Every finding on record at Cobble Hill Health Center Inc

Based on observation, record review, and interviews conducted during survey, the facility failed to ensure that residents are free from physical abuse. This was evident for one of six residents (Resident #1) sampled for abuse. Specifically, the facility surveillance video dated 06/14/2026 from 09:38:24 AM through 09:39:55 AM revealed Certified Nursing Assistant #1 running out of the dining room chasing Resident #1 who walked out of the dining room into the hallway holding a banana. In the hallway, Certified Nursing Assistant #1 grabbed Resident #1 at the back of their neck and used their right hand to hit Resident #1 on the top of their head. During the incident, Resident #1 fell on the floor and hit their head on another resident's wheelchair. Resident #1 did not sustain any visible injuries. This resulted in Immediate Jeopardy to resident health and safety at Past Non-Compliance. The findings are:The facility's policy titled Resident Abuse, Neglect, Mistreatment, Involuntary Seclusion, Misappropriation of Property and Injury of Unknown Origin dated 06/09/2026 documented that each resident has the right to be free from abuse, neglect, mistreatment, involuntary seclusion, and misappropriation of property. Direct care staff are to intervene immediately to stop the activity and protect the residents.Resident #1 was admitted to the facility with diagnoses which include Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills), cerebral infraction (a blocked or narrowed blood vessel cuts off blood flow to the brain) and congestive heart failure (heart muscle becomes too weak or stiff to pump blood efficiently). The Minimum Data Set (a resident assessment tool) dated 04/01/2026 documented Resident #1 had a Brief Interview for Mental Status (used to determine attention, orientation, and ability to recall information) score of 6 out of 15, denoting severely impaired cognition. A 04/02/2026 Comprehensive Care Plan titled Abuse/Neglect documented interventions to assess the resident for signs and symptoms of abuse and/or neglect, to ensure the resident feels safe as it relates to abuse or neglect. The abuse care plan was updated post incident of abuse on 06/14/2026 with interventions to monitor delayed injuries.A behavior care plan dated 04/07/2026 documented interventions for staff to monitor resident closely, attempt to anticipate behavior and redirect as needed. The facility surveillance video dated 06/14/2026 from 09:38:24 AM through 09:39:55 AM revealed Certified Nursing Assistant #1 running out of the dining room chasing Resident #1 who walked out of the dining room into the hallway holding a banana. In the hallway, Certified Nursing Assistant #1 grabbed Resident #1 at the back of their neck and using their right hand, hit Resident #1 on the top of their head. During the incident, Certified Nursing Assistant #1 grabbed Resident #1's hands and Resident #1 staggered backwards and landed on the floor in a seated position, striking their head on a wheelchair where another resident was seated. Certified Nursing Assistant #1 then attempted to pick Resident #1 up from the floor, but Resident #1 resisted. Certified Nursing Assistant #1 then let go of Resident #1's hands, picked up the banana from the floor, and then hit Resident #1 on their upper back while the other resident was watching the incident. Certified Nursing Assistant #1 then walked away (into a room) leaving Resident #1 sitting on the floor. The surveillance video ended at 09:39:55 AM.No staff members were seen in the hallway during the incident between Resident #1 and Certified Nursing assistant #1. Two residents were observed sitting in wheelchairs in the hallway (only one resident appeared to be watching incident) with overbed tables in front of them. The Summary of Investigation dated 06/14/2026 documented at approximately 9:40 AM, Certified Nursing Assistant #1 observed Resident #1 exit the dayroom with a banana in their hand. Certified Nursing Assistant #1 went to Resident #1 to retrieve the banana. Certified Nursing Assistant #1 then grabbed Resident #1 by their posterior neck and while they were struggling with Resident #1 for the banana, Resident #1 fell on the floor landing on their buttocks. Certified Nursing Assistant #1 proceeded to grab the banana from Resident #1 while Resident #1 was still on the floor. Resident #1 had no visible injuries, no changes in behavior or mental status and did not recall the incident. Certified Nursing Assistant #1 was immediately escorted off the unit while Assistant Director of Nursing remained with Resident #1 until local law enforcement arrived. Certified Nursing Assistant #1 was interviewed by local law enforcement officers; then escorted out of the building. The investigation concluded that Certified Nursing Assistant #1 physically abused Resident #1. On 06/15/2026 an x-ray was done of Resident #1's cervical spine, bilateral hips, sacrum and coccyx. The x-ray results revealed no fracture.A nursing progress note dated 06/14/2026 at 4:25 PM by Licensed Practical Nurse #1, documented on 06/14/2026 at 9:30 AM, Resident #1 was observed sitting on the floor in the hallway.A nursing progress note dated 06/14/2026 at 10:48 PM by Assistant Director of Nursing #1, documented at around 9:50 AM, writer was called to the unit by Licensed Practical Nurse #1 who informed them that Resident #1 was struck by Certified Nursing Assistant #1. On arrival, Resident #1 was observed sitting on the floor upright. Body assessment revealed no visible injury at this time. Physician's progress note dated 06/18/2026 at 3:50 PM documented resident was seen secondary to having been physically abused. Resident #1 has dementia and does not recall the incident. During an interview on 06/24/2026 at 12:03 PM, Certified Nursing Assistant #1 stated they were monitoring the dining room the morning of 06/14/2026. They stated that at approximately 9:39 AM, they followed Resident #1 out of the dining room. Certified Nursing Assistant #1 stated they did not hit Resident #1, but while they were struggling to take the banana from Resident #1, the resident fell onto the floor. During an interview on 06/24/2026 at 12:47 PM, Certified Nursing Assistant #2 stated that on 06/14/2026 (unsure of time), they observed Resident #1 sitting on the floor in the hallway screaming and Certified Nursing Assistant #1, who was standing over Resident #1, punched Resident #1 on their upper back with a closed fist. They called out to Certified Nursing Assistant #1 and asked them what they were doing, but they did not respond. Certified Nursing Assistant #2 stated Licensed Practical Nurse #1, who was inside the nursing station, came to see what was happening (unsure of time). During an interview on 06/24/2026 at 1:50 PM, Licensed Practical Nurse #1 stated that on 06/14/2026, they were at the nursing station (unsure of time) when they heard Resident #1 screaming in Spanish from the hallway at around 9:40 AM. Licensed Practical Nurse #1 stated they left the nursing station and observed Resident #1 sitting on the floor in the hallway and Certified Nursing Assistant #1 appeared to be hitting the resident on their back. Licensed Practical Nurse #1 stated they instructed Certified Nursing Assistant #1 to stay away from Resident #1 and then, using their cell phone, immediately called the Assistant Director of Nursing and informed them of the incident. During an interview on 06/24/2026 at 3:17 PM, Registered Nurse #1 stated they were performing a medication pass in the hallway when they heard Resident #1 yelling, but they could not understand what Resident #1 was saying. Registered Nurse #1 stated they looked to see what was happening and they observed Licensed Practical Nurse #1, who was the charge nurse, screaming at Certified Nursing Assistant #1 telling them to stop what they were doing to Resident #1. Registered Nurse #1 stated they observed Resident #1 sitting on the floor and Certified Nursing Assistant #1 using their closed hand to punch Resident #1 in their back. During an interview on 06/24/2026 at 11:16 AM, Assistant Director of Nursing #1 stated that on the day of the incident, they were called by Licensed Practical Nurse #1 at approximately 9:50 AM, informing them that they saw Certified Nursing Assistant #1 hitting Resident #1. Assistant Director of Nursing #1 stated they immediately went to the unit and observed Resident #1 sitting on the floor in the hallway and Certified Nursing Assistant #1 standing at the entrance of the dining door away from Resident #1. Assistant Director of Nursing #1 stated that Licensed Practical Nurse #1 notified them that Resident #1 went into the dining room picked up a banana and walked out when Certified Nursing Assistant #1 went after them to take back the banana. Assistant Director of Nursing #1 stated there was a struggle between Certified Nursing Assistant #1 and Resident #1 and Resident #1 fell on the floor and Certified Nursing Assistant #1 struck them on the back of their head and upper back. Assistant Director of Nursing #1 stated that they assessed Resident #1, who had no visible signs of injuries, bruise, redness or discoloration. Assistant Director of Nursing #1 stated that Licensed Practical Nurse #1 stayed with Certified Nursing Assistant #1 in a secure room on the unit while they assessed Resident #1. Assistant Director of Nursing #1 stated after they completed the resident's assessment, they escorted Certified Nursing Assistant #1 off the unit to the nursing office where they stayed until local law enforcement arrived. Assistant Director of Nursing #1 stated they notified the Director of Nursing and called 911. Assistant Director of Nursing #1 stated they continued to monitor Resident #1 for changes, and there were no changes from their baseline. During an interview on 06/25/2026 at 12:41 PM, Medical Doctor #1 stated they were made aware of the incident on 06/15/2026 by the Assistant Director of Nursing who reported that Certified Nursing Assistant #1 struck Resident #1. Medical Doctor #1 stated they performed a full physical assessment and emotional assessment and there were no visible injuries or changes in mental status in Resident #1. Medical Doctor #1 stated Resident #1 was unable to recall the incident.During an interview on 06/25/2026 at 11:49 AM, the Administrator stated the Director of Nursing informed them on 06/14/2026 at approximately 10:00 AM, that there was an incident of abuse at the facility on the 5th floor. The Administrator stated they informed their Chief Executive Officer and came to the facility at approximately 10:30 AM. The Administrator stated they reviewed the surveillance video and when the police officers arrived at the facility it was reviewed again. The Administrator stated they spoke to the police officers after they reviewed the surveillance video. The Administrator stated that the police officers interviewed Certified Nursing Assistant #1, then escorted them out of the facility to the police car. The Administrator stated that Resident #1's plan of care was discussed and interventions implemented. During an interview on 06/25/2026 at 12:57 PM, the Director of Nursing stated that when they were notified of the incident, they immediately instructed the Assistant Director of Nursing to call 911 and then notified the Administrator. The Director of Nursing stated that local law enforcement arrived at the facility at approximately 11:00 AM and reviewed the surveillance video recording. The Director of Nursing stated the police officers called their supervisor who also came to the facility, and they were escorted to Resident #1's unit. The Director of Nursing stated the police officers spoke with Resident #1 and staff members who witnessed the incident. The Director of Nursing stated that the police officers handcuffed Certified Nursing Assistant #1 at the police car.Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to surveyors' s onsite visit on 06/24/2026. A Plan of Correction is not required for this citation.10 New York Codes, Rules and Regulations 415.4(b)(1)(i)The facility took immediate corrective actions and was found to be in substantial compliance on 06/23/2026.On 06/14/2026, facility immediately removed Certified Nursing Assistant #1 off the unit and subsequently terminated them on 06/19/2026. On 06/14/2026 local law enforcement was contacted and escorted Certified Nursing Assistant #1 out of facility.On 06/14/2026, the Assistant Director of Nursing assessed Resident #1 with no visible injuries. Radiology Report of bilateral hips with pelvis, coccyx, spine and skull dated 06/14/2026 was negative for fracture. On 06/15/2026 the Resident was assessed by a psychiatrist who determined there was no changes in mental or psychosocial status; the resident did not recall the incident. On 06/14/2026, the abuse policy was reviewed with no revisions. On 06/14/2026, an Interdisciplinary Stand-up Meeting was held post-incident.On 06/14/2026 in-service on resident abuse was initiated for all staff with 83% of available staff receiving education to date and education remains is ongoing. On 06/15/2026, registered nurses conducted a skin assessment on all 40 residents on the dementia unit to rule out abuse. On 06/15/2026 an Ad Hoc Meeting with department heads and the Medical Director was held.

