Every finding on record at Comprehensive Rehabilitation and Nursing Center at

Based on observation, record review and interviews conducted during survey, the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accident/hazards for one (Resident #2) of seven residents reviewed for accidents. Specifically, on 04/21/2026 at 8:14 PM, Resident #2, who had moderate cognitive impairment, exited the facility through the front doors after being let out by Licensed Practical Nurse #2 and left unsupervised. Two hours later, Resident #2 was located approximately 0.3 miles away from the facility by a staff member. This resulted in no actual harm that was Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm, serious impairment, serious injury or death to Resident #2's health and safety. The findings include:The facility policy and procedure titled Elopement Preventions and Protocol for Missing Resident dated January 2025 documented residents who are cognitively impaired, wander, and/or have emotional disturbances may predispose them to the risk of leaving the facility without prior notification/approval. Residents will be protected from actual/potential harm in a safe and secure manner. The policy defined elopement as having evidence that a resident has left the building without authorization and undetected by staff.The facility policy and procedure titled Unsafe Wandering and Elopement updated 04/14/2026 documented it is the policy of the facility to deliver resident focused care safely, respecting rights and the dignity of the individual. Elopement occurs when a resident successfully leaves the facility undetected and unsupervised and enters harm's way. Elopement is not an issue exclusively related to residents with cognitive impairment. All employees are responsible for ensuring the safety of residents. If the employee has any suspicion that the resident should not be unattended the employee will notify the Nursing Supervisor for assistance.Resident #2 had diagnoses that included seizures (a sudden uncontrolled surge of electrical activity in the brain), cerebral infarction (stroke-the death of brain tissue caused by disrupted blood supply) with right side hemiparesis (weakness of one side of the body) and aphasia (difficulty with speech). The Minimum Data Set (a resident assessment tool) dated 04/15/2026 documented Resident #2 was usually understood and understands and had moderate cognitive impairment. Resident #2 exhibited verbal behaviors directed toward others and was independent with transfers, ambulation and wheelchair mobility up to 150 feet.The undated care plan identified by the Director of Nursing as current prior to the 04/21/2026 elopement incident, documented Resident #2 was at risk for falls related to seizures, repeated falls, hemiplegia (paralysis on one side of the body) and hemiparesis.There was no documented evidence Resident #2 was assessed to be safe outside of the facility unsupervised.Review of the Kardex Report (a guide used by staff to provide care) dated 04/21/2026 revealed Resident #2 ambulated independently with hemi walker (type of assistive device) up to 150 feet.The Wandering/Elopement Risk Assessment completed on 04/21/2026 at 1:06 PM, documented Resident #2 was comatose (prolonged state of deep unconsciousness), wheelchair bound and was at a low risk for elopement.Review of a Provider Note dated 03/25/2026 completed by Medical Director #2, revealed Resident #2 was evaluated for advanced care planning (review of advanced directives and capacity) and lacks capacity to make decisions.The Health Status Note signed and dated 04/21/2026 at 11:00 PM by Registered Nurse Manager #2 documented Resident #2 was unable to be found during the hour of sleep medication pass. After the staff had searched all units and common areas inside the facility Registered Nurse Manager #2 noticed Resident #2's empty wheelchair located at the front lobby and they began to search the outside perimeter, instructed staff to search the immediate vicinity with their vehicles and were to return to the facility within five minutes. Registered Nurse Manager #2 documented they searched the rear of the building and when they re-entered the building staff had returned to the facility with Resident #2. They documented Resident #2 was laughing upon return, had no visible injuries, no complaints of pain, they were fully dressed, had their coat and quad cane (assistive device) with them. Registered Nurse Manager #2 documented upon return, Resident #2 continued with exit seeking behaviors, they were placed on safety checks and a wander alert device (a device to detect wandering) was applied to their left ankle. They notified the Director of Nursing, Medical Provider, and attempted to contact Resident #2's family.The Long-Term Care Acute Visit note signed and dated 04/22/2026 at 12:00 PM by Physician Assistant #1, documented Resident #2 reported they were attempting to go home so they could go outside to smoke.Review of the facility Investigation Summary Form completed by the Director of Nursing dated 04/22/2026 documented on 04/21/2026 at 8:14 PM, Resident #2 told Licensed Practical Nurse #2 they needed to go outside to retrieve a package. Licensed Practical Nurse #2 allowed them to go outside, and Resident #2 did not return to the facility. Resident #2 was noted to be missing when staff could not locate them during the evening medication pass. Licensed Practical Nurse #4 located Resident #2 with their assistive device (cane) on a main road where the speed limit was 30 miles per hour and was returned to the facility at 10:48 PM with no injuries noted. The facility investigation concluded Resident #2 attempted to leave the facility against medical advice, they returned to the facility, and the social worker was to work