Every finding on record at Charles T Sitrin Health Care Center Inc

Based on record review and interviews, the facility failed to ensure a resident received adequate supervision and failed to identify and reduce hazards and risks for one of one resident (Resident #1) reviewed. Specifically, Resident #1 was admitted to the Neurodegenerative Unit with a history of suicidal ideations and hearing voices they referred to as demons. On [DATE], Resident #1 was found unresponsive in their room with a cord wrapped around their neck; cardiopulmonary resuscitation was initiated; Emergency Medical Services arrived and transported the resident to the hospital where they were pronounced deceased . This resulted in Immediate Jeopardy to Resident #1 and placed all 13 residents on the Neurodegenerative Unit with history of suicidal ideations at risk for the likelihood of serious harm, serious impairment, serious injury, or death. Findings include: The 01/2022 facility policy Suicidal Ideation, documented staff who witnessed a resident in the Neurodegenerative Care Unit make a suicidal statement would immediately notify the nursing supervisor, provider, licensed clinical social worker, the [NAME] President of Long-Term Care Services and the Director of Nursing. Resident #1 had diagnoses including Huntington's disease (a progressive neurological disease), suicidal ideations, dementia with psychotic disturbances, post-traumatic stress disorder, epilepsy (seizure disorder), and mild intellectual disabilities. The [DATE] Behavior Management Plan completed by Neurodegenerative Unit Program Director/Social Worker #9 documented the resident may verbalize suicidal ideations or attempt to bring a pillowcase to their neck. If the resident made suicidal statements or attempted to bring a pillowcase to their face/neck, remain with the resident to maintain safety and immediately notify nursing/social work. The resident referred to their suicidal ideation thoughts as demons. When expressing these thoughts or speaking of voices in their head, staff can call the resident's pastor at any time of day or night to bring comfort to the resident. The [DATE] Neurodegenerative Unit Program Director/Social Worker #9 progress note documented the resident, at times, heard voices in their head, which they referred to as demons. At breakfast, the resident stated, voices are saying bad things to me. The resident was provided with emotional support, mood state was stable, no concerns at this time. There was no documented evidence Neurodegenerative Unit Program Director/Social Worker #9 asked the resident for clarification of the bad things the voices were saying or the attending physician was notified of the voices. The [DATE] at 12:30 PM Neurodegenerative Unit Program Director/Social Worker #9 progress note documented the resident became agitated stating they felt they were trapped in a cage and wanted to go outside. The resident eventually calmed down, went to their room but almost immediately exited their room and began walking fast paced toward the TV room. The resident entered the TV room, walked toward the window and grabbed a vase off the windowsill. The vase was secured from the resident's hand and additional staff were called. The resident could not be safely calmed and attempted to hit the social worker and the nurse with the vase, kicked and attempted to bite the social worker's arm. Re-direction was attempted by offering a movie, video game, 1:1 card games, taking a nap, or calling their pastor. The resident was not amenable to any of these options. The resident leaned their head on the social worker's shoulder and was agreeable to sit down. Once calmed the resident briefly went to their room and almost immediately exited their room and walked to the TV lounge with a fast pace, was asked if they wanted to watch a movie and agreed. Upon entering the lounge the resident walked toward the windows, grabbed a vase off the windowsill and aggressively hit the window. The vase was secured, and the charge licensed practical nurse and a certified nurse aide arrived to assist. They held the resident and after approximately 8 minutes, the resident was calmed. The resident was assisted to the nursing desk, their pastor was called and the resident stated they felt better. Staff were told to immediately report to the resident's room if they heard noises which could indicate the resident was hitting the window. To ensure safety, all decorative objects were removed from the windowsills in the TV room. The [DATE] at 9:26 PM Licensed Practical Nurse #5 progress note, documented the resident approached the nursing station at 7:30 PM stating they wanted to call their aunt, and they did not like being at the facility and felt like they were in prison. The resident continually made the comment they wanted to leave and did not like it here. After the phone call, the resident went back to their room and went to bed. The [DATE] at 9:05 AM incident report completed by Registered Nurse #3 documented the resident was observed lying on the floor next to their bed; did not appear to be breathing and did not have a pulse. There was a cord wrapped around their neck. Code Blue (emergency alert) was called, staff began cardiopulmonary resuscitation and 911 was called. The resident was transferred to the hospital by Emergency Medical Services at 9:34 AM. There were no predisposing environmental, physiological, or situational factors. Local law enforcement and the medical examiner were made aware. The [DATE] hospital record documented the resident had ligature marks (an impression or pattern left on the skin by a constricting material) on the anterior (front) neck upon admission and was pronounced deceased at 9:53 AM.During an interview on [DATE] at 10:34 AM, Certified Nurse Aide #7 stated they were not aware of the demons the resident spoke of, but knew the resident had suicidal ideations. They stated before the resident was admitted , Neurodegenerative Unit Program Director/Social Worker #9 sent out information received from Developmental Disabilities Services Office regarding the resident. At their previous residence, the resident escaped out of a window, tried to jump off a bridge, tried to put a pillowcase to their neck, and escaped into traffic. They were never told the resident was an imminent danger to themselves. There was no way to know if the resident was a hazard to themselves, two days was not enough time to know how the resident would react. On [DATE], they last saw Resident #1 at approximately 7:00 AM lying in their bed, however they did not enter the room at that time. At approximately 8:50 AM, Licensed Practical Nurse #5 came to the dining room and informed them the resident was cold and unresponsive. When they and Licensed Practical Nurse #5 entered the resident's room, the window screens were busted out and the resident was found on the floor. When they rolled the resident over, they saw a cord wrapped around the resident's neck, not anchored to anything but wrapped tightly and tied off. During an interview on [DATE] at 11:37 AM, Neurodegenerative Unit Program Director/Social Worker #9 stated when the resident was admitted they were concerned about risk of elopement as the resident had tried to jump out of a window at their previous residence. They stated there were zero warning signs the resident wanted to harm themselves and nothing of concern. They did a self-harm assessment on admission, determined there was no risk and added the behavior care plan because of the resident's history of suicidal ideation. The resident talked about voices in their head. They stated they put all their focus on the resident's risk of elopement. The resident was never placed on frequent checks as they determined there was nothing of concern at the time. They and the staff monitored changes in mood state and behaviors outside their baseline. The resident was not there long enough to get a baseline.During an interview on [DATE] at 1:08 PM, Licensed Practical Nurse #5 stated they were aware Resident #1 had a history of suicidal ideation. Residents who were at risk of harming themselves should have their call bell taken away and given something else to use, or if they said they were going to suffocate themselves their pillow should be removed and possibly place the resident on frequent checks. Resident #1 was not on hourly checks. At approximately 8:50 AM on [DATE], they found the resident unresponsive lying on the floor of their room face down with their upper body under the bed. They placed their hand on the resident's back, and it felt cold. They also attempted to arouse the resident by saying their name and there was no response. They left the room to get help. Certified Nurse Aide #7 and Licensed Practical Nurse #5 entered the room and turned the resident over onto their back and that is when they noticed the cord around the resident's neck. During an interview on [DATE] at 1:28 PM, Attending Physician #10 stated many people at the facility worked on determining the resident's risk for self-harm. When a resident had a history of suicidal ideation, everything was based on the resident's needs. They spoke with the resident regarding suicidal ideations during their initial evaluation and the resident stated they were not thinking or planning suicide. They only asked the resident about suicidal ideations because of the resident's history of suicidal ideation. If there was an immediate risk, they would have sent the resident to the Emergency Department for evaluation. The best they could do to keep a resident safe was to talk to the resident and make the best determination they could. During an interview on [DATE] at 2:15 PM, the Administrator stated Neurodegenerative Unit Program Director/Social Worker #9 thoroughly screened all the residents with referrals. Residents with behaviors like suicidal ideation had a behavioral care plan. They looked for a change in behavior or when a resident verbalized suicidal ideations. Resident #1 was set up with a behavioral care plan prior to their admission from Developmental Disabilities Services Office. Developmental Disabilities Services Office never said the resident was a danger to themself or made us aware of any of the apparent self-harm attempts. They did not know the resident jumped out of a window, ran into traffic, or tried to jump off a bridge. Developmental Disabilities Services Office told us the resident was non-ambulatory and could not feed themselves, which was not the case. There were no signs of depression or suicidal ideation. Three days was probably not enough time to get to know the resident. 10 NYCRR 415.12(h)(2)_____________________________________________________________________Immediate Jeopardy was identified, and the Administrator was notified on [DATE] at 12:39 PM. The Administrator was notified on [DATE] at 2:15 PM the Immediate Jeopardy was lifted based on the following corrective action plans:-All staff were educated on suicide prevention and awareness. All licensed staff were educated on the facility's suicidal ideation evaluation form. The facility attestation documented 86% of staff were educated with a plan to educate any remaining staff prior to the beginning of their next work assignment. The educational presentation was reviewed by New York State Surveyors and determined to be complete and an acceptable plan.-Staff interviews conducted on [DATE] verified understanding and retention of education provided-Suicidal ideation evaluation form was created and all residents on the Neurodegenerative Unit with a history of suicidal ideations were evaluated.-All residents with a history of suicidal ideations were immediately assessed by the attending physician and a licensed master social worker.

Based on record review and interviews, the facility failed to ensure the services provided or arranged by the facility were provided by qualified persons for three of three licensed nurses reviewed (Licensed Practical Nurses #5, #11 and #12) reviewed. Specifically, Licensed Practical Nurses #5, #11 and #12 performed cardiopulmonary resuscitation on Resident #1 without having valid cardiopulmonary resuscitation certification. Findings included: The facility policy Code Blue/Cardiopulmonary Resuscitation Policy, revised 05/2024, documented a code blue page alert was utilized to alert individuals within the facility to an acute medical emergency in a particular area of the building. Residents who had full code status would be delineated by a red name wristband and a red heart cardiopulmonary resuscitation sign in their room. Registered staff would verify the code status, assess the resident, and initiate the code team response by alerting additional staff in the area for assistance. Cardiopulmonary resuscitation must be initiated for all witnessed and unwitnessed arrests for residents with full code status. Trained staff would begin cardiopulmonary resuscitation and automated external defibrillator usage as indicated and resuscitative measures continued.Resident #1 had diagnoses including Huntington's disease (a progressive neurological disorder), suicidal ideations and post-traumatic stress disorder.The [DATE] physician order documented the resident's code status as full code (perform chest compressions/cardiopulmonary resuscitation when there is no pulse and/or respirations) with no limitation on medical interventions.The [DATE] at 9:05 AM facility investigation report completed by Registered Nurse #3 documented Resident #1 was observed lying on the floor next to their bed. The resident did not appear to be breathing and did not have a pulse. There was a cord wrapped around their neck. Code blue (emergency response) was called, and staff began cardiopulmonary resuscitation. The resident was transferred to a hospital. Staff investigation statements documented:-[DATE] by Licensed Practical Nurse #5. During a medication pass the resident was found on the floor in their room and was unresponsive. They saw the red wrist band on the resident indicating they were a full code and called a Code Blue. Three nurses from the rehabilitation unit responded with a crash cart and they initiated cardiopulmonary resuscitation and applied an automatic external defibrillator. Cardiopulmonary resuscitation continued until the paramedics arrived and took over. -[DATE] by Licensed Practical Nurse #11. At 9:02 AM on [DATE] there was an announcement for a Code Blue on the neurodegenerative unit. They observed a small patient on the floor with blood coming from the mouth and nose with a cord wrapped around their neck two times. The resident did not have a pulse or respirations. Cardiopulmonary resuscitation was initiated, and they completed multiple rounds of compressions. Licensed Practical Nurse #12 proceeded to take over compressions for Licensed Practical Nurse #11 while they suctioned the resident.-[DATE] by Licensed Practical Nurse #12. When they entered Resident #1's room Licensed Practical Nurse #11 was performing compressions (CPR). They jumped in to assist in reviving the resident until emergency medical services took over.The facility provided a list of staff with current cardiopulmonary resuscitation certification. There was no documented evidence that Licensed Practical Nurse #5, Licensed Practical Nurse #11 and Licensed Practical Nurse #12 were certified in cardiopulmonary resuscitation. During an interview on [DATE] at 1:08 PM Licensed Practical Nurse #5 stated they completed online modules for cardiopulmonary resuscitation but had not finished hands on, so they were not currently certified.During an interview on [DATE] at 9:42 AM Licensed Practical Nurse Educator #13 stated they did not track cardiopulmonary resuscitation certifications for staff.During an interview on [DATE] at 12:29 PM Licensed Practical Nurse #11 stated any staff that was certified or was trained could perform cardiopulmonary resuscitation. They stated they did not possess a current certification in cardiopulmonary resuscitation.During an interview on [DATE] at 1:22 PM Director of Nursing stated any staff that was not certified in cardiopulmonary resuscitation could perform cardiopulmonary resuscitation under the good Samaritan law. The Education department tracked staff's cardiopulmonary resuscitation certifications. 10 New York Codes Rules and Regulations 415.11(c)(3)(ii)

Based on record review and interviews during the abbreviated survey (NY00323986), the facility did not ensure residents received adequate supervision and assistance devices to prevent accidents for one (1) of three (3) Residents (Resident #2) reviewed. Specifically, Resident #2 sustained a fracture of unknown origin to their left arm. The facility investigation identified family members were known to have transferred the resident and there was no evidence the family was educated on safe transfer techniques prior to the identification of the fracture. Findings include: The facility policy Transferring/Ambulation of Residents, revised 7/2002, documented residents were transferred or ambulated as indicated by the physical therapist's recommendations and/or the physician's/physician assistant's order. The transfer and/or ambulation procedure must be adhered to at all times and recorded in the resident care plan. The policy did not include parameters for non-staff transfers. Resident #2 had diagnoses including cerebral vascular accident (stroke), left-sided hemiplegia (paralysis), osteoporosis (weak and brittle bones), and dementia. The 7/14/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, had a stroke and left sided paralysis, and required extensive assistance of one for stand/pivot transfers. The 2/21/2022 Physical Therapist #15 Physical Therapy Discharge Summary documented the resident was able to perform bed to chair transfers with maximum assistance of 1 staff, but remained inconsistent, often due to being resistive and refusing care. Recommendation to nursing included maximum assistance of 2 staff for transfers. The Comprehensive Care Plan revised 4/2023, documented the resident had impaired mobility, range of motion, balance and endurance related to cerebral vascular accident/hemiparesis/hemiplegia. Interventions included durable medical equipment; left sided quarter bed rail; and for bathing, dressing, and toileting, refer to the resident care instructions. The care plan did not address the family assisting the resident in transfers or ambulation. The 9/14/2023 (prior to arm injury) resident care instructions documented Resident #2 required extensive assistance of one for a stand/pivot transfer, was independent and self-propelled backwards in their wheelchair, required extensive assistance for dressing upper/lower body, and was non-ambulatory. The 9/12/2023 at 11:56 AM Licensed Practical Nurse #12 progress note documented the resident complained of left arm/shoulder pain. Their left arm was paralyzed from a stroke and was more flaccid (limp) than usual. There was no bruising or redness observed. The physician and supervisor were made aware. There was no documented evidence Resident #2 was assessed by a qualified professional on 9/12/2023 after complaining of left arm/shoulder pain. Nursing progress notes completed by Licensed Practical Nurse #12 documented: - on 9/13/2023 at 8:41 AM, the resident refused care and yelled at the certified nurse aide. The resident could be heard hollering down the hall. At 8:50 AM, they were moved to the dining room for breakfast and they refused to eat. - on 9/13/2023 at 1:36 PM, the resident had continued complaints of left arm/shoulder pain, and their left arm continued to be more flaccid than normal. Nurse Practitioner #18 went in to see the resident and the family representative was present. An x-ray of the left arm and shoulder and routine Tylenol (pain reliever) were ordered. The 9/13/2023 at 1:59 PM nursing progress note by Registered Nurse #10 documented the resident had a new order for an x-ray and family was present and aware. The 9/13/2023 (untimed) physician order documented x-ray to left shoulder and humerus (arm bone) one time for one day. The 9/13/2023 at 1:45 PM x-ray report documented two views of the left shoulder were completed. Impression was an acute fracture of the proximal (near) humerus (arm bone). The 9/13/2023 (untimed) physician telephone order documented apply immobilizer sling to affected extremity. Licensed practical nurse to confirm placement and fit every day on every shift for left humerus fracture. The 9/13/2023 at 9:56 PM Accident/Incident report completed by Registered Nurse #10 documented they were notified Resident #2 had bruising to their left arm on their biceps (muscles on the front side of the upper arm) and triceps (muscles on the back of the upper arm). The bruise was greenish purple in color and measured 1.5 centimeters by 0.5 centimeters. There were no injuries noted prior to or after the incident. Contributing factors were gait imbalance (the way a person walks), weakness and incontinence. The resident had an immobilizer in place to their left arm, was resting in bed, and denied any pain or discomfort. The medical provider and the family representative were notified. The 9/14/2023 Registered Nurse #10 written statement documented upon investigation, family and staff often transferred the resident and had not received proper training from facility staff to do this. Family was told they needed to receive training from the therapy department for any further transfers. The 9/14/2023 (untimed) Investigative Summary report completed by the Assistant Director of Nursing documented the resident had an injury of unknown origin. Witness statements were obtained, and abuse was ruled out based on staff, resident, and family representative interviews. Based on witness statements and staff interviews, it was discovered prior to the incident (injury) family transferred the resident to and from the bathroom, recliner, and bed without staff in the room. An injury from the resident's diagnoses, lack of assistance with transfers, or low energy with those transfers could not be ruled out. The resident's care plan was updated, and a physical therapy referral was placed for transfer training for the family. The 9/14/2023 at 2:11 PM Physical Therapy referral by Licensed Practical Nurse #12 documented family transferred the resident at times and a referral was needed for transfer training. There was no documented evidence Resident #2's family received transfer training prior to the injury identified on 9/14/2023. The 9/18/2023 at 2:47 PM physician progress note documented the resident was seen for a sick visit and had sustained a left humeral fracture. No rough or mishandling of the resident occurred per resident and family interviews and no recent falls were documented. The resident had a history of stroke with left-sided paralysis and osteoporosis and the loss of movement could have contributed to worsening osteoporosis. The physician documented they understood staff as well as family transferred the resident and even if best outcomes were intended, those fractures could have occurred. There was no evidence the fracture was related to a fall or mishandling of the resident. During an interview on 5/19/2025 at 11:47 AM, Certified Nurse Aide #11 stated Resident #2 required assistance of 1 staff with the use of a gait belt (belt used to assist with transfers), could bear weight on one leg and pivot. The resident's family often transferred the resident to the bathroom and then rang the bathroom call light for assistance. The family would also transfer the resident to the recliner or into bed after lunch. Certified Nurse Aide #11 told the nurse the family transferred the resident but could not recall the date. On 9/13/2023, the aide reported the resident's left arm appeared more flaccid than normal and their left arm had bruising. They had not noticed any bruising prior to that day. Certified Nurse Aide #11 stated the family was trained on transfers after the resident was discovered to have a fractured arm. During an interview on 5/20/2025 at 9:55 AM with Licensed Practical Nurse #12, they stated Resident #2 required extensive assistance from staff for all their activities of daily living except eating. They transferred to the bathroom with assistance of one and would grab the bars. They would also grab the rail on the bed with transfers. Licensed Practical Nurse #12 was aware the family transferred the resident long before the injury to their left arm. The nurse thought Physical Therapy provided education on transfers to the family. If they witnessed family assisting with a transfer, they would have notified their supervisor and documented it. They did not see any notifications or training documented. During an interview on 5/20/2025 at 2:10 PM, the Director of Therapy Services stated Resident #2 was discharged from physical therapy on 2/21/2022. At the time of discharge, the resident required extensive assistance of 2 for transfers and could stand and pivot. The Director of Therapy stated they were not aware family transferred the resident and there was no documentation of family education for transfers. If family was transferring the resident, they would want to be notified and would have a discussion. They relied on nursing to put a referral into therapy for notification if family education was needed. If nursing had knowledge of family transferring the resident, they should have submitted a referral. It was important to educate family for resident safety. During an interview on 5/21/2025 at 10:33 AM, Physical Therapist #14 stated Resident #2 was low functioning, could not ambulate and sat in a reclining chair. The resident transferred with a stand/pivot method for toilet transfers with extensive assistance of one staff. They did not recall doing any recent evaluations. They were not aware family transferred the resident prior to their injury. If they had been notified the family was transferring the resident, they would have educated them for safety. They did not recall giving the family any transfer education and would have recommended family not transfer Resident #2 due to their diagnosis of stroke as it was not safe. They stated nursing should have placed a referral for physical therapy if they knew the family had transferred the resident. During an interview on 5/22/2025 at 2:50 PM, the Director of Nursing stated Resident #2 sustained a fracture to their left arm and they completed an investigation. They were alerted by Certified Nurse Aide #11 during their investigation family transferred the resident prior to the injury. They had no prior knowledge of family transferring the resident. They stated they did not witness any family transfers and if they had witnessed it, they would not necessarily have put a physical therapy referral in if they thought the family transferred the resident safely. There was no policy addressing family transferring a resident or training for transfers. They expected to be notified if other nursing staff witnessed family transferring the resident if they thought it was unsafe, then they would put a referral into therapy for transfer training. They stated they knew the resident's family had transfer training after the injury due to a referral being placed. 10NYCRR 415.12 (h)(1)

Based on record review and interviews during the abbreviated survey (NY00341115), the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care person-centered care plan, and the resident's choices for one (1) of three (3) residents reviewed (Resident #1). Specifically, Resident #1 was reported by family to be choking on liquids and there was no documented evidence the resident was assessed by a qualified professional to determine if a modification to their diet was required. Findings include: The facility policy Acute Change of Condition, revised ,d+[DATE], documented all staff were responsible for identifying and reporting a change in a resident's condition. The licensed practical nurse initiated the Acute Change in Condition Communication Form and reported clinical findings to the registered nurse. The registered nurse was to do the following: review the form; assess the resident's symptoms, mental status and physical function; email the Acute Change in Condition Form to the group; contact the physician; communicate with the resident's family to discuss the change in condition; document their assessment in a progress note, any other observations, nursing interventions, notification of the physician and any new orders; continue to monitor following initiation of treatment; and update the provider if there was no improvement or further decline. The provider would review the findings and possible cause of the change in condition with the nurse and develop a plan for initial workup and treatment. The provider would document in the electronic record. Resident #1 had diagnoses including dementia. The [DATE] Minimum Data Set Assessment documented the resident had severely impaired cognition, required set-up or clean-up assistance with eating, and was not on a mechanically altered diet. The [DATE] Refusal of Treatment Resident Release Form, signed by the resident's family member documented the family member refused the resident's recommendations for a modified soft diet. The family was aware the resident was at risk of aspiration, illness, and death according to the signed release. The [DATE] physician order documented regular diet, regular texture, thin consistency. The [DATE] Comprehensive Care Plan documented the resident had a nutritional problem. Interventions included to monitor tolerance of diet consistency, consult speech therapy as needed, and staff were to notify the provider of change in condition requiring interventions/plan of care changes. The [DATE] hospital report documented the resident had an unwitnessed fall and was found in a large pool of blood from a lacerated forehead. The resident's eyelids were edematous (swollen) and bruised and a computed tomography scan (specialized x-ray) showed multiple nasal fractures and possible nasal septal (center of nose) fracture. The [DATE] at 2:36 PM Registered Nurse #10 progress note documented the resident returned from the hospital and was taking in minimal oral liquids and nothing nutritionally due to injury to their nose that did not allow the resident to breath effectively. The [DATE] Physician #9 progress note documented the resident returned from the hospital in some pain, intakes were low, and they hoped pain control would help. New orders included to start 2 liters of normal saline (mixture of water and salt) via intravenous route and a fentanyl patch (narcotic medication delivered through the skin) would be added for pain. The [DATE] at 2:24 PM Registered Nurse #10 progress note documented the resident still had decreased oral intake, complained of a sore throat, and was able to clear oral secretions on their own. The [DATE] at 9:58 PM Licensed Practical Nurse #3 progress note documented the resident's family reported the resident was choking on liquids. Licensed Practical Nurse #3 checked the resident's mouth, and the resident had no liquids in their mouth. There was no documented evidence a qualified professional was notified to assess the resident after they were reported choking. The [DATE] to [DATE] Interdisciplinary Team progress notes and physician progress notes did not address concerns related to the resident's alleged choking on liquids. There were no physician orders related to diet modification and no therapy screenings completed during this time. The Comprehensive Care Plan was not updated to address swallowing concerns. The [DATE] at 2:30 PM Registered Nurse #10 progress note documented the resident complained of shortness of breath and wheezing in their lungs. A chest x-ray obtained showed pneumonia. New orders were implemented for Invanz (antibiotic) intramuscularly (administered into a muscle), oral steroids (medication to decrease inflammation), and breathing treatments (inhaled medications). The [DATE] at 2:22 PM Registered Nurse #10 progress note documented staff reported the resident had increased lethargy, had a fever, and was not rousable. Respirations were increased and the resident had increased oral secretions. The provider was notified and ordered morphine and Ativan (narcotic medications). The [DATE] at 12:42 PM Registered Nurse #20 progress note documented the resident was found expired. The [DATE] Autopsy Report documented the resident's cause of death was aspiration pneumonia complicating facial trauma. During a telephone interview on [DATE] at 8:31 AM, Licensed Practical Nurse #3 stated when a resident had a change in condition, they took vital signs, documented in a progress note, and called the supervisor to assess. When Resident #1 fell , they had a gash on their forehead and a bloody nose. There was no bruising. When the resident returned from the hospital, their whole face was bruised. On [DATE], they could not recall if they notified a supervisor about the alleged choking. They stated it was their normal routine to notify a supervisor when a resident had a change in condition because they did not want to take any chances. During a telephone interview on [DATE] at 11:24 AM, Registered Nurse #10 stated they were the current Assistant Director of Nursing and was Resident #1's Unit Manager when they were at the facility in 2024. They expected a registered nurse to be notified of a resident's change in condition so the registered nurse could assess the resident. The physician and family should be notified, and a progress note documented. If a family reported a resident was choking on liquids, they expected a registered nurse be notified for an assessment because the resident would be at risk of aspiration. They were not aware there was no registered nurse assessment completed on [DATE] and there should have been an assessment. During a telephone interview on [DATE] at 10:33 AM, Speech Therapist #19 stated they expected a supervisor assessment if a family reported a resident was choking on liquids. Any nurse could generate a referral to speech therapy so therapy could assess, and they expected a therapy referral for a resident choking on liquids. When Resident #1 was documented as choking on liquids, this was a change in condition for the resident, especially with the recent nasal fracture, and they expected the resident to be assessed by a supervisor and referred for speech therapy. Even with the signed consent form documenting the family refusing the modified solid foods, the resident should have had a medical follow up for the change in condition with liquids. 10NYCRR 415.12