Based on observation, record review and interview, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation result in serious bodily injury, to the State Survey Agency. This was evident in one (1) (Resident #370) of five (5) residents reviewed for accidents. Specifically, Resident #370 had an unwitnessed fall on 03/20/2026 and was later diagnosed with an acute subcapital left hip fracture on 03/23/2026. The resident had severe cognitive impairment and was unable to provide information regarding the circumstances of the fall. Despite the unwitnessed nature of the incident and discovery of a major injury, the facility failed to report the incident to the New York State Department of Health.The findings Include:The facility's policy and procedure titled Resident Abuse, Neglect, Mistreatment, Involuntary Seclusion, Misappropriation of Property, Injury of Unknown Origin with a last revised date of 07/01/2025 stated that initial report of alleged or actual abuse, neglect, or injury of unknown origin are reported according to the State and Federal requirement upon receipt by the Director of Nursing, Assistant Director of Nursing, or the Administrator.Resident #370 had diagnoses that included Atrial Fibrillation, Coronary Artery Disease, and Heart failure.The admission Minimum Data Set (a resident assessment tool) dated 03/13/2026 documented that Resident #370 had severe impairment in cognition. The assessment documented that the resident required supervision or touching assistance for eating, partial/moderate assistance for oral and personal hygiene, and substantial/maximal assistance of staff for other activities of daily living.The facility's investigative summary completed by the Assistant Director of Nursing and reviewed by the Director of Nursing and Administrator documented that on 03/20/2026 at approximately 10:30 AM, the nursing staff was notified by the resident's roommate that Resident #370 was on the floor. The resident was evaluated by Medical Doctor #1 with no treatment orders. On the evening following the initial fall, Resident #370 was observed with some discomfort on the left lower extremity, x-rays of the left leg including ankle and knee were completed with no acute abnormalities. On 03/23/2026, Resident #370 was noted with increased pain, moaning and groaning when left leg is touched. [NAME] worder was obtained for x-ray of left hip which revealed acute sub capital fracture. On 05/19/2026 at 10:12 AM, Assistant Director of Nursing #1 was interviewed and stated the incident was not reported because they believed the fracture was due to the fall. They stated that they interviewed Resident #370's roommate who observed the resident on the floor but did not know how Resident #370 fell.On 05/19/2026 at 11:11 AM, Director of Nursing was interviewed and stated that the incident was not reported to the New York State Department of Health because the fracture was related to the fall and therefore is not considered as injury of unknown origin.05/19/2026 at 10:53 AM, the Administrator was interviewed and stated that Resident #370's injury was not reported because they believed Resident #370's fracture was related to the fall and although the fall incident was not witnessed, the injury was not suspicious.

Based on observation, record review, and interview, the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised following a significant change in condition and ongoing pain management interventions. This was evident in one (1) of three (3) residents reviewed for pain management out of 35 total sampled residents. Specifically, Resident #1's comprehensive care plan for potential pain was not reviewed and revised despite the resident exhibiting actual pain.The findings include:The facility policy titled Comprehensive Care Plan and Baseline Comprehensive Care Plan with a last reviewed date of 04/2026 documented the interdisciplinary team will review and revise the care plan upon a change in condition and as needed.Resident #1 had diagnoses that included osteoarthritis, vertebral low back pain, and hypertension.The Quarterly Minimum Data Set, dated [DATE] documented Resident #1 had intact cognition, required assistance with activities of daily living and was not on pain management.A physician's order last renewed on 04/30/2026 included acetaminophen 1000 milligrams every eight hours as needed for chronic pain, Asper Creme Lidocaine 4% patch to the left knee daily, and Gabapentin 300 milligram twice daily for pain.A nurse's progress note dated 04/13/2026 at 1:38 pm documented that Resident #1 reported left knee pain rated 6/10 at 11:30 AM. After receiving Tylenol, the resident continued to complain of worsening left knee pain rated at 10/10. The physician was notified and ordered a STAT dose of ibuprofen and a STAT left knee x-ray.A pain management consultation dated 04/14/2026 at 11: 59 AM documented Resident #1 had complaints of acute intermittent left knee pain aggravated by activities of daily living and requiring multiple pain management interventions, including medication adjustments. The stated goals were to reduce pain to a manageable level and improve function, endurance, and range of motion.The care plan titled Pain, Potential effective 02/06/2025, was last evaluated on 03/12/2026 with interventions such as monitoring for pain and avoiding activities that exacerbate pain, monitor behaviors and assess for pain/discomfort if change in behavior is noted, promote proper body alignment.Record review revealed that following Resident 1's complaints of significant left knee pain, pain management consultation, medication changes, and ongoing treatment, the care plan was not reviewed or revised to reflect the resident's actual pain condition, pain location, goals, or interventions. The resident continued to have a Potential Pain care plan despite documented evidence of active pain requiring treatment.On 05/15/2026 at 1:47 PM, Registered Nurse #4 stated that Resident #1 complained of left knee pain, initially rated 6/10 and later 10/10 despite intervention. Registered Nurse #4 acknowledged that Resident #1 should have had an actual pain care plan rather than a potential pain care plan and stated that nursing staff were responsible for updating the care plan. Registered Nurse #4 could not explain why the care plan had not been revised.On 05/20/2026 at 12:21 PM, Registered Nurse #8, who was the Unit Manager, stated that residents receiving pain management should have an actual pain care plan in place and stated they were not sure what happened as to why Resident #1's care plan was not revised.On 05/20/2026 at 12:12 p.m., the Director of Nursing stated that Unit Managers oversee care plan completion and monitor compliance through meetings and audits but could not explain why Resident #1's care plan had not been updated.10 New York Code, Rules and Regulations 415.11

