet links that were resources for the resident's primary language other than English and there were no additional communication policies and procedures. The 8/2/23 at 6:31 PM progress note by the Director of Nursing (DON) documented Resident #119's first language was [not English], and the resident spoke minimal English. The language services should be used whenever possible for clear and efficient communication. During observations on 9/5/2023 at 12:34 PM and 9/6/2023 at 11:44 AM Resident #119 was in their room with no visible writing board, communication/picture board, or book. On 9/8/2023 at 10:50 AM Resident #119 was observed and interviewed with the use of visual cues including pointing to the bulletin board, asking about a poster or picture board, and showing hand movements of opening a book. Resident #119 indicated that a picture board or book would be helpful to ask for assistance. Resident #119 looked for a book or poster in their wardrobe, dresser, and nightstand and there was no communication book or picture board present in the room. During an interview and observation on 9/11/2023 at 9:27 AM, Resident #119 was ambulating in their room, and agreed to the use of a language line (language service that assists with translation via telephone). There was no communication board or book present in the room. With the use of visual cues, to represent a book, Resident #119 grabbed their book bag and stated, book bag for to go home. During an interview on 9/11/2023 at 11:28 AM, certified nurse aide (CNA) #8 stated there was only one resident on the unit who used a communication board, and it was not Resident #119. They stated they were not able to understand Resident #119 and had never seen a communication board or book in the resident's room. If the resident rang their call bell, CNA #8 stated they had to ask several simple questions or point to items to understand what the resident was asking for. They stated the resident rarely rang for anything. The Nurse Manager was responsible for updating the care plan. During an interview on 9/11/2023 at 2:03 PM, registered nurse (RN) #3 stated that communication devices used on the unit were a board or book. The tools were provided by social work and came with the residents when they transitioned from the rehabilitation unit to the long-term care unit. They stated Resident #119 did not use a communication device and the resident was unable to communicate freely. RN #3 stated that staff would have to use simple questions to determine the resident's needs. During an interview on 9/12/2023 at 9:33 AM, licensed practical nurse (LPN) #7 stated that specific communication methods included the use of housekeepers for interpretation of some languages, boards, tablets, and writing, depending on the resident. Resident #119 did not have any communication devices. LPN #7 stated they thought the resident would be receptive to a communication board, as it was hard to communicate with them. They used visual cues to understand the resident's needs. Communication boards would be brought in for the resident by the family. Resident #119 never had visitors but spoke freely and with ease with family in their primary language via Facetime on their personal phone. During a follow-up interview with Resident #119 on 9/12/2023 at 11:00 AM, the language line interpretation service was attempted. An interpreter for Resident #119's primary language was not available. Resident #119 dialed their personal phone with the name Cellular Customers Service, the customer service agent stated the resident's full name and the resident wanted to know when they could leave the hospital and go home. During an interview on 9/12/2023 at 11:59 AM, social worker #6 stated that speech therapy was responsible for creating communication boards and books for residents receiving therapy. If social work was aware of a resident with English as a second language, they would create a binder with the resident's primary language and images, and this would be in their care plan. Social Worker #6 stated they were unaware if Resident #119 had a communication board or binder. During an interview on 9/12/2023 at 12:29 PM, the Director of Nursing (DON) stated communication devices included whiteboards, picture boards, and tablets for Facetiming with providers and family. The communication book was on each unit. They stated they were unsure if anyone had tried a language line with Resident #119. When the DON tried to get a language line, they were told they had the language communication books, but could not recall who advised them. They stated a communication line was needed for Resident #119, and they were trying to figure out what they could do to help. Resident #119 was unable to explain their needs and desires without a language line. 2) Resident #506 had diagnoses including glaucoma (an eye disease that can cause loss of vision). The 8/23/2023 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, wore corrective lenses, and had adequate ability to see with glasses or other visual appliances. An 8/17/2023 progress note by registered nurse (RN)/Unit Manager #47 documented the resident wore glasses. The 9/6/2023 care plan documented the resident had a visual function deficit related to glaucoma. Interventions included to encourage glasses to be worn, keep glasses clean and in good repair, monitor for changes, adapt activities to visual limitations, and schedule appointments with ophthalmology as needed. Resident #506 was observed: - on 9/5/2023 at 11:39 AM, was seated in their room in a wheelchair wearing glasses. The glasses were broken and had white tape on the dark frame. - on 9/6/2023 at 9:36 AM, seated in their wheelchair in the common television area, wearing glasses with white tape on the bow of the glasses. - on 9/7/2023 at 9:53 AM and 10:53 AM, seated in their wheelchair in the common television area, not wearing their glasses. At 1:04 PM, the resident's glasses were observed in the top drawer of the resident's bedside stand. The white tape remained on the bow, and the bow was separated from the frame. - on 9/8/2023 at 10:25 AM, seated in the common television area not wearing their glasses. During an observation and interview on 9/11/23 at 10:32 AM, the resident was seated in their wheelchair in their room and was not wearing their glasses. They stated they liked to draw, watch tv, and listen to music. The resident stated they could not see when their glasses were not on. The resident stated their glasses had been broken for quite some time and the nurses were aware. During an interview on 9/11/2023 at 11:19 AM, licensed practical nurse (LPN)/Unit Manager #31 stated they had been trying to make an eye appointment for the resident with no success. They stated the resident transferred to their unit with the broken glasses and they were unsure how long the glasses had been broken. 3) Resident #143 was admitted to the facility with diagnoses of cerebral infarction (stroke), dysphasia (speech impairment), and hemiplegia (paralysis) of the left side. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #143 had moderately impaired cognition, had clear speech, could understand others, and required supervision with activities of daily living (ADLs). The comprehensive care plan (CCP) dated 8/24/2023 documented communication difficulty including inability to be understood with speech, unclear speech, and repeatedly saying pat pat. Interventions included a communication board, speech therapy as ordered, anticipate resident's needs, monitor for changes, and the resident did not like to use the communication board. There was no documentation the resident had a preferred name other than their legal name. Speech language pathologist (SLP) #42's progress notes documented: - on 4/27/2023 the resident was assessed to have marked difficulty with cognitive-communicative skills. - on 6/2/2023 the resident communicated 4 out of 20 target words, was able to articulate numbers 1-10 with moderate verbal cues and additional time, and experienced difficulty with naming tasks revolving around days of the week, months of the year, and the alphabet. - on 6/12/2023 the resident became overly frustrated and emotional with speech attempts which increased the inability to understand language. - on 8/17/2023 the resident had reached their highest practical level with skilled services. The resident continued to experience difficulty producing words with maximum verbal and visual cues and clinician prompt. Observations of Resident #143 were made: - on 9/5/2023 at 11:56 AM, certified nurse aide (CNA) #8 addressed the resident as back-pack in the common dining area in the presence of other residents. - on 9/6/2023 at 12:15 PM, CNA #2 called the resident back-pack in the resident's room. - on 9/7/2023 at 10:04 AM, CNA #8 and CNA #36 referred to the resident as back-pack in a conversation with the resident. - on 9/7/2023 at 1:35 PM, an unidentified resident called Resident #143 back-pack. During a telephone interview on 9/6/2023 at 12:15PM, Resident #143's family member stated the resident had no way to communicate with staff. They stated the resident could answer yes/no questions only. The communication issue was a result of a stroke the resident suffered 6 months ago. During an interview on 9/7/2023 at 10:30 AM Resident #143 was only able to answer yes/no questions. The resident was asked if the staff called them back-pack, the resident nodded yes and began to cry. When asked if they liked to be referred to as back-pack the resident waved their arms in a back and forth motion and shouted no. The resident acknowledged they did not like being called backpack and buried their head in their hand and cried. During an interview on 9/7/2023 at 12:55 PM, CNA #36 stated they call the resident pat pat. CNA #36 stated the second-floor staff, where resident previously resided, reported to the first-floor staff they had called the resident pat pat since the resident was admitted . CNA #36 stated they had never asked the resident if they wanted to be called something other than their legal name. CNA #36 stated the resident's care card did not list any other name the resident preferred to be called. During an interview on 9/7/2023 at 1:05 PM, CNA #8 stated they call the resident pat pat. CNA #8 stated staff had called the resident pat pat since the resident moved to the first floor. CNA #8 stated the care card did not list resident preference to be called any other name than their legal name. During an interview on 9/11/2023 at 10:38 AM, Resident #143 acknowledged they did not want to be called back-pack. The resident was asked if the staff called them pat pat and the resident shouted no and began to cry. When asked if they wanted to be called anything other than their legal name, the resident nodded their head no and began to cry. During an interview on 9/11/2023 at 2:08 PM, SLP #42 stated Resident #143 had receptive and expressive language deficits. The resident refused to use a communication board because they became very frustrated. The resident was not able to write or use a keyboard. The SLP stated the resident did not like to be called by any other name than their legal name. The SLP stated the resident was very clear about how they wanted to be addressed. NY10CRR 415.11 (c)(1)

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00315085 and NY00318580) conducted 9/5/2023-9/12/2023, the facility did not ensure residents were treated with respect and dignity and cared for in a manner that promoted quality of life and protected the residents' rights for 2 of 5 residents (Residents #70 and 133) reviewed. Specifically, Resident #133 wore other residents' clothing that did not fit and attended an appointment wearing the clothing; Resident #70's urinary catheter collection bag was not covered and visible to other residents and visitors. Findings include: The facility policy Quality of Life-Dignity revised 3/2023 documented residents shall be treated with dignity and respect at all times. Treated with dignity meant the resident would be assisted in maintaining and enhancing their self-esteem and self-worth. Residents shall be groomed as they wish. Residents shall be encouraged and assisted to dress in their own clothes. Staff should promote dignity and assist residents as needed by helping residents to keep urinary catheter bags covered. 1) Resident #133 was admitted to the facility with diagnoses including cerebral infarction (stroke), morbid obesity, and diabetes. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, did not display behaviors, did not reject care, and required extensive assistance of one or two people with activities of daily living (ADLs) including bathing. The comprehensive care plan (CCP) dated 8/1/2023 documented Resident #133 required one person assistance with bathing and dressing. The care instructions card (undated) documented the resident required one person assistance and supervision with dressing. During an interview on 9/6/2023 at 9:46 AM, Resident #133 stated that the peach colored pants they were wearing were not their pants. The resident stated their clothes went to the laundry 2 weeks ago and had not been returned. They stated that the staff gave them the peach colored pants to wear because they had an appointment out of the building and needed to be dressed. The resident stated they did not agree with wearing another resident's clothing and this made them feel undignified. The resident stated when they asked staff for their own clothing, staff stated they could not find them anywhere in the facility. During an interview on 9/8/2023 at 10:16 AM, Resident #133 stated that on 9/7/2023 they had to wear another resident's clothes for an appointment outside of the building. The resident stated they refused to wear the clothes and insisted that staff find their clothes. The resident stated staff could not find their clothes anywhere in the building, so they agreed to wear another resident's clothes to make the appointment on time. They stated the clothes they were provided were too big and staff at the medical appointment commented about the oversized clothing. The resident reported they were embarrassed to be dressed and sent out of the building in another resident's oversized clothes. During a telephone interview on 9/11/2023 at 11:50 AM, certified nurse aide (CNA) #8 stated they dressed Resident #133 in another resident's clothes last week and was unable to recall the date. CNA #8 stated the person responsible for residents' laundry was recently on vacation and when they were away whoever did the laundry did not return it timely. They stated they looked everywhere in the facility but could not find clothing that belonged to Resident #133. They stated the resident was upset and they made CNA #8 aware they did not want to wear another resident's clothing. During an interview on 9/11/2023 at 1:32 PM, registered nurse (RN)/Unit Manager #3 stated residents should not be dressed in clothing that did not belong to them. They expected staff to search for resident's clothing until it was found. This included going to the laundry area of the facility to search for the clothing. They stated it was not an acceptable practice to dress a resident in another resident's clothes and it was not dignified for the resident. During an interview on 9/12/2023 at 12:41 PM, the Director of Nursing (DON) stated residents should not be dressed in other residents' clothing, and if they were it was not a dignified experience for the resident. They stated all resident clothing was labeled with the residents' name. If clothing that belonged to another resident was found in a closet, the articles should be returned to the rightful owner if labeled. 