Based on record review and interviews during the abbreviated survey (NY00368525) the facility failed to ensure residents were free from abuse for one (1) of seven (7) residents reviewed (Resident #1). Specifically, Resident #1 was physically removed, against the resident's will, from the dining room by Licensed Practical Nurse #4, who then continued to have an altercation in the hallway, which resulted in the resident falling several times. The facility's failure to protect residents from abuse resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #1 and placed all 173 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death. Findings include: The facility policy, Prohibition of Abuse Policy and Procedure Including Definitions of Abuse and All Other Terms Associated with Abuse and Serious Bodily Injury, revised 10/2024, documented all residents would be treated with respect and consideration. Employees were expected to behave in an orderly fashion and any action which was injurious, insulting, or detrimental to a resident was prohibited. Staff were in-serviced at general orientation, annually, and as needed on abuse. Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Involuntary seclusion was the separation of a resident from other residents against the resident's will. The facility would maintain a proactive atmosphere to prevent abuse, neglect, mistreatment, and exploitation of residents. The facility policy, Neuro-Patient/Resident Behavioral Review, revised 8/2024, documented the interdisciplinary team would identify residents who had behaviors that interfered with activities of daily living, interactions, and care. The interdisciplinary team would develop and implement interventions to diminish disruptive, inappropriate, and harmful behaviors, and provide guidance and education to family and care providers for effective intervention for positive behaviors and interactions. All staff hired to the neuro unit received an eight-hour Strategies for Crisis Intervention and Prevention training to learn strategies for behavior de-escalation and appropriate measures for physical intervention. Resident #1 had diagnoses which included Huntington's disease (a neurogenerative disorder that affected the brain and nervous system), chorea (involuntary irregular movements), and ataxia (lack of muscle coordination). The 12/9/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment with inattention, disorganized thinking, had no behaviors, utilized a walker for mobility, and was independent with all activities of daily living. The 11/19/2024 Behavior Management Plan documented the resident had problem behaviors of agitation and impulsivity. The resident's triggers for behavior included when staff attempted to provide the resident with assistance, administer medications, informed the resident they could not do something due to safety concerns, when the resident asked for food or a drink that was not immediately provided, and when the resident's personal mail was opened for them. Signs of escalation included increased chorea, raising their voice or mumbling angrily, huffing and puffing, not making eye contact, and aggressively moving or pushing their walker. Interventions included: allow the resident independence in their activities of daily living; not offer assistance if their safety was maintained; if the resident appeared unsafe completing a task, offer assistance but refrain from providing the assistance until the resident had agreed; provide a snack or drink when requested; if unable to provide the item immediately, provide a timeframe for when the item would be provided; if showing signs of escalation, attempt re-direction to preferred activities such as video games, watching movies, or having a cup of coffee or soda. The 1/10/2025 facility incident report prepared by the Director of Nursing documented Certified Nurse Aide #5 reported an incident that occurred on 1/3/2025 at approximately 6:00 PM between Licensed Practical Nurse #4 and Resident #1. The camera footage was reviewed with findings the resident was handled roughly by Licensed Practical Nurse #4 and the resident fell at least three (3) times. The incident was reported to Physician #18, the resident's family member, and the local police department. A full skin assessment was completed. The resident was noted to have multiple abrasion areas to their back in various stages of healing which had a treatment date of 12/28/2024, a superficial abrasion to their right wrist and left posterior shoulder, a large hematoma to their right side with yellow-purple discoloration, and their left buttock had swelling. Staff statements documented: - the Program Director of the Neurocare Unit stated on 1/10/2024, Certified Nurse Aide #5 reported they were told by Licensed Practical Nurse #4 about an incident they had with Resident #1 on 1/3/2025 in the dining room. The Program Director of the Neurocare Unit reviewed the footage from the dining room on 1/3/2025. The footage showed at approximately 6:07 PM in the dining room, Licensed Practical Nurse #4 was aggressive with Resident #1, who did not appear to be exhibiting any behaviors which would have warranted their removal from the dining room. Licensed Practical Nurse #4 pushed the resident's walker and table away and pulled the resident out of the dining room by the back of the chair. The altercation ended in the hallway at approximately 6:20 PM and Licensed Practical Nurse #4 became physical with the resident multiple times, resulting in the resident falling at least three times. - Resident #1 was interviewed and stated they spat out their food and they were made to leave the dining room. Resident #1 did not want to discuss the incident further. - Certified Nurse Aide #5 stated on 1/4/2025, Licensed Practical Nurse #4 approached them and stated there was an incident with Resident #1 in the dining room the prior evening. The nurse asked Certified Nurse Aide #5 what to do if a resident had a behavior and needed to be taken down or use the Strategies for Crisis Intervention and Prevention (SCIP) on the resident. Certified Nurse Aide #5 asked the nurse the reason they were asking. Licensed Practical Nurse #4 stated Resident #1 choked on their fish and the nurse wanted the resident to stop eating it. The nurse said the resident became aggressive and started throwing drinks and pushing their table; Licensed Practical Nurse #4 had to remove the resident from the dining room in their chair. Licensed Practical Nurse #4 said none of the staff assisted them and Licensed Practical Nurse #4 did what they had to do to remove the resident from the dining room. Certified Nurse Aide #5 found the story odd. They stated Resident #1mentioned that morning they were hungry and upset over the fish but the aide was unaware of what the resident meant. Certified Nurse Aide #5 reported it to the Program Director of the Neurocare Unit on 1/10/2025 due to another conversation about Resident #1 with Licensed Practical Nurse #4 on 1/9/2025, which made the aide question the nurses' story. - Licensed Practical Nurse #4 stated they entered the dining room to get another resident's dinner and was told by a certified nurse aide (unnamed) that Resident #1 had vomited and needed to leave due to a gastrointestinal illness. Licensed Practical Nurse #4 observed the resident take a large bite, cough, and spit the food onto the plate. The nurse asked the resident if they felt okay and the resident said it was the fish and they were not sick. The nurse offered the resident an alternative, the resident became agitated, pushed their walker and the table and cursed. The resident wanted coffee, they told the resident they would get it and bring it to the resident's room. The resident pushed Licensed Practical Nurse #4 back and the nurse reminded the resident not to put their hands on people. The nurse felt the resident could hurt someone in the dining room as they were escalating and shoving things away. They encouraged the resident to remain calm and leave the dining room. The resident was agitated and began pushing things away from them, and Licensed Practical Nurse #4 took the back of the resident's chair and pulled it from the dining room out the door. The resident jumped from the chair and banged on the dining room door and pushed Licensed Practical Nurse #4 several times. Licensed Practical Nurse #4 grabbed the resident by the center of their shirt and lowered the resident to the floor as the resident kept losing their balance while pushing the nurse. The resident calmed down after several minutes. Licensed Practical Nurse #4 informed Registered Nurse Supervisor #7 of the incident, and they had lowered the resident to the floor to their buttocks by their shirt. - Registered Nurse Supervisor #7 stated on 1/3/2025, Licensed Practical Nurse #4 approached them during their rounds on the neuro unit and informed them there was an incident with Resident #1 in the dining room where the resident became violent, and no staff assisted to calm the resident down. Licensed practical Nurse #4 stated no one wanted to assist as they did not have the proper training when an agitated patient presented with aggressive behavior. They inquired if anyone was hurt and Licensed Practical Nurse #4 stated no. - Certified Nurse Aide #6 stated on 1/3/2025 during dinner, Resident #1 was eating, and they gagged or vomited a little. Licensed Practical Nurse #4 told the resident they had to go back to their room. The resident stated no and was debating with the nurse for a while. Licensed Practical Nurse #4 then pulled Resident #1 from the dining room in their chair. - Certified Nurse Aide #8 stated on 1/3/2025, Resident #1 was eating quickly which led to them vomiting and coughing forcefully. The resident was prompted to slow down, and Licensed Practical Nurse #4 approached the resident to get them out of their chair and out of the dining room. It agitated the resident. There was a lot of arguing that could be heard behind the door outside of the dining room. Certified Nurse Aide #8 stayed in the dining room with the other residents to keep them safe. - Dietary Aide #17 stated on 1/3/2025, Resident #1 vomited, Licensed Practical Nurse #4 told the resident to go back to their room, and the resident refused. The dietary aide heard Licensed Practical Nurse #4 yell at Resident #1 and pull the resident out of the dining room by their chair. Licensed Practical Nurse #4 was pushing the resident out of the room when the resident tried to re-enter. - Licensed Practical Nurse #11 stated they heard Licensed Practical Nurse #4 try to redirect Resident #1, who was trying to re-enter the dining area. Licensed Practical Nurse #4 was saying No! You cannot hurt other people and it looked like Resident #1 was charging toward the nurse who put their hands up in a stop motion below their waist. Resident #1 fell as they charged the nurse, and the resident stated, You pushed me down. Licensed practical Nurse #11 went to intervene, and Licensed Practical Nurse #4 informed them the resident was trying to hit another female resident in the dining room. The resident kept stating they wanted to go into the dining room, and they thought Licensed Practical Nurse #4 was trying to redirect the resident. They told Licensed Practical Nurse #4 to call the supervisor, to let the resident calm down, and that the resident could not re-enter the dining room due to it being locked from the outside so there was no need to stand in front of the door. -Certified Nurse Aide #10 stated on 1/3/2025, Licensed Practical Nurse #4 and Resident #1 had a verbal conversation about the resident leaving the dining room, and the resident refused to leave. The aide was feeding another resident and did not get involved. Certified Nurse Aide #10 left the dining room did not know what happened after. The facility's surveillance videos from the neurocare unit on 1/3/2025 from 5:58 PM through 6:45 PM included: - at 6:05 PM, Licensed Practical Nurse #4 approached Resident #1 who was sitting at their table in the dining room. Licensed Practical Nurse #4 pushed the table slightly away from Resident #1 and stood in front of an unidentified resident as they appeared to talk with Resident #1. Licensed Practical Nurse #4 then pushed the table further from Resident #1, then moved it in front of the resident. The resident remained seated their chair, appearing calm. Licensed Practical Nurse #4 made gestures that appeared to indicate for the resident to get up. - At 6:06 PM, Licensed Practical Nurse #4 pushed Resident #1's walker away and turned the four-legged stationary chair so the resident's back was facing the table. The resident attempted to push away while in the chair, Licensed Practical Nurse #4 spun the chair so the back was to Licensed Practical Nurse #4. Licensed Practical Nurse #4 moved the chair backwards with the resident in it while the resident resisted and held onto the pillar wall nearby. Resident #1 then stood up and sat on a rolling stool nearby. Licensed Practical Nurse #4 attempted to pull the resident off the stool by holding the resident under the arms while Resident #1 struggled against them. Once the resident was up from the stool, Licensed Practical Nurse #4 walked with their hands on the resident's torso until the resident sat back into the stationary chair. Licensed Practical Nurse #4 put their face close to Resident #1 while gesturing with their hands and pointing in the resident's face. The resident had not shown any aggression toward the nurse. - From 6:07 PM to 6:08 PM, Licensed Practical Nurse #4 got behind the resident who was on the chair, put their left hand on the resident's shoulder, and pulled the chair back through the dining area with the resident in it while the resident kicked their legs and attempted to remove themselves from the chair. Licensed Practical Nurse #4 pulled the resident back into the chair by the shoulder of their shirt when they attempted to get up. Resident #1 continued to struggle in the chair while Licensed Practical Nurse #4 held their shirt. The resident slid down in the chair at the entry to the dining room and their shirt slid up to their mid-abdomen. Resident #1 appeared to have slipped completely out of the chair, and they hit the floor with their buttocks while Licensed Practical Nurse #4 had ahold of their shirt. Resident #1 got to their hands and knees and attempted to kick out at the nurse while the nurse still had ahold of the resident's shirt. Licensed Practical Nurse #4 closed the door to the dining room, the door struck the resident's foot as it closed. Resident #1 attempted to knock on the door to the dining room and Licensed Practical Nurse #4 was blocking the shut door with their body. - From 6:10 PM to 6:12 PM, Resident #1 was in the hall at the closed dining room door and did not appear to be causing a disturbance. Licensed Practical Nurse #4 came up and positioned themselves between the resident and the door and physically moved the resident backwards. Licensed Practical Nurse #4 moved Resident #1 away from the door as they held the resident's upper arm while pushing on their upper body. The resident stumbled backwards and fell to the floor on their buttocks. The resident's phone dropped to the floor in the struggle. Resident #1 and Licensed Practical Nurse #4 continued to struggle in camera range with Licensed Practical Nurse #4 physically attempting to move the resident around, grabbing at the resident's arms, and pushing at their chest. Licensed Practical Nurse #4 picked up the resident's phone and put it behind the nurses' station. The resident left the area and walked down the hallway towards the other entrance to the dining room and Licensed Practical Nurse #4 ran after the resident. - From 6:13 PM to 6:14 PM, Resident #1 came back to the dining room entrance at the nurses' station, Licensed Practical Nurse #4 followed the resident and got between them and the door. They continued to struggle until Licensed Practical Nurse #4 wrapped their arms around the resident's chest and took them to the floor. Resident #1 got up and headed toward the door again and Licensed Practical Nurse #4 pushed the resident backwards with their hands on the resident's chest. Resident #1 ran down the hallway toward the other entrance to the dining room and Licensed Practical Nurse #4 ran after the resident. - From 6:15 PM to 6:18 PM, Resident #1 paced from the door back to the nurses' station but did not appear aggressive. - At 6:18 PM, Licensed Practical Nurse #4 gave the resident back their phone from behind the nurses' station then continued to put themselves between the dining room door and the resident. - From 6:19 to 6:20 PM, Resident #1 walked away from the situation and down the hallway toward their room. Licensed Practical Nurse #4's timecard and work schedule documented they worked and continued to have access to all residents on 1/4/2025 on the neuro unit, 1/8/2025 on other units, and 1/9/2025 on the neuro unit. During an interview on 1/28/2025 at 2:18 PM, Certified Nurse Aide #6 stated they received no specialized training for the neuro unit at the facility. There was a task list that was available to all staff on the unit that identified the residents' behavioral triggers. If a resident had behaviors, they moved other residents in the area away to safety. Resident #1 did not have a lot of behaviors, they mainly kept to themselves playing video games and using their phone. On 1/3/2025, Resident #1 coughed or gagged on their food and Licensed Practical Nurse #4 told the resident to leave the dining room. Resident #1 told the nurse they were not going to leave and continued to sit at their table. Licensed Practical Nurse #4 pulled the resident's chair and pulled them out of the dining room. They did not see Resident #1 act aggressive toward Licensed Practical Nurse #4 at any time. The resident would sometimes refuse to do something and would be fine if they were left alone. During a phone interview on 1/28/2025 at 3:00 PM, Licensed Practical Nurse #4 stated they worked for an agency and often worked on the neuro unit. They stated the only training they received for that unit was one in-service regarding Strategies for Crisis Intervention and Prevention (SCIP) provided by the facility. They had not had any training on Huntington's disease and learned by reading the care plans. They stated on 1/3/2025, Certified Nurse Aide #6 called them over as the resident had vomited. Another certified nurse aide (not identified) told them the resident needed to leave the dining room. Licensed Practical Nurse #4 stated Resident #1 could escalate quickly. The nurse tried to get the resident something else to eat and the resident pushed away from the table. The nurse told the resident Let's go and the resident swore at them and at other residents. Other residents were telling Resident #1 to be quiet as Resident #1 was very angry and loud. Licensed Practical Nurse #4 pulled the resident's chair to the dining room door as they would have been in trouble if Resident #1 hurt anyone in the dining room. The resident went to one knee softly from the chair as the dining room door closed and the resident was very volatile and immediately slammed the nurse into a wall. Resident #1 was kicking and punching at the door. Licensed Practical Nurse #4 stepped out of the way a couple of times. When the resident dropped their phone, the nurse picked up and put it on the top of the desk so it wouldn't get broken, not behind the desk. They stated they never struck the resident, hit the resident, or tried to hurt the resident. The nurse grabbed the resident by their shirt to keep the resident from falling and gently lowered them to the floor. The nurse attempted to call the supervisor, but no one answered the supervisors' phone. They informed the supervisor of the incident when the supervisor rounded on the floor. The nurse said they lifted the resident out of the rolling chair in the dining room because they saw the resident was going to fall forward. They had pulled the resident's walker away as the resident has a history of pushing it at others when agitated. During an interview on 1/29/2025 at 11:07 AM, Certified Nurse Aide #8 stated on 1/3/2025, Resident #1 had just gotten off a clear liquid diet, so they were eating their food quickly when it was given to them. They choked a little which was not uncommon for them, and it resolved quickly. Licensed Practical Nurse #4 was irritable about it and argued the resident was not supposed to be in the dining room. The aide's back was turned most of the time and they only saw License Practical Nurse #4 trying to get Resident #1 out of the chair. The aide did not see Licensed Practical Nurse #4 drag the chair with the resident in it. Resident #1 was only a little aggressive after Licensed Practical Nurse #4 yelled at the resident regarding the choking. If Resident #1 became agitated and was then left alone, they calmed down. The aide was taught to move other residents out of the area instead of trying to move the agitated resident. No other residents in the dining room were agitated by Resident #1 that they were aware of. During an interview on 1/29/2025 at 12:10 PM, the Program Director of the Neurocare unit stated they assisted with staff training on the unit in conjunction with nursing. The full-time staff hired to the neurocare unit received Strategies for Crisis Intervention and Prevention and an in-depth training on Huntington's disease, Amyotrophic lateral sclerosis (a neurodegenerative disease), and all of the aspects of interdisciplinary care. The staff who floated to the unit and the agency staff received an overview training on Huntington's disease and Amyotrophic lateral sclerosis. If a resident had behaviors, the staff were to utilize the interventions on the resident's behavior plan. Strategies for Crisis Intervention and Prevention were a last resort when all interventions on the behavior plan have been exhausted and did not work. When it had to be utilized, a supervisor was to be notified, and a behavior note was to be documented. Staff should never remove a resident from the dining room by pulling them out on a stationary chair. Staff should never attempt to remove a resident from a chair by pulling them up by under their arms. During an interview on 1/29/2025 at 1:10 PM, the Director of Nursing stated abuse training was given to all staff, including agency staff, yearly. The Program Director of the neuro unit determined the appropriate level of training for the staff on the unit. Resident #1 being pulled out of the dining room on the stationary chair was uncalled for. It was aggressive and could make the resident feel abused, as they could not see backwards and had no control over what was going on. The chair could have also broken which would have caused harm to the resident. If a resident's behaviors were escalated but was in a safe situation, the staff should back off and let the resident calm down. Licensed Practical Nurse #4 continued to escalate the situation by going after the resident. The actions of Licensed Practical Nurse #4 were abusive. The nurse dragged the resident out of the dining room and the resident fell a couple of times due to the nurse's aggression. The resident should have been left in the dining room as they were not behavioral and there were no signs or documentation of the resident choking. During an interview on 1/30/2025 at 9:49 AM, Licensed Practical Nurse #11stated they worked on the neuro unit a few times prior to 1/3/2025 and had not received any formal training for the unit. They were told a few residents had behaviors. On 1/3/2025, they heard Resident #1 state Licensed Practical Nurse #4 pushed them down. Licensed Practical Nurse #11 tried to calm the situation and informed Licensed Practical Nurse #4 they didn't need to stand in front of the dining room door as it was locked. Licensed Practical Nurse #11 was trained in Strategies for Crisis Intervention and Prevention years ago and they did not believe that was what Licensed Practical Nurse #4 utilized, rather they believed the nurse abused the resident. During an interview on 1/30/2025 at 2:28 PM, the [NAME] President of Long-term Care stated the only unit they used physical intervention on was the neuro unit. They used Strategies for Crisis Intervention and Prevention as a last resort if the interventions on the behavior plan did not work. If the training was utilized, there was to be a behavior progress note and an accident and incident report. They reviewed the footage of the incident on 1/3/2025 and stated the behavior of Licensed Practical Nurse #4 was unwarranted and it was abuse. Licensed Practical Nurse #4 should not have removed Resident #1 from the dining room. The resident was sore the next day and had some bruising and abrasions that could have been from the incident. During an interview on 1/30/2025 at 2:48 PM, the Medical Director stated they had not watched the videos of the incident but was made aware. The described actions of Licensed Practical Nurse #4 were abusive and harmful toward the resident. A resident being pulled backwards could cause mental harm and potential physical harm if the resident was to fall or if the chair broke. The nurse's actions were not consistent with any facility protocol. The nurse should have backed away and let the resident calm down instead of being aggressive with the resident and continuously confrontational. During an interview one 2/3/2025 at 1:14 PM, Resident #1's Health Care Proxy (relative) stated they were made aware on 1/10/2025, of the incident that took place on 1/3/2025. They were informed Resident #1 was removed from the dining room and when Resident #1 attempted to re-enter the dining room, the staff member prevented it by pulling on the resident's clothing which resulted in a couple of falls. The were informed the resident was removed from the dining room by their chair being pulled backwards and they fell . Resident #1 was not behavioral and did not need to be removed from the dining room. The resident's relative had not talked to the resident regarding the situation as they did not want to potentially trigger the resident. The resident would have been upset about being removed from the dining room because they love food and would not have understood what was happening. They also would have been upset when their phone was removed from their possession as that was how the resident communicated with family and watched movies. 10 NYCRR 415.4(b)(1)(i) _________________________________________________________________ Immediate Jeopardy was identified, and the facility [NAME] President of Long-term Care and Chief Executive Officer were notified on 1/30/2025 at 5:27 PM. Immediate Jeopardy was removed on 2/2/2025 at 10:21 AM prior to survey exit based on the following corrective actions: - As of 1/31/2025 at 4:15 PM, 100% of staff were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse. - As of 2/1/2025 at 9:00 AM, 100% staff currently working on the neuro unit were trained in Strategies for Crisis Intervention and Prevention. The remaining staff will be educated prior to the start of their next shift or would be removed from the schedule until completed. - As of 2/1/2025 at 3:26 PM, all residents present in the dining room or the hallway for the incident were assessed by a licensed social worker for any harm. - As of 2/1/2025 at 4:30 PM, 87% of all facility staff, including float and ancillary staff were trained on an overview of the Strategies for Crisis Intervention and Prevention. - Staff education sign in sheets were reviewed and compared to the current staff list and no discrepancies were identified. - Staff education was verified during an onsite visit from 1/31/2025 to 2/2/2025. Multiple interdisciplinary staff were interviewed. - Staff were able to report content of education and confirmed the day they received the education and the facility staff who presented the education.