Based on observation, record review, and interview, the facility failed to ensure that the Minimum Data Set assessment accurately reflected each resident's status. This was evident in two (2) (Resident #236, Resident #306) of five (5) residents reviewed for accuracy of assessment. Specifically, 1.) Resident #306's Minimum Data Set assessment did not accurately reflect the indwelling catheter status; and 2) Resident #236's Minimum Data Set assessment did not accurately reflect the use of wander guard. The findings include: The facility's policy on Minimum Data Set Completion with a last revised date of 03/2025 documented that every department will be responsible for accurate completion of assigned Minimum Data Set sections. It also documented completion process will be per Resident Assessment Instruction User manual, which may include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. 1. Resident #306 had diagnoses of Urinary Tract Infection, Dysphagia, and Unspecified Fall. The admission Minimum Data Set, dated [DATE] documented Resident #306 was severely cognitively impaired and had no indwelling catheter. It also documented Resident #306 and their representative participated in the assessment. From 05/15/2026 at 9:35 AM to 05/20/2026 at 9:11 AM, Resident #306 was observed having urinary catheter bag placed in a privacy bag and hanging on right side of their bed. The physician order dated 04/06/2026 documented to provide urinary catheter care to Resident #306 every shift and as needed. The comprehensive care Plan related to urinary incontinence and indwelling catheter was initiated on 04/07/2026. There was no documented evidence that Resident #306's use of indwelling catheter was accurately assessed on the admission Minimum Data Set assessment dated [DATE]. On 05/18/2026 at 9:20 AM, Registered Nurse #2 was interviewed and stated Resident #306 was admitted from the hospital with a urinary catheter on 04/06/2026. On 05/18/2026 at 9:28 AM, the Minimum Data Set Coordinator was interviewed and stated they completed the bladder and bowel section of Resident #306's Minimum Data Set assessment and was not sure why the use of urinary catheter was not documented. 2. Resident #236 had diagnoses of Osteoarthritis, Insomnia, and Urinary Retention. The Quarterly Minimum Data Set, dated [DATE] documented Resident #236 had moderately impaired cognition and had no wander alert bracelet. During multiple observation from 05/15/2026 to 05/20/2026, Resident #236 was observed with a wander alert bracelet worn on the left wrist. A physician's order dated 04/24/2026 included to check wander alert bracelet for functionality. The Treatment Administration Record for April 2026 documented that the wander alert bracelet is in place on Resident #236's wrist. A comprehensive care plan for elopement initiated on 01/30/2026 and last reviewed on 04/30/2026 documented that wander alert bracelet was applied on the resident's left wrist on 1/30/2026. On 05/20/2026 at 1:14 PM, the Minimum Data Set assessor was interviewed and stated they missed coding the use of wander alert device for Resident #236. On 05/20/2026 at 1:16 PM, the Minimum Data Set Coordinator stated that the assessors are responsible in ensuring that the Minimum Data Set assessments are accurate. 10 New York Code, Rules and Regulations 415.11(b)

Based on observation, record review, and interviews conducted during the Abbreviated survey (NY00307820), the facility failed to ensure that the services provided or arranged by the facility meets professional standards of quality. This was evident in 1 out of 3 residents (Resident #1) sampled. Specifically, on 12/27/22 at approximately 06:30am on the night shift (11:00pm-07:00am), Resident #1 was observed on the floormat in their room and was picked up and put back into their bed by Registered Nurse #1. An x-ray result dated 12/28/22 documented that Resident #1 sustained an acute nondisplaced right femur intertrochanteric fracture. The facility's Investigation Summary dated 12/29/22, revealed that Registered Nurse #1 did not report the fall. There was no documented evidence that Resident #1 was assessed by Registered Nurse #1. The facility became aware of Resident #1's fall on 12/29/22 during an interview with Registered Nurse #1. The findings are: The facility Policy and Procedure titled Reporting and Documenting Resident Accident/Incident with reviewed date 11/2023 documented that All residents involved in accident/incidents are assessed by the nurse and the physician. The Registered Nurse assesses all resident's condition when an accident/incident occurs or when resident is eased to the floor. Notifies the physician if the resident's condition requires immediate medical attention or transfer to the hospital. If transfer to the hospital is indicated, notify the designated representative immediately. The facility Policy and Procedure on Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 11/2023 documented that the facility is committed to providing residents with an environment that is free from abuse, neglect, or mistreatment. Resident #1 was admitted to the facility with diagnoses including Osteoarthritis, Osteoporosis, and Dementia. The Minimum Data Set 3.0 dated 12/02/22 documented that Resident #1 was moderately impaired in cognition and required extensive assistance of one-person in transfer, and ambulation and extensive assistance of two persons in bed mobility. A nursing progress note dated 12/27/22 at 3:07pm, by Licensed Practical Nurse #1 who worked on the 07:00am - 03:00pm, documented that Resident #1 had a right hip pain and that bruising was observed on Resident #1's right lower extremity with some scratches. Nursing Supervisor #2 and Nurse Practitioner #1 were notified. A nursing progress note, by Licensed Practical Nurse #2 who worked on the 03:00pm - 11:00pm, dated 12/27/22 at 04:21pm documented Resident #1 observed with two reddened circular areas to the left lateral aspect of Resident #1's left lower extremity. A liner reddened area appeared to be a scratch was observed at Resident #1's inner right lower extremity, and Resident #1 had facial grimacing when Resident #1 was turned. A Physician's Order dated 12/27/22 at 05:06pm documented a bilateral hip x-ray. A late note dated 12/28/22 at 09:22am, by Nurse Practitioner #1, documented that Resident #1 was evaluated on 12/27/22 (no time identified) with facial grimacing and occasional moaning. No falls reported. A Radiology Report dated 12/28/22 documented that a service was provided on 12/28/22 and that the results revealed an Acute nondisplaced, right femur intertrochanteric fracture. A nursing progress note, by Licensed Practical Nurse #3, dated 12/28/22 at 11:22pm documented that Resident #1 was transferred to the hospital for evaluation at 11:20pm. A Hospital After Visit Summary dated 01/04/23 documented that Resident #1 was status post intramedullary nail of the right femur on 12/30/22 without complication. A Facility Investigation Summary dated 12/29/22, documented there was evidence of neglect. Registered Nurse #1 failed to report an incident that led to injury. Initially, Registered Nurse #1 reported that nothing unusual happened on 12/27/22. However, on 12/29/22 Registered Nurse #1 was informed that Resident #1 had sustained an acute right femur intertrochanteric fracture and Registered Nurse #1 sighed and stated that Resident #1 fell on the ground and that they picked up Resident #1, assessed Resident #1, but did not report the fall. During a telephone interview on 02/13/24 at 03:34pm, Certified Nursing Assistant #1 stated that they worked on 12/26/22 on the 11:00pm - 07:00am shift. Certified Nursing Assistant #1 stated that they heard shouting coming from Resident #1's room and asked Registered Nurse #1 to check Resident #1's room. Certified Nursing Assistant #1 stated that they also went to Resident #1's room and observed Registered Nurse #1 in the process of transferring Resident #1 from the floormat to the bed. Certified Nursing Assistant #1 stated that they assisted with putting Resident #1 back in bed. Certified Nursing Assistant #1 stated that they did not observe Registered Nurse #1 assess Resident #1. Certified Nursing Assistant #1 stated that after Registered Nurse #1 put Resident #1 back in bed, Registered Nurse #1 left the room. During a telephone interview on 02/14/24 at 9:10am, Registered Nurse #1, who worked on 12/26/22 on the 11:00pm - 07:00am shift, and that they were at the nursing station when they were asked to go to Resident #1's room. Registered Nurse #1 stated that they went to Resident #1's room and observed Resident #1 on the floormat. Registered Nurse #1 affirmed that they picked up Resident #1 from the floormat and Certified Nursing Assistant #1 assisted them. Registered Nurse #1 stated that they assessed Resident #1's body for bruising and that range of motion was done and that Resident #1 was not in pain. Registered Nurse #1 stated that Resident #1 was observed on the floormat around 06:30am (close to end of shift) and that they did not report the fall. Registered Nurse #1 stated that that were not sure that they wrote about the fall. A subsequent telephone interview on 02/28/24 at 03:27pm, Registered Nurse #1 said that they were aware of the Policy and Procedure on Incident/Accident and that they should have notified their nursing supervisor and medical doctor. Registered Nurse #1 also stated that they should have documented their assessment of Resident #1. Registered Nurse #1 stated that they did not report the fall because it was close to the end of their shift. During a telephone interview on 02/15/24 at 9:47am, Nursing Supervisor #2 stated that Licensed Practical Nurse #1 notified them on 12/27/23 at approximately 08:00am that Certified Nursing Assistant #2 reported to Licensed Practical Nurse #1 that Resident #1 was not themself. Nursing Supervisor #2 stated that they assessed Resident #1 together with Licensed Practical Nurse #1 and Certified Nursing Assistant #2. Nursing Supervisor #2 stated that Resident #1 had a small scratch on their right hip and pushed Nursing Supervisor #2's hand when Resident #1's right hip was touched. There was no swelling or discoloration to bilateral hip and Nurse Practitioner #1 was notified. Nurse Practitioner ordered an x-ray of bilateral hip, Diclofenac gel to apply to right hip and to continue with Acetaminophen for pain. There was no documentation of Nursing Supervisor #2's assessment and findings. During a telephone interview on 02/14/24 at 1:37pm, Nurse Practitioner #1 stated that they were informed on 12/27/22 (can't remember the time and who informed them) that Resident #1 seemed to be in pain when moving their right leg. Nurse Practitioner #1 stated that they were in the building and immediately examined Resident #1. Nurse Practitioner #1 stated that Resident #1 had occasional moaning and facial grimacing when Resident #1 moved their right hip. Nurse Practitioner #1 stated that the x-ray result revealed an acute non-displaced right femur intertrochanteric fracture. Nurse Practitioner #1 stated that they did not order a STAT x-ray because there were no reported falls or trauma. During an interview on 02/06/24 at 3:00pm, the Director of Nursing stated that they conducted the investigation and that Registered Nurse #1 initially stated that nothing unusual happened to Resident #1. The Director of Nursing stated that when they informed Registered Nurse #1 that Resident #1 sustained a right hip fracture, Registered Nurse #1 stated that Resident #1 fell on their shift. The Director of Nursing stated that Registered Nurse #1 stated that they did not report the incident to Nursing Supervisor #1 because they were tired and wanted to go home. The Director of Nursing stated that Registered Nurse #1 failed to report the fall and there was evidenced of neglect. 10 NYCRR 415.11(C)(3)(i)