2) Resident #70 was admitted to the facility with a diagnosis of obstructive and reflux uropathy (obstructed urine flow). The 4/24/2023 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance of two with toileting and bed mobility, and had an indwelling urinary catheter. The comprehensive care plan (CCP) initiated 4/24/2023 documented Resident #70 had bladder needs which required a urinary catheter. Interventions included position catheter collection bag below the level of the bladder and cover with a dignity bag. The following observations of Resident #70 were made: - On 9/5/2023 at 11:24 AM, lying in bed with their uncovered catheter bag clipped to the right side of the bed frame, 1/4 full of amber colored urine and visible from the resident's doorway. - On 9/6/2023 at 1:25 PM, lying in bed with their uncovered catheter bag clipped to the right side of the bed frame, 1/4 full of amber colored urine and visible from the resident's doorway. - On 9/7/2023 at 8:53 AM, lying in bed with their uncovered catheter bag clipped to the right side of the bed frame, 1/4 full of amber colored urine and visible from the resident's doorway. During an interview on 9/12/2023 at 10:11AM, certified nurse aide (CNA) #17 stated they looked at the care card to tell them how to care for a resident and it included specifics including catheter care. They stated Resident #70 had a catheter and the catheter bag was supposed to be kept off the floor and covered with a dignity bag. They stated they took a facility class on catheter maintenance and dignity, and it was important to cover the catheter bag to protect Resident #70's privacy. During an interview on 9/12/2023 at 12:12 PM, licensed practical nurse (LPN) #18 stated all direct care staff should know that catheter bags had to be covered with a blue bag, kept off the floor, and if they noticed a catheter bag not covered, they would cover it immediately. They stated it was important to keep the catheter bag covered to protect Resident #70's dignity. During an interview on 9/12/2023 at 1:45 PM, registered nurse (RN) #19 stated all catheter bags should be covered for resident dignity. They stated Resident #70's care card and care plan told the CNA and LPN to keep the catheter bag covered and all staff members had to attend dignity training. During an interview on 9/12/2023 at 3:12 PM, the Director of Nursing (DON) stated a catheter bag should always be covered. They stated the facility had blue dignity bags that attached to a chair, or a bed and all direct care staff were responsible to keep a catheter bag covered. They stated the facility did in-services on dignity yearly and as needed. They stated it was important to keep Resident #70's catheter bag covered to protect their dignity. 10 NYCRR 415.5(a) 48675

Based on observation and interview during the recertification survey conducted 9/5/2023-9/12/2023, the facility did not ensure the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction were posted in a place readily accessible to residents, family members, and legal representatives. Specifically, the survey results and plan of correction were in a black plastic file bin on the wall, approximately 4-foot off the ground behind a 5-foot sign. Findings include: During the resident council meeting on 9/6/2023 at 10:15 AM, an anonymous resident stated they could not access the previous survey results. During an observation on 9/6/2023 at 1:55 PM, the survey results binder was in a dark corner near the palm scan time clock behind a 5-feet tall by 2-feet-wide facility advertisement sign with clear plastic containers resting at the foot of sign. Survey results binder were in the black file bin approximately 4 feet off the ground. During observations on 9/11/2023 at 12:01 PM and 9/12/23 at 2:25 PM the survey results were observed in a dark corner in a black plastic file bin on the wall next to the employee time clock behind a facility advertisement sign that was 5 feet tall and 2 feet wide, with clear plastic containers resting on the base of the sign. The bin was approximately 4 feet from ground level. The survey results in the binder were reviewed and included the recertification survey from 2/17/2022 and the abbreviated survey from 4/20/2022. It did not include abbreviated survey results from 1/6/2023 and 2/14/2023. During an interview on 9/11/2023 at 3:37 PM, the Activities Director stated the results of the previous survey could be found behind the front desk and the residents could ask for the survey results it if they wanted to view them. The Administrator was responsible for posting the survey results and updating the binder. During an interview on 9/12/2023 at 4:49 PM, the Administrator stated they were unsure who was responsible for posting survey results, but knew they were located next to the employee time clock. The Administrator observed the location of the results, and the binder was in a bin, in a dark corner next to the time clock behind a 5-foot sign. The Administrator acknowledged the facility advertisement sign and stated the sign was normally located across the lobby next to a pillar and was unsure why it was in this location. They stated the file bin was debatably too high to be reached by wheelchair bound residents. 10NYCRR 415.3(1)(c)(1)(v)

Based on observation, interview, and record review during the abbreviated survey (NY 923) the facility failed to ensure that the resident environment remains as free of accident hazards as possible each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed (Resident #6). Specifically, on March 19, 2022, a cognitively impaired resident with exit-seeking behaviors was able to leave the facility undetected. Staff were not immediately aware the resident was missing as staff on duty were unaware of the admission. Three hours after the resident was reported missing by their roommate, law enforcement was called and located the resident approximately 3 miles from the facility. The resident was evaluated at the hospital and returned to the facility. The facility's investigation identified multiple failures in their wander alert device/security systems. Not all failures have been corrected which places 19 residents with wandering behaviors at immediate risk to their health and safety. This resulted in no actual harm with the likelihood for more than minimal harm that was Immediate Jeopardy with Substandard Quality of Care to resident health and safety. Findings include: The Shift Rounds policy effective 4/1/14 documents: - The licensed practical nurse (LPN), Nurse Manager, or Supervisor will assign shift rounds via the assignment sheet. - The certified nursing assistant (CNA) from the on-coming shift and a CNA from the off-going shift will do rounds together. - All CNAs are to remain on the floor until rounds are completed. - It is the responsibility of the Nurse Manager or Supervisor to ensure compliance with the shift rounds. The Elopement Prevention Program policy revised 3/2022 documents: - All units have full locking mechanisms in stairwell doors, which require a keypad code for disengagement. - Exit cameras are in place at the reception desk. - The assigned CNA checks residents identified at risk of elopement every 2 hours and documents in the EMR (electronic medical record) to ensure the wander alert device is in place. - The nursing supervisor will conduct nightly testing of the alert bracelets. - All departments and disciplines will be in-serviced annually on exit door codes to bypass the alarms and when the alarm is sounding, staff are to open the door and check inside the stairwell, ensuring the resident did not exit. The Admission/Re-admission of a Resident policy revised 3/2022 documents: - Place new admission and re-admissions on the front of the 24-hour supervisors lead sheet and make notation on the inside to include assessment and observation for the resident. - The social worker or designee is to place the resident's name label outside of the room. - Complete and distribute the Department Notification Form per the directions on the form. The policy did not include the process for notifying direct care staff of new admissions. Resident #6 had diagnoses including cerebral infarction (stroke), [CONDITION(S)] (difficulty speaking) following cerebral infarction, and disorientation. The 3/19/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, exhibited wandering behaviors and rejection of care, required supervision, and set up assistance for walking, and required limited assistance of one for dressing, transfers, and bed mobility. The 3/18/22 email communications at 11:11 AM and 1:17 PM, from the Director of Admissions to multiple staff members including the Unit 2 registered nurse manager(s) (RNM) #7 and #14 documented: - there were 2 planned admissions for that day at 3:15, Residents #6 and #15. - Both Residents #6 and #15 were noted to be assigned to the same room and bed on Unit 2 (in separate emails). - Both Residents #6 and #15 were assigned the same medical record numbers (in separate emails). The 3/18/22 Daily Census report documented: - Resident #14 was discharged that day (no time noted). - Resident #6 was admitted at 3:34 PM, to the same room and bed on Unit 2 as Resident #14 had resided in. - Resident #15 was not admitted to the facility. - The total number of admissions on 3/18/22 was documented as one. The 3/18/22 hospital discharge summary documented Resident #6 had a history of [CONDITION(S)] accident ([CONDITION(S)], stroke) with expressive [CONDITION(S)]. The resident was recommended to have 24 hour a day, 7 days a week monitoring and was not safe to go home. The resident had a strong history of non-compliance, walked out of the hospital during their admission, and their family brought them back. The 3/18/22 at 5:00 PM Director of Social Services progress note documented Resident #6's family member reported concerns with the resident returning home due to their fluctuating cognitive status. The resident was oriented to person and responded I don't know to most questions. The resident's BIMS (brief interview for mental status) was 2 (out of a scale of 0-15, 15 being intact cognition, 2 being severe cognitive impairment). The 3/18/22 at 6:00 PM registered nurse Supervisor (RNS) #31's progress note documented Resident #6 was admitted from the hospital, was alert and oriented times one (not specified if person, place, or time), seemed confused, and was not answering questions appropriately. The resident was able to follow commands, assessment completed and a wander alert device (activates alarm when exiting doors and elevators) was placed on their right ankle. The 3/18/22 at 6:47 PM Elopement Risk Assessment completed by RNS #31 documented Resident #6 was independently mobile, had a history of actual elopement in the past 6 months from a healthcare facility or from home, was cognitively impaired, was wandering on the unit without purpose, and tried to or did wander off the unit. A score of 5 or more indicated the resident was at risk for elopement, and the resident's score was 10. A wander alert device was applied to the resident's right ankle. Resident #6's comprehensive care plan (CCP), initiated 3/18/22, documented the resident was at risk for elopement. The resident wandered without purpose, attempted to leave the unit unassisted, had impaired safety awareness, potential for elopement, was disoriented, and had a history of attempts/actual elopement. Interventions included wander bracelet, check for placement every shift, staff to intervene when wandering into other rooms, observe for a wandering pattern, offer snacks, observe for anxiety, distress, or verbalizations of desire to leave, prompt and redirect if elopement attempted. RNS #17's progress note on 3/18/22 at 9:00 PM documented Resident #6 was seen trying to get off the unit, the wander alert device was in place, the alarm went off from the elevator and the resident was redirected. Staff were notified for close monitoring. The 3/18/22 11 PM - 7 AM certified nurse aide (CNA) Nursing Assignment Sheet for Unit 2 documented: - CNA #22 was assigned to Rooms 201-211 (referred to as the low side). - CNA # 21 was assigned to Rooms 212-222 (high side). - Resident #13 (moved off the unit 3/17/22) and Resident #14 (discharged [DATE]) were listed in the same room in which Residents #6 and #12 currently resided in on 3/18/22. - Residents #6 and 12 were not listed on the assignment sheet as being current residents. The facility was unable to provide a Nursing Service 24-Hour Report for Unit 2 low side for 3/18/22 day (7 AM -3 PM) or evening (3 PM -11 PM) shifts. The 3/18/22 night shift (11 PM - 7 AM) Nursing Service 24-Hour Report noted low side documented by licensed practical nurse (LPN) #23, did not document Resident #6 was admitted to the room where Resident #12 resided. The 3/19/22 at 4:15 AM, RNS #17's progress note documented around 1:30 AM, RNS #17 was notified by Residents #6's CNA the resident was not in their room. Every room was searched, and the resident was not found. A Code Yellow (announcement for missing resident) was initiated, and the building was searched. Staff looked around the vicinity and found the resident's glasses outside on the ground. The Director of Nursing (DON) was notified, and the search extended outside the facility to nearby streets. The resident was alert, disoriented and confused upon admission. The police were notified, and the resident was found around 4:00 AM and taken to the hospital. The 3/19/22 facility investigation documented: - On 3/19/22 at approximately 1:20 AM, CNA #22 reported to RNS #17 Resident #6 was not able to be located. After a thorough search of the facility and outside surrounding area, the police were notified. - The police located the resident at approximately 3:37 AM, about 3 miles from the facility. The resident was transferred to the hospital for evaluation. - The window in the resident's room was noted with the screen removed, the right window latch completely removed, and the left disassembled, allowing the window to open fully. - The resident's glasses were found on the ground beneath the window. The ground outside the window showed no signs of imprints or impact. - The gated courtyard magnetic lock was found disassembled, allowing the gate to be opened. - The wander device alarm in elevator #2 was evaluated and found to not consistently alarm. - The door leading into the gated courtyard to the right of elevator #2 was noted to be unlocked from the inside, allowing persons to exit the building through the door. The door did not have an alarm as it led to a