Based on record review and interviews during the abbreviated survey (NY00368525) the facility failed to ensure an incident of staff abuse toward a resident was reported to the State Agency, law enforcement, and the Administrator for one (1) of seven (7) residents reviewed (Resident #1). Specifically, facility staff witnessed or were present when Licensed Practical Nurse #4 abused Resident #1 and the incident was not reported to facility Administration, law enforcement, and the New York State Department of Health for seven (7) days. Additionally, Licensed Practical Nurse #4 continued to have access to residents following the witnessed abuse. The facility's failure to report abuse to Administration, law enforcement, and the State Agency resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #1 and placed all 173 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death. Refer to F 600 Free from Abuse and Neglect. Findings include: The facility policy, Prohibition of Abuse Policy and Procedure Including Definitions of Abuse and All Other Terms Associated with Abuse and Serious Bodily Injury, revised 10/2024, documented all employees were ethically responsible to immediately report any observations of abuse, neglect, mistreatment, exploitation, resident-to-resident abuse, or misappropriation of resident property or any crime to the resident to their supervisor. The facility policy, Resident Allegations and Facility Protocols, revised 10/2024, documented federal and state regulations required providers investigate incidents and complaints. An allegation was required to be reported to the State Department of Health within two (2) hours of receiving notification and knowledge of an alleged incident. All investigations were to be thoroughly documented. The resident would be evaluated for any sign of physical and emotional abuse as well as psychosocial changes from their baseline. The perpetrator would be suspended pending investigation if abuse was probable based on witness statement or assigned to another house or unit from the resident involved if abuse could not be determined. Resident #1 had diagnoses including Huntington's disease (a progressive neurodegenerative disorder), chorea (involuntary, irregular movements), and ataxia (lack of muscle coordination). The 12/9/2024 Minimum Data Set documented the resident had severely impaired cognition, inattention, disorganized thinking, had no behavioral symptoms, utilized a walker for mobility, and was independent with all activities of daily living. The 1/10/2025 at 3:03 PM facility report to the New York State Department of Health documented the incident occurred on 1/3/2025 at 6:05 PM and facility management became aware of the incident at approximately 12:00 PM on 1/10/2025. The 1/10/2025 facility incident investigation completed by the Director of Nursing for an incident occurring on 1/3/2025 and reported to Administration on 1/10/205 documented: - Certified Nurse Aide #5 reported to the Program Director of the Neurocare Unit an incident that occurred on 1/3/2025 at approximately 6:00 PM between Licensed Practical Nurse #4 and Resident #1. The camera footage was reviewed in which the resident was seen being handled roughly by a staff member and the resident fell at least three times. - The incident was reported to the Department of Health, Physician #18, the resident's family, and the local police department on 1/10/2025. Staff statements in the facility investigation included: - the Program Director of the Neurocare Unit (where Resident #1 resided) documented on 1/10/2025 at 11:30 AM, Certified Nurse Aide #5 reported they were told by Licensed Practical Nurse #4 about an incident on 1/3/2025 in the dining room between Licensed Practical Nurse #4 and Resident #1. The Program Director of the Neurocare Unit reviewed the video surveillance footage from the dining room for 1/3/2025. They documented Licensed Practical Nurse #4 was extremely aggressive with Resident #1 and Resident #1 appeared to not be exhibiting any behaviors warranting removal from the dining room. The findings of the video surveillance footage was reported to the [NAME] President of Long-term Care and they obtained statements from the staff. They also obtained a statement from Licensed Practical Nurse #4 and suspended them pending the investigation. - Licensed Practical Nurse #4 stated they informed Registered Nurse Supervisor #7 of the incident, and they had lowered the resident to the floor to their buttocks by their shirt. - Registered Nurse Supervisor #7 documented on 1/3/2025, Licensed Practical Nurse #4 approached them during their rounds on the neuro unit and informed them there was an incident with Resident #1 in the dining room where the resident became violent, and no staff assisted to calm the resident down. They inquired if anyone was hurt and Licensed Practical Nurse #4 stated no. - Certified Nurse Aide #6 stated on Friday, 1/3/2025 during dinner Licensed Practical Nurse #4 pulled Resident #1 from the dining room in their chair. - Certified Nurse Aide #8 stated Resident #1 was prompted to slow down with eating, and Licensed Practical Nurse #4 approached the resident to get them out of their chair and out of the dining room. There was a lot of arguing that could be heard behind the door outside of the dining room. They stayed in the dining room with the other residents to keep them safe. - Dietary Aide #17 stated on 1/3/2025 they heard Licensed Practical Nurse #4 yelling at Resident #1 and pull the resident out of the dining room by their chair. Licensed Practical Nurse #4 was pushing the resident out of the room when the resident tried to re-enter. - Licensed Practical Nurse #11 stated they heard Licensed Practical Nurse #4 trying to redirect Resident #1. Resident #1 fell as they charged the nurse, and the resident stated, You pushed me down. They went to intervene and calm the situation. They told Licensed Practical Nurse #4 to call the supervisor and let the resident calm down. - Certified Nurse Aide #10 stated on 1/3/2025, Licensed Practical Nurse #4 and Resident #1 had a verbal conversation about the resident leaving the dining room, but the resident refused to. They were feeding a resident and did not get involved. They left the dining room with the resident they were assisting and did not know what happened after that. Licensed Practical Nurse #4's timecard and work schedule documented they worked and continued to have access to all residents on 1/4/2025 on the neuro unit, 1/8/2025 on other units, and 1/9/2025 on the neuro unit. During an interview on 1/28/2025 at 2:18 PM, Certified Nurse Aide #6 stated on 1/3/2025 Licensed Practical Nurse #4 pulled the resident's chair and pulled them out of the dining room. They did not see Resident #1 act aggressive toward Licensed Practical Nurse #4 at all. They did not report the incident because they did not see anything reportable. During a phone interview on 1/28/2025 at 3:00 PM, Licensed Practical Nurse #4 stated they attempted to call the supervisor when the resident's behavior escalated, but no one answered the supervisors' phone. They informed Registered Nurse Supervisor #7 of the incident when the supervisor rounded on the floor and told them no one assisted due to not being trained. They stated they informed Licensed Practical Nurse #9 of the incident the next day as they wanted advice on how to handle behaviors on the unit. During an interview on 1/29/2025 at 11:07 AM, Certified Nurse Aide #8 stated on 1/3/2025 their back was turned most of the time and they only saw License Practical Nurse #4 trying to get Resident #1 out of the chair, and did not see Licensed Practical Nurse #4 drag the chair with the resident. They stated they did not report the incident due to the situation being odd. They stated it was hard to differentiate behavioral issues from normal behaviors on the unit and when a nurse wanted to control the situation, they did not think they could get involved. They were informed Licensed Practical Nurse #4 told a supervisor, so they thought everyone was aware. During an interview on 1/29/2025 at 12:10 PM, the Program Director of the Neurocare unit stated they were unaware Licensed Practical Nurse #4 reported to Registered Nurse Supervisor #7 they were concerned about the training of the staff due to no one assisting with a behavioral episode that required intervention on 1/3/2025. During an interview on 1/29/2025 at 1:10 PM, the Director of Nursing stated staff should report potential abuse to their supervisor immediately after making sure the resident was safe. If abuse was thought to have occurred, the employee was immediately suspended pending investigation. All staff who witnessed the incident on 1/3/2025 should have notified the supervisor immediately. Licensed Practical Nurse #4 only reported Resident #1 was behavioral to Registered Nurse Supervisor #7. The supervisor asked if anyone was hurt and Licensed Practical Nurse #4 told them no and the situation was dealt with. During an interview on 1/30/2025 at 9:49 AM, Licensed Practical Nurse #11 stated on 1/3/2025, they did not see much of the incident between Resident #1 and Licensed Practical Nurse #4, but they heard Resident #1 say Licensed Practical Nurse #4 had pushed them down. They tried to calm the situation and informed Licensed Practical Nurse #4 they did not need to stand in front of the dining room door as it was locked. They stated they did not report the incident because they did not see the resident fall and because Licensed Practical Nurse #4 told them they informed the supervisor about the incident. During an interview on 1/30/2025 at 10:20 AM, Registered Nurse Supervisor #7 stated they were passing through the neuro unit when they were informed by Licensed Practical Nurse #4 that Resident #1 was behavioral and they had not received any help from the staff. They asked if anyone was hurt, and Licensed Practical Nurse #4 told them no. They did not report the concern and instructed Licensed Practical Nurse #4 to write a behavior note but did not follow up on it as they were reviewed in morning meeting by the interdisciplinary team. During an interview on 1/30/2025 at 2:28 PM, the [NAME] President of Long-term Care stated staff received abuse training during orientation, annually, and as needed based on what was going on in the building. Staff were trained if the abuse was occurring to ensure the resident was safe. It was also dependent on the position of the employee, if it was a direct care staff member they could intervene or they could get a supervisor. A supervisor should be informed if abuse was witnessed. During an interview on 2/3/2025 at 1:12PM, Dietary Aide #17 stated that on 1/3/2025 Licensed Practical Nurse #4 pulled the resident by their chair and dragged them out of the dining room. When the resident attempted to go back into the dining room, the Licensed Practical Nurse was pushing the resident out. They did not know why they did not report the incident to anyone. 10NYCRR415.4 (b) (2) ________________________________________________________________________ Immediate Jeopardy was identified, and the facility [NAME] President of Long-term Care and Chief Executive Officer were notified on 1/30/2025 at 5:27 PM. Immediate Jeopardy was removed on 2/2/2025 at 10:21 AM prior to survey exit based on the following corrective actions: - As of 1/31/2025 at 4:15 PM, 100% of staff were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse. - Staff education sign in sheets were reviewed and compared to the current staff list and no discrepancies were identified. - Staff education was verified during an onsite visit from 1/31/2025 to 2/2/2025. Multiple interdisciplinary staff were interviewed. - Staff were able to report content of education and confirmed the day they received the education and the facility staff who presented the education.

48675 Based on observations, record review, and interviews during the recertification survey conducted 11/12/2024 - 11/19/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the facility's main kitchen and in 4 of 9 house kitchenettes (Magnolia, Cypress, [NAME], and Sycamore) reviewed. Specifically, the main kitchen had multiple unclean surfaces and undated food; and the Cypress, [NAME], Sycamore and Magnolia house kitchenettes had opened and undated food items. Findings include: The facility policy, Cleanliness and Sanitation, revised 3/2017, documented the following guidelines would be followed regarding cleanliness and sanitation of the kitchen equipment, food preparation, storage, dining, and wash areas: - Pots and pans would be free of grease, smooth to touch, and clean with no buildup of debris. - Walls, ceilings, doors, and floors would be free of dust, dirt, stains, spots, and debris. - Refrigerator/Freezer walls, ceilings, and floors would be free of ice, drippings, debris, and the compressor units free of dust/dirt buildup. - The underneath and exterior of the fryer would be free of oil, grease buildup, and dirt. The following observations were made in the main kitchen: - on 11/12/2024 at 10:18 AM, the dairy cooler floor was unclean with food debris. - on 11/14/2024 at 11:37 AM, the walls behind and surrounding the dish machine were unclean with dark stains. - on 11/15/2024 at 11:40 AM, the meat freezer had ice buildup on the floor and icicles on the ceiling. At 11:41 AM, the dairy freezer had a large block of ice on the lower right side of the compressor; at 11:47 AM, there was a metal scoop inside the dry flour container; and at 11:48 AM, the fryer had grease buildup on the left side, underneath, and inside the door and there was food debris on the floor underneath the fryer; and at 11:54 AM, a frying pan on the clean rack had dried thick, black debris on the base of the handle, inside, and underneath the pan. During an observation on 11/15/2024 at 10:43 AM, the Magnolia house kitchenette freezer had opened and undated plastic bags of frozen chicken breasts, hamburgers, hot dogs, and English muffins. There was ice buildup on the frozen meat inside the bags. During an observation on 11/15/2024 at 1:45 PM, the Cypress house kitchenette refrigerator had an undated plastic container of green beans. During an observation on 11/15/2024 at 2:10 PM, the [NAME] house kitchenette freezer had undated frozen hamburgers. During an observation on 11/15/2024 at 2:35 PM, the Sycamore house kitchenette cabinets had two opened and undated 5-pound containers of peanut butter. During an interview on 11/15/2024 at 10:45 AM, Food Service Worker #28 stated they worked in the Magnolia house for 7 years. The frozen food was used for resident's who wanted an alternative meal. The food would come frozen in a large box to the Aspen house, and they would take some of the frozen food to their house and put it in the freezer. They stated there were dates on the large boxes of frozen food and they did not put dates on the food they put in their freezer because they would know when the food went bad and had to be thrown out. During an interview on 11/19/2024 at 11:07 AM, Operations Manager #15 stated they had food labels, and all food items should be dated. After 3 days food was to be discarded and if food was not dated it should be discarded immediately. Frozen food items had to be dated and as long as they stayed frozen, they did not have to be discarded unless there was an expiration date on the box. All items in the freezer should be kept in a sealed bag or container, and if it was not appropriately sealed or dated it should not be given to any resident. They stated the kitchen was cleaned daily. Staff was supposed to clean their work area as they went, and the entire kitchen was cleaned at night before staff left. The fryer was supposed to be wiped down and cleaned every time it was used and if kitchen staff noticed it was dirty they were expected to clean it even if it was not being used. The walk-in coolers and freezers were cleaned weekly and included sweeping, mopping, wiping down shelves, walls, and ceilings. There should never be ice buildup inside the freezers or on the compressor because people could slip, or the compressor could stop working properly and contaminate the food or make it go bad. They stated the scoopers should never be left inside the dry food bins because bacteria could grow. The frying pans were used daily so they were checked frequently, and they should not have any black buildup or dried debris on them because it could cause an infection control issue or get into the resident's food. During an interview on 11/19/2024 at 11:23 AM, Food Service Director #14 stated all food items in the refrigerator or freezer must be dated. Cold food items should be discarded after 3 days and if there was no date it should be discarded immediately. All opened frozen food items should be kept in an airtight container, be dated, and if not used in 2 weeks should be discarded. The main kitchen was cleaned twice a day and staff were expected to keep their work area clean during their shift. At night, all kitchen staff were responsible for cleaning which included mopping and sweeping. There should not be any grease buildup or splatter on or around the fryer and it was supposed to be wiped down after each use. Coolers and freezers were cleaned daily which included sweeping, wiping down the walls and shelves, and checking food dates. The freezers were defrosted once a month by maintenance and should not have any ice buildup inside or on the compressor. The ice could be a safety issue causing people to slip or the compressor might not function properly. Scoopers should not be left in the dried food bins because it could cause cross contamination. Pans should not be used if there was any buildup or dried debris on them because it could get into the resident's food. 10NYCRR 415.14(h)

35045 46276 Based on observations and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meal trays tested (Rehabilitation Unit lunch) and beverages for the [NAME] house breakfast. Specifically, scrambled eggs, home-fried potatoes, toast, applesauce, mixed fruit, corn, milk, orange juice and cranberry juice were not served at palatable temperatures. Findings include: The facility policy, Meal Service, revised 1/2022, documented food was served in a manner to encourage consumption. Food was seasoned and not overcooked to conserve nutrients and flavor. Food was served at acceptable temperatures to prevent the potential of food-borne illness. The facility policy, Temperature Control and Food Holding, revised 1/2023, documented food was maintained at proper temperatures during service to meet resident's expectations for palatability. Cold foods were refrigerated or held in ice and must be held at 40 degrees Fahrenheit or below. Hot foods must be cooked to reach internal temperatures based on food safety guidelines and temperatures must be taken just prior to service to ensure that holding temperatures of 135 degrees Fahrenheit were maintained. Food should be plated right before service to maintain proper temperature and palatability. The 9/18/2024 Resident Council meeting minutes documented: - two residents stated the food was cold and the vegetables were mushy. - one resident stated the vegetables were undercooked. Resident interviews included: - on 11/12/2024 at 10:47 AM, Resident #140 stated the food temperatures were not good and the food did not taste good. Their family would often bring them in meals. - on 11/12/2024 at 10:51 AM, Resident #63 stated the food was mushy, did not taste good, and was served cold. - on 11/12/2024 at 11:04 AM, Resident #139 stated the food was often served late, did not taste good, and they were still hungry after meals. - on 11/12/2024 at 1:58 PM, Resident #475 stated the food was always served cold. - on 11/12/2024 at 2:15 PM, Resident #18 stated the food was served cold when it arrived to their room and it was bland tasting. During an observation of the [NAME] House breakfast on 11/14/2024 at 8:14 AM there were three glasses of orange juice and four glasses of milk on the dining room table with no residents seated at the table. A glass of orange juice and one glass of milk were sampled for temperatures. The 4 ounce glass of orange juice was measured at 58 degrees Fahrenheit, and the 8 ounce glass of milk was measured at 58 degrees Fahrenheit. During an interview on 11/14/2024 at 8:45 AM, Dietary Supervisor #33 stated breakfast service started at 7:30 AM. Drinks should be served when the residents arrived in the dining room and not placed on the table prior to their arrival. They were unsure why drinks were placed and left on the table early. The drinks should be below 40 degrees Fahrenheit. It was not acceptable for milk and orange juice to be 58 degrees Fahrenheit, and they should have been discarded. Dietary Supervisor #33 stated hot foods, such as the scrambled eggs and home-fried potatoes should be 165 degrees Fahrenheit. The measured temperatures of 98 degrees for eggs and 88 degrees Fahrenheit for home-fried potatoes were not acceptable and the residents could be at risk for food-borne illnesses. There was a log to record food temperatures prior to serving and they had not checked any food temperatures prior to serving that morning. During an observation of the Rehabilitation Unit lunch on 11/14/2024 at 1:15 PM, Resident #18's lunch tray was served, and a replacement was requested. Temperatures were measured on the original lunch tray as follows: the applesauce was 65 degrees Fahrenheit; the corn was 130 degrees Fahrenheit; and the cranberry juice was 62 degrees Fahrenheit. During an interview on 11/19/2024 at 11:17 AM, Operations Manager #15 stated cold food items should be served less than 40 degrees Fahrenheit, hot food items should be served above 145 degrees Fahrenheit, and holding temperatures should be 165 degrees Fahrenheit. During an interview on 11/19/2024 at 11:28 AM, Food Service Director #14 stated cold food items should be served at 40 degrees Fahrenheit or less and hot food items should be served at 140 degrees Fahrenheit or more. The orange juice, milk, cranberry juice, and applesauce were not at acceptable temperatures. They stated it was important for hot foods to be served hot and cold food to be served cold to all residents. 10NYCRR 415.14(d)(1)(2) 48052 48675

Based on observations, record review, and interviews during the recertification survey conducted 11/12/24-11/19/24 the facility did not ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #40) reviewed. Specifically, the facility did not follow Resident #40's individualized care plan interventions that included the resident's customary routines, interests, preferences, and choices to enhance their well-being and to guide staff in managing the resident's care. Findings include: The facility policy, Caring for Residents with Dementia, revised 1/2024, documented residents would have regular cognitive evaluations and care plans would be changed accordingly. The resident would have an individualized care plan to have their specific needs addressed which included behavior management and daily living activities. The care plan would be adapted to the resident's current stage of dementia and updated as needed. An individualized behavior care plan would be implemented that listed to prevent or manage behaviors. The facility policy, Behavioral Management Plans, dated 10/2015, documented behavior management plans would be developed and regularly reviewed for residents who had maladaptive behaviors that were disruptive or dangerous to other residents and staff. Behavior plans would be utilized by staff to promote positive, appropriate behaviors and interactions. Behavior plans included identification of behavior problems, triggers for behaviors, signs of escalation, and interventions. Behavior management plans would be placed in the [certified nurse aide] task book on each unit and staff was responsible for reviewing the plan prior to each shift. Behavioral plans would be reviewed monthly, and any changes are approved by the behavioral committee. Resident #40 had diagnoses including Alzheimer's disease, dementia with other behavioral disturbances, and major depressive disorder. The 8/28/2024 Minimum Data Set assessment, documented the resident had severely impaired daily decision making skills, fluctuating inattention, continuous disorganized thinking, physical behavior symptoms that did not affect their participation in activities 1-3 of 7 days, it was important to the resident to have family involved in care discussions, and liked to read books, magazines, and newspapers, listen to music, participate in their favorite activities, and do things with groups of people. The 3/3/2023 Comprehensive Care Plan documented the resident had the potential to be physically aggressive by kicking, slapping, and biting related to their dementia. Interventions included to follow the resident's behavior plan prior to administration of as needed medication. The resident's person-centered care plan of care documented the resident preferred to sleep in and not be disturbed for breakfast and medication administration. Their adult children were agreeable that the resident be allowed to sleep in. Interventions included to feed the resident and give medications when the resident awoke. The revised 5/29/2024 Comprehensive Care Plan documented the resident was dependent on staff for meeting their emotional, intellectual, physical, and emotional needs due to the advanced dementia and cognitive deficits. Interventions included the resident preferred television shows including Law and Order, NCIS, Wheel of Fortune, Jeopardy, and baseball. Engage the resident in simple tasks such as looking at magazines, manicures, holding a doll, going for walks, and talking/reminiscing. The undated Kardex (care instructions) documented to read the resident's behavior plan when the resident was restless or agitated. The resident's behavior plan in the certified nurse aide task book documented the resident was to go to the dining room table for meals and staff was to give the resident objects to fidget with such as stuffed animals, puzzle pieces, magazines, and pop-up toys. Staff was also to provide activities of interest to the resident to do while seated in their recliner chair. The resident enjoyed busy work such as organizing papers or looking at magazines. The 11-7 Get Up List documented the resident was to be dressed and out of bed on the 11:00 PM to 7:00 AM shift. Resident #40 was observed: - on 11/12/2024 at 11:28 AM, sitting in their wheelchair in front of the television in the common area. They were alternating between having their eyes open and closed while they leaned forward and back with their legs crossed. The resident was reaching forward out in front of themself toward the air or touching their face and hair. They were moving their upper body and appeared restless with slow movements. At 11:36 AM, the resident leaned forward to the right, bent at the waist in their wheelchair, as if they were reaching for something and then sat back. - on 11/13/2024 at 8:22 AM, sitting in the dining room, pushed up to the table in their wheelchair, with nothing in front of them except a placemat. At 8:48 AM, the resident was assisted with breakfast by staff. - on 11/14/2024 at 8:33 AM, in the dining room pushed up to the table in their wheelchair and had completed breakfast. The news with the weather was on the common area TV and the resident had their eyes closed as they slightly rocked back and forth. At 11:55 AM, the resident was sitting at the table in the dining room with nothing in front of them. They had their eyes closed and was periodically rocking back and forth with their left hand intermittently touching their face and picking at their shirt. At 12:23 PM, a plate was placed in front of the resident by a certified nurse aide who sat to assist the resident with their meal. - on 11/15/2024 at 9:29 AM, in their room in their wheelchair, parallel with the end of the bed. The television was playing a Christmas movie with the sound on. The resident leaned slightly forward in their chair with their eyes open and legs crossed. The resident's fingers moved continuously. At 11:21 AM, the resident was sitting at a table in the dining room with their hands in their lap. The resident had their head tilted back with their mouth open. There was nothing in front of the resident except their place mat and silverware. At 11:23 AM, the resident's eyes were still closed, and they began to pinch at their sweatshirt. At 11:35 AM, the resident leaned forward and backward in their wheelchair at the dining room table while they moved and crossed their legs. The resident was intermittently moving their hands back and forth under the table and flexing their fingers. At 11:43 AM, the resident had their arms crossed in front them while they rocked back and forth. They lifted their left arm then flexed their left hand against their right arm and grabbed their sweatshirt sleeve. They walked their fingers on their arm and the wheelchair arm. They leaned forward in their seat and then backward. At 12:00 PM, they were pulling at the blanket in their lap. At 12:13 PM, Licensed Practical Nurse #20 sat next to the resident and greeted them while the resident moved their hand back and forth on the empty placemat. - on 11/18/2024 at 11:04 AM, in their wheelchair in their room with the Hallmark Channel on their television while they moved their hand in a fidgeting manner with their eyes closed. At 11:12 AM, the resident sat forward in their wheelchair with their eyes open and awake while they grabbed at their pant leg and their shirt sleeve and then crossed their left leg over their right. The resident was angled slightly, toward the corner and window in the room, away from the television, so it was not in direct line of sight. The Hallmark Channel was on the television and the resident had nothing else in front of them. At 11:28 AM, the resident was brought into the dining in their wheelchair and pushed up to table. The resident was staring ahead with their eyes open and their hands in their lap. The resident had only the placemat and silverware in front of them. There were no distractions or fidget items provided. The resident's leg and hands were moving under the table. They rocked themselves forward and back while readjusting their position in the chair. At 11:30 AM, the resident was fidgeting in their chair, moving their hands, and readjusting their body position frequently. During an interview on 11/18/2024 at 11:47 AM, Social Worker #27 stated the social work department was responsible for cognitive loss and behavior care plans. The nursing department also assisted with a resident's behavior care plan. Social Worker #27 stated they created the behavior plans that were kept in the certified nurse aide task books. The behavior plans were updated as needed and they were reviewed at least yearly to ensure they were up to date. They created the behavior plans by consulting with the staff in the house the resident resided. They also spoke with the resident if the resident could make their needs known and with a resident's family to incorporate likes and dislikes. The staff were aware of the interventions on the behavior plan and the plans were reviewed by the interdisciplinary team prior to being placed in the task book. They stated Resident #40 had their restlessness included on their behavior plan. They stated the staff should be giving the resident items to occupy them in the dining room, particularly a baby doll as that was a calming technique for the resident. During an interview on 11/18/2024 at 1:37 PM, Certified Nurse Aide #19 stated staff was supposed to review the task book every day because it could change. They reviewed the resident behavior plans as needed and received report from the nurse if anything had changed. They stated as part of Resident #40's behavior plan they were supposed to have two certified nurse aides assist the resident because the resident would grab and fight during care. They stated the resident was an early get up from night shift and was always up prior to the start of their shift on the day shift. They stated sometimes they give the resident teddy bears in the dining room, and the resident grabbed onto them as well as an activity blanket. They stated the items were usually given after breakfast when the resident was up in their chair. They stated the resident was sometimes given items to assist with their fidgeting before meals but not always. During an interview on 11/18/2024 at 1:49 PM, Licensed Practical Nurse #34 stated certified nurse aides were supposed to review the task binder every shift which included the behavior plans for the residents. The certified nurse aides should follow what was on the behavior plan. They stated if a resident's care plan included to allow the resident to sleep in, they should not be on the early get up list. If a behavior plan recommended to give the resident something to occupy them in the dining room while awaiting a meal, they should be given what was recommended. They stated they did review the behavior plans in the task book but were unaware Resident #40 was to have items to fidget with when brought to the dining room early. During an interview on 11/18/2024 at 1:59 PM, the Assistant Director of Nursing stated the certified nurse aides, and the licensed practical nurses should look at the task binder on the unit prior to each shift. They stated if a behavior plan was in place, staff were supposed to follow it. If a resident had a care plan indicating they preferred to sleep in and their family was aware the resident may miss a meal or medications, they should not be on the early get up list. During an interview on 11/19/2024 at 11:50 AM Registered Nurse Unit Manager #9 stated they left it up to the charge nurses to determine who was on the early get up list. They stated Resident #40 was on the early get up list when their care plan stated they preferred to sleep in as they had overlooked the fact that the resident liked to sleep in. They stated the resident had advanced dementia and had been taken off most of their medications and was on comfort care per the family wishes. The resident used to fall quite a bit and it was safest to get the resident up. They stated they removed the preference to sleep in from the resident's care plan. They stated they had discussed potentially removing the behavior plan from the resident completely, but it had not been done yet. They stated if the resident's behavior plan documented to give the resident objects to fidget with when in the dining, they staff should have them. 10NYCRR 415.12