Based on observations, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during kitchen observation. Specifically, expired food was observed in the kitchen refrigerator. The findings are: The facility policy titled Labeling and Dating Items dated ,d+[DATE] documented all food items that enter the facility will have the date that the case was received to ensure that all food items entering the facility are utilized using the First In, First Out process. Any items found out of date will note be used and will be discarded. On [DATE] at 09:38 AM, the kitchen Refrigerator #1 was observed with 2 (5 lb) tubs of egg salad with a use by date of [DATE] and 2 (5 lb) plastic containers of egg salad with a use by date of [DATE]. Refrigerator #3 was observed with 2 wrapped whole baked hams with a use by date of [DATE]. On [DATE] at 10:48 AM, Dietary Aide #1 was interviewed and stated they received food deliveries three times a week on Wednesday, Friday and Monday and rotated items using the First In, First Out method. Dietary Aide #1 stated they were shocked that food items were expired because they usually check for expired items in the refrigerators when they looked for inventory. Dietary Aide #1 stated they forgot to check for expired food items. The Food Service Director checked the refrigerators for expired items as well. On [DATE] at 11:45AM, the Food Service Manager was interviewed and stated they checked the refrigerators twice daily for expired items. If items were due to expire the next day, the Food Service Manager discarded them. On [DATE] at 01:23 PM, the Food Service Director was interviewed and stated that each manager did a kitchen walk through daily on each shift. All kitchen staff were instructed to check for expired foods and to use the First In First Out method of rotation. The expired food items found in Refrigerators #1 and #3 were overlooked. 10 NYCRR 415.14 (h)

Based on record review and interviews conducted during the recertification and abbreviated survey (NY00316471) from 2/8/2024 to 2/15/2024, the facility did not ensure allegations involving abuse were reported to the New York State Department of Health within 2 hours of occurrence. This was evident for 2 (Resident #246 and #210) of 38 total sampled residents. Specifically, Residents #246 and #210 were involved in a resident-to-resident altercation that was not reported to the New York State Department of Health within 2 hours. The findings are: The facility policy titled Abuse, Mistreatment, Neglect and Exploitation and Misappropriation of Resident Property dated 11/2023 documented the Administrator and Director of Nursing has the responsibility to report all alleged violations in which there is reasonable cause to believe that abuse, neglect, or misappropriation has occurred. Resident #246 had diagnoses of hypertension and dementia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #246 was severely cognitively impaired. Resident #210 had diagnoses of hypertension and dementia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #210 was severely cognitively impaired. The facility Incident Report dated 5/11/2023 documented Resident #246's son witnessed Resident #210 grab and hit Resident #246. Nursing Note dated 05/11/2023 documented Resident #246's son reported to the nursing staff that Resident #210 grabbed and hit Resident #246. The Aspen Complaint Tracking System intake dated 05/12/2023 documented the facility reported the resident-to-resident altercation between Resident #246 and #210 on 5/12/2023 at 01:38 PM. There was no documented evidence the resident-to resident altercation between Resident #246 and #210 was reported to the New York State Department of Health within 2 hours of occurrence. On 02/14/2024 at 02:08 PM, the Director of Nursing was interviewed and stated the facility reported allegations of abuse and injury of unknown origin to the New York State Department of Health within 2 hours of occurrence. The incident between Resident #246 and #210 occurred on 5/11/2023 at 03:05 PM and was reported to the New York State Department of Health on 5/12/2023 at 10:20 AM. The Director of Nursing stated they interviewed staff and obtained statements prior to reporting an incident. If the facility determined abuse occurred after gathering statements, the incident would be reported. Resident #210 did not intend to harm Resident #246. On 02/15/2024 at 10:38 AM, the Administrator was interviewed and stated suspected abuse and injury were reported to the New York State Department of Health as soon as possible. Resident #246 did not sustain injury and Resident #210 did not have a history of abuse. Staff also did not witness the incident between Resident #246 and #210. The incident was reported the same day. 10 NYCRR 415.4(b)

Based on observations, record review, and interviews conducted during the Recertification survey from 02/08/2024 to 02/15/2024, the facility did not ensure a person-centered Comprehensive Care Plans was developed and implemented to meet a resident's needs. This was evident for 1 (Resident #36) of 2 residents reviewed for Urinary Catheter out of 38 total sampled residents. Specifically, Resident #36's Comprehensive Care Plan was not developed with interventions to address their urinary (Foley) catheter. The findings are: The facility policy titled Comprehensive Care Planning and Baseline dated 10/2023 documented the Comprehensive Care Plan will include measurable goals and timetables to meet the resident's medical, nursing, and psychosocial needs. Resident #36 had diagnoses of Benign Prostrate Hypertrophy and Diabetes Mellitus. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #36 was cognitively intact and had an indwelling catheter. The Physician's Orders dated 12/29/2023 and renewed 1/23/2024 documented Resident #36 received urinary output monitoring every shift and Foley catheter care every shift and as needed. The Comprehensive Care Plan related to urinary incontinence and indwelling catheter initiated 12/28/2023 documented interventions that included assisting with clothing management, maintaining dignity, and providing medications as ordered for Resident #36. There was no documented evidence the Comprehensive Care Plan related to Resident #36's indwelling catheter included interventions to address monitoring the resident's urinary output and providing Foley catheter care. On 02/15/2024 at 12:12 PM, Registered Nurse #5 was interviewed and stated the supervisors and nurses on the unit were responsible for developing Comprehensive Care Plans. Resident #36's care plan related to indwelling catheter should have addressed the resident's need for Foley catheter care. On 02/15/2024 at 01:53 PM, the Assistant Director of Nursing was interviewed and stated the Registered Nurses were responsible for developing and completing care plans. Resident #36's care plan related to indwelling catheter should have been developed with goals and interventions that addressed their need for Foley catheter care. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interview conducted during the Recertification survey from 2/8/2024 to 2/15/2024, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #243) of 3 residents reviewed for Limited Range of Motion out of 38 total sampled residents. Specifically, Resident # 243 did not have bilateral hand rolls in place according to Physician's Order. The findings are: The facility policy titled Activities of Daily Living Care Guidelines dated 10/2023 documented the Certified Nursing Assistant will apply splints, braces, and assistive devices as directed. Resident #243 had diagnoses of Alzheimer's Disease and Anemia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #243 was severely cognitively impaired, had functional limitations on their left upper extremity, and required assistance with activities of daily living. On 2/8/2024 at 10:45 AM, Resident #243 was observed in bed with bilateral hand contractures and no hand rolls in place. On 2/15/2024 at 10:46 AM, Resident #243 was observed with one hand roll in the left hand and no hand roll in the right hand. The Physician's Order dated 3/29/2022 and renewed 01/30/2024 documented bilateral hand rolls were applied to Resident #243 during the day and removed every shift for skin inspection. There was no documented evidence Resident #243's bilateral hand rolls were applied in accordance with the Physician's Order. On 2/15/2024 at 11:10 AM, Certified Nursing Assistant #7 was interviewed and stated Resident #243 required bilateral hand rolls to help the resident extend their hand and fingers. On 2/15/2024 at 11:56 AM, the Occupational Therapist was interviewed and stated Resident #243 was ordered to wear bilateral hand rolls that should only be taken on for hygiene purposes. On 2/15/2024 at 11:10 AM, the Assistant Director of Nursing was interviewed and stated bilateral hand rolls should be in place for Resident #243 in accordance with Physician's Order to prevent further hand contractures. 10 NYCRR 415.12(e)(2)