locked, gated communal area. - The north stairwell #1, when tested , did not detect the wander device alarm in close proximity resulting in a failure to lock the door properly. - CNA #18's statement, included with the investigation, dated 3/21/22 documented they saw Resident #6 arrive to the unit around 4:00 PM on 3/18/22, set up the resident's dinner and did not see them again, as the CNA left the facility at 7:00 PM. - CNA #21's statement, included with the investigation, dated 3/21/22 at 1:15 PM documented they arrived at 4:00 PM on 3/18/22. They went to see Resident #12 for a telephone message between 9 and 10 PM and Resident #6 was touching their window. They redirected Resident #6 and the resident charged CNA #21. CNA #21 reported to 2 Supervisors the resident was messing with the window and thought they were a danger to themself and their roommate. The Supervisor came to CNA #21 around 1:00 AM and said the resident was not in their room. They checked the room, the window was open, looked around the unit, checked the doors and no alarms were sounding. They walked around with the nurse and security staff and were unable to locate the resident. - CNA #22's statement, included with the investigation, dated 3/22/22 documented upon arrival to the facility at 10:21 PM on 3/18/22, they noted someone outside in the parking lot, they came back and saw someone between the bushes. They did rounds at 11:15 PM, and Resident #12 (the resident's roommate) said they thought their neighbor went out the window, heard a lot of noise, and the CNA advised them they would ask about it. CNA #22 asked LPN #23 and CNA #21 where Resident #14 was (resident who previously resided in the room), and they said they were discharged . CNA #22 informed Resident #12 who said they did not believe it. At 2:00 AM, Resident #12 was still worried and reported the resident jumped out of the window. CNA #22 checked again with the Unit Manager and was told Resident #14 was discharged and said there were supposed to be 2 people in that room. CNA #22 said there was only 1 person and they had been trying to tell them since 11:00 PM the resident was missing. The Supervisor told CNA #22 to check rooms and a search began. - LPN #23's statement, included with the investigation, dated 3/22/22 documented they arrived at the floor at 11:35 PM on 3/18/22, began administering pain medications, and at 12:00 AM did tube feedings for 2 residents. During the medication pass, a CNA asked LPN #23 where Resident #14 was, and LPN #23 stated they were discharged . LPN #23 left the floor to get a schedule and upon return, RNS #17 informed them the resident was missing. - RNS #17's statement, included with the investigation, dated 3/21/22, documented on 3/18/22, the resident was assessed by RNS #31, the wander alert device was applied, and the resident went to the elevator twice and was redirected. Around 9 to 10:20 PM, CNA #21 said the resident was doing something to their window and was redirected. At approximately 1:20 AM, the CNA reported there was only 1 resident in the room and the roommate said the resident jumped out of the window and the search was initiated. The facility investigation did not include statements from CNA #33, who was assigned to the Resident #6, RNS #31, who completed the admission, or RN Unit Manger #14 who was notified of the resident's arrival. The investigation did not include any reference of video footage of the facility's exit doors, stairwells, or elevators. On 3/31/22 at 11:25 AM the following observations were made: - The window on the B side of Resident #6's room had 2 missing window handles and was secured shut with a screw into the frame. - On the first floor, 2 doors were located on either side of the elevators (east and west). Both doors led to vestibules. Each vestibule had an alarmed door to a stairwell, and a door leading to an outside courtyard. - The east side interior door to the vestibule was unlocked with no alarm sensor. The door leading to the outside was locked. Security staff at the desk had to deactivate the lock from the desk to exit. - Upon exit to the courtyard, the resident's room window was observed approximately 20 feet above the ground. There was grass and leaf cover on the ground beneath the window. There were no indentations or areas of missing or disrupted grass. - The courtyard was enclosed with a gate. The gate door had no lock and was not secured. An area of the gate door had a partial locking mechanism, with missing pieces (rusted holes where another piece would be secured, areas that did not match up to the stationary part of the gate and had no parts that would connect to each other). - When exiting through the courtyard gate, there were trees and bushes to the left and the parking lot in front of the building. - Upon re-entry to the building, the door remained unlocked, as security staff at the desk (out of view) had to be asked to re-engage the lock. During a telephone interview on 3/31/22 at 4:05 PM, RNS #17 stated Resident #6 was wandering during the evening shift on 3/18/22. One time the resident followed visitors out of the unit to the elevator and another time they went to the elevator alone. The alarm sounded and they were redirected. When CNA #21 reported the resident was agitated and at their window, the RNS did not see anything wrong with the window at that time. There was no Supervisor shift to shift report from evening to night shift because RNS #17 and RNS #31 worked both shifts. Nurses would know about new admissions and the RNS could not recall if they spoke to anyone specifically about Resident #6 being admitted as RNS #31 completed their admission. During a telephone interview on 4/1/22 at 2:30 PM, CNA #33 stated they arrived to work at 7 PM on 3/18/22 and had the low side of the unit where Resident #6 resided. They last saw the resident between 9 to 10 PM when RNS #17 redirected them to not go out the doors of the unit. CNA #33 stated they left at 11:00 PM and did not see the oncoming staff (CNA #22) and did not report off to anyone. During an interview on 4/5/22 at 12:00 PM, LPN #4 stated they worked on 3/18/22 on the low side of Unit 2 until 7:00 PM and handed the medication cart keys off to LPN #20, who was working on the high side of the unit. The LPN had no knowledge of Resident #6's admission during their shift. When residents were admitted during a shift, the admitting RN was to notify the staff and update the rosters. During a telephone interview on 4/1/22 at 10:48 AM, LPN #20 stated they worked the 3 PM-11 PM shift on 3/18/22. LPN #4 worked the low side of the unit until 7 PM, and then turned over the medication cart keys to LPN #20. LPN #4 informed LPN #20 about a new admission. The 11 PM - 7 AM shift nurses were running late, and LPN #20 was late finishing their own duties at the end of the shift. The LPN could not recall what name they said when giving report to the next shift. They stated they always completed a 24-hour report, where they would document any events from the shift including a new admission or discharged resident. Each shift filled out the report and made a copy for the supervisor. The LPN did not hear any alarms during the shift and was not made aware of any concerns related to Resident #6. During a telephone interview with LPN #23 on 3/30/22 at 12:00 PM, they stated: - They worked on Resident #6's unit on 3/18/22 beginning at 11:35 PM. - LPN #23 received report from LPN #20, who stated there was a new admission and provided the name of Resident #15 and not Resident #6. LPN #20 did not provide any information about the new admission as they reported they worked on the opposite side (high side) of the unit and never saw the newly admitted resident. - After getting report and administering some medications, LPN #23 left the unit to get the schedule and upon return, RNS #17 notified them the CNA noticed Resident #6 was missing. - They searched the unit, called the Code Yellow, and the resident was not found. - LPN #23 noted the window was fully open and did not notice if there were any broken pieces or hardware on the floor. - The LPN went outside with the Supervisor and observed eyeglasses on the ground. - The gate latch from the courtyard to the public space was broken and LPN #23 stated they were not aware whether the gate latch was broken before that night. During a telephone interview with CNA #22 on 4/5/22 at 11:18 AM, they stated: - They arrived for work on Unit 2 for the 11 PM to 7 AM shift and had the low side. - The CNA did not receive report from anyone and did rounds on their own due to being the only CNA on that side. - They were not made aware of Resident #6's admission. - Resident #12 (Resident #6's roommate) rang their call bell several times asking about Resident #6 and stated they thought Resident #6 went out the window. - CNA #22 asked CNA #21 and LPN #23 several times and was not told about Resident #6 being admitted , only that Resident #14 was discharged . CNA #22 stated they mentioned the open window and that Resident #12 was asking about their roommate. - The unit assignment sheet and floor roster had Resident #14's name listed and CNA #22 did not know a new resident was supposed to be in that room. - Later in the shift, when CNA #22 mentioned it again, RNS #17 said there were supposed to be 2 people in the room. The CNA stated that was what they were trying to tell them since they arrived, and no one told the CNA about Resident #6 or any new admission. This was approximately 2 AM, and that was when staff began looking for Resident #6. - CNA #22 stated upon arrival to the facility between 10:30 PM and 11:00 PM, they saw someone outside in the parking lot and then near the bushes, in the area of the courtyard and the gate was open. Upon viewing a photograph of Resident #6 after the incident, CNA #22 stated that was who they saw outside. During a telephone interview with Resident #12 (who had intact cognitive function) on 4/1/22 at 11:08 AM, they stated on 3/18/22 later in the evening, Resident #6 appeared to be distressed, confused, and talking to people who were not there. They heard Resident #6 at the window making a lot of noise with the blinds and the window, such as banging sounds. They called for staff and told them they were worried the resident went out the window. The staff left and returned to tell Resident #12 the other resident had been discharged . Resident #12 stated they slept on and off and when they woke again, the resident was still gone, and they reported to staff again. This time staff came in and checked, left, and came back around 2 :00 AM. The screen was not in the window at that time. They staff asked if the resident saw anything, and they stated they did not see the resident go out the window. When interviewed on 3/31/22 at 11:25 AM, the Director of Maintenance stated: - The wander alert sensors in the elevators were always functional, only the sensitivity on Elevator 2 was adjusted to ensure it picked up any device in range. - The east side courtyard exterior door was always locked, and the only way to unlock it was from the security desk. It remained unlocked until security staff were notified to re-lock it. If locked, the bar could be held continuously for approximately 15-20 seconds for emergency exit, and it would open. An alarm would sound that would have to be deactivated with a code. - On 3/19/22, they found the exterior courtyard door latch (or bolt) stuck inside the lock assembly, thus not coming out to engage properly to secure the door. They were unaware of the length of time the lock was stuck. - There was a magnetic lock on the courtyard gate that was not functional, as having a locked gate and locked courtyard door was a fire safety issue. - No issues were noted with any of the alarmed doors in the facility upon inspection and no repairs were made. - The alarm system was not able to generate any alarm activation reports. - All the stairwell doors required a code to open and alarmed upon attempt to open with or without a wander alert device. The doors would open after 15-20 seconds of continual holding, although the alarm would continue to sound until deactivated. During an interview on 3/31/22 at 3:45 PM, security staff #26 stated there was no process for security staff to complete rounds and check the doors. During an interview with the Director of Nursing (DON) on 4/1/22 at 12:08 PM, they stated when CNA #22 notified LPN #23 the resident was not in their room, they were referring to Resident #14, who had been discharged . CNA #22 should have known about Resident #6 from report and did not receive report. The resident's name outside the door was not changed either and it should have been, as it still showed Resident #14's name. The DON worked on the investigation with the Administrator, and they were unable to determine exactly how the resident exited. The DON stated it was not likely the resident went out of the window due to no injuries or other signs. It was possible the resident exited down the elevator and through the east courtyard door. The DON did not view the video footage and was told by the Administrator the resident was not seen on any footage. During an interview with the Administrator on 4/4/22 at 9:35 AM, they stated the 3/19/22 facility investigation was complete, and they were unable to determine how the resident exited the building. The video cameras did not show the resident at the elevators, or the resident could not be seen. The video system was old and difficult to access, with spots cutting in and out. During a telephone interview with Physician #34 on 4/4/22 at 10:06 AM, they stated they were not made aware of Resident #6's elopement and would have expected to be notified or staff should have called the on-call physician. Nursing staff should ensure a shift-to-shift report was done each shift especially if there were new admissions or discharges, or residents with behavioral concerns. The physician stated they felt the issue was related to staffing shortages and not having enough staff on to properly communicate with one another. 10 NYCRR 483.25(d) ------------------------------------------------------------------------------------------------------------------------- Immediate Jeopardy was identified, and the facility Administrator was notified on 4/1/22 at 3:01 PM. Immediate Jeopardy was removed on 4/3/22 at 2:00 PM, prior to survey exit based on the following actions taken: - Resident #6 remained on one-to-one supervision. - 92% of nursing staff were educated on shift-to-shift reporting including review of new admissions and discharges; CNA rounding at shift change; demonstration of shift change reporting; and documentation of all new residents at risk of elopement. Education will continue until 100% of nursing staff of education was completed. - 100% of security staff were educated about ensuring the courtyard door was locked and understanding how the door was locked or unlocked at the desk. - Security staff were to document the courtyard door was checked every 2 hours. - Function and placement checks of resident wander alert devices continued to be completed by the nurse supervisor nightly.