Based on record review and interviews during the recertification survey conducted 11/12/2024- 11/19/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident to meet the medical and nursing needs identified in the comprehensive assessment for 1 of 5 residents (Resident #2) reviewed. Specifically, Resident #2 received an anticoagulant (blood thinner) medication and did not have an individualized care plan for this medication. Findings include: The facility policy, Anticoagulation Therapy, revised 9/2024, documented all residents receiving anticoagulant therapy would have the reason for the therapy included on their care plans. If the resident had an order for anticoagulant therapy on admission, the admitting registered nurse would include the reason for it in the care plan. If the resident was started on anticoagulant therapy after admission, the nurse receiving the order for anticoagulant therapy would ensure that the care plan would be updated with this information. The care plan would be updated concerning anticoagulant therapy by the admission nurse or the nurse receiving the new order whenever anticoagulant therapy was started, and each 30/60-day order reviewed. Resident #2 had diagnoses including dementia and atrial fibrillation (irregular heartbeat). The 10/18/2024 Minimum Data Set assessment documented the resident had intact cognition and was taking high risk medications during the last seven days including an anticoagulant. The 1/18/2024 physician order documented Eliquis (apixaban, an anticoagulant) oral tablet 5 milligrams give one tablet by mouth every 12 hours for blood thinner. There was no documented evidence the use of an anticoagulant was included in the resident's Comprehensive Care Plan initiated 1/18/2024. The November 2024 Medication Administration Record documented the resident received Eliquis 5 milligrams twice a day as ordered from 11/2/2024 through 11/15/2024. During an interview on 11/13/2024 at 8:59 AM, Resident #2 was not sure what medications they took during the day. During an interview on 11/19/2024 at 12:23 PM, Registered Nurse Unit Manager #9 stated the resident did not have a care plan for their anticoagulant and there should have been one in place. The Registered Nurse Manager stated they were responsible for updating residents' care plans with medications and any changes to their care. They did not know why the resident's Eliquis was not included in the care plan. Anticoagulants put the resident at risk for bleeding and staff would need interventions in place to keep the resident safe. They stated they should have updated the care plan when the resident arrived to long term care and with the recent completion of the Minimum Data Set update. 10 NYCRR415.12 (e)(2)

Based on observations, record review, and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not ensure there was an effective pest control program for the main kitchen, the neurology unit, Corridors 1 and 2, [NAME] house, and Sequoia house. Specifically, fruit flies, drain flies and an unknown insect were observed in the main kitchen, the neurology unit, Corridors 1 and 2, and [NAME] house. Additionally, resident family members complained of seeing mice in the Sequoia house. Findings include: The facility policy, Pest Control, last revised 7/2024, documented there was a system in place for staff to report any findings of a rodent or infestation of insects within or near the buildings as well as to ensure that preventative routine pest maintenance was in existence with an outside contractor. The pest control vendor was contracted with the facility to provide monthly service for pest control. The Director of Facilities or Housekeeping Manager were responsible to accompany the vendor on their rounds throughout the buildings and campus to review and sightings/findings that have been submitted in the work order system since previous date of service. The 2024 pest control vendor treatments documented dates of service as 1/25/2024, 2/7/2024, 3/28/2024, 4/25/2024, 5/31/2024, 6/10/2024, 6/26/2024, 7//29/2024, 8/30/2024, and 10/7/2024. The vendor addressed mice, ants, bees including yellow jackets nests, and small drain flies. The vendor made recommendations including installing proper fitting door sweeps, adjusting doors to be rodent proof by properly sealing, sealing gaps in the walls in the kitchen pantries, fixing water leaks in various kitchens, and cleaning kitchen grease traps with proper biodegrade. The following observations were made: - on 11/12/22024 at 11:00 AM, there were 8 drain flies in the corridor 1 and corridor 2 shower room; at 11:22 AM, there was 1 fruit fly in the neurology unit kitchenette; at 11:24 AM there were 5 fruit flies in the neurology unit dining room near the kitchenette; at 11:45 AM there were 3 fruit flies in the neurology unit shower room [ROOM NUMBER]; and at 12:05 PM there was 1 fruit fly in the neurology unit shower room [ROOM NUMBER]. - on 11/14/2024 at 11:45 AM, there was 1 fruit fly in the main kitchen - on 11/15/2024 at 11:54 AM, there were several fruit flies around the dish machine area in the main kitchen; at 2:20 PM, there was 1 unidentified insect crawling inside the kitchen cabinet near the [NAME] unit stove. During an interview on 11/12/2024 at 3:00 PM, Resident #78's family member stated there were mice in the Sequoia house. The facility used mouse traps and the white sticky strips, but they were useless. They had seen baby mice and an adult mouse. They kept Resident #78's personal belongings in plastic containers so the mice could not get to them. During an interview on 11/19/2024 at 10:34 AM, the Director of Facilities stated they oversaw maintenance and housekeeping, and this included pest control. They stated they did not typically review the monthly logs unless staff brought up an issue. It was the Housekeeping Manager's responsibility, but they were no longer employed at the facility. They had just brought the logs to their office to review them. They had issues with mice, and they had pest control come in and address the issue. The staff had smart phones; this is how the work order system worked. The work orders stayed open until the pest control vendor came and addressed them. The mouse traps were checked monthly by the vendor. The drains were checked as needed, they did not have a schedule, and they were checked only when they were alerted to an issue. Pest control was important for sanitary reasons. 10 NYCRR: 415.29(j)(5)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00353770 and NY00356334) surveys conducted 11/12/2024-11/19/2024, the facility did not make prompt efforts to resolve grievances for 1 of 1 resident (Resident #126) reviewed. Specifically, Resident #126 was missing their right hearing aid, and it was not recovered or replaced. Additionally, placement of both hearing aids was documented in the medical record after the right hearing aid was reported missing. The facility policy, Resident and Family Grievance Policy and Procedure, revised 7/2023, documented all residents/patients and their families would be informed of the steps necessary to communicate a formal grievance without fear of retaliation or barriers to service. Grievances could be through written or verbal communication. Such grievances would be brought immediately to the attention of the Director of Nursing and Corporate Compliance Officer for review and evaluation and they would work with staff to resolve the issue. If the resident/family member was dissatisfied with the resolution of the issue, they could contact the Administrator through written or oral communication and if still unsatisfactory, they could contact the Department of Health's centralized intake unit. The facility policy, Misappropriation (Missing or Damaged) Resident Property, revised 9/2023, documented upon receipt of an allegation of misappropriation of resident's property, a missing resident property form would be initiated by the staff member who was informed of the missing/damaged property. All information from the investigation would be documented on the missing property form under the applicable section. If it was determined the facility was liable, reimbursement would be based on either a receipt or the normal life expectancy of an item. Resident #126 had diagnoses of Parkinson's Disease (a progressive neurological disorder), neurocognitive disorder with Lewy bodies (degeneration of areas of the brain and brainstem), and dementia. The 12/20/2023 Minimum Data Set assessment documented the resident had hearing aids, had severely impaired cognition, required substantial/maximum assistance with bathing, personal hygiene, upper body dressing, and the resident considered it very important to take care of their personal belongings. The 12/19/2022 Registered Nurse #13 admission assessment documented the resident had hearing aids for both ears. The Comprehensive Care Plan initiated on 12/19/2022 documented the resident had an activity of daily living deficit related to dementia. Interventions included durable medical equipment and to see certified nurse aide care instructions. The 12/29/2022 Physician #22 order documented bilateral hearing aids every shift. The order was discontinued on 10/19/2023. The 9/2024 Medication Administration Records documented bilateral hearing aids; verify in bilateral ears every shift or in medication cart overnight with a start date of 10/19/2023 and an end date of 11/13/2024. The 9/2024 certified nurse aide task form documented: - on 9/5/2024 at 10:46 AM Certified Nurse Aide #30 documented the resident had both hearing aids present - on 9/5/2024 at 11:16 PM, Certified Nurse Aide #25 documented N/A. The 9/5/2024 at 10:24 PM Licensed Practical Nurse #16 progress note documented the resident's right hearing aid was reported missing on the 3:00 PM-11:00 PM shift by Certified Nurse Aide #25 during PM care. Certified nurse aide #25 removed the left hearing aid and placed it in a box on the resident's dresser. Licensed Practical Nurse #16 placed the box in the medication cart. A missing property form was initiated. The Resident Property- Missing or Damaged Property form initiated on 9/5/2024 and reviewed on 9/6/2024 by Registered Nurse #17 documented the resident's right hearing aid was reported missing during the 3:00 PM-11:00 PM shift on 9/5/2024 during PM care by Certified Nurse Aide #25. On 9/9/2024, Social Worker #27 documented they spoke with the family representative and the expectation was reimbursement for the right hearing aid. A receipt would be provided by the family representative and the approximate value was two-thousand five hundred dollars ($2,500.00). On 9/26/2024, the [NAME] President of Clinical Operations documented Administration stated the facility was not responsible for the resident's missing hearing aid if staff documented it was present during the day shift prior to it missing. The undated and untimed summary investigation report by the Administrator documented the resident had a brief interview for mental status score of 99 (severely impaired cognition), Parkinson's Disease and Lewy body dementia. The resident's right hearing aid was documented by staff as present prior to it missing. The resident may have removed it themself or it could have fallen out due to the resident leaning in their chair. The Administrator documented the Admission Agreement stated the facility was not responsible for the missing hearing aid unless it was due to negligence. The 9/2024 Medication Administration Record documented there were 23 days the resident's bilateral hearing aids were verified in both ears or in the medication cart after 9/5/2024 when the right hearing aid was reported missing. The 10/19/2023 Physician #22 order documented bilateral hearing aids every shift. The order was discontinued on 11/13/2024. The 10/2024 medication administration record documented there were 31 days the resident's bilateral hearing aids were verified in both ears or in the medication cart. The 11/13/2024 at 7:00 AM, Physician #22 order documented left hearing aid, verify in left ear every shift or in medication cart overnight. The November 2024 resident care instructions documented left hearing aid, verify in left ear every shift or in the medication cart. During an observation on 11/13/2024 at 11:43 AM, Resident #126 was sitting in their room. There were no hearing aids in the resident's room or in their ears. During an observation on 11/14/2024 at 10:26 AM, the resident was sitting in the dining room and was not wearing hearing aids in either ear. During an observation on 11/15/2024 at 10:41 AM, the resident was sitting in the with a hearing aid in their left ear only. The November 2024 medication administration record documented 12 days the resident's bilateral hearing aids were verified in both ears or in the medication cart including 11/13/2024, 11/14/2024, and 11/15/2024. During an interview on 11/13/2024 at 9:00 AM, the family representative stated the Resident's right hearing aid was missing, the resident could not manage their own hearing aids (taking them in or out), they complained to the facility and the facility refused to reimburse or replace the hearing aid. They had received several electronic mail communications from the [NAME] President of Operations stating the facility would not be responsible for the lost hearing aid. During an interview on 11/15/2024 at 10:11 AM, Certified Nurse Aide #3 stated Resident #126 was missing their right hearing aid. The resident had a green container their hearing aids were kept in. The nurses would place the hearing aids in the resident's ears in the morning and the certified nurse aids would remove them at bedtime. Certified Nurse Aide #3 stated the resident required total care and staff would have to put the hearing aids in for them. They stated the hearing aids were not working the evening the right hearing aid went missing. During an interview on 11/15/2024 at 10:19 AM, Certified Nurse Aide #26 stated the resident required total care and had hearing aids. Staff had to put the hearing aids into the resident's ears. Certified nurse aide #26 did not recall working the evening the right hearing aid went missing. The certified nurse aides would have to sign that they looked for hearing aids or other personal items before they did the laundry. During an interview on 11/15/2024 at 11:36 AM, Licensed Practical Nurse #4 stated they recalled hearing on the morning of 9/6/2024 that Resident #126's right hearing aid was missing. They searched the house, looked in the washers and dryers and in the Resident's room and hallway and could not find the hearing aid. Licensed Practical Nurse #4 stated they put the resident's hearing aids in their ears in the morning and the evening certified nurse aides took them out and gave them to the evening nurse. The resident could not put their hearing aids in or take them out independently. A missing property form was filled out by the Supervisor and turned into Administration. They stated the family wanted reimbursement for the hearing aid, but they did not know the outcome of the investigation. During an interview on 11/18/2024 at 12:20 PM, Social Worker #27 stated they were aware of Resident #126's missing right hearing aid. They stated the resident had a cognitive decline, sat in a recliner chair, and could not put their hearing aids in or take them out. If a resident's personal property was missing, a missing items form was completed by the staff who first noticed it missing, they in turn filled out their section and obtained the item's value and the form was sent to Administration. Social Worker #27 stated they told the family representative to seek out their insurance for coverage. During a telephone interview on 11/18/2024 at 1:29 PM, the [NAME] President of Clinical Operations stated they were aware of Resident #126's missing right hearing aid, the resident was cognitively impaired and could not put their own hearing aids in or take them out. Their duties had been to assist with missing property investigations, and they filled out their section of the missing items form. When they finished their portion of the report they handed it to Administration. They stated Resident #126 was care planned for staff to put the hearing aids in and take them out every shift, but they were unsure if the facility was responsible for the lost hearing aid. They stated they had concluded that the facility was not liable for the missing hearing aid because nursing staff had documented the day before on 9/5/2024 that their hearing aid was present. During an interview on 11/18/2024 at 3:04 PM, Certified Nurse Aide #25 stated they were familiar with Resident #126, they had glasses and hearing aids. Nursing staff was responsible to put the hearing aids in and take them out during PM care or during naps. Certified Nurse Aide #25 stated they worked on the 3:00-11:00 PM shift on 9/5/2024 and the Resident's right hearing aid was already missing when they came on shift. During an interview on 11/19/2024 at 9:55 AM, the Administrator stated Resident #126 was missing a right hearing aid. They were familiar with the resident, and the resident could not manage their own hearing aids. The Administrator stated the resident's hearing aids were on their treatment plan and staff were responsible for putting them in their ears and taking them out in the evening. The Administrator stated the facility concluded they were not responsible for the lost right hearing aid because staff had documented every day, they were putting them in or taking them out. 10NYCRR 415.13(c)(I)(ii)

Based on observations, record review, and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #17 and #475) reviewed. Specifically, Certified Nurse Aide #31 did not use appropriate personal protective equipment when providing care to Resident #475 who was on transmission based precautions (enhanced barrier precautions); and Resident #17 had an order for transmission based precautions (contact precautions) and did not have those precautions in place. Findings include: The facility policy, Contact Precautions, revised 3/2022, documented contact precautions were used in addition to standard precautions in instances when disease was spread by direct or indirect contact. A physician's order would be placed in the electronic record for contact precautions, an isolation sign would be posted outside the resident's room, and gloves and a gown would be worn when anticipating direct contact with the resident. The facility policy, Enhanced Barrier Precautions, revised 9/2024 documented the utilization of enhanced barrier precautions was an infection control intervention designed to reduce transmission of multidrug resistant organisms (bacteria resistant to antibiotics). Enhanced barrier precautions were used in conjunction with standard precautions and expanded the use of personal protective equipment by using a gown and gloves during high contact resident care activities. 1) Resident #475 had diagnoses including surgical aftercare following surgery on the circulatory system and benign prostatic hyperplasia with lower urinary tract symptoms (enlarged gland that can cause urinary difficulty). The 11/11/2024 Minimum Data Set assessment documented the resident was cognitively intact, occasionally incontinent of urine, had a surgical wound, did not have an indwelling urinary catheter (a tube that drains urine from the bladder), and did not have multidrug-resistant organisms. The Comprehensive Care Plan initiated 11/5/2024, documented the resident had impairment to skin integrity of the neck related to a surgical wound. Interventions included enhanced barrier precautions. The revised 11/11/2024 care plan documented the resident had an indwelling catheter related to urinary retention. Interventions included enhanced barrier precautions. The 11/11/2024 physician order documented the resident was on enhanced barrier precautions every shift. The 11/11/2024 Physician #22 progress note documented the resident was seen for urinary retention and a urinary catheter was in place draining yellow urine. During an observation on 11/14/2024 at 9:28 AM, Resident #475 activated their call light. Certified Nurse Aide #31 walked to the resident's doorway. There was an enhanced barrier precautions sign outside the room and a 3-drawer plastic bin full of personal protective equipment. The resident stated they needed assistance to use the bathroom. Certified Nurse Aide #31 put on gloves and entered the room without putting on a gown. At 9:35 AM, Certified Nurse Aide #31 exited the room without a gown or gloves and walked down the hall to the sink to wash their hands. They stated they were not available for an interview at that time and had to finish helping other residents. During an interview on 11/14/2024 at 11:50 AM, Certified Nurse Aide #31 stated when a resident was placed on precautions a sign was hung outside their room to alert staff, and personal protective equipment was placed outside their room. Resident #475 was on enhanced barrier precautions, and they thought the resident had something like an infection that could have been spread to others. They were supposed to wear a gown and gloves when they provided direct care, but they did not wear a gown when they assisted the resident to the toilet because they got busy and forgot to put one on. They stated they had received education on transmission based precautions and knew it was important to wear a gown when providing care to prevent the spread of infection to themself and other residents. During an interview on 11/18/2024 at 12:30 PM, Licensed Practical Nurse #35 stated residents that had open wounds, catheters, or central lines were put on enhanced barrier precautions. Once they were placed on precautions a sign was hung on their doorframe and personal protective equipment was placed outside their room. All staff received infection control training and learned about the different precautions and what personal protective equipment was needed when providing care. Resident #475 was on enhanced barrier precautions and staff had to wear gloves and a gown when preforming hands on care. They stated it was important to wear the appropriate personal protective equipment to prevent the spread of infection to residents or staff. During an interview on 11/18/2024 at 12:40 PM, Registered Nurse Unit Manager #13 stated enhanced barrier precautions was required for any resident who had an open wound, central line, or catheter. Staff were required to wear a gown and gloves when performing resident care. They stated all nursing staff received training on all transmission based precautions annually and it was important for them to wear the appropriate personal protective equipment to protect the residents and staff from spreading or getting an infection. During an interview on 11/19/2024 at 11:45 AM, Assistant Director of Nursing/Infection Preventionist #36 stated residents with wounds, central lines, catheters, and pressure ulcers were put on enhanced barrier precautions. All nursing staff received education on precautions. They stated they completed random audits on personal protective equipment usage. If Resident #475 was on enhanced barrier precautions, it was important for staff to wear a gown during care to prevent the spread of infection and cross contamination. 2) Resident #17 had diagnoses which included methicillin-resistant staphylococcus aureus infection (a bacterium with antibiotic resistance) in an unspecified site, dementia with other behavioral disturbance, and chronic congestive heart failure. The 9/6/2024 Minimum Data Set assessment documented the resident was cognitively intact, utilized a walker and a wheelchair, was dependent with putting on and taking off footwear, required maximum assistance for lower body dressing, required supervision for transfers, did not have multidrug-resistant organisms, had an active diagnosis of methicillin-resistant staphylococcus aureus infection, and was not on an antibiotic. The Comprehensive Care Plan revised 9/4/2024 documented the resident had Methicillin-resistant Staphylococcus aureus in their right great toe. Interventions included the resident was on contact isolation, the staff were to wear gowns and masks when changing contaminated linens, place soiled linens in bags marked biohazard, bag linens and close bag tightly before taking to laundry, the resident's family and caregivers were to be educated regarding the importance of hand washing, using antibacterial soap, disposable towels, and to wash their hands immediately after activities of daily living, care tasks, and activities, and for the resident to be given antibiotic therapy as ordered. The 7/7/2024 physician order documented the resident was on contact precautions due to Methicillin-resistant Staphylococcus aureus in their right great toe. A 7/9/2024 at 12:41 PM Physician #22 progress note documented the resident was being treated for an infected paronychia (nail infection) which was growing Methicillin-resistant Staphylococcus aureus and was on doxycycline (antibiotic). The November 2024 Treatment Administration Record documented the resident was on contact precautions for Methicillin-resistant Staphylococcus aureus of the right great toe with a start date of 7/7/2024. The Treatment Administration Record was signed as acknowledged 11/1/2024-11/15/2024 (missing 11/15/2024 day signature). The following observations of Resident #17 were made: - on 11/12/2024 at 10:35 AM, their room had no signs indicating they were on contact precautions and there was no personal protective equipment available outside the resident's room. - on 11/13/2024 at 8:54 AM, there were no contact precaution signs on the resident's room door and no personal protective equipment cart or table outside the resident's door. - on 11/14/2024 at 8:26 AM, there were no contact precaution signs outside the resident's room door or a personal protective equipment table or cart. Licensed Practical Nurse #37 left resident's room and an unidentified dietary aide walked into the resident's room without wearing any personal protective equipment. At 11:17 AM and 2:26 PM, there were no contact precaution signs outside the resident's door and there was no personal protective equipment readily available outside the resident's room. - on 11/15/2024 at 9:24 AM, 11:25 AM, and 1:14 PM, there were no precaution signs outside the resident's room door and no personal protective equipment table or cart immediately available outside the resident's room. A 11/15/2024 at 2:08 PM Physician #22 progress note documented the resident had right toe paronychia with Methicillin-resistant Staphylococcus aureus and was being treated with doxycycline. During an interview on 11/15/2024 at 1:17 PM, Certified Nurse Aide #38 stated they knew a resident was on transmission-based precautions and which kind of precautions based on the sign posted outside their room and through verbal report given to them. They knew what personal protective equipment to wear into a transmission-based precaution room by the items set up on the table or in the cart next to the entrance to the resident's room. They stated they currently had no residents in the house on contact precautions. They stated Resident #17 was not on contact precautions as far as they knew. They stated the resident had been on precautions a while back but was not anymore. They stated unless there was a sign posted outside of the resident's room, they only utilized standard precautions. During an interview on 11/15/2024 at 1:23 PM, Licensed Practical Nurse #37 stated they knew a resident was on precautions as there was an order in the computer and there were transmission-based precautions signs outside the resident's room. They stated they knew which transmission-based precaution a resident was on by the infection control book that was at the nurses' station, and it was also listed on the resident's task sheets in the task binder. They stated there were also signs outside the resident's room to identify the type of precautions as well. They knew what personal protective equipment to wear into the resident's room as it was displayed outside the resident's room. They stated unless there was a sign outside a resident's room, they only used standard precautions for a resident. They stated this floor did not have any residents on contact precautions. Resident #17 had a swab for their toe recently as the resident previously had Methicillin-resistant Staphylococcus Aureus, but they did not have the results back. They stated Resident #17 did have a current order for contact precautions related to the previous Methicillin-resistant Staphylococcus aureus infection in their toe. Since it was an active order, the resident should be on contact precautions but when they inquired with their supervisor, they were told not to put the resident on precautions just in case their newest swab came back negative. Since the resident was not on precautions, they should not have been signing for the contact precautions in the record. During an interview on 11/15/2024 1:32 PM, the Assistant Director of Nursing stated transmission-based precautions were determined by a lab test or an exposure to something infectious. There was also enhanced barrier precautions which a resident went on if they any access points where they could get an infection from staff, like a catheter or pressure injuries. They stated Resident #17's test results came back, and the resident had tested positive for Methicillin-resistant Staphylococcus Aureus so they should be placed on precautions. They were unaware the resident had an active order for precautions since 7/7/2024. They stated if a resident had an active order, the resident should have been on contact precautions. The order must not have been discontinued when they were previously able to come off precautions. They stated the nurses should not have been signing off the resident was on contact precautions if they were not. 10NYCRR 415.19(a)(b)

Based on observations, record review, and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not ensure that medications were secure and inaccessible to unauthorized staff and residents, for 1 of 1 resident (Resident #2) reviewed. Specifically, there was a medicine cup full of pills on Resident #2's tray table during breakfast. Findings include: The facility policy, Storage and Administration of Medications, revised 9/2024, documented medications were administered with a physician/nurse practitioner/physician assistant order and should be given by a licensed nurse. All medications should be maintained in a medication cart that can be locked. When administering oral medications to residents, the nurse should stay with the resident until they are sure the medication has been swallowed. Do not leave medication on a meal tray or bedside table to be taken at the resident's discretion. Resident #2 had diagnoses including dementia, chronic kidney disease, and anxiety disorder. The 10/18/2024 Minimum Data Set assessment documented the resident had intact cognition, was independent with eating, and took high-risk medications including antipsychotics, antidepressants, anticoagulants (blood thinners), diuretics (water pills), and opioids. During an observation and interview on 11/13/2024 at 8:59 AM, Resident #2 was sitting up in bed eating breakfast. There was a plastic medicine cup containing multiple pills on the resident's tray table. The resident stated they were not sure what the pills were, they cannot take all the pills at once and the nurse leaves the pills on the table to take when they are done eating. During an observation and interview on 11/13/2024 at 9:02 AM, Licensed Practical Nurse #10 stated they left the pills at Resident #2's bedside because there were so many, and the resident had taken several big potassium pills first. They left the cup of pills with the resident because the resident would take them after they ate their breakfast. They would keep checking on the resident to see how many were left until all the pills were taken. They stated they were unsure what all the pills were off the top of their head. The medication cup of pills was taken to the medication room and the nurse was able to verify and identify with the electronic record and blister packs all 21 pills which included: - Namenda 10 milligrams, white pill with 172 imprinted and was for dementia. - isosorbide 20 milligrams, 2 white round tablets used for their congestive heart failure. - diltiazem HCL 180 milligrams, one big blue capsule used for hypertension. - Cymbalta 20 milligrams, 1 brown capsule- used for depression - allopurinol 100 milligrams, 1 white circle pill with score, used to treat gout. - metolazone 2.5 milligrams, 1 pink circle pill use to treat fluid overload with congestive heart failure. - Multaq 400 milligrams, a white oblong pill inscribed with the number 4142 used to treat fluid overload. - metoprolol 100 milligrams, 1 pink round pill used to treat hypertension. - torsemide 20 milligrams, 4 white pills inscribed with PA 917, used to treat fluid overload. - Eliquis 5 milligrams, one pink oblong pill used as a blood thinner, to prevent clotting. - Protonix 40 milligrams, 1 oval shaped pill used to treat acid reflux. - sertraline 50 milligrams, 1 and a half blue tablets used to treat depression. - Tylenol 500 milligrams, 2 white tablets, to equal 1000 milligrams, used to treat pain. - lactase oral tablet 9000 units, 1 oblong pill used for lactose intolerance. - multivitamin, one red circle pill, for a nutritional supplement. During an additional interview on 11/13/2024 at 9:51 AM, Licensed Practical Nurse #10 stated they updated the electronic record to reflect the time the medications were taken, had worked at the facility for a long time, received a medication competency, and knew they should not have left the medications at the resident's beside. It was unsafe as another resident could take them, or the resident's health could be affected in a negative way if not taking their medications on time. The resident received several medications for their heart and for hypertension. During an interview on 11/15/2024 at 10:48 AM, Resident #2 stated they did not care when they took their medication but was unable to take all the medications at one time. During an interview on 11/19/2024 at 11:58 AM, Registered Nurse Unit Manager #9 stated the medication nurse should never leave medication at a resident's beside or on the tray table unless there was an order for the resident to self-administer their medications. Resident #2 did not have an order to self-administer medications. They were not aware that the resident could not take all their medications at once. It was unsafe to leave medications with a resident that did not have an order to self-administer medications. The safety risk increased in the house where Resident #2 resided because they had the highest number of dementia residents there. There were a lot of residents that walked around, they could take the medications not prescribed for them and could get sick from taking them. It was a dangerous situation and was basic nursing practice to not leave medication at the bedside for the resident to take later. 10NYCRR 483.45 (g)(h)