Based on observation, record review, and interviews conducted during the Recertification survey 02/08/2024 to 02/15/2024, the facility did not ensure a resident requiring dialysis services received such services consistent with professional standards of practice. This was identified for 1 (Resident #645) of 38 total sampled residents. Specifically, there was no Physician's Orders for Resident #645 to receive hemodialysis treatment. The findings are: The facility policy titled Hemodialysis dated 09/04/2023 documented all dialysis residents will be monitored pre and post dialysis treatment. Resident #645 was admitted to the facility on [DATE] with diagnoses of Hypertension, Diabetes, and Hyperlipidemia. The Comprehensive Care Plan related to hemodialysis initiated 1/31/2024 documented Resident #645 received dialysis treatment at a dialysis center. The Nursing Hemodialysis Communication Form dated 2/1/2024, 2/3/2024, 2/6/2024, 2/8/2024, and 2/10/2024 documented pre and post dialysis monitoring and vital signs for Resident #645. There was no documented evidence Resident #645 had a Physician's Order to receive hemodialysis treatment 3 times weekly. On 02/14/2024 at 11:37 AM, an interview was conducted with Registered Nurse #6 who stated Resident #645 received hemodialysis treatment 3 times weekly and the monitoring was documented on the Communication Form. On 02/14/2024 at 03:39 PM, an interview was conducted with Medical Director #1 who stated Resident #645 had chronic kidney disease and received hemodialysis treatment from a dialysis center. There should have been a Physician's Order for Resident #546 to receive hemodialysis treatment. 10 NYCRR 415.12

Based on observation, staff interview, and record review conducted during the Recertification survey, the facility did not ensure food storage in accordance with professional standards. Specifically, undated and expired food was observed in the Kitchen and Storage Room during the Kitchen Task. The findings are: The facility policy titled General Purchasing of Food and Non Food Products last revised ,d+[DATE] documented all items received in the kitchen will be dated by the storeroom worker. Refrigerated foods and opened boxes/cans/bottles are to be dated. The following was observed in the facility Kitchen on [DATE] at 10:20 AM: 1) Refrigerator #3 and, 2 packages of sliced ham deli meat, 4 packages of smoked ham deli meat , and 9 packages of turkey breast deli meat undated; 2) the Cook's Refrigerator contained housemade cranberry sauce dated [DATE]; raw cubed steak and pork shoulder unlabeled and undated; 4 plastic bins of cut vegetables without a date. The following was observed in the Kitchen on [DATE] at 09:44 AM: 1) the Storage Room opened bottles of vinegar, sweet and sour sauce, honey, and crushed red pepper without a delivery, open, or use by date; 2) the Cook's Refrigerator: 2 packages of raw pork undated; plastic bins of cut vegetables not dated; 2 packages of ground turkey not dated; 1 package frank/sausage not dated or labeled with product name; 3) refrigerator #1 - 9 plastic bins with biscuits / pastries not dated; Rolls wrapped in plastic wrap not dated. An interview was conducted on [DATE] at 02:55 PM with Dietary Aide (DA) #1 who food items are rotated on Monday to prepare for deliveries on Tuesday and Thursday. DA #1 uses a marker to write the delivery date on all boxes. An interview was conducted on [DATE] at 03:08 PM with the Chef who stated DA #1 dates boxes delivered to the facility. Items that need to be defrosted or refrigerated are placed in a container and masking tape is used to label the container with the date. The Chef uses the manufacturers guidance to determine expiration dates; however, stated there were some items that were not stored according to manufacturers labeling. An interview was conducted with the Food Service Director (FSD) on [DATE] at 03:48 PM who stated items are dated upon delivery. Food items that are taken out of their original packaging are dated when being stored. A orange sticker may be applied to foods that need to be used first. 415.14(h)

Based on record review and interviews conducted during the Recertification Survey and Complaint Survey (NY00286786), the facility did not ensure each residnet received adequate supervision to prevent accidents. Specifically, Resident #365 was allowed Out on Pass (OOP) unescorted without a safety assessment or Physician's Order (MDO). The resident did not return to the facility and remained unaccounted for until the facility was informed the resident was hospitalized . This was evident for 1 of 1 resident reviewed for Accidents (Resident #365). The findings are: The facility policy titled Residents OOP initiated 3/98 and last revised 2/19 documented licensed nurses inform the Attending Physician (MD) of a resident's request for OOP. Resident # 365 had diagnoses of Schizophrenia, Major depressive disorder, and recurrent pain. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 365 was cognitively intact and required supervision for transfer, walk in room, walk in corridor, locomotion on unit, and extensive assistance for locomotion off unit. MDO initiated on 11/17/2021 documented Resident # 365 to ambulate 150 feet with rollator and 1 staff supervision 2 times daily (for at least 15 minutes/day) to increase/maintain ambulation skills. Comprehensive Care Plan (CCP) related to Activities of Daily Living (ADL) initiated 9/7/2021 and last updated 11/15/2021 documented Resident # 365 required rollator and supervision for locomotion on unit, walk in corridor, walk in room, and 1-person physical assist for locomotion off unit. OOP Forms documented Resident #365 left the facility OOP unescorted on 10/15/2021 and 10/25/2021. MD assessment dated [DATE] documented Resident # 365 was alert, ambulated with assistance, and at high risk for falls. Nursing note dated 11/16/2021 documented Resident # 365 had a fall on the unit. Resident Accident/Incident Report dated 11/16/2021 documented Resident # 365 had a fall on the unit, was referred to rehabilitation department, and was educated re: fall safety. OOP Forms documented Resident #365 left the facility OOP unescorted on 11/16/21. Clinic/Outside Appointment Schedule on 11/18/2021 documented Resident # 365 had a scheduled clinic appointment with urology and transportation was scheduled. OOP Forms documented Resident #365 left the facility OOP unescorted on 11/18/21. Nursing note dated 11/18/2021 documented Resident # 365 did not return from OOP at the end of day and the facility was unable to locate Resident # 365. Incident/Accident Report dated 11/19/2021 documented Resident # 365 left unit with OOP to clinic appointment and did not return to facility. Nursing note dated 11/22/2021 documented Social Worker at the hospital called and reported Resident #365 was admitted to the hospital on 11/21/2021 due to a fall at home. There was no documented evidence in the medical record Resident #365 was assessed by the MD to determine risk and safety of unescorted OOP. On 12/06/21 at 11:51 AM, an interview was conducted with Registered Nurse (RN) # 3 who stated residents can go OOP unescorted after MD assessment and MDO in place. RN #3 made an error when issuing Resident #365 an OOP to go to a clinic appointment. RN #3 thought there was an MDO for Resident #365 to go OOP unescorted, but realized there was no MDO. On 12/06/21 at 12:50 PM, an interview was conducted with Physical Therapist (PT) who stated Resident # 365 was assessed after a fall on 11/16/2021 and PT recommended Resident #365 be escorted to clinic appointments for safety. On 12/06/21 at 04:32 PM, a telephone interview was conducted with the MD who stated they could not recall if they issued a MDO for OOP for Resident #365. MD was unfamiliar with the facility policy on OOP and did not know if MDO was required. On 12/06/21 at 05:04 PM, an interview was conducted with the Medical Director who stated if the nurse contacts the MD re: a resident's request to go OOP unescorted, the MD should not have to write an MDO. It is sufficient if the nurse documents in the medical record that the MD was made aware. On 12/07/21 at 11:39 AM, an interview was conducted with Director of Nursing (DON) who stated residents who request an OOP unescorted for social activities must speak with the social worker or nurse. The MD provides medical clearance and an MDO. Residents who go to clinic appointments unescorted do not require an MDO for OOP. 415.12(h)(2)

Based on record reviews and staff interviews conducted during the recertification and complaint (NY00274854) survey, the facility did not ensure that person-centered care plans were developed and implemented. Specifically, there was no documented evidence a comprehensive care plan (CCP) related to verbally aggressive behavior towards others was developed for Resident #251. This was evident for 1 of 8 residents investigated for Abuse out of a total sample of 38 residents (Resident #251). The findings are: The facility policy titled Interim/CCP reviewed 07/2021 documented new problems between Minimum Data Set (MDS) assessment periods will be documented on the Episodic CCP Form and a CCP will be initiated. On 12/01/21 at 10:12 AM, an interview was conducted with Resident #251 who stated they did have a altercation with another resident in the computer room. The resident declined to discuss any further. Resident #251 had diagnoses of Hepatic Failure, Alcohol use with alcohol-induced psychotic disorder, and Wernicke's Encephalopathy. The MDS dated [DATE] documented the resident had intact cognition and required supervision to extensive assistance of one person for Activities of Daily Living (ADL). Nursing Note (NN) dated 8/8/2021, documented Resident #251 was upset because they could not stay in the computer room and was bored. The nurse walked away after Resident #251 became more upset and could not be redirected. NN dated 9/13/2021, documented Resident #251 presented with a new behavior of screaming and yelling. Interventions provided to the resident included providing a calm, structured environment, checking for unmet needs, redirection, and engaging in activities. NN dated 9/14 and 9/15/2021 documented Resident #251 was yelling, threatening, cursing at others and was pacing. NN dated 9/15/2021 documented on 9/13 at 6 PM, was called to the resident's unit. Resident #251 was in their room agitated and reporting they felt attacked. Resident #251 became more agitated and verbally aggressive after police came and left. The resident's daughter was present and reasoned with resident. Psychiatric Consult dated 9/17/2021, documented Resident #251 had capacity to make decision and was disappointed, insulted and angry due to recent altercation. The resident was unable to recognize own involvement, had poor insight, appeared hostile and guarded, and refused medication and psychiatric treatment. There was no documented evidence in the resident's medical record a CCP related to the resident's verbally aggressive behaviors was developed. On 12/03/21 at 02:22 PM, an interview was conducted with Registered Nurse (RN) #6 who stated Resident #251 was easily triggered and can get angry when things don't go their way. RN #6 was aware of the NNs documenting the resident's behavior. After reviewing Resident #251's medical record, RN #6 stated there was no CCP related to behaviors in place and RN #6 was unable to provide a reason the CCP was not initiated. On 12/06/21 at 11:09 AM, an interview was conducted with License Practical Nurse (LPN) #1 who stated Resident #251 yells and screams at times. LPN #1 wrote the behavior notes but was not responsible for initiating CCPs. It was an oversight if the CCP for behaviors was not in place for Resident #251. On 12/08/21 at 12:39 PM, an interview was conducted with the Director of Nursing (DON) who stated care plans are initiated for any episodic behaviors or change in medical condition. The RN initiates the CCP if a resident had an incident and there was no CCP in place. The person who reported the incident to the Department of Health (DOH) should ensure CCP documentation is in place. The MDS department also reviews resident CCPs to ensure they are in place and updated. The DON was unable to provide a a reason Resident #251 did not have a CCP related to altercations in place. 415.11(c)(1)