Based on interview and record review during the abbreviated survey (NY 789) conducted 4/6/2022, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 5 residents reviewed (Resident #1). Specifically: - When the resident's Stage II (partial thickness loss of skin layers) pressure ulcers to the right and left buttocks deteriorated (increased in size) and had drainage, there was no documented evidence the ordered treated of Z Guard (barrier cream) was assessed for continued appropriateness and the treatment order was not changed. - The resident developed a deep tissue injury (DTI, injury to underlying tissue from prolonged pressure) to the sacrum and a treatment was not ordered timely. - When the resident's DTI was noted to open and had depth, the protective treatment remained in place ([MEDICATION(S)], a foam dressing) and was not assessed for effectiveness. - The resident received all nutrition via tube feedings and when Active Liquid Protein (supplement) was recommended by the registered dietitian (RD), it was not implemented timely resulting in the resident receiving 20 grams (g) protein per day less than their assessed needs. - The resident was not reassessed by the RD/clinical nutrition staff after the Stage II pressure ulcers deteriorated or after the resident developed a DTI to ensure the tube feeding regimen was adequate to promote healing. The resident was subsequently hospitalized with [CONDITION(S)] secondary to the DTI which opened into a large unstageable pressure ulcer. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. Findings include: The facility policy Prevention of Pressure Ulcers dated 7/16/19 documents the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/17/21 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, they required extensive assistance with bed mobility, toileting, and personal hygiene and was dependent on staff for transfers. The resident had an indwelling catheter, was always incontinent of bowel, and had a feeding tube. They were at risk for developing pressure ulcers and had two Stage II pressure ulcers on admission. The resident's weight was 182 pounds. The 10/11/21 Braden Assessment (risk for developing pressure ulcers) documented the resident was at mild risk for pressure ulcer development related to being chairfast, having occasional moisture, having slightly limited sensory perception and mobility, and having adequate nutritional status. The 10/11/21 at 6:44 PM, registered nurse (RN) #4's progress note documented the resident had an area of concern to bilateral buttocks and a treatment was in place with interventions implemented. The resident needed total care for activities of daily living (ADL) and turning and positioning was in place. The 10/11/21 registered dietitian (RD) #9's Nutritional Assessment documented the resident arrived from the hospital with two Stage II pressure ulcers on the right buttock and coccyx. The resident's assessed nutritional needs were 1913 calories and 108 grams (g) protein per day which provided 1.2-1.4 g of protein per kilogram of body weight. The resident was tube fed and the tube feeding plus the Active Liquid Protein (ALP, protein supplement) recommended by the RD would provide 2090 calories and 110 g of protein per day and would meet the resident's assessed needs. The resident's tube feeding order alone (without ALP) provided 1890 calories and 80g protein per day and did not meet the resident's assessed nutritional needs to promote wound healing. The 10/11/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The 10/11/21 comprehensive care plan (CCP) documented the resident was at risk for impaired skin integrity, they had an actual skin impairment, and had issues with ADLs. Interventions included 2-person assistance with bed mobility and transfers, turn and position every 2 hours, pressure redistribution mattress and cushion, incontinence management, protective skin care every shift and as needed, nutrition consult, treatments, and alert provider/wound team of red/open areas. The 10/12/21 Wound RN #6's skin assessment documented the resident had: - Stage II pressure ulcer to the right buttock with serous exudate (clear drainage) and measuring 0.5 centimeters (cm) x 0.5 cm x 0.1 cm, and - Stage II pressure ulcer to the left buttock with serous exudate and measuring 1 cm x 0.3 cm x 0.1 cm. Interventions included a low air loss mattress (a mattress with multiple air tubes that alternately inflate and deflate). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - On 10/12/2021, Z Guard (skin protectant) to the right and left buttock Stage II pressure ulcers. Cleanse with wound cleanser, pat dry, and apply to both buttocks twice daily and as needed. - On 10/13/21, check placement and function of air mattress every shift. - On 10/14/21, ALP 30 cubic centimeters (cc) mixed with 200 cc of water twice daily. This order was entered 3 days after being recommended by the RD. The 10/13/21 care instructions documented the resident had a tube feeding and a pressure relieving cushion in the wheelchair. They required total assistance of 2 with a Hoyer (mechanical lift) and extensive assistance of 2 for bed mobility and turning and positioning. The resident had a Foley (urinary) catheter and used briefs. The 10/15/21 physician assistant (PA) #15's progress note documented Wound RN #6 requested the resident to be seen for a DTI that was a Stage II pressure ulcer previously. The note did not document the location of the DTI, a plan for the DTI, or an ordered treatment. There was no documentation the RD/clinical nutrition staff were notified for a reassessment of the resident's needs after the resident developed a DTI. The 10/18/21 Wound RN #6's skin assessment documented the following: - right buttock Stage II, unchanged measuring 0.5 cm x 0.5 cm x 0.1 cm with serous exudate. - Left buttock Stage II, unchanged measuring 1 cm x 0.3 cm x 0.1 cm with serous exudate. - A suspected DTI of the sacrum measuring 7.5 cm x 10 cm that had no exudate and the ulcer was dark pink/red. The 10/18/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - to the suspected DTI of the sacrum, cleanse, apply skin prep (protective film) and [MEDICATION(S)] (dressing) every 3 days. - Continue Z Guard to right and left buttock. - Active Liquid protein, 30 (cc) mixed with 200 cc of water twice daily (unchanged from the 10/14/21 order). The 10/19/21 History and Physical contained no documentation the physician was aware of pressure ulcers. The 10/25/21 Wound RN #6's skin assessment documented: - the right buttock Stage II pressure had deteriorated. The ulcer had serosanguinous (bloody drainage) exudate and measured 2.5 cm x 4.5 cm x 0.1 cm. The wound bed had pale pink tissue, and surrounding skin was abnormal. Z Guard was to continue as the treatment. - The left buttock Stage II pressure ulcer had deteriorated. The wound had serosanguinous exudate and measured 8.3 cm x 5 cm x 0.1 cm. The wound bed had pale pink tissue/eschar (black dead tissue), and surrounding skin was abnormal. The treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - The sacral DTI measured 7.5 cm x 10 cm x 0.1 cm and [MEDICATION(S)] was to continue. There was no documentation the resident was reassessed by clinical nutrition staff after the resident's Stage II ulcers deteriorated (increased in size and had drainage) or when the DTI was identified. The 10/29/21 PA #15's progress note documented the resident's family wanted them sent to the hospital for [CONDITION(S)] (swelling) in right lower leg and hand. The [CONDITION(S)] was new but was stable and per the supervising physician, was an expected process of [CONDITION(S)] due to brain bleed. The 10/29/21 twenty-four-hour report documented the resident was sent to hospital at 12:35 PM. The 10/29/21 at 1:37 PM, emergency room note (written 1 hour after discharge from the facility) documented the resident came to the hospital after the family member found them with hand swelling and felt they were not getting adequate care. The family member also reported they noticed the resident's sacral pressure ulcer was getting worse. The assessment included: - a large unstageable sacral pressure ulcer with surrounding [CONDITION(S)] (redness). The ulcer was necrotic (dead, non-viable tissue) in the center with surrounding maceration (skin broken down by moisture) and the ulcer had a foul odor. - The resident's temperature was 101.6 Fahrenheit (F). - Laboratory values were significant for leukocytosis as the resident's white blood cell (WBC) count was elevated at 14.9 (normal = 4-10, indicator of infection). - The resident was admitted for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/30/21 at 3:18 AM, Hospital Report documented the resident had DTIs on the sacrum/coccyx and DTIs on the left and right buttocks. On 3/24/22 at 9:28 AM, RD #9 stated in a telephone interview, they typically became aware of pressure ulcers during morning report. They stated they wanted to be aware of new or deteriorating pressure ulcers so they could assess the resident's nutritional needs and ensure their needs were being met and to make changes if needed. RD #9 stated Resident #1 was at high nutritional risk because they had a feeding tube. They were aware the resident was admitted to the facility with pressure ulcers and recommended Active Liquid protein twice daily. They stated they did not believe they were aware the resident developed new pressure ulcers while they were at the facility and was not aware the pressure ulcers they were admitted with had deteriorated. RD #9 stated if they had been aware of those things, they would have documented a reassessment and possibly recommended the protein supplement to be increased. On 3/24/22 at 1:44 PM, Wound RN #6 stated in a telephone interview: - Z Guard was a preventative treatment and usually used for shallow skin breakdown and redness. It was not a treatment used for pressure ulcers. For Stage II pressure ulcers they typically used [MEDICATION(S)] AG and covered with [MEDICATION(S)] dressing. - The resident had two Stage II pressure ulcers on admission, and they believed they recommended Z Guard because the ulcers were so small at that time. - When they documented the resident's Stage II pressure ulcers deteriorated on 10/25/21, the Stage did not change but the width and length increased, and the wound was not in the same condition as it was previously. They recommended the Z Guard treatment continue at that time. They documented the resident's left buttock pressure ulcer had eschar and if the wound had eschar, the ordered treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . - A DTI was an injury that prevented knowing what the depth of the injury was. They typically recommended turning and positioning, an air mattress, skin prep to the surrounding skin and to cover a DTI with [MEDICATION(S)] for protection. - On 10/15/21, they believed the resident's DTI was located between the right and left pressure ulcers and when they saw it, it was large, and they asked the provider to assess. - A treatment should have been ordered for the DTI on the day it was identified, and the DTI treatment was not ordered timely. - On 10/25/21, they documented the resident's DTI depth changed from 0 cm to 0.1 cm and at that time the DTI should have been classified as an unstageable pressure ulcer instead of a DTI. At that time, there was no slough (moist, stringy dead tissue), but they still could not tell what was beneath the wound bed. For an unstageable ulcer, they typically ordered a treatment that debrided the skin because the wound would not heal without it. They stated the treatment that was previously in place ([MEDICATION(S)] dressing) and continued was not an appropriate treatment. They stated they should have changed the treatment at that time and was not sure why they did not. - They were responsible to notify the RD of residents' skin issues and after they did weekly wound rounds, they gave the RD a report of residents with pressure and what the plan was for their wounds. On 3/25/22 at 1:24 PM, certified nurse aide (CNA) #12 stated in a telephone interview, the resident was not capable to turn in bed on their own and required turning and positioning by staff and total care for all other ADLs. They recalled bathing the resident and the resident had sores on their bottom. On 3/29/22 at 9:42 AM, RD #9 was re-interviewed and stated ALP was a protein supplement that was part of the facility's wound protocol. When they recommended ALP, the recommendation was sent via email to nursing and nursing implemented the recommendation. The physician was also emailed and would sign the order afterwards. If they recommended ALP during a weekday, they would expect the ALP to be implemented the next day. RD #9 stated some nurses at the facility did not have email addresses and that was a problem when they were trying to make a recommendation and did not have anyone to email their recommendations to. RD #9 stated they were not aware that it took 3 days to implement ALP after they recommended it for the resident. They stated the order was not implemented timely and the resident was not meeting their recommended calorie/protein needs when they went 3 days without ALP. On 3/29/22 at 12:58 PM, LPN #16 stated in a telephone interview, the facility required them to write a note on a resident's skin if they noted a change in condition. They changed the resident's dressing on 10/27/21 though could not recall the appearance of the resident's pressure ulcers that day. They stated, if they did not write a note, then they did not observe any issues. On 3/29/22 at 1:12 PM, RN #14 stated in a telephone interview, on admission, a head-to-toe assessment was to be completed and the Wound Nurse typically came at the same time to examine the resident's skin. For admissions that arrived later in the evening, the Wound Nurse would not be at the facility and the RN completed the skin assessment. RN #14 stated when they did the assessment, they would document exactly what they saw and generally continued the ordered treatments from the hospital. On 10/11/21, they assessed the resident's skin on admission and did not recall what the resident's skin issue was. The resident may have come from the hospital with a dressing in place and they sometimes left the dressing in place, did not look at the wounds, and then the Wound Nurse would assess the next day. RN #14 stated if they did not document what they saw when they admitted the resident then they most likely left the dressing in place from the hospital and did not do a full skin assessment. On 3/30/22 at 10:48 AM, the attending physician stated in a telephone interview: - they expected nursing to complete a head-to-toe assessment on admission and expected them to remove any dressings placed by the hospital to assess the skin under the dressings. - If issues were found, they expected one of the providers to be called for a treatment order. - Treatment orders should be implemented immediately. - They became aware of residents' pressure ulcers by reviewing the medical record including hospital records and assessments. - They expected one of the providers to evaluate a resident with pressure ulcers within a week of admission. - Treatments to Stage II pressure ulcers were based on facility protocol. Stage II pressure ulcers were open and if the open area was due to shearing, then barrier cream would be appropriate. If the ulcer was open due to pressure, barrier cream might not be appropriate. - When a wound deteriorated, the treatment needed to be changed. - The RD should assess resident with new wounds and when wounds deteriorated, and this should be done as soon as possible. - When the resident developed a DTI on 10/15/21, they expected the provider to document their assessment and plan in the note. They stated 3 days without a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] - When they completed the resident's History and Physical 10/18/21, it was possible the Wound Nurse did not have their notes uploaded in the computer for them to review. - It was the nurse practitioner's (NP) job to round with the wound nurse and report the physician any skin issues that they could not handle. On 4/12/22 at 10:15 AM, PA #15 stated in a telephone interview they expected the Wound RN to stage pressure ulcers and to come up with a wound plan. On 10/15/21, they were asked to see the resident for a new DTI that was previously a Stage II. They did not recall what the treatment plan was and probably discussed it with Wound RN #6. Barrier cream that was ordered for the Stage II was not an effective treatment and was not an effective treatment when the resident developed a DTI and the barrier cream continued. An order was not obtained timely after the resident developed the DTI and went 3 days without an effective treatment. 10NYCRR 415.12(c)(2)