Based on record review and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not ensure residents received psychotropic drugs necessary to treat a specific condition and had behavioral interventions in place, and did not ensure residents as needed (prn) psychotropic drugs were limited to 14 days or had documented physician rationale and indications for extending the drug past 14 days for 2 of 7 residents (Residents #17 and #62) reviewed. Specifically Resident #17 received an antipsychotic medication and did not have an appropriate indication for use and did not have a person centered care plan with non-pharmacological interventions for behaviors; and Resident #62 had an as needed order for Haldol (antipsychotic) that was not limited to 14 days and there was no rationale and indication for the continued use of the medication documented by the physician. Findings include: The facility policy, Ordering and Administration of Psychotropic Medications, revised 12/2018, documented the use of psychotropic medication was based on the medical doctor or nurse practitioner's order to treat a specific condition after a full review of the resident's medication regiment and medical history. The medication selected would be chosen with consideration as to the most effective medication with the fewest possible side effects and used in the lowest possible dose. The interdisciplinary team would also review the resident's behavior and recommend alternative means of treating in addition to medication which would be included on the resident's plan of care. Psychotropic medications should not be used solely for poor self-care, restlessness, occasional crying/yelling, impaired memory, or being uncooperative with care. Routine psychotropic medication was reviewed by the medical doctor or nurse practitioner at scheduled 30- and 60-day visits. As needed psychotropic medication orders were limited to 14 days. Antipsychotic as needed medications could not be extended beyond 14 days and to be renewed, the medical doctor or nurse practitioner made a face-to-face evaluation for the appropriateness of the medication every 14 days. Specific resident behaviors were documented in the electronic medical record. The behavior documentation was utilized for tracking of the number and type of ongoing behaviors to determine effectiveness of medication and the potential for gradual dose reduction. 1) Resident #17 had diagnoses including dementia with other behaviors, delusional disorders, and psychotic disorders with delusions with known physiological condition. The 9/6/2024 Minimum Data Set assessment documented the resident was cognitively intact, was feeling down, depressed, or hopeless for several days, had no delusions, hallucinations, or behaviors, received antipsychotic medication, and did not receive antidepressant medications. The Comprehensive Care Plan documented: - initiated on 9/21/2023 the resident had a psychosocial well-being problem related to dementia, and their mood was stable. Interventions included encourage participation from the resident who depended on others to make decisions; provide opportunities for the resident and family to participate in care. - initiated on 12/18/2023 the resident used psychotropic medications related to depression and history of delusions related to dementia. Risperidone (antipsychotic) was discontinued on 12/22/2023 and Rexulti (antipsychotic) was started on 12/23/2023; Lexapro (antidepressant) was discontinued on 1/25/2024; and Seroquel was started on 10/15/2024. Interventions included to monitor for any adverse reactions to psychotropic medications and monitor and record occurrence as needed for any behavior symptoms and document per policy. There was no documented evidence of a person centered care plan to address the resident's potential for behavioral symptoms related to their diagnosis of delusions and psychosis. The June 2024 Behavior Monitor documented the resident had two episodes of yelling and screaming on 6/1/2024. The 6/18/2024 Assistant Director of Nursing progress note documented the resident was discussed on medical rounds due to increased fatigue on Seroquel 25 milligrams twice a day. A new order was given for Seroquel 25 milligrams once a day. There was no documentation why the resident was receiving an antipsychotic. The 6/2024 Medication Administration record documented 25 milligrams of Seroquel in the morning and at bedtime for anxiety with a start date of 6/13/2024. The order was discontinued on 6/18/2024 and the resident was started on 25 milligrams at bedtime for anxiety on 6/18/2024. The 6/24/2024 social services note by Licensed Master Social Worker Consultant #40 documented they met with the resident for a supportive visit to address their increased anxiety. They attempted to obtain reason as to why the resident became more anxious. They discussed relaxation and breathing techniques during the visit. There was no documented evidence relaxation and breathing were included in the resident's care plan. The 8/21/2024 pharmacy review documented the resident was receiving the antipsychotic agent Seroquel but lacked an allowable diagnosis to support its use. The pharmacy review listed appropriate diagnoses and conditions to which the provider had circled Mania, bipolar disorder, depression with psychotic features, treatment and signed 8/30/2024. The 9/20/2024 pharmacy review documented the resident's diagnoses needed to be updated to reflect the diagnosis on the pharmacy recommendation from 8/2024. A physician order dated 10/15/2024 documented Seroquel (an antipsychotic) 25 milligrams at bedtime for mania, bipolar depression with psychotic features. There were no physician progress notes from 6/2024-11/15/2024 addressing the resident's need for an antipsychotic medication. During an interview on 11/18/2024 at 11:47 AM, Social Worker #27 stated they were unsure why Resident #17 was on Seroquel. They stated the diagnosis listed in the computer was for mania related to bipolar depression with psychotic features. They stated it may have been prescribed when the resident was in the community, but they had never seen the resident behave in an erratic way. The resident denied a history of depression and anxiety when they had asked the resident but when the resident gets upset about her physical condition, staff intervention helped. There were no major concerns with anxiety or behaviors that would need a care plan. During an interview on 11/18/2024 at 1:59 PM, the Assistant Director of Nursing stated Resident #17 had episodes of anxiety. The resident did not have a lot of episodes, most of their anxiety was pain medication related. The resident had a history of depression and occasional delusions related to misidentification syndrome. They stated the resident did not recognize people by their face sometimes and only recognized names. They stated the resident changed from Risperdal to Rexulti in December 2023 due to being excessively sleepy and they were taken off the Rexulti in January 2024 due to falls. They stated they did not know why the provider chose Seroquel for the resident's anxiety. They stated the resident was started back on the antipsychotic for anxiety. They received phone calls from the resident two to three times a day, even at night, related to the resident wanting pain pills or a pill for oxygen. During a telephone interview on 11/19/2024 at 10:49 AM, Physician #22 stated the pharmacy reviewed psychotropic medications quarterly and they reviewed the medications with nursing if there were changes in the resident's condition such as increased behaviors. They stated they renewed medications every 60 days. They stated Resident #17 had underlying dementia and had episodes of delusional thinking and fixed false beliefs. The resident had Capgras syndrome, where they believed someone was not who they said they were and had some psychotic features. The resident was on Seroquel for their fixed false beliefs and delusions related to their dementia. They were unaware of any diagnosis of bipolar disorder in the resident's medical history and did not recall why that was the diagnosis assigned to the Seroquel. They stated when the resident was off all psychotropic medication from January 2024 to June 2024, the resident had waxing and waning moments of delusions. They stated the resident had anxiety but was also a mixed clinical presentation of issues as the resident's fixed false beliefs drove their anxiety and that was part of their progressive dementia. They stated the resident should have had a behavioral modification care plan as that should be a part of everyone's plan of care. 2) Resident #62 had diagnoses including Huntington's disease (a genetic brain disorder causing nerve cells to break down and die), anxiety disorder, homicidal ideations, and violent behavior. The 8/12/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had fluctuating inattention and disorganized thinking, had no behaviors, required maximum assistance to dependence for most activities of daily living, received antipsychotic medication on a routine and as needed basis, a gradual dose reduction had not been attempted, and a gradual dose reduction was not documented by a physician as clinically contraindicated. The undated Comprehensive Care Plan documented the resident had a behavior problem of agitation related to their diagnosis of Huntington's disease. The resident was accusatory toward staff related to sexually inappropriate comments regarding their spouse and false accusations of abuse. Interventions included administer medication as ordered, anticipate and meet the resident's needs, provide opportunity for positive interactions, discuss the resident's behavior with them if reasonable, explain all procedures for resident care prior to start, monitor behavior episodes and report any changes, praise improvement in behavior, report refusals of meals or fluids to charge nurse, serve the resident meals in hallway to prevent overstimulation and distress, and if the resident referenced self-harm and/or suicidal thoughts staff were to immediately notify social work, nursing, and the provider and implement suicide protocol safety precautions for a minimum of 30 days, until the resident's mood state was adequately re-assessed to ensure resident's safety. The resident utilized psychotropic medications related to behavior management due to the Huntington's Disease which included 2 milligrams of Haldol (an antipsychotic medication) either by mouth or by injection every 6 hours as needed. Interventions included to administer medications as ordered and to monitor for side effects and effectiveness. The 8/8/2024 Physician #22 order documented the resident was to receive 2 milligrams of Haldol by mouth every 6 hours as needed for agitation. There was no end date on the medication. Medication Administration Records documented Haldol oral tablet 2 milligrams by mouth every 6 hours as needed for agitation with a start date of 8/8/2024. There was no end date documented on the Medication Administration Records. The resident received 2 milligrams of Haldol as needed: - nine times in August 2024 on 8/9/2024 at 8:57 PM, 8/12/2024 at 12:35 AM, 8/14/2024 at 7:36 PM, 8/15/2024 at 7:47 PM, 8/16/2024 at 8:03 PM, 8/22/2024 at 3:03 PM, 8/22/2024 at 3:04 PM, 8/26/2024 at 3:29 PM, and 8/30/2024 at 4:15 PM. - five times in September 2024 on 9/4/2024 at 4:29 PM, 9/13/2024 at 7:52 PM, 9/14/2024 at 8:26 PM, 9/15/2024 at 9:48 AM, and 9/28/2024 at 12:29 PM - three times in October 2024 on 10/5/2024 at 4:44 PM, 10/20/2024 at 12:05 PM, and 10/23/2024 at 3:50 PM. - once in November 2024 from 11/1/2024-11/19/2024 on 11/14/2024 at 4:11 PM. Nursing progress notes corresponding to Medication Administration for as needed Haldol documented: - on 8/9/2024 at 8:57 PM by Licensed Practical Nurse #43the resident was yelling/screaming at their roommate and rolling themself onto the floor mat. - on 8/12/2024 at 12:35 AM by Licensed Practical Nurse #44 the resident was agitating and screaming. - on 8/14/2024 at 7:36 PM by Licensed Practical Nurse #43 the resident was anxious, agitated and yelling out. - on 8/15/2024 at 7:47 PM by Licensed Practical Nurse #43 the resident was agitated/yelling at roommate, climbing onto mats at bedside. - on 8/16/2024 at 8:03 PM by Licensed Practical Nurse #45 for agitation. - on 8/22/2024 at 3:03 PM and 3:04 PM by Licensed Practical Nurse #43 for increased anxiety/agitation. - on 8/26/2024 at 3:29 PM by Licensed Practical Nurse #43 for increased anxiety/agitation, yelling out for an alcoholic drink. - on 8/30/2024 at 4:15 PM by Licensed Practical Nurse #43 for increased agitation/anxiety/yelling out. - on 9/4/2024 at 4:29 PM by Licensed Practical Nurse #43 for increased anxiety/agitation/yelling/cursing loudly and rolling self off the bed onto mats. - on 9/13/2024 at 7:52 PM by Licensed Practical Nurse #43 for agitation, screaming at staff, refusing shower and resistive/combative with care. - on 9/14/2024 at 8:26 PM by Licensed Practical Nurse #46 for increased anxiety, heard calling staff inappropriate names and making accusations. The resident was unable to be redirected and continued to yell louder and more frequently. - on 9/15/2024 at 9:48 AM by Licensed Practical Nurse #46 for continuously yelling out about lying, cheating spouse. Attempts to redirect and changing topic ineffective. - on 9/28/2024 at 12:29 PM by Licensed Practical Nurse #46 no reason documented. - on 10/5/2024 at 4:44 PM by Licensed Practical Nurse #46 crying out and yelling about their spouse. Asking where they went, attempted redirection and playing music with no success. - on 10/20/2024 at 12:05 PM by Licensed Practical Nurse #47 verbal agitation toward staff, unable to redirect. - on 10/23/2024 at 3:50 PM by Licensed Practical Nurse #43 for increased anxiety/agitation/cursing at staff. - on 11/14/2024 at 4:11 PM no nursing note. There was no documented evidence the use of the as needed Haldol was re-assessed every 14 days. During an interview on 11/18/2024 at 1:22 PM, Licensed Practical Nurse #41 stated the providers did not enter medication orders into the system. They stated as needed psychotropics were entered in for a duration of 14 days then they were reviewed by the medical provider. After they were initially reviewed, they were unsure if a review had to be done every 14 days after that. They stated on 10/13/2024 Resident #62's as needed antipsychotic order was reviewed by Physician #23. When the order was entered after review, it should have had an end date of 14 days. They stated they had forgotten to make the end date 14 days. They stated the providers were in every week and as needed. The resident had delusions and yelled out but was easily redirected. During an interview on 11/18/2024 at 1:40 PM, Registered Nurse Unit Manager #17 stated non-pharmacological interventions were to be utilized prior to as needed psychotropic medications. They were unsure how often as needed psychotropic medications had to be reviewed. The as needed psychotropic medications were reviewed by Licensed Practical Nurse #41 when the providers rounded on the unit. Resident #62 had delusions, suicidal ideations, verbal abuse towards staff, and yelled but they were not a danger to themself or others. The as needed antipsychotic for Resident #62 should not have an indefinite end date. The order was non-compliant with the policy with having no end date. During a telephone interview on 11/19/2024 at 10:50 AM, Physician #22 stated psychotropics were reviewed by pharmacy at least quarterly, with changes in condition, and when nursing requested due to increased behaviors. The Huntington's unit usually had a younger population that came in on psychotropic medication so there was no concrete answer. They stated as needed psychotropic medication was reviewed every 14 days, and the order should only be for 14 days. They were unaware of why Resident #62's as needed antipsychotic had an indefinite end date, and they also did not know why it was not caught previously. They stated the nursing staff put the orders into the electronic medical record after it was verbally given to them by the provider. The neurological unit was a specialized unit, and most residents needed an as needed psychotropic medication as they could be dangerous to themselves or others due to their diagnoses. The electronic medical record usually notified the nurses when a medication was due for a renewal, and they notified the provider. When prescribing or renewing a psychotropic as needed medication, they reviewed the symptoms and the frequency of the symptoms. Resident #62 showed behaviors in which an as needed Haldol order was necessary. The order, however, should have been put in per regulations to only be for 14 days and then reviewed every 14 days after that. During a telephone interview on 11/19/2024 at 11:26 AM, Pharmacy Consultant #42 stated medication reviews were done monthly, which included as needed psychotropic medications. The as needed psychotropic medications must be renewed every 14 days. They stated they wrote a template for the provider and the provider signed it for a specific reason if the order was going to be renewed for another 14 days. On admission, the provider had not wanted to take any psychotropic medications away from the resident. During the resident's stay there were multiple notes about the resident's behaviors. The resident had Huntington's Disease and the Haldol was appropriate for their behaviors. 10 NYCRR 415.12(1)(2)(i)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00356334) surveys conducted 11/12/2024-11/19/2024, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 5 residents (Resident #73) reviewed. Specifically, clinical nutrition staff did not assess Resident #73 following a significant weight loss. Findings include: The facility policy, Nutrition Assessments, dated 3/2022, documented the nutrition documentation was timed with [Minimum Data Set] schedules and care plan reviews or based on the resident's risk level and changes in nutritional status. Documentation should capture comprehensive and relevant findings and need for care plan revisions. The quarterly assessment was used to track resident status in-between comprehensive assessments to ensure risk indicators were monitored and interventions were implemented timely to minimize significant changes in resident status. The frequency of assessments was at least every 90 days but was also determined by the condition or nutritional risk level of the resident. Resident #73 had diagnoses including Alzheimer's disease, heart failure, and diabetes. The 9/27/2024 Minimum Data Set assessment documented the resident had severely impaired cognitive skills, it was important for the resident to receive snacks between meals, required set-up assistance for eating, received a mechanically altered diet, weighed 156 pounds, did not have an unplanned weight loss, nutritional status was triggered and was addressed in the care plan. The 2/27/2023 physician order documented the resident's weight was to be obtained on the first Wednesday of the month, every month during the day shift. The Comprehensive Care Plan revised 9/24/2024 documented the resident had a nutritional problem or potential nutritional problem related to severe cognitive deficit, advanced age, dysphagia (difficulty swallowing) diet restrictions related to altered consistency, moderate malnutrition, history of significant weight gain, and the potential for weight fluctuations due to daily diuretic use. The goal was for the resident to tolerate their pureed diet and to maintain adequate nutritional status by consuming greater than or equal to 75% of their meals. Interventions included the resident was to be fed by staff with drinks in mugs with lids and straws, honor food and fluid preferences, monitor the resident's intakes, monitor weights as ordered, monitor consistency tolerance, and provide and serve fortified food to compensate for periods of poor intake. The resident received Super Cereal (fortified cereal) at breakfast and fortified pudding at lunch three times a week. The resident's Kardex (care instructions) documented the resident required a deep divided dish, drinks in mugs with lids and straws, was to be fed by staff, was a hydration risk, and was on a regular diet with pureed texture. The 10/1/2024 Dietetic Technician #21's Nutrition Comprehensive Assessment documented the resident's most recent weight was taken on 9/10/2024 and was 156.4 pounds and they did not have a weight change. Their desired body weight range was 154-164 pounds. The resident's weight declined 3% since their June 2024 weight of 162 pounds. The resident's dietary preferences included fortified pudding at lunch three times a week and Super Cereal at breakfast. The resident's intakes were 25-75% for breakfast, lunch, and supper. The resident had fat wasting at their orbital and muscle wasting at their clavicles. The goals were adequate fluid intake, maintenance of nutrition parameters, acceptance of fortified foods/supplements, and to maintain their weight plus or minus 5 pounds. The 11/4/2024 sixty-day progress note by Physician #23 documented the resident continued a gradual and expected clinical decline and the resident's oral intake was diminished. The resident's creatinine had crept up. The provider discontinued the resident's diuretic. They documented the increase in creatine was likely a result of the resident's overall clinical and age-related decline with concurrent decreased oral intake. The certified nurse aide Point of Care response for What percentage of the meal was eaten? from 11/1/2024 to 11/18/2024 documented 9 out of 72 responses the resident consumed 75-100% of their meal. The resident refused their meal 17 of 72 responses. Resident #73's weight record documented the resident weighed 153.8 pounds on 10/4/2024 and 144.6 pounds on 11/6/2024 (a significant 6% weight loss in 1 month). There was no documented evidence Resident #73 was assessed by clinical nutrition staff after a 6% significant weight loss. Resident #73 was observed: - on 11/14/2024 at 8:35 AM in the dining room being assisted with breakfast by Certified Nurse Aide #18 who stated the resident did not want to eat their mashed potatoes and was spitting them out, but they liked the pureed fruit. - on 11/15/2024 at 12:14 PM, in the dining room being assisted with lunch by Certified Nurse Aide #19. The resident was declining to eat lunch but drank some orange juice. Licensed Practical Nurse #20 stated the resident usually liked sweets. Certified Nurse Aide #19 attempted to give the resident their fortified pudding and the resident accepted a couple of bites of the pudding. During an interview on 11/19/2024 at 11:05 AM, Dietetic Technician #21 stated residents were assessed quarterly unless there was a significant change. They were responsible for all the assessments, plans of care, and interventions for the residents in long-term care. The nurses and Nurse Managers did not notify them of resident weight loss, it was their responsibility to look at the weekly or monthly weights. They stated they had not assessed Resident #73 since their last assessment on 10/1/2024. They stated they had written down the resident had a weight loss from 153 pounds to 144 pounds but had not looked at the resident. They stated a resident with significant weight loss should be assessed immediately with the onset of weight loss. They stated the goal for residents, unless they were on comfort care, was to maintain their weight as able and optimize their intakes. They were aware Resident #73's intake fluctuated but their goal would be for the resident's weight to trend back toward where it was. They stated they reviewed provider progress notes when they updated the care plans. Unless the weight order was discontinued their goal for a resident would always be to maximize their intake and maintain their weight. They stated it was important to assess a resident's weight loss when it happened as the resident's calorie needs may need to be calculated at a different rate and higher calorie interventions may need to be implemented. During an interview on 11/19/2024 at 10:49 AM, Physician #22 stated they expected Resident #73 to continue to decline. They stated they were unaware if the registered dietitian or dietetic technician were aware of the resident's decline. They stated they expected the resident to continue to decline and ideally, they would like the resident to continue to consume a normal intake, but it was unlikely due to their advanced dementia with diminished hunger and thirst. 10NYCRR415.12(i)(1)

Based on record review and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not ensure residents were screened for serious mental disorders, intellectual disabilities, and related conditions prior to admission to the facility for 1 of 35 residents (Resident #104) reviewed. Specifically, there was no documented evidence Resident #104 had a Preadmission Screening and Resident Review Level I completed by a qualified screener prior to admission to the facility to determine if the resident had a mental disorder, intellectual disability, or a related condition. Findings include: The facility policy, New York State Department of Health Screen Form, revised 1/2017, documented a screening form would be completed preadmission and when a resident's condition or circumstances change such that the outcome indicated a change in placement or as a psychiatric condition developed or when a nursing home admission that was originally determined to be less than 30 days exceeded beyond that time. The medical records department would be notified if a level II review was required. The facility policy, Admission of Individuals with Mental Illness/Developmental Disability, dated 11/2023, documented the [New York State Screen] form (DOH-695) would be reviewed by the Director of Admissions or designee as part of the decision making process. If item #23 (mental illness diagnosis) or items #24, #25, #26 are checked 'yes' then a level II Preadmission Screen for Resident Review must be completed as follows: -for individuals who trigger for a mental illness, the level II Preadmission Screen for Resident Review must be completed. Results of the level II Preadmission Screen for Resident Review must be received by the facility and must indicate that skilled nursing facility placement is appropriate prior to offering a bed/admitting the individual. Should the assessments indicate that skilled nursing facility placement was not appropriate, the facility would not admit the individual. Resident #104 had diagnoses including dementia with other behavioral disturbances. The 6/10/2021 Minimum Data Set admission assessment documented the resident was admitted from an acute hospital, they did not require a level II Preadmission Screen Resident Review, they had severely impaired cognition, and required extensive assistance with most activities of daily living. There was no documented evidence Resident #104 had a Level I Preadmission Screen Resident Review completed prior to admission to the facility as required. During an interview on 11/19/2024 at 1:30 PM, the Administrator stated they were unaware every resident needed a Preadmission Screen Resident Review completed and they would defer all questions to social services. During an interview on 11/19/2024 at 1:36 PM, Director of Social Services #39 stated before a resident was admitted to the facility, hospitals would complete a Patient Review Instrument and Preadmission Screen for Resident Review (New York State Department of Health form 695) and send it to them. It was a source of referral, and they would always get the Patient Review Instrument and screen from either the hospital or transferring nursing home. All Residents from New York State were required to have a screen completed. Resident #104 came from another state, so they did not have one completed. A Level I screen determined the level of care required and if a resident was appropriate for a nursing home/skilled care. If they were able to receive a lower level of care, the screening would be a formality for their facility. If the Level II screen was triggered by the Level I screen for developmental disability or serious mental illness, it would list what special services were needed for the resident. If a resident came from another state, services would be determined based on the records from the transferring facility. Director of Social Services #39 stated they did not think other states completed a Preadmission Screen for Resident Review. Resident #104 did not have either a mental illness or disability or they would not have admitted them. If they felt the resident required more care, they would have completed a screening, but it would have been completed after they were admitted and would not be accurate. 10NYCRR 415.11(3)

Based on interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not protect and promote the rights of the residents were maintained for 182 of 182 residents residing in the facility. Specifically, mail was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens and residents of the United States. Findings include: The facility policy, Resident's [NAME] of Rights, revised 9/2024, documented each resident was encouraged and assisted throughout their period of stay, to exercise their rights as a resident, and as a citizen, or resident of the United States and of the State of New York. The undated facility policy, Resident Mail, documented all mail would be delivered by the post office mail carrier to the front desk receptionist in the main building who would then sort resident personal mail including cards and letters. Mail would then be placed into the house/unit mailboxes for pick up. A staff representative from the long-term houses will come daily to the main building to pick up the resident personal mail and distribute it to the appropriate resident location. During a resident group interview on 11/13/2024 at 11:38 AM, 7 of 7 anonymous residents stated they did not get mail delivered on Saturdays. The mail room was only open Monday through Friday, and they were unsure who delivered the mail. During an interview on 11/14/2024 at 12:02 PM, Front Desk Receptionist #2 stated mail was delivered to the front desk from the post office. The accounting office sorted through it and removed the bills. When the mail sorting was finished, the mail was placed in the mailroom and the long-term care housing unit secretaries picked it up Monday through Friday. Mail was not delivered to residents on Saturdays because it no one was available to pick it up on the weekends. During an interview on 11/15/2024 at 11:29 AM Unit Secretary #5 stated they delivered resident mail for the long-term care houses during the week. There was no mail delivery to residents on Saturdays. They assumed the post office delivered the mail to the facility but was unsure if anyone brought it to the residents. During an interview on 11/18/2024 at 11:12 AM Recreation Leader #6 stated they helped Unit Secretary #5 deliver mail on Wednesdays and there was no one there to deliver mail on Saturdays. If mail was delivered to the facility on Saturdays, residents would have to wait until Monday to receive it. During an interview on 11/18/2024 at 1:39 PM, Bus Driver # 8 stated they drove the transportation bus for the facility's adult day care home. They stated they go to the post office and pick up mail during the week for the facility and drop it off at accounting. They did not pick up mail on the weekends. During an interview on 11/19/2024 at 12:12 PM, the Administrator stated the mail was delivered during the week from the post office and the mail was then sorted and placed into the mail room. Staff would come pick up the mail and distribute it to the residents. Mail was not delivered from the post office on the weekends and the residents received no mail. 10NYCRR 415.3(d)(2)(i)