Based on interviews and records review conducted during the recertification and complaint survey (NY 549), the facility did not ensure that an alleged violation involving Abuse was reported to the New York State Department of Health (NYSDOH) within the acceptable timeframe. Specifically, one allegation of resident to resident abuse, involving Resident #122 and #203, was not reported within 2 hours. This was evident for 2 of 8 residents reviewed for Abuse (Resident #122 and #203). The findings are: The facility policy titled Resident Abuse, Neglect, Exploitation, Mistreatment, Involuntary Seclusion, Misappropriation of Property effective 7/98 and reviewed 4/21 documented allegations of abuse are to be reported to the NYSDOH in adherence to state and federal requirements. Resident #203 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 203 had moderately impaired cognition and required limited to extensive assistance of one person for Activities of Daily Living (ADL). A Nursing Note dated 8/10/2021 documented Resident #122 was sitting in the hallway when Resident #203 walked into Resident #122's room. Resident #122 followed Resident #203 into the room. The Certified Nursing Assistant (CNA) heard a commotion, entered the room, and observed Resident #122 and #203 arguing. Resident #122 scratched Resident #203 and Resident #203 punched Resident #122 in the back. Registered Nurse (RN) #6 assessed both residents and the Medical Doctor (MD) was made aware. Resident # 122 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #122 had severely impaired cognition and required extensive assistance of 1 person for Activities of Daily Living (ADL). The Accident/Incident Report was initiated 8/10/2021 and documented the facility investigated the incident between Resident #122 and #203. The investigation was completed and signed 8/16/21 by the Assistant Director of Nursing (ADNS). The Hospital Emergency Response Data System (HERDS) documented the facility reported the incident to the NYSDOH on 8/17/2021. An interview was conducted on 12/08/21 at 12:12 PM with the ADNS who stated they were unaware of the reporting requirements for abuse allegations and would need to check the NYSDOH regulation. An interview was conducted on 12/08/21 at 01:05 PM with the Director of Nursing (DON) who stated suspected abuse should be reported to the NYSDOH within 24 hours. If the alleged abuse resulted in injury, a report should be made immediately. The facility has 5 days to complete their investigation and report to the NYSDOH. 415.4(b)(1)(i)

Based on observations, record review, and interviews during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, a Certified Nursing Assistant (CNA) was observed using a blood pressure cuff (BPC) on multiple residents without sanitizing the BPC and hands between residents. This was evident for 1 of 5 floors (Unit - 5B) observed for Infection Control. The findings are: The policy titled Cleaning Nursing Equipment last reviewed 03/2021 documented, in between use with each resident, the BPCs are cleaned with [MEDICATION(S)] wipes and given a 3-minute drying. Wipes are to be placed in the garbage, gloves removed, and hands washed. On 12/01/2021 at 11:02AM, CNA #7 was observed on the 5B unit with ungloved hands, applying a BPC to the right upper arm of Resident #54. CNA #7 placed the BPC into the holder attached to the BP machine and walked to Resident #120 who was sitting at their room door. CNA #7 applied the BPC to the bare left lower forearm of Resident #120. CNA #7 entered the room and applied the BPC to the bare upper left arm of Resident #145, removed the BPC, exited the room, and placed the BPC and BP machine at the nursing station. CNA #7 did not sanitize the BPC and did not don gloves or perform hand hygiene in between each resident use. On 12/01/2021 at 12:23PM, CNA#7 was interviewed, and stated BPCs and hands are to be sanitized in between each resident use. This prevents the spread of infection. CNA #7 would normally perform hand hygiene and sanitize the BPC in between each resident but was not thinking at the moment and did not sanitize the BPC or hands in between Resident #54, #120, and #145. On 12/01/2021 at 12:35PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated shared equipment should be cleaned after each resident and should be sanitized and let it dry 3-5 minutes before using on the next resident. Staff must perform hand hygiene in between residents when using a shared device. On 12/07/2021 at 03:28PM, the Infection Preventionist (IP) was interviewed and stated the IP does weekly observations of the facility, conducts monthly departmental infection control observations, and conducts audits and inservice if issues are found. Shared devices (i.e., BPCs) are to be sanitized and given 3 minutes in between each resident use. Staff are to don gloves and perform hand hygiene and change gloves in between each resident when using a shared device. 415.19 (a)(1),(b)(4)

Based on interviews and record reviews conducted during an abbreviated survey (NY 073), the facility did not develop and implement a baseline care plan within 48 hours for a resident with known food allergies. This was evident in 1 out of 5 residents sampled, (Resident #1). Specifically, Resident #1 was admitted to the facility on [DATE] with food allergies to Fish, Peanut, Seafood and Iodine. On 04/12/2019, Resident #1 was served fish on his lunch tray and reported that he took a bite of the fish. Subsequently, Resident #1 had an Anaphylactic reaction and was transferred to the Hospital where he was intubated and admitted to the Intensive Care Unit (ICU). A Nutrition Care Plan was noted in place with no mention of food allergies or intervention for food allergies. Findings include: The Dietary Department's Policy on Food Allergies with effective date 11/2016 states to document all known allergies in the Nutritional Assessment and in the Care Plan. A 48 hours Nutrition Care Plan was noted in place with no mention of food allergies. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was also legally blind. The physician's orders [REDACTED].#1 had Allergies to Contrast Dye; Fish; Iodine; Peanuts and Seafood. Resident #1's Electronic Medical Record (EMR) Home Page has a Color-Coded Alert for Allergy to Fish, Seafood, Peanuts, Iodine and Contrast Dye. Review of Dietary and Nursing Care Plans from 04/09 to 04/11/2019, revealed no mention of food allergies. Review of the Nursing Progress notes dated 04/12/2019 at 3:44PM, revealed that Resident #1 was served lunch in his room at 1:15PM. Fish allergy was noted on the tray ticket. The Certified Nursing Assistant (CNA) went to remove the fish from the resident's plate. Resident #1 reported to the CNA that he took one bite of the fish before he realized that it was fish. Resident #1 reported that his throat was closing. STAT (immediately) [MEDICATION NAME], oral [MEDICATION NAME] and oral [MEDICATION NAME] 50mg given. Resident #1 was placed on 1:1 monitoring. At 1:49 PM, Resident #1 stated that he cannot breathe. Pulse Ox slowly dropping. [MEDICATION NAME] administered and 911 called and the resident was transferred to the Hospital. The Resident Accident/Incident Report dated 04/12/2019 documented that Resident #1 reported that his throat was closing after he ate fish. Resident #1 had an Anaphylactic reaction to fish. Review of the Nursing Progress Note dated 04/12/2019 at 10:32PM, revealed that Resident #1 was admitted to ICU. The Director of Food Service was interviewed via telephone on 10/08/2019 at 1:41PM. She stated that when a resident is admitted to the facility, the team meets with the resident or family within 48 hours to discuss and confirm accuracy of information on the Patient Review Instrument (PRI). The Dietitian has 72 hours to meet with the resident and compete the resident's assessment and CP. Upon inquiry, the Director of Food Service acknowledged that the Comprehensive Care Plan did not addreess Resident #1's Food Allergies and stated that it was an oversite. 415.11 (c)(1) .