Based on observation, record review, and interviews conducted during an abbreviated survey (#NY 581), it was determined for 2 of 5 residents (Residents #1 and 2) reviewed for elopement the facility did not ensure the environment was free of accident hazards and did not provide adequate supervision to prevent accidents. Specifically, for Resident #1 a Wanderguard (device that detects wandering) and/or increased supervision was not provided as planned, the resident exited the building, and staff were unaware she was missing. For Resident #2, there was contradictory documentation in the comprehensive care plan (CCP) and the elopement risk assessment, inaccurate documentation of the use of a Wanderguard, and staff did not know what frequent or increased monitoring meant. This resulted in Immediate Jeopardy, Substandard Quality of Care and the potential for serious harm that is Immediate Jeopardy to the health and safety of the facility's 36 residents currently at risk for wandering. The immediate jeopardy was removed on 7/18/2015 prior to the survey exit. Findings include: 1) Resident #1 had [DIAGNOSES REDACTED]. The resident's elopement/AMA (against medical advice) risk assessment, dated 6/9/2015 at 7 PM, documented the resident was pacing, cognitively impaired, and wandered. The documented interventions included placing the resident's photograph at the reception desk and periodic safety checks. RN (registered nurse) Supervisor #1's progress note, dated 6/9/2015 at 7:10 PM, documented the resident was confused and wandered the unit; the resident's family reported she wore a Wanderguard at a prior facility due to wandering; RN supervisor #1 was unable to obtain a Wanderguard for the resident; she placed the resident's photograph at the front desk; and started the resident on frequent visual checks. RN #5's progress note, dated 6/23/2015 at 9:04 PM, documented the resident wandered out of the building, was put on periodic visual checks and a Wanderguard was applied to the resident. In an undated written statement from a facility security officer, he documented that on 6/23/2015 the police called the facility and reported they found the resident downtown and would return her to the facility. The Administrator's elopement investigation, dated 6/23/2015, documented the resident was found on the first floor and told staff she was having difficulty finding the front door. Staff assisted the resident with exiting the front door and stated there was never any indication she was anything but a visitor. The Administrator implemented a time out for staff to make sure people who exited the building were visitors, not residents. In the three page investigation, the Administrator did not include: the resident's need for a Wanderguard; that the facility did not provide a Wanderguard until after the resident eloped; and that staff did not provide frequent monitoring of the exit seeking resident. RN Supervisor #1 was interviewed on 7/14/2015 at 4 PM and on 7/16/2015 at 2:55 PM. She stated she was very concerned about the resident's confusion and history of wandering. She felt the resident was at moderate to high risk for elopement and needed a Wanderguard. RN #1 stated there was no Wanderguard available at that time and she contacted the Administrator on 6/23/2015. She stated the Administrator reported he did not have a Wanderguard available in the building and the resident needed to wait until an order of Wanderguards, expected on 6/20/2015, arrived. She stated she informed the unit staff they needed to watch the resident closely and to page the Supervisor if they had any difficulty. She stated she did not assign a specific staff member to monitor the resident and did not identify a frequency for the monitoring. She stated everyone was aware of the resident's risk for elopement; the resident's picture was placed at the nurse's stations and the front desk at the entrance to the facility. RN #1 stated she badgered the Administrator throughout the time period of 6/9 -6/23/2015 that the resident needed a Wanderguard. She stated she asked the Administrator if she could reassess residents who had Wanderguards to see if one could be given to the resident and he said no. RN #1 stated as soon as the resident eloped, the Administrator immediately obtained a Wanderguard from another facility. During interview with the Administrator on 7/14/2015 at 3 PM and on 7/16/2015 at 10:30 AM, he stated he watched the facility's video surveillance and saw the resident exit the front door on 6/23/2015 at 1 PM. He stated that staff were unaware the resident was missing until the police called at 1:40 PM. He stated he placed an order for [REDACTED]. The Administrator stated that the facility did not have a Wanderguard available from 6/9 - 6/24/2015. He stated after the resident eloped on 6/23/2015 he immediately obtained a Wanderguard for her from another facility. The Administrator stated that frequent monitoring was checking the resident once per 8 hour shift. During interview with the DON (Director of Nursing) on 7/15/2015 at 2:15 PM, he stated the resident scored 5 on the elopement risk assessment and at that score staff could use different interventions. He stated a score above 5 meant the resident was at high risk for elopement. The DON stated if the resident had a Wanderguard on 6/23/2015 the elevator would have locked, and sounded a bell preventing the resident from getting to the first floor. During interview with CNA (certified nurse aide) #3 on 7/16/2015 at 11:40 AM, she stated she did not work the day the resident eloped; she was assigned to care for the resident on a routine basis; and she spoke with nursing staff often about the resident's confusion and wandering. She stated when the resident was assessed to need a Wanderguard and one was not available, staff were supposed to check on her frequently. She stated she was not provided with training on frequent monitoring of residents and even without training, CNAs should know where their assigned residents were at all times. During interview with LPN (licensed practical nurse) #4 on 7/16/2015 at 11:50 AM, she stated she heard staff on the unit saying the resident needed a Wanderguard and one was not available. She stated the resident needed a Wanderguard as she frequently wandered around the unit and repeatedly stated she wanted to go home. She stated when there was no Wanderguard for the resident, the staff tried to keep an eye on her as much as possible and no one was assigned to monitor the resident at a particular frequency. During interview with LPN #6 on 7/16/2015 at 1:50 PM she stated staff knew the resident needed a Wanderguard. She stated the resident frequently said that she was ready to go home and packed up her belongings several times. The LPN stated that RN Supervisor #1 wanted the resident to have a Wanderguard, reported there were none available and that she spoke with the Administrator who directed staff to wait for a shipment of Wanderguards to arrive. The LPN stated the resident did not receive a Wanderguard until she eloped on 6/23/2015 when the Administrator obtained one from another facility. The LPN stated she did not recall the Supervisor giving instructions for how often the resident should be monitored. She stated that usually 15 minute checks would have been ordered and they were not ordered for this resident. The LPN stated she was unable to define periodic visual checks and frequent visual checks. The resident's elopement precautions the form documented that on 6 days during 6/9/2015 - 6/23/2015 the resident had a Wanderguard in place and it was functioning. The resident did not have a Wanderguard at that time. The resident's medical record, dated 6/9 - 6/23/2015, did not document the resident's exit seeking behavior and if evidence frequent visual checks occurred. A Wanderguard purchase order documented five Wanderguards were ordered by the facility on 5/25/2015. A postal service tracking report documented the product order, dated 5/25/2015, was delivered to the facility on [DATE]. 2) Resident #2 had [DIAGNOSES REDACTED]. The elopement/AMA (against medical advice) risk assessment, dated 6/5/2015, documented the resident was independent with mobility, wandered on the unit, was cognitively impaired, demonstrated impaired decision making, and had a mental illness that made her unpredictable. The assessment documented the resident was not at risk for elopement or for leaving AMA. The comprehensive care plan (CCP), updated on 6/5/2015, documented the resident was at risk for elopement and wandering as she attempted to leave the unit unattended. The resident had impaired safety awareness and her Wanderguard was discontinued following the elopement risk reassessment. The nursing documentation of elopement precautions for 6/6 -6/30/2015 inaccurately documented they verified placement of the resident's Wanderguard on 19 of 25 days. Staff documented they checked on the resident once per shift, except for the day shift on 6/28/2015 when there was no documentation that the resident was checked on. The current resident information sheet (care instructions), last modified on 7/6/2015, documented the resident was alert, confused, and needed frequent monitoring as an elopement precaution. The 7/8/2015 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, disorganized thinking that fluctuated, and moved about her room and the unit with supervision. The nursing documentation of elopement precautions for 7/1 - 7/15/2015 included: - staff visually checked the resident once per shift every day; and - staff verified the placement of the resident's Wanderguard 14 out of 15 days. The current physician's orders [REDACTED]. The orders documented the Wanderguard was initially ordered on [DATE]. During interview with the Administrator on 7/16/2015 at 10:40 AM, he stated the facility did not have a policy for providing frequent monitoring to residents and that frequent monitoring was to check on a resident once per shift. During interview with the DON (Director of Nursing) on 7/16/2015 at 12:30 PM, he stated the resident scored less than 5 on the elopement risk assessment meaning she was not at risk for elopement; staff felt there was some risk as she wandered; and she was placed on frequent monitoring. During interview with LPN (licensed practical nurse) #2 on 7/16/2015 at 2:42 PM, she stated the resident was to be monitored frequently, staff kept her in an area where she was highly visible, such as the dining room, and the resident liked to spend most of the day in the dining room. LPN #2 showed the surveyor the resident's electronic medical record and stated staff were prompted every shift to observe the resident and document in the record. She stated staff should not have documented they checked the resident's Wanderguard for placement as she did not have a Wanderguard. During interview with RN (registered nurse) #1 on 7/16/2015 at 2:55 PM she stated the resident was not actively exit seeking and did not have a Wanderguard. RN #1 stated staff felt the resident was at risk for wandering, and needed to monitor her frequently. She stated she could not specifically define what frequently monitored meant. ---------------------------------------------------------------------------------------- The immediate jeopardy was removed on 7/18/2015 based on the following corrective actions taken by the facility: - Policies and procedures for frequency of resident supervision were revised. - The majority of staff were educated and trained on the revised policy and procedure on resident supervision. - Quality assurance monitoring was initiated by administrative staff to ensure compliance with the revised policy and procedure. 10NYCRR 415.12(h)(1)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY 581), it was determined for 2 of 5 residents (Resident #1 and 2) reviewed for elopement, the facility did not ensure Administrative staff administered the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, for Residents #1 and 2, the Administrative staff did not develop a policy and procedure for frequent monitoring of residents at risk for elopement in order to provide the appropriate level of supervision as planned. This resulted in Immediate Jeopardy, Substandard Quality of Care and potential for serious harm that is Immediate Jeopardy to the health and safety of the facility's 36 residents currently at risk for wandering. The immediate jeopardy was removed on 7/18/2015 prior to the survey exit. Findings include: Refer to F323. The Administrator's elopement investigation regarding Resident #1, was dated 6/23/2015 and documented the resident was found on the first floor and told staff she was having difficulty finding the front door. Staff assisted the resident with exiting the front door and stated there was never any indication she was anything but a visitor. The Administrator implemented a time out for staff to make sure people who exit the building are visitors, not residents. In the three page investigation, the Administrator did not include: the resident's need for a Wanderguard; that the facility did not provide a Wanderguard from 6/9/2015 to 6/23/2015 when the resident eloped; and that staff did not provide frequent monitoring of the exit seeking resident. During interview with the Administrator on 7/14/2015 at 3 PM and 7/16/2015 at 10:40 AM he stated the facility did not have a frequent monitoring policy, and frequent monitoring meant to check on a resident once per shift. The Administrator stated, after the resident eloped, he watched the facility's video surveillance and saw the resident exited the front door on 6/23/2015 at 1 PM. He stated that staff were unaware the resident was missing until the police called at 1:40 PM. He stated he placed an order for [REDACTED]. He stated after the resident eloped on 6/23/2015 he immediately obtained a Wanderguard for her from another facility. During interview with the DON (Director of Nursing) on 7/16/2015 at 12:30 PM, he stated the resident scored less than 5 on the elopement risk assessment meaning she was not at risk for elopement; staff felt there was some risk as she wandered; and she was placed on frequent monitoring. ---------------------------------------------------------------------------------------- The immediate jeopardy was removed on 7/18/2015 based on the following corrective actions taken by the facility: - Policies and procedures for frequency of resident supervision were revised. - The majority of staff were educated and trained on the revised policy and procedure on resident supervision. - Quality assurance monitoring was initiated by administrative staff to ensure compliance with the revised policy and procedure. 10NYCRR 415.26