on a discharge plan. During an observation and interview on 07/06/2026 at 1:22 PM, Resident #2 was observed sitting in their wheelchair in the activity room, wander alert bracelet was observed on their left ankle. Resident #2 stated they ran away because there was nothing to do at the facility and they were bored. Resident #2 stated they exited the facility through the front door and could not recall if there were any staff around when they left the building. Resident #2 stated a staff member had returned them to the building. They stated they were not injured and had not attempted to leave the facility again. During an observation and interview on 07/09/2026 at 8:40 AM, the Maintenance Director stated the facility's main entrance doors (inner set of doors) were equipped with a wander alert system and a 15 second delayed egress mechanism (a specialized door security setup which delays the door's opening for 15 seconds while sounding an alarm, which allows staff time to respond to potential unauthorized exits). The Maintenance Director stated both the wander alert system and the 15 second delayed egress mechanism were active 24 hours per day. The doors were held in the closed position by a magnetic locking system (electromagnet mounted on the door frame and a plate fixed to the door, when energized, it generates a powerful magnetic bond that secures the door), and between the hours of 8:00 AM to 8:00 PM, the facility's receptionist was present and had a button to allow entry and egress through these doors. The Maintenance Director stated between the hours of 8:00 PM and 8:00 AM, there was no receptionist on duty. To leave the facility during those hours, a person must know the numeric code to release the magnetic locking system, or push on the door and wait for 15 seconds for the doors' magnetic locks to release. They stated if a person activated the 15 second delayed egress, an audible alarm sounded and would continue until the numeric code was entered into the keypad on the wall. During an interview on 07/07/2026 at 12:00 PM, Registered Nurse Manager #2 stated they were the nursing supervisor on 04/21/2026 when around 10:00 PM, they were notified by Licensed Practical Nurse #3 that they were unable to locate Resident #2 in the facility. They stated all staff were immediately made aware and began to search outside facility grounds and surrounding areas. Registered Nurse Manager #2 stated they completed an outside search of the back of the facility and when they came inside, Licensed Practical Nurse #4 had returned to the facility in their private vehicle with Resident #2. Registered Nurse Manager #2 stated Resident #2 had no injuries upon return and were unsure how the resident exited the building. They stated Resident #2 had reported to them they wanted to go home but would not say how they exited the building. They stated Resident #2 returned to the facility approximately 10-15 minutes after being made aware they were missing, and they had notified the Director of Nursing.During a telephone interview on 07/07/2026 at 2:29 PM, Licensed Practical Nurse #3 stated at approximately 10:00 PM, they went to administer medications to Resident #2 and were unable to locate them. Resident #2 did not have any prior exit seeking behaviors and should not be left outside alone for safety reasons, they could wander or get hurt.During an interview on 07/07/2026 at 3:03 PM, the Director of Nursing stated the video surveillance footage from 04/21/2026 was no longer available to be reviewed, they were only able to go back 30 days. They stated they reviewed the video surveillance footage on 04/22/2026 which revealed Licensed Practical Nurse #2 punched out at the time clock near the front door, walked over to the front door and opened the door for Resident #2. The Director of Nursing stated Licensed Practical Nurse #2 and Resident #2 walked out of the facility together at approximately 8:30 PM, and it was dark outside. The Director of Nursing stated Resident #2 was located by Licensed Practical Nurse #4 on a main road, sitting at a bus stop, approximately a half mile from the facility. They stated upon return to the facility, Resident #2 was placed on 15-minute safety checks, and a wander guard was applied. The Director of Nursing stated during the investigation, they had interviewed Resident #2 who stated they wanted to go outside and had asked the nurse to let them out to get a package. The Director of Nursing stated Resident #2 had no prior exit seeking behaviors but was unhappy at the facility because they were not allowed to smoke. The Director of Nursing stated Licensed Practical Nurse #2 refused to provide a statement and was terminated on 04/22/2026 after the video surveillance footage was reviewed. They stated residents were never to be left outside unsupervised for safety reasons. The Director of Nursing stated Licensed Practical Nurse #2 should not have left Resident #2 outside unattended, they had a history of a stroke with weakness, they could have fallen or been severely injured. They stated it was careless and should not have happened.During a telephone interview on 07/07/2026 at 3:23 PM, Medical Director #1 stated they expected staff to follow facility protocols to ensure resident safety. They stated they would have expected the nurse to have gone outside with Resident #2 then bring the resident and package back inside. Medical Director #1 stated Resident #2 should not have been left alone outside as it placed them at risk for environmental injuries, falls or could have been hit by a car.During a telephone interview on 07/08/2026 at 3:21 PM, Licensed Practical Nurse #4 stated, at approximately 10:15 PM on 04/21/2026, they located Resident #2 sitting on a bench in front of a cemetery with their assistive