Based on record review and staff interview during the re-certification survey, the facility did not ensure completed Minimum Data Set 3.0 (MDS) comprehensive and non-comprehensive assessments were electronically submitted and transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System in a timely manner. Specifically, admission, annual, significant change, and quarterly assessments were not transmitted within fourteen (14) calendar days after the assessments were completed. This was evident for 18 of 19 residents reviewed for the Resident Assessment facility task (Resident #'s 7, 6, 11, 22, 17, 15, 21, 9, 35, 16, 19, 10, 20, 50, 18, 12, 13, and 14). The findings include but are not limited to: The facility does not have a policy and procedure for MDS Submission and Transmission. CMS RAI Version 3.0 Manual (Dated (MONTH) (YEAR))- Chapter 5 titled Submission and Correction of the MDS Assessments documented: The MDS completion date must be no later than 14 days after the assessment reference date (ARD) for all non-admission, OBRA, and PPS assessments. The MDS completion date must be no later than 13 days after the entry date for admission assessments. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. 1) Resident #11 was admitted on [DATE]. The Annual assessment had an ARD 03/19/19. It was completed on 04/02/19 with care plan completion also on 04/02/19 and submitted on 05/08/19. The Quarterly assessment had an ARD 12/24/18. It was completed on 01/07/19 and submitted on 01/29/19. Another Quarterly assessment had ARD 07/10/18. It was completed on 07/16/18 and submitted on 08/13/18. 2) Resident #13 was admitted on [DATE]. The Annual assessment had an ARD of 07/13/18. It was completed on 07/24/18 with care plan completion on 07/26/18. It was submitted 08/13/18. The Quarterly assessment had an ARD of 12/24/18. It was completed on 01/07/19 and submitted on 01/29/19. Another Quarterly assessment had an ARD of 03/26/19. It was completed on 04/09/19 and submitted on 05/06/19. 3) Resident #22 was admitted on [DATE]. The Quarterly assessment had an ARD of 03/26/19. It was completed on 04/09/19 and submitted on 05/06/19. 4) Resident #17 was admitted on [DATE]. The Annual assessment had an ARD of 03/19/19. It was completed on 04/02/19 and submitted on 05/08/19. 5) Resident #10 was admitted on [DATE]. The Quarterly assessment had an ARD of 07/11/18. It was completed on 07/19/18 and submitted on 08/13/18. The Quarterly assessment had an ARD of 12/22/18. It was completed on 01/05/19 and submitted on 01/29/19. The Annual assessment had an ARD of 03/17/19. It was completed on 03/31/19 with care plan completion on 04/07/19 and submitted on 05/08/19. On 05/14/19 at 11:29 AM, the RN MDS Director (RN #3) was interviewed. He stated they have 14 days from the ARD to complete, sign, and submit MDS assessments for annual and quarterly assessments. He stated he has 14 days from admission to complete and sign admission assessments, and after admission assessment is completed he has 14 days to submit it. RN #3 stated he started this position in (MONTH) (YEAR) and is responsible for scheduling and auditing books as they are completed. He further stated he is not authorized to submit completed books yet because he is waiting to gain access. RN #3 stated he had already identified that MDS assessments were not all being submitted timely and it was discussed during quality assurance meetings. The previous MDS coordinator who was responsible for submitting books was overwhelmed, and that is why he was hired. Currently, the other MDS coordinator still does all the submitting.

Based on observations, record reviews, resident and staff interviews, the facility did not ensure comprehensive care plans were reviewed and revised by the interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident. Specifically, (1) a comprehensive care plan for a resident who smokes was not evaluated for effectiveness of interventions and changing goals (Resident #11). 2) The care plan for Resident #395 was not revised to reflect identification of onset of [MEDICAL CONDITION]. This deficient practice was evident for 2 of residents. The facility policy and procedure titled, Completing Care Plans and Care Plan Meetings in the EMR (Dated 08/18) documented the following. As per CMS guidelines for Requirements of Participation for Long Term Care Facilities, Phase 2, facilities must have completed customized Care Plans for every resident within 48 hours of admission .the resident's care plan must be individualized, reflect interdisciplinary approach and reviewed within the specified time frames expressed for each goal .Clinical staff will assess/evaluate each resident upon admission/readmission and as focuses are identified. Clinical staff will initiate/update and review the resident's care plans as scheduled .Each care plan must have goals with review dates and goals should be measurable, specific, attainable, realistic, and time bonded. Interventions should address the needs of the resident, resolve the problem, maintain the resident's strengths, and identify which disciplines are responsible for each intervention .Care plans to be reviewed quarterly and updated as needed .Care plan meetings . The findings are: 1) Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/09/19 at 12:06 PM, resident #11 doorway frame was observed with a red flag. Resident#11 was then observed asleep in bed but easily awakened. Observed bedside drawer next to his bed and on top, there was an opened lap top. A Marlboro cigarette box and 8 lighters were observed placed on top of the keyboard out in the open. On 05/09/19 at 03:05 PM, resident #11 was observed sitting outside in the designated smoking area which is up the ramp on the right side of the main entrance in his wheelchair next to the ash tray already smoking with his right hand. Observed resident #11 with a burnt hole on his right pant leg by the knee. Observed resident #11 holding the cigarette above the same area where the burnt hole is but the ashes were not landing on his knee and was being blown away instead. Resident #11 then completed the cigarette and threw it on the floor. Resident #11 then took another cigarette to smoke and lighted it up. On 05/09/19 at 04:56 PM, resident #11 bedside drawer next to his bed were a total of 9 lighters, 8 on the laptop and 1 by the side of the laptop, and a box of Marlboro cigarettes. The Minimum Data Set (MDS) 3.0 Annual assessment dated [DATE] was reviewed. Resident is cognitively intact. Resident is mostly independent with set up for transfer, and locomotion on and off unit. Resident documented with currently using tobacco. The Comprehensive Care Plan (CCP) titled, Smoking Plan of Care (Effective date 07/06/18) documented resident with a psychosocial history that reveals resident is a known smoker and is a unsupervised smoker. Goals were not marked off for resident. Interventions with effective dates of 09/13/18 included the following. Review smoking policy with resident and family on admission, readmission, and as needed. Check clothing regularly for signs of unsafe smoking. Provide smoking apron as needed. Encourage smoking cessation. Provide education on risks of smoking behavior. Notes documented on 10/15/18 and 3/18/19 that resident have no changes and is an unsupervised smoker in front of the building. The Smoking Risk Assessments were reviewed from 04/2017 to current as per availability. Smoking Risk Assessments were completed on 04/04/17, 07/03/17, 10/01/17, 12/30/17, 01/11/19, and 05/10/19. There were no Smoking Risk Assessments completed for the year of (YEAR). All assessments documented resident as an unsupervised smoker. Social Work assessments were reviewed from 1/2018 to Current, 5/2019 and there were no documentation regarding smoking found. Social Work notes were reviewed from 1/2018 to Current, 5/2019 and the following were documented. On 01/16/19, .Worker educated the resident about upcoming changes to our smoking policy which will mean that residents must keep their smoking materials at the nursing station. Worker informed him that this change would be taking place in the near future for .to be prepared .Staff will continue to monitor his smoking and functional ability for proper placement alternatives. On 01/23/19, .is still able to go out on a daily basis to smoke and remain independent in eating and transferring and able to leave the facility to smoke . On 01/28/19, .he continues to follow the smoking guidelines There was no documentation regarding staff acknowledging resident with a burnt hole on his pants. There was no documentation in both facility policies and resident record regarding where smoking paraphernalia should or supposed to be kept. On 05/09/19 at 12:06 PM and at 03:05 PM, resident #11 stated he smokes four (4) times a day where smoking is allowed out in the front on the ramp where there's an ash tray. Resident #11 stated he just goes downstairs without telling anyone and he tells the security guard by the entrance that he's going outside. He further stated staff does not question him and he does not need a pass to go outside. Resident stated he was not assessed for safe smoking and did not sign any contract or agreement. He further stated he has always held on to his own cigarettes and lighters and he does not keep it locked up anywhere. On 05/10/19 at 02:21 PM, and on 05/13/19 at 11:28 AM and at 12:21 PM, the Director of SW stated the following. The policy for smoking is residents going out in pass to smoke. Currently the policy is being worked on. In the meantime, the SW is responsible for identifying if a resident is a smoker or not upon admission. Then the SW will educate the resident that this is a non-smoking facility. The resident is also evaluated using the smoking risk assessment. If the resident is deemed alert and oriented, and a unsupervised/safe smoker, the resident can smoke outside in the front of the building. These same residents hold onto their own smoking materials since they are deemed safe. Smoking assessments can be completed by both nursing and SW and are done upon admission, quarterly, and as needed. The smoking rules are discussed with the resident and/or family during the time the smoking assessments are completed. Smokers are monitored and supervised by checking their clothes and determining if there was a significant change in their status. The director of SW further stated he has not seen smoking materials in resident room or burn holes on resident clothes before since resident had always compiled with the rule to smoke out in the front. He further stated a smoking contract is only provided to residents who were determined to be a unsafe smoker. The SW is responsible for developing and updating the smoking CCP. There was no response as to why the smoking CCP was not completed to reflect measurable goals and if the interventions were effective or not. The CCP should be updated and revised quarterly and as needed. 2). Resident #395 a [AGE] year-old admitted with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set 3.00 assessment dated [DATE] identified the resident as moderately impaired with her cognition. The resident requires extensive assist with two ( 2) persons in all care areas except eating. On 05/07/2019 at 11:04 AM the resident was observed in bed with 2 1/2 siderails up, lying in a bariatric bed, with Foley catheter connected to bedside bag with dark orange colored urine, with intravenous fluid of [MEDICATION NAME] 5 % sodium chloride (D5NACL ) infusing on left forearm. Oxygen by nasal cannula connected to an oxygen tank at 2 liters. Resident was observed with bilateral [MEDICAL CONDITION] of the upper and lower extremities with no devices in place. Resident was visited again on 05/13/2019 at 10:55 AM and 05/14/2019 at 11:50 AM . Resident with oxygen and with Foley catheter connected to bedside bag . Bilateral [MEDICAL CONDITION] of upper and lower extremities was noted . The resident was interviewed on 5/14/19 at 11:00 AM. The resident stated that no devices were being used on her upper or lower extremities. The physician's notes located in the interdisciplinary notes of the resident's record documented: resident non - compliance with use of [MEDICAL CONDITION] that resulted in CO2 retention leading to decrease mentation . PE with dependent [MEDICAL CONDITION] /pressure ulcer-- under the breast stage 2 / cognitive impairment of dementia / [MEDICAL CONDITIONS] with [MEDICAL CONDITION] of upper and lower extremities . Diuretic EF ( ejection fraction ) 70 % as per chart review . Based on X-ray with pleural effusion . Plan : monitor for increase [MEDICAL CONDITION] and signs and symptoms of [MEDICAL CONDITION] exacerbation. With pacemaker and target PR is 60-100 beat /minute . Resident has also a [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP ) for Cardiac care dated 03/27/2019 did not address resident's [MEDICAL CONDITION]. It was not identified as a problem there were no measurable goals or interventions documented to ddress the [MEDICAL CONDITION]. No other care plan in the record addressed the resident's [MEDICAL CONDITION]. On 05/14/2019 at 10:50 AM the Registered nurse unit manager (RNUM ) was interviewed. She was asked what care plan or interventions were in place for the resident's [MEDICAL CONDITION]. She stated that she developed the CCP for cardiac and respiratory care, but that she did not develop plan of care that addressed [MEDICAL CONDITION] or the resident's pace maker. 415.11(c)(2)(i-iii)