Based on observation, record review, and interview during the abbreviated survey (NY00339657), the facility did not maintain an effective pest control program so that the facility was free of pests for 4 of 10 nursing units (Sequoia, Sycamore, Chestnut, and Aspen) reviewed. Specifically, evidence of mouse droppings and mouse infestation was observed on the Sequoia, Sycamore, Chestnut, and Aspen units. Findings include: The undated facility policy Pest Control documented a system was in place for staff to report any findings of a rodent or infestation of insects within or near the buildings as well as to ensure that preventative routine pest maintenance was in existence with an outside contractor. Pest Control Treatment records documented the following: - on 5/20/2024, under the technician comments section, skilled nursing buildings inspected for reports of mice. Placed rodent glue boards. - on 5/31/2024, under the technician comments section, regular service of all scheduled areas and equipment. Addressed mouse issues throughout inpatient rehab services and skilled nursing buildings. Traps were placed.The same record documented under open conditions Sycamore unit door sweep repaired on 4/25/24, Hickory unit dining room door sweep repaired 3/28/24, Cypress unit dining room door sweep repaired, Sequoia unit door sweep added, Aspen unit door sweep repaired, Chestnut unit entrance door adjusted to fully close gap, Aspen unit gaps in ceiling around plumbing to be sealed, Cypress unit door to employee fridge needed to have hole sealed. A facility work order spread sheet for pest control sightings for the past six months from 6/3/2024 to 1/1/2024, documented the following: - On 1/2/2024 there was a dead mouse found in the cabinet next to the sink with the community center kitchen. - On 1/3/2024 a mouse was reported in resident room [ROOM NUMBER] in the Sequoia unit. - On 1/4/2024 several staff and residents were noticing mice in their rooms on the Sycamore unit. - On 2/8/2024 mouse traps were needed in resident room [ROOM NUMBER] within the Sequoia unit. - On 2/8/2024 a mouse trap was requested by housekeeping for resident room [ROOM NUMBER] within the Sycamore unit. - On 2/8/2024 a mouse trap was requested by housekeeping for resident room [ROOM NUMBER] within Sycamore unit. - On 2/8/2024 a mouse trap was requested by housekeeping for resident room [ROOM NUMBER] within Sycamore unit. - On 2/21/2024 a mouse was seen by the closet in resident room [ROOM NUMBER] within the Sycamore unit. - On 3/25/2024 mouse traps needed for resident room [ROOM NUMBER]. - On 4/5/2024 there were mouse droppings found in resident room [ROOM NUMBER] within the Chestnut unit and the family requested traps. - On 4/15/2024 there were mouse droppings in resident room [ROOM NUMBER] under the refrigerator. - On 4/23/2024 a resident's family requested cleaning of resident room [ROOM NUMBER] as there were mouse droppings under the refrigerator. - On 4/25/2024 mouse droppings were in resident room [ROOM NUMBER] on the Sequoia unit. - On 4/30/2024 mouse droppings were under the refrigerator in resident room [ROOM NUMBER] on the Sequoia unit. - On 5/3/2024 a mouse running around the dirty utility room in the Sequoia unit. - On 5/8/2024 a mouse in a trap at the door to resident room [ROOM NUMBER] in the Chestnut unit. - On 5/10/2024 a housekeeper saw a mouse in resident room [ROOM NUMBER] in the Sequoia unit. - On 5/28/2024 a mouse at front of the Chestnut unit. - On 6/1/2024 a mouse was in resident 812 and had chewed through a bag of popcorn. - On 6/1/2024 a mouse was stuck in a trap and still alive within resident room [ROOM NUMBER]. - On 6/2/2024 another mouse was stuck in resident room [ROOM NUMBER]. - On 6/3/2024, two mice were seen running on the countertop and floor to the stove within the Aspen unit kitchen. During observations the following areas had evidence of mouse infestation: - On 6/5/2024 at 10:57 AM, there were signs of rodent infestation with mouse droppings under the resident's refrigerator and in the bottom of the clothes closet within resident room [ROOM NUMBER] on the Sequoia unit. - On 6/5/2024 at 11:18 AM, there were 2 mouse droppings in the bottom of the resident's clothes closet in room [ROOM NUMBER] on the Sycamore unit. - On 6/5/2024 at 11:28 AM, there were 4 mouse droppings in the rear storage room under the baker's rack within the Sycamore unit. - On 6/5/2024 at 11:57 AM, there were 3 mouse traps under an ottoman at the entrance to resident room [ROOM NUMBER] on the Chestnut unit. - On 6/5/2024 at 12:17 PM, there was evidence of mouse infestation in the pantry of the Aspen unit. Under the food storage racks there was a trail of mouse droppings along the left side of the room that was approximately 12 feet long. There were 3 individual creamers on the floor in the path that were damaged and had leaked under the racks. During an interview on 6/5/2024 at 10:00 AM, the Director of Facilities stated they had a pest control vendor in regularly. Dealing with mice had been an ongoing issue. They treated the areas of identified concerns. All staff and resident sightings were put into the work order system that all staff had access to. There were no bait stations installed outside the skilled nursing units. This past Friday (5/31/2024) the pest control vendor recommended bait stations be set up outside and the facility asked for a quote. Maintenance staff tried to take care of any identified areas of breach around the buildings. The issue with mice was challenging and on going with the open fields around the skilled nursing units. Bait stations should help to keep the mice outside. During an interview on 6/5/2024 at 10:30 AM, the Housekeeping Supervisor stated mice had been an on and off issue for some time now. Work orders for pest control sightings were saved and reviewed with the pest control vendor when they were onsite. If the units had an immediate pest concern the vendor should be called for treatment. They normally came once a month. During the pandemic the mouse issue was really bad with everyone eating in their rooms. They tired to keep all areas as clean as possible. Some areas such as closets and dressers were difficult to gain access to if residents would not allow it. Nursing staff could help gain access to some areas in resident rooms. The mice were better than they had been but treatment with vendors continued. During an interview on 6/5/2024 at 10:57 AM, Resident #1's spouse stated that mice in the resident's room had been a problem for a long time (almost 2 years). Mice had been in the hallways and there were mouse droppings under the refrigerator in their spouses' room as well as in their dresser drawers. During an interview on 6/5/2024 at 11:05AM, the Director of Facility's stated the Sequoia and Sycamore units were both on the end opposite the fields. They seem to be the units that had more occurrences of mice. During an interview on 6/5/2024 at 11:49am, Licensed Practical Nurse #4 stated mice had been seen and if they were seen they needed to be reported in the work order system on the computer. Mice had been an ongoing issue and staff reported when mice were seen. The pest control vendor came in regularly to treat the mice. During an interview on 6/5/2024 at 11:57am, Resident #2's spouse stated they brought mouse traps in to help with the mice. They did not mind helping catch mice and understood how challenging it could be in the area. They put the mouse traps under the ottoman and had not seen any since last week. It had gotten much better over the past few months. They had killed a few mice in the early parts of the year. During an interview on 6/5/2024 at 12:17 PM, Certified Nurse Aide #6 stated they had not been in the pantry and was unaware of the mouse droppings. They had seen mice in other units but not so much on the Aspen unit. 10NYCRR 415.29(j)(5)

Based on record review and interview during the Abbreviated survey (NY00331215) the facility did not ensure a resident with pressure ulcers received 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 #5). Specifically, Resident #5 was found with a skin impairment and was not assessed timely by a qualified professional and the medical provider was not notified timely of the areas for consideration of a treatment order. Additionally, the licensed practical nurse applied ointment and a dressing without an assessment or order provided by a qualified professional. Findings include: The Skin and Wound Treatment Protocol revised 12/2018 documented: - for a Stage 2 (partial thickness loss of skin layers, presenting with shallow open ulcer with red or pink wound bed) treatment was cleanse the wound and surrounding tissue with normal saline, apply Solosite (wound gel) with a padded dressing, every shift and as needed, until assessed by the wound team. - for skin tears, the treatment was to cleanse with normal saline, apply bacitracin (antibiotic ointment), and cover with non-adherent dressing. The Skin Care Protocol policy revised 1/2024 documented: - when an area was identified during routine care, licensed nursing staff will complete the Interdisciplinary Notification Form and send to appropriate staff (the interdisciplinary team). - Licensed staff will immediately notify the registered nurse Supervisor/Manager. - The registered nurse Supervisor/Manager will assess the wound/skin issue and document in the appropriate section of the electronic medical record. - Determination of the treatment will be made the by registered nurse Supervisor/Manager and written in the physician's order book and signed per skin care protocol if the nurse had not spoken to the physician or nurse practitioner. - The skin care team will further evaluate said patient/resident during the next scheduled rounds or sooner if necessary. Resident #5 had diagnoses including peripheral vascular disease (impaired blood flow from build up in the arteries), diabetes, and dementia. The 11/29/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, was dependent on staff for dressing, and required partial assistance for bed mobility. The resident was at risk for developing pressure ulcers and had no unhealed pressure ulcers. The comprehensive care plan, revised 9/1/2023, documented the resident had a pressure ulcer to to the bottom of the left heel and a Stage 1 pressure area (area not open but reddened) to the left achilles. Interventions included: administer medications as ordered; heel floats (to elevate the heels) in bed; and treatments per physician orders. The 12/23/2023 at 7:38 PM, licensed practical nurse #13's progress note documented upon doing the skin prep (to toughen the skin) treatment to the resident's heels, they noticed a small open area, (smaller than a dime) to back of the left ankle above the heel. Licensed practical nurse #13 cleansed the area with normal saline and applied bacitracin (topical antibiotic ointment) and a non-stick dressing, and wrapped with gauze. The resident expressed some discomfort, and the Supervisor was made aware. There was no documentation of an assessment by a qualified professional, no documented evidence an appropriate treatment was initiated, and no documentation the medical provider was notified to determine if a treatment order was needed. The 12/27/2023 at 11:31 AM, registered nurse Manager #4's progress note documented the resident was seen on wound rounds for a surgical site on their arm. There was no documentation related to the resident's left ankle wound. The 12/28/2023 at 8:06 PM, skin/wound progress note entered by registered nurse #14 documented the left posterior (back) ankle was noted with an open area/pressure ulcer. The area was cleansed with normal saline, wound gel was applied and a padded dressing. The skin and wound team were to evaluate for appropriate treatment. The 1/3/2024 Skin/Wound Assessment documented the resident had a new Stage 2 pressure ulcer on the left heel, measuring 0.9 centimeters in length by 0.8 centimeters in width. The onset was noted as 1 week prior, with a scab to the wound bed, light serous exudate (light to clear wound drainage), and no odor. The wound note included: a left posterior ankle pressure ulcer, cleanse with normal saline, apply Xeroform (antimicrobial wound dressing), cut to size, and cover with Allevyn (bordered padded dressing). There were recommendations for one size larger shoes or slippers and the resident wished to continue using their current sneakers which may be the reason for the pressure ulcer. The 1/3/2024 physician's order documented to the left posterior ankle pressure ulcer: cleanse with normal saline, apply Xeroform cut to size, cover with Allevyn, every 48 hours and as needed. During a wound treatment and dressing change observation on 1/25/2024 at 10:30 AM with registered nurse Manager #4, the resident stated the area to the back of their heel was sore and the area was open and red. Registered nurse Manager #4 completed the treatment as ordered. During an interview with registered nurse Manager #4 on 1/25/2024 at 10:45 AM, they stated when a new skin impairment was identified, the licensed practical nurse was to notify the registered nurse Supervisor immediately. The registered nurse Supervisor would send an email to the interdisciplinary team, which included unit mangers and the nurse practitioner. The registered nurse Supervisor was to assess the area upon notification and initiate a treatment. The facility had a standard initial treatment of Solosite (wound gel) that the registered nurse could initiate and enter the order until the next time the wound team completed rounds, which was every Wednesday. The treatment should occur immediately until the wound team could see the resident, unless the area was severe, then the medical provider should be notified. It should not have been five days from the initial identification of the wound until the wound was assessed and treatment initiated. During an interview with the Director of Nursing on 1/25/2024 at 12:00 PM and 3:30 PM, they stated upon surveyor inquiry, they spoke to registered nurse Supervisor #10, who was working on 12/23/2023. The registered nurse Supervisor stated they were not notified of the new skin impairment. The Director of Nursing reviewed the Supervisor's phone for messages and did not find any related to Resident #5 and their heel wound. Although licensed practical nurse #13 documented they notified the Supervisor, there was no apparent notification. The protocol for new skin impairments included registered nurse Supervisor notification, the Supervisor would assess the area immediately (or as soon as possible) and send an email to the interdisciplinary team. They had a standard initial treatment of Solosite wound gel and dressing, which would remain in place until the wound team assessed the wound. The Director of Nursing was uncertain of the reason licensed practical nurse #13 applied bacitracin to the area, as that was a standard first aid treatment for skin tears. The bacitracin was not part of the protocol for pressure ulcers. The Director of Nursing was unable to locate any treatment orders or assessments prior to 12/28/2023 and stated the area should have been assessed and treated on 12/23/2023. During an interview with registered nurse Supervisor #10 on 1/26/2024 at 1:50 PM, they stated they worked as Supervisor on 12/23/2023 and did not receive any calls or messages from licensed practical nurse #13 related to Resident #5's skin impairment. The Supervisor did not observe Resident #5's ankle wound and did not direct licensed practical nurse #13 to apply bacitracin to the area. The protocol for identification of new skin impairments was to notify the Supervisor, the supervisor would assess the area immediately or as soon as able that shift, initiate the skin protocol and treatment, and email the interdisciplinary team for inclusion on next the wound rounds. During an interview with licensed practical nurse #13 on 1/29/2024 at 12:00 PM, they stated on 12/23/2023, they notified the Supervisor on duty about Resident #5's heel. They could not recall who they spoke to and stated they also told the Supervisor they were going to use the bacitracin as a treatment and the supervisor stated approval. The licensed practical nurse stated there were standard treatments to initiate for new skin areas such as skin tears and they thought that treatment was appropriate, per their recent training. 10 NYCRR 415.12(c)(2)

Based on observation, interview, and record review during the recertification and abbreviated surveys (NY00289926) the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents reviewed (Resident #103). Specifically, on/around July 2, 2022, a cognitively impaired resident (Resident #103) with exit-seeking behaviors was able to leave their facility house undetected. Staff were not immediately aware the resident was missing. The resident was located by resident service aide (RSA) #3 who was entering an adjacent house and they notified staff in the Aspen house a resident was found outside. Licensed practical nurse (LPN) #1 indicated the resident likely eloped through a window because a screen was observed on the ground near a window outside of the Aspen house where the resident resided. The facility did not notify the New York State Department of Health (NYSDOH) of the incident until January 26, 2023, after the Department questioned the facility about a report of a possible elopement. The facility did not educate staff or provide additional supervision to the resident once they were returned to their house. The facility investigation was not completed timely and did not identify how and when the resident exited the facility. Windows accessible to residents in the common areas of Aspen house were observed to open 26-30 inches and resident room windows were able to open 8 inches. Resident #103 continued to exhibit wandering and exit seeking behaviors. This resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #103's health and safety. The facility's failure to provide adequate supervision placed 16 residents with elopement detection devices at immediate risk to their health and safety. Findings included: The facility policy Elopement Risk Assessment revised 11/2022 documented upon admission a resident's potential to wander/ elope would be assessed by the registered nurse (RN) utilizing the Elopement Risk Assessment in the electronic medical record and would be completed within 14 days of admission, quarterly, and with any significant changes thereafter. The RN should complete an elopement risk assessment when a resident's change in condition indicated a change in wandering/ elopement risk. The facility policy Placement of Wanderguard [wander alert device] Bracelet revised 11/2022 documented when a resident was identified by staff to be at risk for wandering and potential elopement from the facility, the resident would have a wander alert device placed by a nurse or designee. The wander alert device would be added to the task list and the comprehensive care plan (CCP) would be updated. The wander alert device information would be entered into the wander alert device system monitor. The wander alert device would be checked each shift by the charge nurse and documented in the electronic medical record. The wander alert device would be tested weekly and documented in the electronic medical record. Resident #103 had diagnoses including Alzheimer's disease, dementia with behavioral disturbances, and difficulty walking. The 5/5/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, wandered 1-3 of 7 days, required supervision and assistance of 1 when walking in their room, required supervision when walking in the corridor, supervision, and assistance of 1 for locomotion on the unit, was not steady during walking but was able to stabilize with staff assistance, did not use a mobility device, and used a wander elopement alarm daily. The resident's comprehensive care plan (CCP) initiated on 8/26/20 documented the resident was an elopement risk and wandered related to a history of attempts to leave facility unattended, impaired safety awareness, and wandering aimlessly. Interventions included a wander alert device, offer a snack, take the resident for a walk, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situations, and take to an alternate location as needed. Staff were to read the resident's behavior care plan, revised on 1/10/23 (this was a paper document located at the nursing station separate from the electronic medical record). The 1/10/23 behavior care plan documented the resident was known to wander the halls and go into other resident's room and to try to exit the house. The resident was at risk for elopement. Wandering occasions were more frequent and were leading to other related behaviors. Behaviors tended to happen on the 3:00 PM-11:00 PM shift when the resident sun downed (increased confusion occurring in the late afternoon and lasting into the night). Interventions included to redirect the resident to a safe location, provide a snack, toilet the resident, ambulate, assist with calling family, engage in activity that would be intriguing to them such as folding towels, and make sure that the wander alert alarm and alarm on their door was working properly. The undated care instructions for Aspen house staff members documented the resident was issued a sensory alarm for a bedroom threshold to alert staff when they were exiting their room. The resident was an elopement risk and had a wander alert device. They were able to ambulate with a device and was independent walking in the corridor and their room. Staff were to follow the resident's behavior care plan. The Elopement risk assessment dated [DATE] completed by social worker (SW) #11 documented Resident #103 was ambulatory, had a history of wandering, had a diagnosis of dementia, and wandered in the past month. Progress notes documented: - on 5/16/22 licensed practical nurse (LPN) #2 documented the resident was wandering the unit this shift and was not easily directed. - on 5/17/22 SW #11 documented they were aware the resident continued to wander around. - on 5/23/22 LPN #2 documented the resident wandered all over the house especially in the AM. - on 5/24/22 LPN #2 documented the resident followed a (unidentified) resident service aide (RSA) out of the door while the food cart was being brought outside. Per the RSA the resident was across the room but moved quickly. Their wander alert device was intact, and the system was working properly, but the door opened before the resident was close enough for the doors to lock. The resident was easily redirected inside, and the family was made aware during the care plan meeting that day. The CCP for elopement documented it was revised on 5/25/22. No additional interventions or goals were documented. Progress notes documented: - on 6/29/22 SW #11 documented they were aware the resident continued to wander around the hallways. - on 7/2/22 LPN #1 documented the resident went out the dining room door and was sitting in a chair outside. The door alarm did not go off, they were not aware the resident was outside until RSA #3 alerted them upon entering the house. The door was locked at that time. Certified nursing assistants (CNAs) #6 and #7 found a hall window screen pushed out and laying on the ground. There was no documented evidence the resident was assessed by a nurse, or if the Administrator, medical provider, or resident representative were notified of the event. There was no documented evidence the facility investigated how the resident was able to exit the cottage, how long the resident was outside, or if the incident was reported to the NYSDOH as required. The July-November 2022 progress notes documented the resident was frequently restless, wandered the hallways and into other resident rooms, tried to unlock the kitchen doors, and attempted to open the outside doors of the cottage. The 11/5/22 quarterly elopement risk assessment documented the resident was ambulatory, cognitively impaired, had a history of wandering in the past month, and had a wander alert device for trying to exit the cottage. The December 2022 progress notes documented: -on 12/2/22 by LPN #2 the resident was trying to get out the front door this AM and would not move away from the door. - on 12/9/22 by LPN #2 the resident was wandering and exiting seeking. - on 12/19/22 by LPN #2 the resident was trying to elope from the front doors and was difficult to redirect. The January 2023 progress notes documented: - on 1/3/23 by LPN #2 the resident was wandering all over the unit trying to get out of the front door and had flipped the tables over in the dining room. - on 1/24/23 by LPN #2 the resident was restless, walking around the dining room, and going towards the doors. They were not able to be redirected. The following observations of Resident #103 were made: - on 1/23/23 at 11:19 AM, the resident was seated in a chair in the hallway wearing a wander alert device on their right ankle. - on 1/24/23 at 11:53 AM, the resident was brought into the dining room for their lunch meal. At 12:08 PM, the resident was attempting to go into the kitchen area. The half door was locked, and they tried to open the door. LPN #2 redirected the resident back to their table. During a telephone interview with the complainant on 1/24/23 at 3:27 PM, they stated they were informed the resident was found outside unattended on 7/2/22. During a telephone interview with LPN #1 on 1/26/23 at 9:26 AM, they stated they usually worked in Resident #3's house (Aspen) on the 3:00 PM-11:00 PM shift and Resident #103 often wandered the unit. They stated sometime during the summer they were working on evenings and the resident was found outside unattended. RSA #3 found the resident seated in a chair outside of the house and alerted the LPN that Resident #103 was outside unattended. LPN #1 stated they were unsure how long the resident was outside and or how the resident got outside without setting off the alarms. They thought the resident got out by pushing out a window screen in the hallway. The resident's wander alert device was on and functioning when they were brought inside. Once the resident was brought inside, they let registered nurse Supervisor (RNS) #4 know about the incident. They stated once they informed RNS #4 it was the RNS's responsibility to start an incident report. LPN #1 stated after this incident the resident was trying to open the hallways windows and push on the screens. They stated that was why a dresser was placed in front of the hallway windows. The following observations were made: - on 1/26/23 at 9:50 AM, 6 windows at the end of the hallway in the Aspen house were open fully and did not have window restrictors (to avoid opening the windows too widely). There was an unsecured dresser in front of 4 of the 6 windows. - on 1/26/23 at 9:58 AM, the opened Cypress House multipurpose room had a window that was able to be opened fully and did not have a window restrictor device. - on 1/26/23 at 10:05 AM, all 6 Aspen Unit hallway windows opened more than 9 inches and had no restrictors. During an observation on 1/26/23 at 10:30 AM, in the presence of Maintenance Director #21, all three of the Aspen house exit doors locked immediately when the wander alert device was approximately 8 to 10 feet from the doors (the 8 foot distance was near the 6 windows in the hallway). It would be possible for a person with a wander alert device to open a window without setting off the device alarm. During an interview with LPN #2 on 1/26/23 at 11:04 AM, they stated Resident #103 wandered the unit and wore a wander alert device. The resident did try to get out the door and had been found outside of the front door in the summer. They were unsure who found the resident outside, and they did not know how the resident was able to get outside. They stated the resident did go to the hallway windows to look outside, touched the windows, ran their hands along the windows, and touched the holiday decorations that were on the windows. Resident #103 had tried to open the windows in the past. If the resident was close to the exit door near the windows the alarm would go off, but they were unsure if the alarm went off when the resident was near the windows across the hallway from the exit door. They thought the windows at the end of hallway opened all the way and they usually tried to make sure they were locked. The hallway windows opened wider than the resident's bedroom windows. The bedroom windows had window restrictors on them to stop them from opening all the way. The following observations were made: - on 1/26/23 at 11:10 AM, The Cypress house multipurpose room had two windows that opened fully and lacked restrictors. - on 1/26/23 at 11:16 AM, The Hickory house multipurpose room had two windows that opened fully and lacked restrictors. During a telephone interview with RNS #4 on 1/26/23 at 1:15 PM, they stated they were the RN Supervisor for the houses on the weekends. They were aware that Resident #103 wandered and there was an incident in the summer when the resident was found unattended outside the Aspen house seated on a bench. They were alerted to the incident by LPN #1, and they reported it to the former Director of Nursing (DON) #22 via telephone. RNS #4 stated the DON seemed nonchalant about the incident. RNS #4 stated they assessed the resident but did not document their assessment. Staff could not come up with a conclusion as to how Resident #103 got outside. RNS #4 stated they had staff keep a close eye on the resident but did not document any interventions they put into place following the incident. They did not start an investigation because they were waiting to hear what needed to be done from former DON #22 as they did not have any experience with elopements. They felt once they reported the incident to former DON #22 it was the DON's responsibility to report the incident to the NYSDOH. They could not recall who the oncoming nursing supervisor was who worked the shift after them and was unsure if they told them about the incident. During a telephone interview with certified nursing assistant (CNA) #6 on 1/26/23 at 2:03 PM, they stated Resident #103 was pleasantly confused and wandered the house. The resident frequently wandered towards the doors and windows at the end of the hallway. They were working the day the resident was found outside. They were assisting another resident when they were alerted Resident #103 was found outside unattended. They were unsure how the resident was able to get outside because they did not hear any alarms go off and the resident had their wander alert device on. They were unsure how long the resident was outside. Once the resident was brought inside the house, they observed the hallway window opened all the way and a screen was found pushed out on the ground. During a telephone interview with CNA #7 on 1/26/23 at 1:51 PM, they stated Resident #103 was found outside one evening in the summer by RSA #3. LPN #1 and CNA #7 assisted the resident inside the house. They did not hear any of the alarms go off and were unsure how the resident was able to leave the house. They had heard the day shift had caught the resident trying to open the windows. They thought the resident was able to get outside through the windows at the end of the hallway. CNA #7 stated they had found a screen pushed out on the ground and alerted LPN #1. After this staff placed a dresser by the window. During a telephone interview with RSA #3 on 1/26/23 at 3:26 PM, they stated Resident #103 was known to wander. They had found the resident outside sitting in a chair by the side entrance alone before dinner during the summer. They let LPN #1 know the resident was outside alone and the resident was brought inside. They stated someone asked them what time they found the resident outside but did not recall if anyone asked them additional information about the incident. During an interview with the Administrator on 1/26/23 at 5:27 PM, they stated an elopement was when a resident was able to leave the premises unknown. If there was an elopement at the facility an investigation would be started and would be reported to the NYSDOH. They expected staff to report any possible elopements to the RNS who should then report it to the Assistant Director of Nursing (ADON) or DON and then to them. They expected staff to document the incident in the medical chart and start an investigation immediately. They were unaware of Resident #103 being found outside, unattended on 7/2/22 until the NYSDOH started asking. The current DON found a nursing progress note by LPN #1 documenting the resident was found outside. The Administrator stated if former DON #22 was aware of the incident they should have started an investigation and reported it to them. They stated there was no investigation completed because they were unaware of the incident. If they had been made aware of the incident, they would have reported it to the NYSDOH. During an interview with physician #10 on 1/30/23 at 11:26 AM, they stated they were aware of Resident #103's wandering behaviors. They stated they were not aware the resident was found outside alone and would expect staff to notify them. If they were made aware they would have seen the resident and documented their encounter. They were not notified of the incident until last Friday (1/27/23). During an interview on 1/30/23 at 3:15 PM, Maintenance Director #21 stated that they were not aware the windows in the Aspen house common area opened fully and lacked window stops. They thought they would have an 8 inch stop on them. They stated they had not heard of any residents getting out through the windows or maintenance staff replacing window screens found on the ground. They were not aware of multi-room windows able to fully open and did not know why they were installed without stops. The building was set up to have windows closed, especially in common areas to ensure that the HVAC (heating, ventilation, air conditioning) worked adequately. During an interview with SW #11 on 1/31/23 at 8:48 AM, they stated they were aware that Resident #103 had wandering behaviors, pulled on doors, and wore a wander alert device. They completed the resident's May 2022 Wandering Risk Assessment, and the resident was considered at high risk for wandering. They were aware of an incident when the resident was trying to sit on a bench outside of the house and was brought back inside. They stated the incident was discussed in AM report and staff could not figure out how the resident was able to get outside. They did not recall the screen found on the ground being discussed during the meeting. They stated Resident #103 should not be outside unattended as they were busy, and their wandering behavior put them at risk, and they could have wandered into the woods or the roadway. -------------------------------------------------------------------------------------------------------------------- Immediate Jeopardy was identified, and the facility Administrator was notified on 1/26/23 at 9:18 PM. Immediate Jeopardy was removed on 1/28/23 at 6:38 PM, prior to survey exit based on the following actions taken: - 321 on-duty staff (approximately 86% of staff) were educated regarding elopement definition, identification of elopement and reporting. The facility had approximately 35 agency/per diem staff who would complete training prior to the start of next scheduled shifts. -Completion of elopement and wandering assessments, and revision of the comprehensive care plan for Resident #103. Revisions included 1:1 interventions when the resident was exhibiting exit seeking behaviors, notification of the nursing supervisor of any behaviors that may precipitate elopement, a threshold alarm in the dining room, and a sensory alarm was placed in the resident's recliner. -Restrictors were placed on all common area windows in the long term care houses, allowing no more than an 8 inch opening. -A complete audit of all windows was done to ensure window restrictors were in place. -A companion care aide would be placed with Resident #103 when staffing allows. -An RN Supervisor would be alerted by staff whenever a resident at risk for elopement was attempting to exit the facility. The RN Supervisor would then contact the administrative nurse (DON or ADON) on call to make an immediate plan to ensure resident safety. -Wandering information would be documented on the 24-hour shift to shift report, to ensure the interdisciplinary team was aware. 10 NYCRR 415.12(h)(1) 44838