Based on observation, record review, and interview conducted during the standard and abbreviated surveys (NY 019 and NY 944), it was determined for 4 of 24 sampled residents (Residents #2, 13, 14, and 16), the facility did not provide the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically: - For Resident #2 a stool sample was not tested for blood as ordered, the resident experienced a gastrointestinal (GI) bleed, and ordered follow-up consults were not provided. - For Resident #13, who took [MEDICATION NAME] (water pill) prior to admission, [MEDICATION NAME] was not ordered at the time of admission without a documented rationale, a medical recommendation to increase the dosage of [MEDICATION NAME] was not implemented, and the resident did not receive [MEDICATION NAME] as ordered. - For Resident #14 a change in condition was not fully reported to the medical group. - For Resident #16 vascular consults documented a surgical wound was not properly packed on 2 occasions, and abscess developed in the wound which required a surgical procedure treatment. This resulted in actual harm of a surgical intervention for a wound abscess for Resident #16, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #2, 13 and 14. Findings include: 1) Resident #16 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP), dated 1/7/2015, documented the resident was at risk for impaired skin integrity, due to a surgical wound, with a goal for the resident to remain free from infection. Interventions included weekly skin evaluations by a registered nurse (RN), monitoring of the wound with each dressing change, and wound care as ordered. The vascular clinic report, dated 1/27/2015, documented the resident had recent removal of a left infected femoral to femoral bypass graft, and was seen after hospital discharge. The resident's left groin wound had drainage and tunneling measuring 5 centimeters (cm) deep at 9 o'clock and 3 cm at "1 o'clock." The tunnels were packed with [MEDICATION NAME] gauze (removes dead tissue)and the superficial wound was covered with [MEDICATION NAME] AG (protective barrier to promote wound healing). The treatment was to be done daily. The physician's orders [REDACTED].'clock", covered with [MEDICATION NAME] AG and dry dressing, and changed daily. The treatment administration records (TAR) documented the resident's treatment was administered from 1/28 - 1/31/2015. The Minimum Data Set (MDS) assessment, dated 2/2/2015, documented the resident was cognitively intact, was independent with locomotion, on and off the unit, dressing and eating. The resident required supervision with bed mobility, transferring, toilet use and hygiene. The resident did not ambulate, was frequently in pain, and had a surgical wound. The vascular clinic report, dated 2/3/2015, documented the resident's groin wound had tunneling of 6 cm at 9 o'clock and 4.2 cm at 3 o'clock. The report documented the tunneling at 9 o'clock was not packed and recommendations included packing the tunneling's at 9 o'clock and 3 o'clock with 1/4 inch [MEDICATION NAME] gauze and cover with [MEDICATION NAME] AG for 1 week, then pack with plain gauze once a day, and cover with [MEDICATION NAME] AG. On 2/3/2015, the facility's nurse practitioner (NP) documented on the vascular clinic note for nursing to please follow the order. The physician order, dated 2/4/2015, documented the resident's left groin wound was to be cleansed with normal saline, packed in [MEDICATION NAME] gauze at 9 and 3 o'clock, covered with [MEDICATION NAME] AG and a dry dressing, and changed daily during day shift. The TAR documented the resident's treatment was administered from 2/1 - 2/10/2015. The physician order, dated 2/11/2015, documented the resident's left groin wound was to be cleansed with normal saline, [MEDICATION NAME] AG and cover with dry dressing daily on the day shift. The physician order [REDACTED]. The TAR documented the resident's treatment was administered from 2/11 - 2/12/2015. The nursing 24 hour report, dated 2/12/2015, documented there was green drainage from the resident's groin wound, the wound was hard and reddened, an antibiotic was ordered, and the Nurse Manager was aware. The vascular clinic report, dated 2/13/2015, documented the resident stated she woke with night sweats and denied fever. The left groin wound had small amounts of yellow slough (soft moist dead tissue), the wound tunneling at 9 o'clock measured 5 cm with large amounts of pus, and the wound tunneling at 3 o'clock measured 3 cm. A wound culture was obtained. The report documented the resident was status [REDACTED]. The recommendation was to send the resident to the operating room for incision and drainage of the left groin wound due to persistent abscess. The hospital discharge report, dated 2/20/2015, documented the resident was admitted from 2/13 - 2/20/2015 for incision and drainage of the left groin wound which tested positive for group A streptococcus (bacterial infection). The resident was prescribed antibiotics, had wet to dry dressing changes until purulence (pus) resolved, and a Wound V.A.C (vacuum assisted closure, device that promotes wound healing) was applied. The wound care physician's evaluation, dated 2/27/2015, documented the left groin wound measured 1.5 cm x 13 cm x 1 cm, with 5 cm tunneling at 8 o'clock, and the Wound V.A.C. dressing was to be changed 3 times per week. On 2/27/2015 at 10 AM, registered nurse (RN) Manager #14 was observed completing the resident's Wound V.A.C. dressing change. The resident's left groin wound measured approximately 1.5 cm x 12 cm x 0.5 cm, and was draining a scant amount of red drainage. The vascular clinic was contacted on 3/2/2015 at 10 AM, and was not available for interview. During an interview with RN Manager #14 on 3/2/2015 at 10:20 AM, she stated that the resident occasionally pulled out the wound packing because she did not like the way it felt. She stated she was not able to provide documentation to support this. During an interview with licensed practical nurse (LPN) #16 on 3/2/2015 at 10:25 AM, she stated she was the treatment nurse on duty when the resident was seen at the vascular clinic on 2/3/2015 and 2/13/2015. LPN #16 stated she packed the resident's wounds according to the physician's orders [REDACTED]. She stated she did not pack the resident's groin wound on 2/13/2015 because the resident left early for her appointment. She stated prior to the 2/13/2015 appointment, the last packing would have been done on 2/12/2015, and she did not work that day. LPN #16 stated she had never witnessed an instance when the resident had pulled out the wound packing. The TAR documented LPN #16 administered the packing to the resident's groin wound on 2/3/15 and 2/12/2015. During an interview with the resident on 3/2/2015 at 10:30 AM, she stated she never pulled packing from the left groin wound. The resident stated she recalled the vascular physician was upset during the 2/3/2015 and 2/13/2015 visits because the wounds were not packed properly. She said she recalled the physician documented on the note so the facility would correct the problem. During an interview with nurse practitioner (NP) #15 on 3/2/2015 at 3:20 PM, she stated the resident was prone to infection due to poor circulation. NP #15 stated that incorrectly packing the resident's surgical wound possibly contributed to infection and subsequent surgery. 2) Resident #13 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 1/9/2015, documented the resident was cognitively intact. The hospital discharge summary, dated 12/2/2014, documented the resident had shortness of breath, [MEDICAL CONDITION] exacerbation, and initially received [MEDICATION NAME] (water pill), 80 milligrams (mg) twice a day. The summary documented during the resident's hospitalization the [MEDICATION NAME] dosage was "decreased to 40 mg daily alternating with 80 mg daily" due to the resident having low blood pressure levels. The nursing progress note dated 12/2/2014 at 1:36 PM, documented the resident was admitted to the facility, and the nurse practitioner was to review the medication orders. The resident's admission weight was 167.8 pounds. The admission orders [REDACTED]. The history and physical dated 12/5/2014, documented the resident was admitted from the hospital where he was treated for [REDACTED]. The resident had a trace amount of [MEDICAL CONDITION] (swelling) of both legs. The physician documented the resident was not on [MEDICATION NAME] currently as it was discontinued in the hospital due to low blood pressure. The registered dietitian (RD) assessment, dated 12/5/2014, documented the resident weighed 167.8 pounds, and had weighed 154.7 pounds at the hospital. The RD documented she questioned the resident's hospital weight. The weight record documented the resident weighed 176.2 pounds on 12/9/2014 (8.4 pound gain from the weight the RD documented on 12/5/2014). The nurse practitioner's (NP) progress note, dated 12/10/2014, documented the resident had slight non-[MEDICAL CONDITION] to both legs and was to be started on [MEDICATION NAME] 20 mg daily. The NP order, dated 12/10/2014, documented the resident was to receive [MEDICATION NAME] 20 mg daily. The Medication Administration Record [REDACTED]. The licensed practical nurse's (LPN) progress note, dated 12/15/2014, documented the resident had increased [MEDICAL CONDITION] in both legs. The NP progress note, dated 12/15/2014, documented the resident had [MEDICAL CONDITION] of both legs and told her he thought his legs had swelled up "a lot." The NP documented the resident was on [MEDICATION NAME] 20 mg daily and the plan was to increase the [MEDICATION NAME] to 40 mg daily. The NP order, entered into the electronic medical record by a registered nurse (RN) on 1/2/2015, documented on 12/15/2014 the NP ordered [MEDICATION NAME] 40 mg daily for the resident. The resident's 12/2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. There was no documented evidence the resident received [MEDICATION NAME] from 12/16 - 12/24/2014. The weight record documented the resident weighed 175 pounds on 12/24/2014. The LPN Manager's progress note, dated 12/24/2014, documented the resident had increased [MEDICAL CONDITION] of both legs, complained of discomfort in his calf, and was to be seen by the NP. The NP progress note, dated 12/24/2014, documented the resident had 1+ lower leg [MEDICAL CONDITION], was currently receiving [MEDICATION NAME] 40 mg in morning, the plan was to add 20 mg of [MEDICATION NAME] in the afternoon, and continue with weekly weights. The MAR, dated 12/2014, documented the resident received [MEDICATION NAME] 20 mg every afternoon from 12/25 - 12/30/2014. The MAR indicated [REDACTED]. The LPN progress note, dated 12/30/2014, documented the resident went to an appointment at a clinic that day. The LPN documented the resident's family member reported the resident was admitted , from the appointment, to the hospital for [MEDICAL CONDITION]. The hospital discharge summary, dated 1/2/2015, documented: - The resident was initially discharged from the hospital on [DATE] and during that hospitalization , [MEDICATION NAME] was decreased to 40 mg daily alternating with 80 mg daily. - At the clinic visit on 12/30/2014, the resident had gained 30 pounds in 3 weeks and was sent directly to the emergency room . - The resident complained of shortness of breath even at rest and presented with swelling of both legs and pain in the left leg. - A possible reason for [MEDICAL CONDITION] exacerbation was the decrease in the resident's [MEDICATION NAME] dosage. - The resident was treated with intravenous (IV) [MEDICATION NAME], placed on 1.5 liter (L) per day fluid restriction, a low salt diet, and 40 mg [MEDICATION NAME] twice a day was recommended. When interviewed on 2/27/2015 at 1:50 PM, LPN Manager #5 stated: - the NP was probably at the facility when the resident was admitted ; - when the NP wrote an order nursing entered the order into the electronic medical record; - that would had been the case with the resident's 12/15/2014 [MEDICATION NAME] order; - she could not find that the resident received [MEDICATION NAME] after 12/15/2014 on the MAR; - she could not remember if the [MEDICATION NAME] had been discontinued; and - she would attempt to locate the handwritten NP order for [MEDICATION NAME] on 12/15/2014 and provide it to the surveyor. When interviewed on 3/2/2015 at 11:40 AM, NP #15 stated she had signed the resident's admission orders [REDACTED]. She stated when she was not present, the nurses received the hospital discharge packet, including discharge medication orders, and notified her. She stated she reviewed discharge orders via telephone with nursing. She stated nursing was responsible for entering physician/NP orders into the resident's electronic medical record. When re-interviewed on 3/2/2015 at 12:20 PM, NP #15 stated the resident's [MEDICATION NAME] orders