Based on observations, record review and staff interviews during the re-certification survey, the facility did not ensure food was handled under sanitary conditions. Specifically, (1) a food service worker did not have on gloves before touching raw food (2) a food service worker did not have on gloves before covering a pan of cooked baked chicken with aluminum foil after touching the lid of a garbage can and (3) a food service worker did not wear a hairnet during the entire lunch meal service on one of the unit's dining room. This pattern of deficient practice was evident during the kitchen and dining facility tasks of the re-certification survey. The finding is. The facility's policy and procedure titled Proper Use of Gloves documented that disposable gloves should be discarded after a specific task. The policy and procedure titled Personal Hygiene documented wear a hairnet, hat or hair coverings while on duty to confine hair. On 05/09/19 at 11:08 AM, Cook #1 was observed using an uncovered round, gray garbage can with wheels to discard the plastic wraps of 8 rolls of a ten(10) pound (lb) raw ground beef which were individually wrapped. The ground beef were on a food push cart which was situated next to the steam kettle. The uncovered garbage can was next to the food cart. He slit open the plastic wrap open in the middle with a knife. He then puts the raw ground beef into the industrial-type steam kettle. He discards the plastic wrap into the uncovered garbage can. He stated that he is putting the raw ground beef in a kettle so he could partially removed the blood by draining with water. Approximately after opening the 4th of the 5th the plastic bag, he rinsed the knife in the sink, pushed the uncovered plastic, gray garbage can with his gloved hand, holding the top of the lined garbage can with his gloved hand to the side of the kettle. He continued slitting the remaining rolled, plastic-wrapped raw ground beef and putting the rest of the ground beef in the kettle. On 05/09/19 at 11:18 AM, another garbage can with no lid was observed in the other section of the cook's area where thawed fish was being seasoned for the night's dinner. On 05/09/19 at 02:38 PM, Cook #2 was observed at his cook's table, threw out something in the garbage can which was covered and lifted the lid with his bare hand. Then he went back to his working table where he was covering baked chicken in a quarter pan, and covered the pan of chicken with an aluminum foil Cook did not wash his hands or donned gloves before touching the aluminum . On 05/09/19 at 02:53 PM, Cook #1 was interviewed regarding the garbage can that has no lid and was pushed to the side on 05/09/19 11:08 AM. He stated that there was no lid that morning, it could have been behind it. He stated that the proper procedure for the use of gloves is that he will put his gloves on and put the paper inside the garbage can, then throw out the gloves, wash the hands and dry them good before touching the aluminum foil to cover the chicken(baked) in a quarter pan. There is a possibility of bacteria contamination and possibly people will get sick eating the contaminated food. We get in-service on the wearing gloves, how to sanitize equipment, how to clean his knives and handling meats. On 05/09/19 at 03:02 PM, Cook #2 was interviewed. He stated that there are two( 2 )big cans by the cook's area. The garbage cans must be covered at all times, basically for contamination reason and odors. The person who eats contaminated food may end up sick and might end up in the hospital. The garbage receptacles, the gray ones, which you need to lift the cover to throw out something. The lid is still contaminated so they need to use gloves. Most of the time, the cooks need to wear gloves, especially when handling meat. The cooks are not supposed to lift the lid with bare hands and touch any food because of cross-contamination when preparing food and feeding residents. On 05/09/19 at 03:12 PM, the Food Service Director(FSD) was interviewed. She stated that lifting the lids with bare hands, and then touching the food will result in food becoming contaminated(cross contamination). NYS laws state that you cannot use bare hands while preparing and cooking food. On 05/09/19 at 12:40 PM Dietary Aide(DA) was observed serving the soup in the dining room of one of the units. She was not wearing a hairnet although wearing disposable gloves. On 05/09/19 at 12:43 PM Staff was asked if she was wearing a hair net and she stated she is not wearing a hairnet. She forgot to put on one. On 05/09/19 at 02:44 PM DA was interviewed. She said you need to wear a hairnet so food will be healthy. She stated that there is no bacteria in her hair since the hair was pulled very tight away from her face. She also stated that if there is hair on the food, the food will be nasty, there will be bacteria and it is not healthy. The people who eats them may feel disgusted and, not healthy. She said she had in-service, this is the first time it happened, and never happened to her. On 05/09/19 at 03:12 PM, FSD was interviewed. Dietary aides on the floors who dishes out the meals for the Residents are all required to wear a hairnet when serving the food. It's basic food safety, prevention of cross - contamination and prevention of food - borne illness. Food safety also includes washing hands, wearing hairnets/beard guards. 415.4(h)

Based on observation, record review and interview during the recertification survey, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life. Specifically, a resident was observed on two different occasions with crumbs, food debris, and wet spill stains on their clothing. This was evident for 1 resident reviewed for Dignity (Resident #296). The finding is: The facility admission agreement documented residents are provided with assistance and/or supervision, when required, with activities of daily living (ADLs) under the basic daily rate. The facility policy on AM care /PM care, revised on 12/1/2014, documented: AM care begins at 5:00 AM and PM care begins at 6:30 PM. All residents unable to care for themselves are provided total care. The purpose is to refresh the resident, maintain cleanliness, comfort and neatness. Resident #296 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition and was rarely understood. The resident required the extensive assist of one person with dressing and hygiene, and the resident was able to feed herself after set-up assistance. On 05/07/2019 at 11:20 AM, during the initial tour of the unit, the resident was observed wearing a hospital gown covered with crumbs and pieces of food debris. The resident's breakfast tray was still on the table in front of her. On 05/13/2019 at 2:34 PM, the resident was observed seated in her geri chair in the entrance of her room dressed in a gray T-shirt and sweat pants. The T-shirt was wet from the neck down, and there were food particles on the chest area and the resident's mouth. The State Agent (SA) could smell the scent of the food that was eaten for lunch on the resident. Lunch was served at 12:00 PM and completed at 1:00 PM. The Comprehensive Care Plan (CCP) for ADLs documented the resident had self-care deficits related to impaired cognition and dementia. The CCP goals for 90 days were to have ADL and personal needs met, for resident to be clean and odor free daily, and for resident to be appropriately dressed and groomed daily. The interventions included assist with dressing needs and provide AM and PM care. On 05/13/2019 at 2:35 PM, the Certified Nursing Assistant (CNA) assigned to the resident was interviewed. The CNA stated that she assisted the resident with setting up the meal tray, but she did not remove the resident's meal after she finished the meal. She stated that someone else assisted her because she was attending to another resident. On 5/13/19 the unit charge Registered Nurse was also interviewed. She stated that the staff should be on top of this. 415.3 (c0(1)(i)