device (cane) on a main road with a speed limit of 30 miles per hour, approximately 0.3 miles from the facility. Licensed Practical Nurse #4 stated Resident #2 initially refused to come back to the facility and stated they wanted to go home. They stated Resident #2 eventually agreed to return and brought Resident #2 back to the facility in their personal vehicle with no injuries. Licensed Practical Nurse #4 stated upon return to the facility, Resident #2 continued to exit seek and made statements of wanting to leave. They stated a wander guard was applied, and Resident #2 was placed on one-to-one monitoring.During an interview on 07/09/2026 at 2:02 PM, the Administrator stated the facility was responsible for resident safety and expected their staff to follow the safety protocols as they were trained. The Administrator stated Licensed Practical Nurse #2 did not follow facility protocols and was terminated for neglect of job duties.New York Code Rules and Regulations 415.12 (h) (1) (2) The Survey Team determined the immediacy was removed on 07/10/2026 at 7:00 PM based on the following corrective actions taken by the facility:-The facility educated all available staff working on 07/09/2026 and 07/10/2026 regarding not allowing any residents outside without a registered nurse s or unit manager reviewing safety awareness. All staff that were not available will not be allowed to work until training is completed by the registered nurse supervisor. Survey team verified 85% of all active staff had been educated.-All nurse managers and registered nurses were trained on evaluating residents for safety awareness.- New policy and procedure for safety awareness and outside privileges was implemented on 07/10/2026. New evaluation form was created for registered nurse supervisors and unit managers to complete.- All residents were evaluated for safety awareness and outside privileges by unit managers on 07/10/2026.

Based on interview, and record review conducted during the survey the facility failed to have evidence that all alleged violations were thoroughly investigated for three (Resident #3, #4 and #5) of ten residents reviewed for abuse . Specifically, the facility investigations were not thoroughly investigated. Issues included lack of interviews/witness statements from staff regarding a staff to resident verbal abuse allegation and lacked provider and family notifications (#3); lacked statements from staff regarding missing personal items (wallet and credit cards) (#4) and lacked a documented investigation and statements into a sexual abuse allegation (#5). The findings include: The facility policy and procedure Abuse Prevention, Identification, Investigation, Protection and Reporting dated 10/14/2025 documented that investigations of abuse will include but not limited to identifying and interview all involved persons, including the alleged victim, the alleged perpetrator, witness, and other involved persons who may have knowledge of the abuse. 1. Resident #3 had diagnoses of dementia and aphasia (a language disorder that affects the ability to speak, understand, read or write). The Minimum Data Set (a resident assessment tool) dated 09/14/2025 documented that Resident #3 was severely cognitively impaired. The Comprehensive Care Plan dated 09/09/2025 documented that Resident #3 had a self-care deficit due to dementia and muscle weakness requiring extensive assistance of one staff member. Review of an investigation summary form completed by the Director of Nursing dated 11/20/2025 at 2:35 PM documented that an abuse allegation occurred with Resident #3. There was one witness statement from Certified Nurse Aide #5 that documented Certified Nurse Aide #1 called the resident an expletive and demeaning word. There were no other witness statements in the investigation file. It documented that the physician was not notified about the abuse allegation. Review of the progress notes dated 11/19/2025 to 11/26/2025 revealed no documentation that the physician nor was the family notified of the abuse allegation. A telephone call was made to Certified Nurse Aide #5 on 07/09/2026 at 8:32 AM. A message could not be left due to their voicemail being full. No call-back was received. During an interview on 07/09/2026 at 8:33 AM, Certified Nurse Aide #1 (accused) stated they did not abuse Resident #3. They stated that they were training another certified nurse aide (#4) at the time of the alleged incident, who witnessed the incident. During an interview on 07/09/2026 at 11:30 AM, Licensed Practical Nurse #1 stated that they were working the day shift on 11/20/2025. They stated they were not asked and did not fill out a witness statement for any incident. They stated normally that if there was a reported allegation of abuse, they would be expected to fill out a witness statement even if they did not witness it. During an interview on 07/09/2026 at 11:45 AM, Registered Nurse Unit Manager #1 (was not working at the time of the allegation) but stated that they would obtain statements from all the staff not just the witness. They stated that they would notify the physician and the resident's family. They stated they would ensure that the resident felt safe. They stated that they would interview other residents who were on that staff members' rotation to see if they had any complaints or if they felt safe as well. They stated, I would expect social work to follow up with the resident to ensure they feel safe. During an interview on 07/09/2026 at 12:24 PM, Resident #3's daughter, they stated that they did not receive communication from the facility about an allegation of abuse. During an interview on 07/09/2026 at 12:58 PM, Resident #3's spouse stated they were not informed about the allegation of abuse. During an interview on 