were documented on the hospital discharge under the category of pending discharge orders, so if she was not at the facility, the nurses would not have told her the resident was on [MEDICATION NAME] in the hospital, and that was why [MEDICATION NAME] was not ordered for him at the time of admission. When re-interviewed on 3/2/2015 at 12:40 PM, LPN Manager #5 stated she was on duty when the resident was admitted and did not remember handing the NP the resident's hospital discharge packet. Consults and testing: 3) Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 10/31/2014, documented the resident had severely impaired cognition, required limited to extensive assistance with activities of daily living (ADL), received anticoagulant (blood thinner) therapy, and had 1 venous ulcer. A nurse practitioner (NP) progress note, dated 12/3/2014, documented the resident was lethargic, not her usual self, and had a history of [REDACTED]. The resident's [MEDICATION NAME] (blood thinner) was discontinued because of [MEDICAL CONDITION] and a history of a lower leg hemorrhage. The NP documented an order was written for the resident to have a complete blood count (CBC) laboratory test the next day. A laboratory (lab) report, dated 12/4/2014, documented the resident had low hemoglobin (red blood cells) of 7.9 grams/deciliter (g/dL) (normal = 11.7-15.5 g/dL), low hematocrit (percentage of blood that is red blood cells) of 24.3 g/dL (normal = 35-45 g/dL), and low platelets of 108 thousand per microliter (mcL) (normal = 140-400 thousand/mcL). A notation handwritten on the lab report by the NP documented that stool for occult blood was ordered on [DATE] and no report was found. An NP progress note, dated 12/9/2014, documented the resident was slightly lethargic, had a hemoglobin of 8 g/dL, a hematocrit of 24.7 g/dL, a platelet count of 111 thousand/mcL. The resident was scheduled for a transfusion of 2 units of blood, needed a hematology referral, and a stool for occult blood test. A NP progress note, dated 1/5/2015, documented the resident was to restart [MEDICATION NAME] 2 mg at bedtime for [MEDICAL CONDITION]. A nursing progress note, dated 1/7/2015 at 2 PM, documented the resident had a leg wound that was bleeding and the NP discontinued [MEDICATION NAME]. The comprehensive care plan (CCP), dated 1/7/2015, documented the resident had [MEDICAL CONDITION] and was at risk for bruising/bleeding. Interventions including to monitor blood work for an alteration in the platelet count and monitor for bleeding [MEDICATION NAME] longer than 20 minutes. An NP progress note, dated 1/8/2015, documented the resident had [MEDICAL CONDITION], was taken off [MEDICATION NAME], and was being referred to cardiology for follow up. A lab report dated 1/12/2015 documented the resident had: - a low hemoglobin of 7.8 g/dL; - a low hematocrit of 23.9 g/dL; - a low platelet count of 107 thousand/mcL; - a high creatinine (measures kidney function) of 3.40 milligrams/deciliter (mg/dL) (normal = 0.60-0.88 mg/dL); and - a high BUN (measures kidney function) of 88 mg/dL (normal =7-25 mg/dL). A NP progress note, dated 1/14/2015, documented the resident was lethargic and had abnormal blood work on 1/12/15. The resident was referred to hematology and nephrology on 12/2014 and had not yet been scheduled for an appointment. The NP documented It was reiterated to nursing the resident needed to see the nephrologist as soon as possible due to indications of [MEDICAL CONDITION]. The NP documented due to the resident's lethargy, and hemoglobin of 7.8 g/dl, and appointment was to be set up for the resident to receive 2 units of packed red blood cells at the outpatient transfusion center the next day. A registered nurse progress note dated 1/15/2015 at 11:04 AM, documented at 7:40 AM, she was called to the resident's room "right now." The resident was getting ready to leave for the blood transfusion, and "vomited bright red blood clots into a wash basin. It was [MEDICAL CONDITION]/3 full." The resident had severe abdominal pain and a blood pressure of 240/105. The NP was notified and the resident was transferred to the hospital. A hospital discharge report, dated 1/22/2015, documented the resident was admitted to the intensive care unit on 1/15/2015 with an acute gastrointestinal (GI) bleed, acute kidney failure secondary to blood loss, and severe [MEDICAL CONDITION]. Upon admission, the resident had a hemoglobin of 8 g/dL, a hematocrit of 17 g/dL, a BUN of 91 mg/dL, and a creatinine of 3.5 mg/dL. The resident was transfused with 3 units of packed red blood cells, was stabilized, and was discharged on [DATE] with orders to follow up with [MEDICATION NAME] in one month. A NP progress note, dated 1/30/2015, documented the resident was referred to [MEDICATION NAME] for follow up of a GI bleed, and to cardiology for [MEDICAL CONDITION] after [MEDICATION NAME] was discontinued on 1/7/2015. A lab report, dated 2/18/2015, documented the resident had: - a high potassium of at 6.0 millimoles per liter (mmol/L) (normal = 3.5-5.3 mmol/L); - a creatinine of 2.74 mg/dL; - a BUN of 88 mg/dL; a hemoglobin of 7.8 g/dL; - a hematocrit of 23.9 g/dL; and - a platelet count of 97 thousand/mcL. A note written on the lab report by the NP documented the resident had been referred to nephrology. An NP progress note, dated 2/17/2015, documented the resident was referred to cardiology for [MEDICAL CONDITION], and [MEDICAL CONDITION], and was not a candidate for [MEDICATION NAME] due to a recent GI bleed. A NP progress note, dated 2/19/2015, documented the resident had low hematocrit/hemoglobin levels, the previous day, and was to have a transfusion of 2 units of packed red blood cells as an outpatient. The resident was to receive IV fluids for an elevated creatinine level. The NP documented requests for nephrology and [MEDICATION NAME] consults as they were not provided when previously ordered on [DATE] and 1/30/2015. There was no documented evidence in the resident's medical record that the stool for occult blood testing was obtained as ordered by the NP. There was no documented evidence in the resident's record that referrals for hematology, cardiology, nephrology, or [MEDICATION NAME] were scheduled as ordered by the NP. During an interview with registered nurse (RN) Manager #14 on 2/27/2015 at 10 AM, she stated NP #15 discontinued all of the resident's ordered referrals several weeks ago because the resident was seen by those specialists when hospitalized for [REDACTED]. During an interview with the NP #15 on 3/2/2015 at 10:40 AM, she stated that RN Manager #14 approached her on 2/27/2015 and stated a surveyor inquired about the resident's referrals and she told the surveyor the NP canceled the referrals. NP #15 stated RN Manager #14 asked her to sign orders discontinuing the referrals, and she told RN #14 the referrals needed to be scheduled as previously ordered. NP #15 stated she ordered stool for occult blood in 11/2014 and 12/2014 they were never done and she was not sure why. NP #15 stated it was possible the resident's treatment would have changed had the stool for occult blood test been completed. During an interview with RN Manager #14 on 3/2/2015 at 12:40 PM, she stated the resident had NP orders for stool for occult blood testing and she was not sure why it was not done. 4) Resident #14 had [DIAGNOSES REDACTED]. The resident was aphasic (unable to speak), and was admitted to the nursing home with a percutaneous endoscopic gastrostomy tube (PEG, feeding tube) and a Foley catheter (urinary drainage tube). The nurse practitioner's (NP) progress note, dated 2/2/2015, documented the resident's vital signs were normal and both lungs were clear. The licensed practical nurse (LPN) progress note, dated 2/5/2015 at 3:22 PM, documented the resident was lethargic "this morning" and ate poorly at breakfast. The resident's PEG tube site had a moderate amount of purulent drainage (pus) and the registered nurse (RN) Manager was notified. The note documented the resident had not voided during the shift, the Foley catheter was reinserted, and drained 300 cubic centimeters (cc) of urine. The resident's temperature was 98.8 degrees (Fahrenheit) F, blood pressure was 110/56, heart rate was 85, and respirations were 18. The was no documented evidence in the medical record the physician was notified of the resident's lethargy or the purulent drainage from the PEG tube site. The Minimum Data Set (MDS) assessment, dated 2/6/2015, documented the resident had moderately impaired cognition, unclear speech, and sometimes made himself understood. The LPN progress note, dated 2/6/2015 at 5 AM, documented the resident's oxygen saturation (measure of oxygen in the blood) was 86% on room air, and oxygen was administered at 2 liters per minute (lpm). The resident's temperature was 96.8 degrees F, blood pressure was 160/82, heart rate was 85, and respirations were 18. There was no documented evidence in the medical record the physician was notified the resident's oxygen saturation was 86% on room air and that oxygen was administered. The LPN note dated 2/7/2014 at 7:14 AM, documented the resident had a temperature of 102 degrees F at 4 AM, was given Tylenol, and the temperature was now 99 degrees F. The resident was cool and clammy, had a fingerstick blood sugar of 421 (normal 80 - 120), and a blood pressure of 138/72, heart rate of 74, and an oxygen saturation of 98%. The Supervisor notified the NP who ordered to monitor the resident. The registered nurse (RN) Supervisor progress note, dated 2/7/2015, at 8:50 AM, documented the resident routinely received 10 units of insulin every morning, the 7 AM - 3 PM shift Supervisor was notified of the resident's temperature and blood sugar level, and would follow up with the NP in the morning. The RN supervisor progress note, dated 2/7/2015 at 4:25 PM, documented: - the previous shift supervisor reported the resident's blood sugar level was 466 and 10 units of routinely scheduled long acting insulin was given before breakfast. - the resident's blood sugar was 524 and 5 units of Humalog (fast acting insulin) was given per medical; - the resident's blood sugar was 530 before lunch and 5 units of Humalog was given per medical; - the resident was lethargic, and had congestion in the right upper lung; and - the resident was given Tylenol for a temperature of 100.0 degrees F. - "asked on call for abx (antibiotic) until a u/a (urinalysis) obtained stated needed to get a u/a on Monday. - the resident's blood pressure was 113/63, heart rate was 88, respirations were 18, and oxygen saturation was 92% on room air. - the certified nurse aides (CNA) were directed to place cool compresses on the resident, and remove the sheets. - reported to supervisor and staff to monitor, and alert medical of worsening symptoms. The RN Supervisor's progress note, dated 2/7/2015 at 6:04 PM, documented that at 5:45 PM, the resident's temperature was 100 degrees F, fingerstick blood sugar level was 598, the right upper lung remained congested, and he remained lethargic. The NP was notified and ordered to administer 5 units of Humalog insulin. The RN Supervisor's progress note dated 2/7//2015 at 7:12 PM documented that at 6:40 PM, the resident was less responsive; had a fingerstick blood sugar of "hi", an oxygen saturation of 87% on room air, a temperature of 100 degrees F, a blood pressure of 98/61, a heart rate of 108, and respirations of 18. The NP was notified and ordered 10 units of Humalog insulin, and to call the laboratory for a immediate pick up of the resident's u/a sample. The resident was given oxygen at 2 lpm and, the oxygen saturation was 93%. The RN documented there was no immediate pick up from the laboratory that day (Saturday) and the next pick up was Monday. "Will update NP with next assessment in 45 min." The RN Supervisor's progress note dated 2/7/2015 at 7:31 PM, documented that at 7:20 PM, the resident's blood sugar remained over 600, the NP was notified, and the resident was transported to the hospital, via ambulance. The hospital emergency department note dated 2/7/2015 documented the resident had increased lethargy over the past few days, and a blood pressure of 101/0. The resident's [DIAGNOSES REDACTED]. When interviewed on 2/20/2015 at 1:05 PM, RN Supervisor #2 stated she called medical twice during the shift for the resident's elevated blood glucose levels and was told to give 5 units of insulin. She stated there was a concern with the resident's blood sugar levels, as they were still high after the insulin was given. RN Supervisor #2 stated she did not review the resident's medical record prior to assessing the resident and believed the change in the resident's condition was elevated blood sugar levels. When interviewed on 2/20/2015 at 1:15 PM, LPN #16 stated on 2/7/2015 at 7:30 AM, the resident was diaphoretic (profuse sweating), she obtained a blood glucose level, and it was greater than 500. The LPN stated she notified the RN Supervisor, who stated she would call the physician. The LPN stated she took the resident's vital signs 3 - 4 times during the shift, stated they were fine in the morning, and during the afternoon the resident had a low grade temperature, and Tylenol was given. When interviewed on 2/26/2015 at 3:45 PM, RN Manager #14 stated she was not notified of the purulent drainage from the resident's PEG tube, or of the resident's oxygen saturation being 86% and 87% on room air. When re-interviewed on 2/27/2015 at 10:40 AM, RN Supervisor #2 stated she reported to the NP the resident's blood sugar levels and asked for an antibiotic as the resident may have had an infection. The RN stated she did not recall if she told the NP the resident's lungs were congested. The RN did not notify anyone else of the changes in the resident's condition, as she thought it was an acute episode of high blood sugars that "we could take care of." When interviewed on 2/27/2015 at 2:20 PM, the physician stated he expected the RN Supervisor to report the resident lung sounds, and any physical observations to the on-call practitioner when report was provided. The on-call NP was unavailable for interview. 10NYCRR 415.12