Based on record review and staff interviews conducted during the abbreviated survey (#NY 337), it was determined the facility failed to ensure the medical care for 1 of 7 sampled residents (Resident #1) was adequately supervised by a physician. The resident received anticoagulant (blood thinner) medications for 13 days without having the daily laboratory (lab) testing performed as ordered, to ensure the correct medication dosage was prescribed. Specifically, Resident #1 was newly diagnosed with [REDACTED]. The resident was ordered to have daily lab testing of [MEDICATION NAME] time (PT) and international normalized ratio (INR). The testing was done for 2 days, and the resident continued to receive the same medications for 13 days, without the ordered lab tests. Resident #1 experienced a [MEDICAL CONDITION] and expired in the hospital. This resulted in actual harm to Resident #1 that was Immediate Jeopardy. The Immediate Jeopardy situation was removed on [DATE], prior to the abbreviated survey exit conference. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The nurse practitioner (NP) progress note dated [DATE] documented nursing requested she see the resident due to swelling of the right leg. The NP recorded the resident's right leg was larger than the left leg, from just below the knee to the ankle, and a venous doppler (an ultrasound test to determine blood flow) would be done. The venous doppler of the resident's right leg dated [DATE] documented the resident had an extensive and at least partially occlusive [MEDICAL CONDITION] throughout the deep venous system of the right leg. The NP orders dated [DATE] documented the resident was to receive [MEDICATION NAME] 90 milligrams (mg) every 12 hours, [MEDICATION NAME] 5 mg by mouth every day, and daily PT testing. In an interview with the Director of Nursing (DON) on [DATE] at 2 PM, she stated when a PT was ordered, an INR was also automatically done by the lab. On [DATE], the NP documented she was notified that the resident's venous doppler was positive for a [MEDICAL CONDITION] on [DATE], The NP started the resident on [MEDICATION NAME] and [MEDICATION NAME] on [DATE], with daily PT testing to start on [DATE]. The NP documented the [MEDICATION NAME] would be discontinued when the resident's INR was greater than 2.0. Review of the resident's medical record in [DATE] revealed there was no documented NP or physician order [REDACTED]. The lab report dated [DATE] documented the resident's PT was 15.3 seconds and INR was 1.2; on . The NP orders dated [DATE] documented to increase the resident's [MEDICATION NAME] dosage from 5 mg daily to 7 mg daily. The lab reports the resident's PT was 15.3 seconds on [DATE] and 17.2 seconds on [DATE]. The resident's INR was 1.2 on [DATE], and 1.4 on [DATE]. There was no further documentation after [DATE] that the resident received further PT/INR testing while in the facility. The attending physician's progress note dated [DATE] documented the resident was seen for a 60 day visit. The physician documented the resident was "doing well." The note recorded the resident had no swelling of his legs or calf tenderness. The physician did not document the resident's [DIAGNOSES REDACTED]. In an interview with the attending physician on [DATE] at 2:30 PM he stated when he saw the resident, on [DATE], he looked at the resident's leg and did not see anything. He stated he looked at the resident's orders and did not see the orders for [MEDICATION NAME] or daily PT/INR testing. The physician stated those must have been in another part of the resident's medical record. The nursing note dated [DATE] documented the resident continued on [MEDICATION NAME] for [MEDICAL CONDITION] of the right leg. The note recorded "swelling continues" of the resident's right leg. The [DATE] Minimum Data Set (MDS) assessment documented the resident was severely impaired cognitively. The MDS recorded the resident needed extensive assistance with his activities of daily living (ADLs). The MDS documented the resident had a [MEDICAL CONDITION] and was receiving anticoagulant medications. Review of nursing notes dated [DATE], 13 and 14, 2012 revealed the resident's right lower extremity remains swollen". The nursing note dated [DATE] at 5:39 AM documented the resident's face was cleaned and "small amount of bleeding continues." The nursing note dated [DATE] at 2:22 PM documented the resident was "cut shaving yesterday" and had a dry scant amount of blood on his chin. The note recorded the NP was "notified and evaluated". The plan was to "put ice (on it) to stop bleeding", "with effect" was noted. Review of the resident's medical record showed no documentation by the NP of the above incident or an order to treat the resident's "cut" with ice. There was no documentation by the NP regarding the anticoagulant medications the resident was receiving or the absence of daily PT/INR testing as ordered. Nursing notes dated [DATE], 18, 19, 20 and 21, 2012, each documented the resident's right lower extremity remained swollen. The resident's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] at 8:15 AM, nursing notes documented the resident was pale, diaphoretic, not easily aroused and unable to open his eyes. The resident's pulse was weak and breathing was labored. The note recorded the resident had a moderate amount of dark blood in his brief coming from the rectum. The NP note of "Discharge/Transfer" dated [DATE] at 8:34 AM, documented the resident had bright red rectal bleeding and a blood pressure of ,[DATE]. The NP noted the resident was verbally unresponsive, with difficulty breathing. The resident was on [MEDICATION NAME] and [MEDICATION NAME] since [DATE] due to right leg [MEDICAL CONDITION]. The NP recorded the resident was sent to the hospital for evaluation. The hospital admission note dated [DATE] recorded the resident was diagnosed with [REDACTED]. The hospital lab report dated [DATE] documented the resident's PT was 82.6 seconds and INR was greater than 10. The physician ordered the resident to receive 2 units of packed red blood cells and 2 units of frozen plasma. The hospital's Adult Resuscitation Report, dated [DATE], documented the resident expired before the transfusion was complete. The death certificate, dated [DATE], documented the cause of the resident's death was cardio-respiratory arrest, acute [MEDICAL CONDITION] infarction and GI bleed. The attending physician was interviewed on [DATE] at 2:30 PM. He stated that he looked at the resident's leg and did not see anything. He stated he looked at the resident's orders and did not see the orders for [MEDICATION NAME] or daily PT/INR testing. He stated those must have been in another part of the resident's medical record. In summary, the facility failed to ensure the medical care of the resident was adequately supervised, by a physician, when the resident received anticoagulant medications for 13 days without ordered daily laboratory testing (PT/INR) to verify the correct dosage was prescribed. The Immediate Jeopardy was removed prior to the abbreviated survey exit conference as the developed and implemented plans to address the immediacy of risk in the form of licensed staff having been re-educated in response to the significant medication and labwork issue. The facility also completed a full-house medication audit of residents on anticoagulant therapy, therefore removing the immediacy of risk. 10NYCRR415.15(b)(1)(i)(ii)

Based on record review and staff interviews conducted during the abbreviated survey (#NY 337) it was determined for 1 of 7 residents (Resident #1) reviewed for anticoagulant (blood thinner) medications the facility failed to ensure a system was in place to: provide care and services required to assess medication effect on residents; provide safe medication administration follow up; and provide physician ordered laboratory testing necessary to evaluate the effectiveness and appropriate dosage of administered anticoagulants. Specifically, Resident #1 was newly diagnosed with [REDACTED]. The nurse practitioner (NP) ordered daily laboratory testing of [MEDICATION NAME] time (PT) and international normalized ratio (INR), which was done for 2 days. The resident continued to receive the anticoagulants for 13 more days, without having the ordered laboratory testing done. The resident experienced [MEDICAL CONDITION], and was sent to the hospital's Emergency Department. The resident's PT was found to be 82.6 (reference range 11.7 - 14.5 seconds) and the INR was greater than 10 (INR range for [MEDICAL CONDITION] 2.0 - 3.0). The resident expired. This resulted in actual harm that was Substandard Quality of Care and Immediate Jeopardy to the health and safety of Resident #1. The Immediate Jeopardy situation was removed on [DATE], prior to the abbreviated survey exit conference. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The nurse practitioner (NP) progress note dated [DATE] at 11:15 AM, documented the resident's right leg, from just below the knee to the ankle, was larger in size than the left leg. The NP noted a venous doppler (an ultrasound test to determine blood flow) would be done. The venous doppler of the resident's right leg dated [DATE] documented the resident had an extensive and at least partially occlusive [MEDICAL CONDITION], throughout the deep venous system of the right leg (from his hip to his foot). The registered nurse (RN) progress note dated [DATE] at 3 PM documented the resident had a [MEDICAL CONDITION] of the right leg. The RN recorded the NP was made aware and orders were obtained for [MEDICATION NAME] 90 milligrams (mg) subcutaneous injection every 12 hours and [MEDICATION NAME] 5 mg by mouth daily. The RN documented "daily [MEDICATION NAME] to start on Wednesday" [DATE]. The NP orders dated [DATE] documented the resident was to receive [MEDICATION NAME] 90 mg subcutaneous every 12 hours, [MEDICATION NAME] 5 mg by mouth daily, and daily PT testing. In an interview on [DATE] at 2 PM, the Director of Nursing (DON) stated when a PT was ordered, an INR was automatically performed by the laboratory, as well. The NP note dated [DATE] documented she was notified on [DATE] that the resident's venous doppler was positive for [MEDICAL CONDITION]. The NP recorded the resident was started on [MEDICATION NAME], and daily PT testing on [DATE]. The NP documented the [MEDICATION NAME] would be discontinued when the resident's INR was greater than 2.0. There was no documented NP or physician order, on the resident's medical record, to discontinue the [MEDICATION NAME] when the resident's INR was greater than 2.0. The resident's laboratory report dated [DATE] documented the PT was 15.3 seconds, and the INR was 1.2. The NP orders dated [DATE] documented to increase the resident's [MEDICATION NAME] dosage from 5 mg to 7 mg daily. The laboratory report dated [DATE] documented the resident's PT was 15.3 seconds and the INR was 1.2. The [DATE] report documented a PT of 17.2 seconds and an INR of 1.4. The anticoagulation flowsheet documented the resident's PT/INR results for [DATE] and 8, 2012. No further PT/INR results were recorded. The physician's progress note dated [DATE] documented the resident was seen for a 60 day visit, and was doing well. The progress note recorded the resident's extremities (arms/legs) were without [MEDICAL CONDITION], "no calf tenderness." The report did not document the resident's [MEDICAL CONDITION] or orders for [MEDICATION NAME] and daily PT/INR testing. The [DATE] Minimum Data Set (MDS) assessment documented the resident was severely impaired cognitively. The MDS recorded the resident needed extensive with his activities of daily living. The MDS documented the resident had a [MEDICAL CONDITION] and was receiving anticoagulant medications. The [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nursing note dated [DATE] at 5:39 AM documented the resident's face was cleaned "small amount bleeding continues." The [DATE] at 2:22 PM nursing note documented the resident was "cut shaving yesterday" and had a dry scant amount of blood on his chin. The note recorded the NP was notified, evaluated the resident and "put ice to stop bleeding"; with effect noted. Review of the resident's medical record showed no documentation by the NP for the incident as noted above, or an order to treat the resident's "cut" with ice. There was no documentation by the NP regarding the anticoagulant medications the resident was receiving or the absence of PT/INR testing daily as ordered. The MAR indicated [REDACTED]. The nursing progress notes dated [DATE], 18, 19, and 20, 2012 documented the resident received [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION]. There was no documentation the resident had PT/INR testing done. The [DATE] progress note by LPN #1 documented the resident was pale, diaphoretic, not easily aroused and unable to open his eyes to either verbal or touch stimuli. The resident pulse was weak and his breathing was labored. The note recorded the resident had a moderate amount of dark blood noted in the brief from the rectum. The resident was transferred to the hospital. The resident transfer sheet dated [DATE] documented the resident had bright red rectal bleeding, was on [MEDICATION NAME] and [MEDICATION NAME] and the last INR was 1.4 on [DATE]. The resident was verbally unresponsive. The transfer sheet documented the resident was to have had follow up PT/INR testing which was not done. The hospital Emergency Department report dated [DATE] at 8:57 AM, documented the resident the resident developed bright red rectal bleeding "since yesterday". At 10:55 AM, physician orders [REDACTED]. The transfusion report documented the transfusion began at 11:10 AM and stopped at 11:58 AM. The hospital "Adult Resuscitation Report", dated [DATE] documented the resident "coded" and resuscitation efforts started at 11:58 AM. The report specified the family requested not to resuscitate the resident and cardiopulmonary resuscitation was stopped at 12:13 PM. The resident expired. INTERVIEWS: The unit secretary was interviewed on [DATE] at 10:30 AM. She stated on [DATE] there was an order for [REDACTED]. LPN #5 was interviewed on [DATE] at 12:15 PM. She stated the order for the daily PT testing was not recorded on the report sheet. She said she did not see the order for daily PT/INR and therefore did not know the resident was on daily PT testing. She stated she missed it and she did not know why. The unit RN was interviewed on [DATE] at 2:15 PM. She stated on [DATE], the doppler revealed the resident had a [MEDICAL CONDITION]. She said she called the NP who ordered [MEDICATION NAME] and daily PT/INR testing to start [DATE]. The RN said the nurse in charge of the house monitored these parameters, and everyone had a piece in this, we all messed up. The NP was interviewed on [DATE] at 10 AM and [DATE] at 11 AM. She stated she saw the resident on [DATE] and ordered the venous doppler test. When he was diagnosed with [REDACTED]. The NP said unless they told her something was going on with the resident, she would not go back and check on the resident. She stated she did not check the resident's PT/INR test results. The NP said she saw the resident on [DATE] and sent him to the hospital. The attending physician was interviewed on [DATE] at 2:30 PM. He stated that he looked at the resident's leg and did not see anything. He stated he looked at the resident's orders and did not see the orders for [MEDICATION NAME] or daily PT/INR testing. He stated those must have been in another part of the resident's medical record. In summary, the facility failed to ensure a system was in place to provide care and services required to assess medication effect on the resident; to provide safe medication administration follow up; and physician ordered laboratory testing necessary to evaluate the effectiveness and appropriate dosage of the administered anticoagulants. The Immediate Jeopardy was removed prior to the abbreviated survey exit conference as the facility developed and implemented plans to address the immediacy of risk in the form of licensed staff having been re-educated in response to the significant medication and labwork issue. The facility also completed a full-house medication audit of residents on anticoagulant therapy, therefore removing the immediacy of risk. 10NYCRR415.12(l)(1)

Based on observations, training materials and medical record review, and staff interviews conducted during the extended recertification survey, it was determined the facility failed to ensure each resident received adequate supervision and assistance to prevent choking and/or aspiration, for 44 of the 44 residents on altered consistency diets (Residents #1, 5, 9, 10, 12, 18, 21, and 25-41 on pureed diets, and Residents #2, 6, 7, 17, 19, 22, 23, and 42-54 on mechanical soft diet) residing in the facility's 9 houses, as the facility: failed to implement Resident #6's physician orders [REDACTED]. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to residents' health and safety and Substandard Quality of Care to the 44 residents on altered consistency diets in the 9 houses. The facility implemented appropriate measures to remove the Immediate Jeopardy prior to the survey exit. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY OF September 4, 2009. Findings include: The Immediate Jeopardy situation was removed on August 24, 2010, as the facility trained staff to ensure residents at risk for choking and aspiration will receive food according to their diet orders. Resident service aides (RSAs), certified nurse aides (CNAs), licensed nursing staff and dietary staff were trained to recognize altered diet textures to ensure their appropriateness. Dietary supervisory staff and cooks will be responsible to assure food consistencies leave the main kitchen with the proper texture and quality. 1) Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. On June 7, 2010, the speech language pathologist (SLP) evaluation documented the resident had severe dysphagia and coughed with mechanical soft solids. A pureed diet with pudding-thick liquids and restorative swallowing therapy were recommended. On June 8, 2010, the SLP progress note documented the resident was receiving restorative swallowing therapy. The resident's June 18, 2010 video fluoroscopy report documented recommendations to provide the resident with a puree diet with nectar-thick fluids, 6 small meals per day, and alternating bites and sips of food/fluid. The June 26, 2010 Minimum Data Set (MDS) assessment, documented the resident had modified independence with decision making; a short-term memory deficit; required supervision and 1 person to assist with eating; and had chewing and swallowing problems. The July 23, 2010 swallowing evaluation documented the resident requested soft sandwiches at meals, and it was ordered to determine the appropriate diet/aspiration risk. Recommendations included a follow-up video fluoroscopy for possible diet upgrade. On August 2, 2010, the resident's video fluoroscopy report documented recommendations for a mechanical soft, with vegetables cut small, and nectar-thick fluids. Other recommendations included 6 small meals per day, 1:1 supervision with meals to encourage small bites/sips, double swallow per bite, and alternating sips and bites. On August 2, 2010, a physician's orders [REDACTED]. The resident's comprehensive care plan (CCP), updated August 2, 2010, documented the resident's dysphagia, his need for a mechanical soft diet with nectar thick liquids. Interventions were small bites/sips, SLP re-assessment per physician order, and to be upright 90 degrees at meals and 30 minutes after meals. The physician's orders [REDACTED]. The resident's Feeding Techniques form (used by care givers for feeding guidelines), was updated "August 2010" by the SLP. The form documented the resident was to take small bites and sips, and was to be upright during meals, and for 30 minutes following meals. The physician's orders [REDACTED]. The August 11, 2010 nursing notes documented the resident was transferred from the rehabilitation unit in the main building to a long term care "house". On August 20, 2010 at 6:38 PM, nursing notes documented the resident "tolerates 3 regular sized meals will discontinue 6 small meals" per day. Physician orders, dated August 20, 2010, documented to "change diet to mechanical soft, nectar thick liquids." The surveyor observed the resident between 8:18 - 9:00 AM on August 19, 2010 during the breakfast meal. The resident ate in the dining room, and his meal ticket documented his diet order was mechanical soft. The surveyor observed the resident receive whole (regular)consistency bacon, toast, and eggs. The resident fed himself and ate all the eggs and toast, and half the bacon. Staff members were observed to be in and out of the dining room, without encouraging the resident to alternate his bites and sips, take double swallows, or eat slowly. On August 19, 2010 at 9:00 AM, the resident service aide (RSA) was asked about the whole bacon she served to the resident that morning. The RSA stated she did not believe she needed to modify the consistency of breakfast foods for residents on mechanical soft diets. On August 23, 2010 at 8:35 AM, the surveyor heard a certified nurse aide (CNA) tell the RSA that Resident #6 refused to get out of bed and wanted a grilled cheese sandwich for breakfast. A CNA was observed to deliver the grilled cheese sandwich and beverages to the resident's room and leave the food in the room. The surveyor observed the resident eat all the grilled cheese sandwich and take sips of the beverage, without staff's presence in the room. The surveyor observed no staff members return to the resident's room until 9:20 AM, when they removed the resident's meal tray. The surveyor observed the resident at lunch on August 23, 2010 at 12:20 PM, as he ate lunch in his bed. The resident received ground ham, whole consistency cauliflower, French fries, a brownie, orange juice, and water. No staff were observed to be present in the resident's room during the meal. When the resident was finished, the surveyor observed a CNA remove the tray from the resident's room. The resident ate 1/4 of the ham and the brownie, and drank 1/4 of the orange juice. The resident did not eat the whole cauliflower or the French fries. On August 24, 2010 at 8:45 AM, the SLP was interviewed. She told the surveyor she developed the Feeding Techniques form for residents, and staff were expected to follow the feeding instructions on those forms. The SLP stated she checked the accuracy and implementation of the Feeding Techniques when she conducted dysphagia rounds and when she updated the resident's CCP. The SLP initially stated she did not feel Resident #6 needed 1:1 supervision with meals, as residents in the houses generally ate in the dining rooms, and had not heard the resident was having difficulty with meals. The SLP stated she was unaware the resident ate 2 meals in his room the prior day, and said she did not re-evaluate the Feeding Technique form's recommendations for 1:1 supervision and to encourage double swallows, to determine their appropriateness. In summary, for Resident #6, the facility: - failed to ensure the physician's orders [REDACTED]. - failed to ensure oversight was provided of the RSA to ensure the resident received the proper consistency of food, as he received whole consistency bacon when his diet order specified he was to receive mechanical soft foods; - failed to ensure the SLP evaluated and ensured the resident's current Feeding Techniques were adequate and accurate. 2) Resident #12 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP), originally initiated on May 22, 2008 (and last reviewed by the SLP on July 8, 2010), documented the resident presented with dysphagia (swallowing difficulty) and required a pureed consistency diet with pudding thick liquids. Interventions included checking the resident for pocketing food (storing food between cheek and gums) after meals; providing total feeding assistance with constant supervision during meals; feeding the resident small bites and sips; and seating the resident upright at 90 degrees during the meal and for 30 minutes after the meal. On January 8, 2010 the SLP assessment documented the resident's "swallowing abilities remain impaired"; and noted the resident required "a puree diet with pudding thick liquids." The Minimum Data Set (MDS) annual assessment, dated January 10, 2010, documented the resident had poor short and long term memory problems, was lethargic at times, required total assistance with all activities of daily living (ADLs), had chewing and swallowing problems, and was on a mechanically altered diet. The MDS did not document feeding or other treatment restrictions, other than Do Not Resuscitate. On March 2, 2010 at 8:58 PM, a nursing note documented the resident's oxygen saturation rate went down to 83% while on 3 liters of oxygen per minute and after a nebulizer treatment. The physician ordered the resident sent to the emergency room for an evaluation. On March 10, 2010 at 1:50 PM, a nursing note documented the resident returned from the hospital with a discharge [DIAGNOSES REDACTED]. The note specified the resident was non-verbal and unable to make her needs known. On March 10, 2010, physician orders [REDACTED]." Nursing notes dated March 11, March 12, and March 14, 2010, each documented the resident was coughing during the meal, and they stopped feeding (the) resident. On March 15, 2010, the registered dietitian (RD) documented the resident's "feeding is stopped if coughing is noted during meals." Review of the resident's CCP revealed there was no documented directive for staff to stop feeding the resident if coughing when they were feeding the resident. On March 24, 2010, a nursing note documented the resident's "comfort care order was discontinued" as the resident was "now stable". There were no documented changes in the resident's July 11, 2010 quarterly MDS assessment (from the January 2010 MDS) regarding the resident's chewing and swallowing problems, periods of lethargy, and the need for total feeding assistance. The resident's "Feeding Techniques" form, dated July 16, 2010 by the SLP, was located in a binder by the dining room for use by staff assisting the resident with meals. This form documented the resident needed constant supervision at all meals; was to be fed by staff; the resident was to take small bites and sips; was to be checked for pocketing of food after meals; and was to be seated upright at 90 degrees at and 30 minutes after meals. The form did not identify the concern of the resident's coughing when eating. The surveyor observed the resident in the dining room from 5:30 PM to 6:15 PM on August 18, 2010, during the evening meal. The resident's thickened pureed soup was placed in front of her at 5:30 PM. The marinated salad was observed with "pieces" in the salad. The salad was tasted by 2 surveyors who felt/tasted pieces of tomato skins in the pureed salad. The resident started receiving feeding assistance with her soup at 5:50 PM, 20 minutes after the soup was initially put in front of her. The surveyor observed the resident gagging and coughing profusely when fed the soup, the ham salad, and the marinated salad. The certified nurse aide (CNA) continued to feed the resident for 4 to 5 minutes, as the resident increased her coughing. The CNA asked the licensed practical nurse (LPN) if she should give the resident the milk. The LPN was observed to nod to the CNA. The CNA then fed the resident pudding-thick milk and her pudding (dessert). The resident was observed to stop coughing, when provided the smooth, homogenous pudding-thick milk and pudding. In summary, for this resident with a history of aspiration pneumonia and a pureed consistency diet order, as the - facility failed to ensure the resident was served a sufficiently pureed marinated vegetable; - facility staff failed to feed the resident according to her individualized plan of care, as they continued to feed her a food that resulted in an increased coughing. - failed to provide oversight of dietary and house staff to ensure the resident was served the proper food consistency. 3) The job description for "Resident Services Aides" (RSAs), dated April 2009, was reviewed. Their documented duties included housekeeping, linen, and food service responsibilities and their supervisor was the House Manager. The job description documented the RSAs would "assist with meal prep as directed including menus, proper heating of food items, ability to serve proper consistency, cleaning tables, (and) washing dishes after meals as directed." The facility's undated "Food, Nutrition, and Equipment Orientation" for the RSAs documented the "RSA may have to puree or chop a residents food until the proper consistency arrives" (due to a possible delay when a resident's diet changes). "Usually within one day the correct food item" will be "in the house." The orientation checklist specified that each house had a food processor for this. On August 19, 2010 at 10:20 AM, the registered nurse (RN) Staff Educator was interviewed in relation to the training and oversight of RSAs who prepared altered consistency foods for the residents in the 9 houses. The RN educator stated RSA were trained by dietary and a SLP during orientation. After orientation, the RN educator said RSAs were paired up with other RSAs, who completed tasks with them in the houses. The RN educator stated the facility did not have competencies for the preceptor RSAs to ensure they were qualified to train other RSAs on proper food consistency. When asked, the staff educator said there were competencies for the RSAs and would provide copies of these for all the current RSAs; (no completed competencies were received prior to exit). The RN educator said RSAs were directly supervised by the licensed practical nurses (LPNs) in the houses and said the LPNs received the same training as the RSAs. The staff educator provided a copy of the training material provided to the RSAs. The training materials used by dietary and SLP did not include how to alter the consistency of food. The RN told the surveyor to ask the Assistant Food Service Director and the SLP (speech language pathologist) about this part of the training, "as they were the ones who taught that part of the orientation." On August 19, 2010 at 12:10 PM, the Assistant Food Service Director was interviewed and stated she did not cover how to puree or alter the consistency of food in RSA orientation. She stated RSAs were trained by the existing RSAs. On August 19, 2010 at 12:55 PM, the SLP, who performed RSA orientation, stated in an interview that she taught the SLP portion of the training at RSA orientation, and did not cover altering the consistency of foods. The SLP stated the RD more closely monitored the consistency of food during weekly dysphagia (swallowing difficulty) rounds at the lunch meal. The registered dietitian (RD) was interviewed on August 19, 2010 at 1:45 PM. She stated she conducted dysphagia rounds with the SLP at the lunch meal. She stated clinical nutrition staff did not do meal rounds at breakfast, because of the schedules of the clinical nutrition staff. On August 19, 2010 at 2:10 PM, the RN Staff Educator provided a copy of a blank RSA Orientation Checklist. She stated the checklist was supposed to be completed by the RSA's preceptor (trainer). She stated she did not have completed forms on the current RSAs, as the facility was in the process of implementing this checklist. The Educator stated the facility did not have competencies on the current RSAs. The job description for House Manager, "revised August 2010", was reviewed. There was no documentation that specified the House Manager would ensure RSAs were adequately trained to prepare altered consistency foods for the residents with chewing and swallowing problems. A licensed practical nurse (LPN) from Mulberry House was interviewed on August 20, 2010 at 8:10 AM. The LPN stated she was "in charge" of the house and oversaw the RSAs. The LPN said she was to make sure the residents had the "right consistency of food" by checking that food matched the diet on the residents' meal tickets. In summary, the facility failed to ensure RSAs were provided with an effective training program by qualified staff, and given oversight to ensure their competence in preparing altered consistency foods, for the residents who were at risk for choking and aspiration. 10 NYCRR 415.12(h)(1&2)

Based on observations, review of medical records, menus/recipes, and staff training materials, and interviews with staff and family members during the extended recertification survey, it was determined the facility failed to ensure residents received food prepared in a form designed to meet individual needs for 24 residents with pureed diet orders (Residents #1, 5, 9, 10, 12, 18, 21, and 25-41), and 20 residents with mechanical soft (ground) diet orders (Residents # 2, 6, 7, 17, 19, 22, 23, and 42-54) in 9 of the facility's 10 buildings. Specifically, - the Food Service Director failed to take immediate action to protect residents on puree consistency diets when mashed potatoes were improperly prepared and served to residents on pureed diets. - the facility failed to adequately puree foods in the main kitchen (including potatoes, corn, Salisbury steak, marinated vegetable salad, and cole slaw) to a smooth, homogenous consistency. - the facility failed to ensure staff routinely evaluated puree food for acceptable consistency prior to serving to the residents. - failed to provide recipes and food service procedures for staff to follow to ensure properly processed altered consistency diets. - the facility failed to adequately process mechanical soft consistency foods, before serving cole slaw to residents in 8 of 9 houses (including Residents #49, 53, and 54) and before serving regular bacon to Residents #6, 7, 19, and 48 on mechanical soft diets. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety for the 44 residents on altered consistency diets. The facility implemented appropriate measures to remove the immediate jeopardy concerns prior to survey exit. Findings include: The Immediate Jeopardy situation was removed on August 24, 2010, as the facility conducted daily meal observation rounds to ensure proper food consistencies were delivered from the main kitchen and served to the residents. 1) On August 18, 2010 at 12 PM, resident service aide (RSA) #14 was observed serving residents in the Cypress house. Residents #9, 10, 12, 21, and 28's meal tickets documented they were on pureed diets and were observed to receive mashed red skin potatoes with chunks of potato and pieces of potato skins. The surveyor observed the Food Service Director watching the meal service in the Cypress house dining room at that time. A surveyor sampled a puree consistency lunch meal in the Sequoia house on August 18, 2010 between 12:20 PM and 12:30 PM. The pureed corn and Salisbury steak were not processed to a smooth and homogenous consistency. According to the list of residents' diet orders provided by dietary on August 18, 2010, Residents #36-39 in Sequoia were on puree diets. At 12:25 PM on August 18, 2010, RSA #14 provided a sample of the pureed meal to the surveyor. At the time, RSA #14 stated she received 1 potato product that day to serve to all the residents in Cypress house. The pureed potatoes (tasted by the surveyor) were not smooth, contained chunks of potato, and pieces of potato skins. The pureed corn was not smooth and had pieces of skins; and the pureed Salisbury steak was not smooth and homogenous. During an interview on August 18, 2010 at 3:50 PM, the Food Service Director stated "regular" garlic mashed potatoes with skins were served to 9 resident houses, except Sequoia, where the RSA #10 noticed the potatoes were not pureed "well enough", and used her own initiative, processed the mashed potatoes to a smooth and homogenous consistency in the "house" kitchen. While he observed inadequately prepared pureed food in Cypress house, the Food Service Director failed to stop the service of the regular mashed potatoes with chunks and skins, failed to stop the service of the pureed corn and failed to stop the service of pureed Salisbury steak to the Residents #9, 10, 12, 21 and 28 on puree diets in Cypress house. During an interview with the Food Service Director on August 18, 2010 at 3:50 PM, he was asked about the lunch meal served to the residents that day. He stated the mashed potatoes for lunch were sent from the main kitchen to each of the houses were not the potatoes that were planned. The director stated he noticed the mashed potatoes during the meal and asked the cook about them after the meal's service. He said those potatoes were not a pureed product as planned. He stated the pureed corn served was supposed to be a commercially processed product, and said the pureed Salisbury steak was processed by the cooks in the main kitchen. On August 18, 2010 at 4:30 PM, the Speech Language Pathologist (SLP) intern was interviewed and stated puree food should be uniform and smooth, without lumps, and corn should be "as creamy as possible." She stated if a food was not smooth, it should not be served. When asked about the risk to residents, the SLP intern stated the degree of risk depended a resident's ability to chew and their individual diagnoses. She said residents who were at the greatest risk of choking/aspiration were those residents with [DIAGNOSES REDACTED]. The Food Service Director stated in an interview on August 19, 2010 at 10:00 AM, the cook (who currently was not available for interview) prepared the garlic mashed potatoes with chunks of potato and pieces of skins rather than potatoes on the planned menu because she wanted to use this product up before it had to be thrown away. On August 22, 2010, at 12:45 PM, a family member of Resident #18 (who was on a pureed diet) stated to the surveyor she came to the facility almost daily at mealtime. She stated she spoke to the Assistant Food Service Director about the mashed potatoes with pieces of skins in them served last week and was told the facility had purchased too much of the product and needed to use them up. She stated she voiced concerns at other times about inadequately pureed food to the Assistant Food Service Director, and did not feel they adequately looked into those concerns. The Quality Assurance Coordinator was interviewed on August 24, 2010 at 10:15 AM. She stated the Quality Assurance Committee had not audited food consistency because they were not aware of any complaints regarding food consistency. In summary, - the Food Service Director failed to stop the meal service when he observed food being served that was inadequately pureed. - the facility failed to adequately puree foods in the main kitchen (including potatoes, corn, and Salisbury steak to a smooth, homogenous consistency. - failed to provide oversight to resident houses at mealtime, to ensure residents on puree consistency diets were served the proper consistency food. 2) The Food Service Director was interviewed on August 18, 2010 at 3:50 PM and asked about the training the cooks received for pureeing food. The Food Service Director did not state any specific staff training. He did provide a manufacturer's instructions for "Thicken Up", a commercial food thickener. The Food Service Director stated cooks were to follow the instructions on the thickener which detailed the amount of food, liquid and thickener to combine when pureeing food. The thickener's instruction addressed amounts of thickener to add to liquids and to soup; it did not document amounts of thickener to be added to puree each specific food item to the proper consistency. During the 3:50 PM interview of August 18, 2010, when the Food Service Director was asked about monitoring the adequacy of altered consistencies, he stated regular checks of food consistency were not done in the main kitchen. He stated the regular garlic mashed potatoes with skins were served at the noon meal that date to all the houses, except for Sequoia where the RSA noticed the potatoes were not pureed well "enough" and blended them herself in the processor. Recipes were requested for the lunch meal foods when the Food Service Director was interviewed on August 18, 2010 at 3:50 PM. A copy of a recipe for Salisbury steak was provided at the time of the interview. Later that day, another copy of the Salisbury Steak recipe was provided with an additional handwritten recipe for pureed inserted on the bottom of the page. The pureed Salisbury Steak did not provide specific amounts of "cooked meat" and "gravy" to use to ensure the proper pureed consistency. A recipe for pureed corn was not available at the time, as the Director stated the facility usually planned to use a commercially processed pureed product. The Assistant Food Service Director was interviewed on August 20, 2010 at 12:15 PM, and stated, up until 3 months ago, a contract food service company supplied the meals to the residents in the 9 houses. When asked what the process was 3 months ago, the Assistant Food Service Director stated she could not give the surveyor a complete description of how much cooking the RSAs did, because "each house was different." She stated she thought the RSAs cooked breakfast to order, but did not puree food, as the previous contract food service company sent all foods pureed at the breakfast meal. In an interview on August 20, 2010 at 2:15 PM, the Food Service Director stated kitchen staff were not trained on preparing altered consistency food after the main kitchen took over food preparation from the contract company. He stated most of the cooks worked for the facility for many years and believed they knew how to make the different food consistencies. He did not have the cooks demonstrate competency in pureeing and altering food consistency. The Food Service Director stated when new cooks were hired, they were trained how to make altered consistency foods by the facility's existing cooks. On August 23, 2010 at 10:25 AM, the Head Cook who prepared the puree Salisbury Steak, puree corn and mashed potatoes for the noon meal on August 18, 2010 was interviewed. She stated she did not taste food after she pureed it, and did not test the consistency of the product. On August 18, 2010 at 5:25 PM, the surveyor observed the supper meal in the Cypress house. Resident service aide (RSA) #11 stated at that time, that the marinated vegetable salad was pureed in the main kitchen. The pureed marinated vegetable salad was tasted by the surveyor and pieces of vegetables and skins were tasted in the salad. Residents #9, 10, 12, 21, and 28 were observed to receive the pureed salad. Resident #12 was observed coughing after taking a few bites of the pureed marinated vegetable salad. When the recipe for pureed marinated vegetable salad was requested from dietary, the registered dietitian (RD) provided the surveyor on August 19, 2010 at 1:45 PM with an undated photocopy of the recipe for whole (regular) consistency marinated vegetable salad. On the bottom of the recipe sheet were hand-written instructions for pureeing the salad. There were no specific amounts of vegetables and salad dressing documented to be used to ensure the proper consistency. On August 24, 2010 at 10:50 AM, the RD was re-interviewed. She stated there were no recipes for the RSAs to follow when cooking in the houses. In summary, the facility: - failed to provide recipes and food service procedures for the staff who prepared food in the main kitchen and in the houses, to ensure proper food consistencies. - failed to ensure all dietary workers (including cooks) were trained effectively and demonstrated competency in preparing altered consistency foods to meet the needs of the residents on pureed diets. - failed to ensure staff routinely evaluated puree food to ensure its acceptable consistency prior to serving to the residents. 3) The surveyors observed the noon meal on August 20, 2010 between 12:35 PM and 12:55 PM, in the Cypress, Hawthorne, Hickory, Mulberry, and [MEDICATION NAME] houses. The resident service aide (RSA) in each house stated they received regular (whole), mechanical soft (ground), and pureed cole slaw. The RSAs stated they served the pureed cole slaw as it came from the kitchen. According to these residents' diets (diet orders provided by dietary on August 18, 2010) Residents #5, 9, 10, 12, 18, 21, 26, 27, 28, 33, 34, 40, and 41 had orders for puree diets. During the noon meal on August 20, 2010 between 12:35 PM and 12:55 PM, in the Cypress, Hawthorne, Hickory, Mulberry, and [MEDICATION NAME] houses. The pureed cole slaw was observed to have visible pieces of carrot throughout the product. The surveyors asked for a sample of the pureed cole slaw in all of the houses, and were told there was none available to sample. A surveyor observed the lunch meal in the Hawthorne house on August 20, 2010 at 12:35 PM. RSA #6 stated in an interview at that time, that she received 3 batches of cole slaw (regular, ground and puree) and did not think the ground cole slaw was ground "enough". She stated she processed the cole slaw further in the food processor. She stated she checked the consistency of the ground cole slaw when she was done processing it. The surveyor observed the noon meal on August 20, 2010 between 12:45 PM and 12:55 PM, in the Hickory and [MEDICATION NAME] houses. The "mechanical soft" cole slaw, received from the main kitchen, was not "ground" to a proper consistency when served to the residents. According to the list of residents' diets, provided by dietary on August 18, 2010, Residents #49, 53, and 43 had orders for mechanical soft diets. On August 19, 2010 at 12:55 PM, the Speech Language Pathologist (SLP) stated in an interview, she was not regularly involved in reviewing foods served, although in the past, she checked consistencies when asked. The SLP stated she and the RD conducted weekly dysphagia (swallowing difficulty) rounds, and thought the RD looked at the food served. In summary, the facility: - failed to adequately train kitchen staff to prepare mechanically soft and pureed food to the proper consistency. - failed to ensure dietary supervision was effective in providing oversight to cooks and house staff responsible for preparing residents' food consistency. 4) VARIED FOOD PREPARATION TECHNIQUES IN THE DIFFERENT HOUSES BY THE RESIDENT SERVICE AIDS (RSAs): The Food Service Director initially stated in an interview on August 18, 2010 at 3:50 PM, that the main kitchen pureed all the food that was served, and said the food was "normally not processed any further" in the residents' 9 houses. Later during the interview, the Food Service Director stated RSAs prepared breakfast, and pureed or "ground" the food, if needed. - On August 18, 2010 between 3:50 and 6:30 PM, resident service aide (RSA) #13 was observed adding thickener, without measuring, to a pan of pureed beef soup in the Chestnut house. At that time, RSA #13 told the surveyor she added the thickener, because the soup was "looking too thin." She referred the surveyor to the posted thickening instructions. When asked why she did not follow the posted instructions, RSA #13 stated she did not know how many ounces were in the pan, so she added a little bit at a time, until the soup looked "thick enough to serve". The surveyor observed RSA #13 to serve the pureed thickened soup to Residents #31 and 32 for supper. On August 24, 2010 at 8:45 AM, the SLP stated in an interview, RSAs should always follow instructions when thickening soups. She stated RSAs should always measure the thickener and the product. The SLP said each single serving of soup should be thickened. She said whole pans of soup should not be thickened, as the exact number of servings in the pan was not known. Additional interviews and observations of 9 RSAs from the day and evening shifts were conducted in 7 of the facility's 9 houses (Chestnut, Magnolia, Hawthorne, Mulberry, Cypress, Aspen, and [MEDICATION NAME]) on August 18, 2010 between 3:50 PM and 6:30 PM, and on August 19, 2010 between 1:55 PM and 3:15 PM. These observations and interviews revealed some RSAs in the houses further processed mechanical soft and pureed food sent from the main kitchen, when they determined the food was not the proper consistency. For example: - 7 of the RSAs (RSAs #5, 6, 7, 8, 9, 11, and 13) stated they pureed various foods. - 4 RSAs (RSAs #1, 2, 3, and 13) stated they re-processed pureed food sent from the main kitchen, if the consistency "did not look right". None of these 4 RSAs stated they notified the main kitchen when they had concerns with proper food consistency. - 6 RSAs (RSAs #1, 3, 6, 8, 9, and 13) stated they added "thickener" or a "liquid" to food to alter its consistency. These RSAs referred the surveyors to the thickening charts posted in the kitchens. These thickening charts, posted in the house kitchens, addressed thickening liquids and soups. There were no documented guidelines for making puree consistency food. - When the surveyor asked the RSAs during the above interviews, no RSA was able to provide the surveyors with recipes located in the "houses" for them to follow when preparing breakfast, or when altering the consistency of foods. On August 19, 2010 at 8:00 AM, RSA #6 was observed in the Hawthorne house cooking breakfast. Residents #6, 7, 19, and 48's meal tickets documented they were on mechanical soft diets and were to receive ground breakfast pork. The surveyor observed RSA #6 serve Residents #6, 7, 19, and 48 regular (whole) consistency bacon. The surveyor interviewed RSA #6 immediately following the breakfast meal, stated she did not believe she needed to make modifications to the breakfast foods for residents on mechanical soft diets. At 12:15 PM on August 19, 2010, the Speech Language Pathologist (SLP) told the surveyor that residents on mechanical soft (ground) diets should receive ground bacon. She stated she did not know if the ground bacon came from the main kitchen or if it was done in the houses by the RSAs. Observations of RSAs altering the consistency of food without following a recipe, include: - On August 19, 2010 at 8:52 AM in Magnolia house, a surveyor observed RSA #5 place scrambled eggs in the blender with milk. RSA #5 stated he added "just a little bit" of milk and pureed the eggs. The eggs were served to Residents #1 and 35 and were a diluted product. - During the breakfast meal on August 19, 2010 at 9 AM in the Hawthorn house, RSA #6 was observed preparing Resident #5's (who was on a puree diet) breakfast meal. RSA #6 placed eggs and hot water in the food processor and added thickener. When asked how much thickener to add, RSA #6 stated "a little at a time" until the food "looks like pudding". She then heated pre-pureed bread in the microwave, added hot water and mixed the eggs and pureed bread together on the resident's plate. RSA #6 stated sometimes, she tasted the pureed food to make sure it tasted the same as the regular food. The pureed food was observed to be watery and runny on the Resident #5's plate. - On August 19, 2010 between 1:55 PM and 3:15 PM, the surveyors interviewed RSA #5 who stated he pureed eggs and bacon; RSAs #7 and 8 each said they pureed eggs; RSA #9 said he pureed eggs, pancakes, and toast; RSA #11 stated she pureed eggs and salads; RSA #13 said she pureed salads and meats. At 1:45 PM on August 19, 2010, the RD was interviewed and stated she did not know whether RSAs in the houses pureed or ground the meats at the breakfast meal. She stated she would find out. At 2:45 PM, the RD called the surveyor, and stated bacon and sausage were sent to the houses raw, and needed to be cooked and/or processed by the RSAs in the houses. - On August 20, 2010 at 8:15 AM, the surveyor observed RSA #9 working in Mulberry house, as he pureed food in a blender. RSA #9 placed hot water, scrambled eggs, and toast in the blender and processed them. The surveyor observed RSA #9 add 1/4 teaspoon of thickener to the egg/toast mixture and told the surveyor he added thickener to the food mixture because he thought it looked too thin. The mixture was served to Resident #27 and had an unappetizing, thick appearance. - On August 20, 2010 at 8:20 AM, RSA #15 in the [MEDICATION NAME] house told the surveyor that she pureed food that "weren't pureed" in the main kitchen. She stated she pureed eggs for Residents #40 and 41 that morning. In summary, the facility: - failed to deliver pureed and mechanical soft consistency foods at the proper consistency to the residents' houses for the RSAs to serve to the residents. - failed to ensure the food (including bacon, eggs toast, and soup) processed by the RSAs in the residents' houses were adequately processed to meet the pureed and mechanical soft diet consistency criteria. - failed to implement a system to ensure residents were provided with the proper consistency food. - facility failed to adequately process mechanical soft consistency foods, before serving regular bacon to Residents #6, 7, 19, and 48 on mechanical soft diets. 10 NYCCRR 415.14(d)(3)

Based on observations, review of medical records, facility policies, procedures, and inservice records, and staff interviews conducted during the extended recertification survey, it was determined the facility's administrative staff failed to administer the facility in a manner that enabled its resources to be used effectively and efficiently to protect the health and safety of residents. Specifically, the Administrator failed to ensure effective systems were in place to provide residents with food prepared in a form that was designed and consistent to meet the individual needs of residents with swallowing difficulties. The Administrator failed to ensure staff who prepared foods with altered consistency were trained and were provided with oversight to ensure proper food consistency was served. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of 44 residents on altered consistency diets, including 24 residents with pureed diet orders (Residents #1, 5, 9, 10, 12, 18, 21, and 25-41), and 20 residents with mechanical soft diet orders (Residents # 2, 6, 7, 17, 19, 22, 23, and 42-54). The facility implemented appropriate measures to remove the Immediate Jeopardy situation prior to survey exit. Findings include: The facility employed corrective measures prior to the completion of the survey that removed the IJ. These measures included: - training of resident service aides (RSAs), certified nurse aides (CNAs), licensed nursing staff and dietary staff to recognize altered diet textures. - daily meal observation rounds to ensure proper food consistency is served in the dining room and stored in the refrigerators. - weekly Dysphagia Team's rounds will include comments that address the appropriate food consistency. - dietary supervisory staff and cooks will be responsible to assure the consistency of foods leave the main kitchen with the proper texture and quality. F323 Accidents - This is a repeat deficiency from the September 4, 2009 survey in relation to residents being at risk for choking/aspiration. In the current survey, the Administrator failed to ensure that residents at risk for choking/aspiration and on puree and mechanical soft diets were provided adequate supervision and failed to ensure staff were provided training and oversight for food preparation. This resulted in Immediate Jeopardy to resident health and safety and Substandard Quality of Care. F365 Food Form - The Administrator failed to ensure residents received food prepared in a form designed to meet individual needs as the facility failed to provide RSAs with written recipes and procedures to follow when preparing mechanically altered foods. This resulted in Immediate Jeopardy to residents' health and safety. At 9:00 AM on August 20, 2010, the surveyor interviewed the Administrator. She stated the facility started the process of preparing food for the "houses" in May 2010 when meals were sent down to the houses 7 days a week from the main kitchen. She stated she had not been informed of any problem with the preparation of the food until the Director of Food Service spoke to the surveyors. She stated it was her understanding the cook, who had been an employee for over [AGE] years, "goofed" by providing the wrong potatoes. When asked, the Administrator stated she was unaware the Director of Food Service failed to intervene when he observed the wrong potatoes being served to the residents on pureed diets. During the 9 AM interview on August 20, 2010, the Administrator stated she was unaware of other problems with altered consistency foods (other than the potatoes on August 18, 2010.) The Administrator stated if there was a "perpetual" problem, she would have heard about it from the staff. She stated the facility had 27 Resident Service Aides (RSAs) and said they all were trained. She said she was aware that some RSAs did a better job than others. The Administrator stated she knew the residents did not like the previous food service delivery system and the facility was now trying to "do it ourselves" since May (2010). 10 NYCRR 415.26