Based on observation, record review, and interview conducted during the standard and abbreviated surveys (NY 019 and NY 944), it was determined for 3 of 8 residents (Residents #1, 14, and 18), reviewed for pressure ulcers, the facility did not ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and residents with pressure ulcers received the necessary treatment and services to promote healing. Specifically: - Resident #1 was admitted with a Stage II pressure ulcer and a reassessment and evaluation by the wound care physician was not completed timely. - Resident #14 developed a blanchable area of redness on the coccyx, an assessment was not documented, and upon discharge, the resident presented to the emergency room with a Stage II pressure ulcer. - Resident #18 developed a pressure ulcer from a Foley catheter in 8/2014, the pressure ulcer was not routinely assessed, progressed to a Stage III, and the resident required placement of a suprapubic catheter (urine drainage tube inserted through the lower abdomen). This resulted in actual harm that is not immediate jeopardy for Resident #18 and no actual harm with potential for more then minimal harm that is not immediate jeopardy for Residents #1 and 14. Findings include: 1) Resident #18 had [DIAGNOSES REDACTED]. The licensed practical nurse (LPN) note dated 7/27/2014 at 12:59 PM, documented the tip of the resident's penis had an elongated tear and there was a small amount of bloody drainage in the brief. The LPN documented the wound nurse was notified to assess the resident. The Wound registered nurse (RN) progress note dated 8/27/2014 at 1:42 PM, documented the resident was assessed for an "opened area" to the back aspect of the head of the penis caused by a chronic Foley catheter. The Wound RN documented a treatment of [REDACTED]. The LPN progress note dated 8/27/2014 at 1:43 PM, documented the resident was assessed by the Wound RN and the resident needed to be seen by "medical" for a "non-urgent issue." The LPN documented a note was left in the nurse practitioner's (NP) communication book to assess the resident. There was no documentation an order was written for the leg strap for the Foley catheter or that it was added to the resident's treatment administration record (TAR) in 8/2014. The 8/2014 TAR documented the Vaseline gauze treatment was provided as ordered. Between 8/27/2014 and 10/29/2014, the resident was seen by medical providers on 6 occasions including on 9/8/2014 and 9/19/2014 by the NP; on 9/20/2014 by the attending physician; on 9/25/2014 and 9/29/2014 by the NP, and on 10/8/2014 by the attending physician. The NP and attending physician's progress notes did not document an assessment of the tear on the resident's penis from the Foley catheter. The Wound RN progress note dated 10/29/2014 at 3:43 PM, documented the resident had a Stage III pressure ulcer to the urinary meatus, which was facility acquired on 8/28/2014, from the Foley catheter and it measured 0.0 centimeters (cm) x 1.4 cm x 6 cm. The note documented the resident was to have a leg strap to keep the Foley catheter in place. The RN skin assessment dated [DATE] at 10:19 AM, documented the resident had a Stage III pressure ulcer on the urinary meatus measuring 0.7 cm x 0.5 cm x 0 cm. The nursing progress note dated 11/3/2014, documented the resident was seen by the wound care physician and recommendations included a suprapubic catheter due to the pressure ulcer caused by the Foley catheter. The NP progress note dated 11/10/2014 documented the resident had just returned from a urology appointment and insertion of a suprapubic catheter was planned. The next Wound RN wound tracking note (after the initial note completed on 10/29/2014) was dated 11/25/2014 at 12:04 PM, and documented the Stage III pressure ulcer to the resident's urinary meatus measured 0.5 cm x 0.3 cm x 0.3 cm, and the resident was scheduled for a suprapubic catheter. The nursing progress note dated 12/12 2014 documented the resident returned from the hospital after insertion of a suprapubic catheter. The Wound RN measured the resident's wound from 12/2/2014 - 1/13/2015 as follows: - on 12/2/2014, 0.5 cm x 0.3 cm x 0.5 cm; - on 12/12/2014, 3.0 cm x 2.5 cm x 0 cm; - on 12/19/2014, 0.3 cm x 0.3 cm x 0.3 cm; - on 1/2/2015, 0.4 cm x 0.2 cm x 0.2 cm; and - on 1/13/2015, 0.6 cm x 0.4 cm x 0.4 cm. The Wound RN's progress note dated 1/13/2015 documented the prior pressure ulcer to the resident's penis was now classified as a non-pressure erosion caused by the Foley catheter. The note documented the resident was to be referred to plastic surgery due to the edges of the wound rolling and the wound physician was asked to assess the area. The wound care physician evaluation dated 1/16/2015 documented the resident had a pressure ulcer of greater than 140 days duration that measured 3 cm x 1 cm x 0.5 cm with a surface area of 3 cm and granulation (healing) tissue was present. The wound had improved since the Foley catheter was removed, healing was stagnated, and further healing required plastic surgery. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was comatose, required total assistance for all activities of daily living (ADL), and had one Stage III pressure ulcer not present on admission with measurements or tissue type not assessed. The comprehensive care plan (CCP) updated 2/13/2015, documented the resident had a suprapubic catheter used to treat a pressure ulcer. The CCP was updated on 2/18/2015 and documented the resident had a Stage III pressure ulcer on the penis starting 10/31/2014 and weekly skin evaluations were to be done by an RN. On 2/27/2015 at 11:37 AM, the surveyor observed the pressure ulcer on the underside of the resident's penis during the treatment. The pressure ulcer was an elongated slit with pink and moist tissue to the base with depth of unknown measurement. During an interview with licensed practical nurse (LPN) #10 on 2/27/2015 at 11:45 AM, she stated she was not sure how long the pressure ulcer had been present. She stated the pressure ulcer had improved since the catheter was removed and previously had more drainage. During an interview with LPN #11 on 3/2/2015 at 10:05 AM, she stated the pressure ulcer to the penis occurred around six months ago and worsened from the Foley catheter and the resident's movements. The worsening of the pressure ulcer stopped once the catheter removed and now it had stayed around the same. During an interview with LPN Manager #5 on 3/2/2015 at 10:12 AM, she stated she was notified on 8/27/2014 about the pressure ulcer to the resident's penis and reported it to the wound nurse who ordered a treatment for [REDACTED]. She stated the resident was seen by urology and was not referred from there to plastic surgery as they did not feel more could be done. During an interview with NP #15 on 3/2/2015 at 11:24 AM, she stated no one specifically asked her to look at the pressure ulcer on the resident's penis. She stated she made a referral to urology on 11/3/2014. During an interview with Corporate Wound RN (RN #12) on 3/2/2015 at 12:10 PM (who was previously the Wound RN for the facility), she stated she assessed the resident on 8/27/2014 and made recommendations for treatment and follow-up. She stated the resident should have been followed weekly by the wound care RN and that should have been documented. She stated she left her position as the facility's Wound Care RN in 9/2014 and was not sure what happened after that. The Wound RN who replaced her left the facility in 2/2015. She stated the resident's pressure ulcer should also have been followed by the attending physician or NP. During an interview with the Director of Nursing (DON) on 3/2/2015 at 12:30 PM, she stated the facility had a weekly skin meeting where Nurse Managers reported issues. She stated the resident would have been discussed over the summer and she could not find a record that his pressure ulcer was monitored at that time. She stated pressure ulcers should be followed weekly by an RN. During an interview with the attending physician on 3/2/2015 at 2:30 PM, he stated he did routine visits and staff had not made him aware of the resident's skin concerns. During an interview with the wound physician on 3/2/2015 at 3:05 PM, he stated he saw the resident once or twice, nothing could be done, and he recommended a plastic surgery consult. 2) Resident #14 had [DIAGNOSES REDACTED]. The admission head to toe assessment, dated 1/30/2015 at 6:25 PM, by the registered nurse (RN), documented the resident had a Foley catheter and his skin was intact. The RN progress note, dated 1/30/2015 at 7:13 PM, documented the resident was admitted from the hospital at 5 PM, and the resident's skin was intact and the resident's admission assessment was complete. The Braden Scale (pressure ulcer risk assessment) dated 1/30/2015 at 6:38 PM, documented the resident was at moderate risk for developing pressure ulcers related to very limited sensory perception; occasionally moist skin requiring an extra linen change "approximately" once a day; being chairfast; having limited mobility; and having the potential for friction and shearing. The Braden Scale documented the resident's skin "probably slid to some extent against the sheets, chair, and other devices." The "Special Information" form (care instructions), dated 1/30/2015 at 7 PM, did not contain documentation directing the certified nurse aides (CNA) to provide preventative skin care interventions to the resident. The comprehensive care plan (CCP) initiated on 1/31/2015 at 11:58 AM, and revised on 1/31/2015 at 12:56 PM, documented the resident was at risk for impaired skin. Interventions included turning and positioning every 2 hours, a pressure relieving cushion in the chair, incontinence management, and preventative/protective skin care. The resident's buttocks were not documented as a site for impaired skin integrity. The NP (nurse practitioner) progress note dated 2/2/2015, documented the resident's skin was "unremarkable." The physician's orders [REDACTED]. There were no corresponding nursing or medical progress notes on 2/2/2015 documenting the reason the [MEDICATION NAME] was ordered or documenting an assessment of the resident's skin. The Minimum Data Set (MDS) assessment, dated 2/5/2015, documented the resident had moderately impaired cognition, required total assistance for activities of daily living (ADL), had impaired range of motion on one side of the body, was frequently incontinent, was at risk for developing pressure ulcers, and had MASD (Moisture Associated Skin Damage). There was no documented evidence the CCP was updated to include the resident's development of MASD. The RN progress note, dated 2/7/2015 at 7:31 PM, documented the resident was sent to the hospital with elevated blood sugars. The hospital emergency room physician progress notes [REDACTED]. When interviewed on 2/26/2015 at 3:45 PM, RN Manager #14 stated [MEDICATION NAME] was ordered on [DATE] due to the resident's bottom being red and blanchable. RN #14 stated she did skin rounds on every resident on the unit that day and saw his buttocks at that time. She stated she did not document an assessment at the time she observed his skin and was going to check the resident's skin when she returned to work on Monday but by then, the resident had been transferred to the hospital. She stated she did not remember reassessing the resident using a Braden Scale after she assessed his buttocks and obtained an order for [REDACTED]. When interviewed on 2/27/2015 at 10 AM, CNA #22 stated the resident's bottom was red and excoriated since admission and that she made the RN Manager aware. When interviewed on 2/27/2015 at 10:10 AM, licensed practical nurse (LPN) #16 stated the resident's bottom was red since admission, and she believed [MEDICATION NAME] ointment was ordered upon admission as a skin barrier cream. When interviewed on 2/27/2015 at 10:10 AM, CNA #23 stated the resident's bottom was reddened since admission. When interviewed on 2/27/2015 at 11:50 AM, the Assistant Director of Nursing (ADON) stated his role included monitoring and tracking wounds and he did not remember seeing the resident for skin issues. He stated skin redness should be documented, and it was not acceptable to institute treatment without documenting a skin assessment. When interviewed on 2/27/2015 at 1:55 PM, the Director of Nursing (DON) stated when [MEDICATION NAME] was initiated, she expected documentation of an assessment to be done. 3) Resident #1 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 2/11/2015, documented the resident was at risk for impaired skin integrity and a goal was to be free from skin breakdown. Interventions included the resident would be turned and positioned every 2 hours, had pressure reducing devices for chair and bed, required weekly skin checks. A skin condition assessment dated [DATE], documented the resident had a Stage II pressure ulcer on the coccyx that measured 2 centimeters (cm) x 2.3 cm and surrounding skin was reddened, macerated, and excoriated. The assessment documented the resident was to be seen by the wound team. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired, the resident required extensive assistance with activities of daily living (ADL), had limited range of motion in arms and legs, and had a Stage II pressure ulcer. A physician progress notes [REDACTED]. A Wound Care registered nurse (RN) skin condition assessment dated [DATE], documented the resident had a Stage II pressure ulcer on the coccyx and measurements remained unchanged from 2/11/2015. During an observation on 2/26/2015 at 8:50 AM, the resident had a Stage II pressure ulcer near the right inner buttock that measured approximately 3 cm x 0.5 cm, with a small amount of bright red drainage. The surrounding skin was reddish purple, abraded and measured approximately 5 cm x 3 cm. During an interview with registered nurse (RN) Manager #14 on 2/27/2015 at 9:30 AM, she stated she did the initial wound evaluation on the resident on 2/11/2015 and made a wound team referral. RN Manager #14 stated the resident should have been seen by the wound team, including the wound care physician, within 7 days of the referral. She stated she notified the Wound Care RN on 2/12/2015 that an evaluation was needed and the resident's first evaluation was scheduled for today (2/27/2015). A wound care physician initial evaluation dated 2/27/2015, documented the resident had an unstageable deep tissue injury on the right buttock that measured 4 cm x 0.5 cm x not measurable, with moisture associated [MEDICAL CONDITION] (inflammation). Recommendations included a [MEDICATION NAME] dressing (promotes healing) every 3 days, barrier cream to the buttocks every shift, and off loading the area. During an interview with the Assistant Director of Nursing (ADON), who was the Wound Care RN, on 2/27/2015 at 12:15 PM, he stated he was recently hired and learned of the resident's skin issue on 2/13/2015 when he reviewed the 24 hour report. He stated, at that time, the resident had excoriation and a treatment was ordered. The ADON stated he assessed the resident on 2/23/2015 and measurements were unchanged from 2/11/2015. The ADON stated the resident was seen by the wound care physician on 2/27/2015, that the pressure ulcer was a Stage II that measured 4 cm x 0.5 cm, and had moisture associated [MEDICAL CONDITION]. He stated the resident should have been followed every 7 days and was not followed up in a timely manner. 10NYCRR 415.12 (c)(2)