07/09/2026 at 1:15 PM, Social Worker #1 (not working at facility at the time of the allegation) but stated that they would try to get a statement from the residents even if they were cognitively impaired. They stated that they would do a follow-up visit to ensure that the residents were doing fine. They stated that they would check with other residents who were on that staff member's rotation to see if those residents were abused by that staff member. They stated they would document it in the investigation. A telephone call was made to Social Worker #2 who was employed at the facility at the time of the incident on 07/09/2026 at 1:21 PM. They did not return the call. During an interview on 7/9/2026 at 1:30 PM, Medical Director #1 (not working at time of allegation) but stated that they would expect the facility to notify them about any allegation of abuse. They stated that they or their nurse practitioner would see the resident within 24 hours to examine them. They stated they would document that in their progress notes. During an interview on 07/09/2026 at 2:46 PM, Certified Nurse Aide #4 stated that they worked with Resident #3 and Certified Nurse Aide #1 on the day of the alleged abuse. They stated that Certified Nurse Aide #1 never abused Resident #3. They stated if they saw someone being abused, they would have reported it to their nurse. Certified Nurse Aide #4 stated no one asked them for a statement. During an interview on 07/10/2026 at 10:58 AM, the Director of Nursing stated that the process for investigations for allegations of abuse was that the house supervisor was to obtain statements from all the staff, make sure the resident was safe, and notify the physician so that they can do an assessment. They stated that the family should be notified within 24 hours. They stated that accused staff would be sent home pending the outcome of the investigation. They stated that there should be something documented in the progress notes and in the investigation report. The Director of nursing stated they did not get any other statements from staff. During an interview on 7/10/2026 at 11:29 AM, the Administrator stated that they expected statements from all the staff that were working on the floor that day whether they witnessed the incident. They stated they expected social work to follow up with the resident to ensure that the resident feels safe. They stated they would expect the physician and the family to be notified about any allegations. They stated if there was a concern about abuse then they would interview residents who were on that staff member's rotation to ensure those residents were safe. During an interview on 7/10/2026 at 12:22 PM, Medical Director #2 stated that they would expect staff to call them and inform them of any allegations of abuse so they can do an assessment on the resident. They stated they expected social work to assess the residents for their wellbeing. 2. Resident #4 had diagnoses including cellulitis of both lower extremities (a common, potentially serious bacterial infection of the skin), chronic kidney disease and depression. The Minimum Data Set, dated [DATE] documented Resident #4 was cognitively intact, understands and was understood by others. Review of the electronic medical record revealed there was no documented evidence of a Personal Belongings Checklist for Resident #4.Review of the facility investigation Summary Report dated 12/08/2025 initiated by the Director of Nursing documented Resident #4's wallet and credit cards went missing on and about 11/26/2025. Resident initially stated it was just a license and no money. Review or the Progress Notes completed by Licensed Practical Nurse #8 dated 12/08/2025 at 12:10P PM documented Resident #4 agreed to be transferred to Unit 5 this morning with Director of Nursing present. Resident belongings packed and transferred to Unit 5. Resident belongings included a phone charger, personal mail, nail filer, nail clipper, Christmas card and a check book inside a red wallet type holder with photos of cardinals on it. No other monetary valuable items noted in holder. Writer asked residents to have social work lock up the check book and resident has agreed to have it locked away. There was no other documented evidence in the progress notes regarding the missing credit card. Review of the fully completed facility investigation provided by the Director of Nursing on 07/10/2026 there was no documented evidence the facility obtained resident and/or staff statements regarding Resident #4's missing wallet with credit cards. During an interview on 7/10/2026 at 12:30 PM, the Director of Nursing stated that was all they had for the facility's investigation that was in the folder provided. Staff were interviewed at the time, and no one had seen the resident with a wallet or credit cards. The Director of Nursing was unsure why Resident #4's statement or staff statements were not obtained. During an additional interview on 07/13/2026 at 10:45 AM, the Director of Nursing stated they were unable to provide Resident #4's Personal Belongings Check List, and it could not be located and was not downloaded in the Electronic Medical Record.Durning an interview on 07/13/2026 at 11:45 AM, the Administrator stated they believed the family filed a police report for the missing credit cards. The Administrator also stated they reviewed the entire facility investigation file and there were no staff or resident statements regarding if staff ever saw the missing wallet with the credit cards and there should be.3. Resident #5 had diagnoses that included dementia, hypertension (high blood pressure), and chronic kidney disease. The Minimum Data Set, dated [DATE] documented Resident #5 was usually understood, usually understands and had severe cognitive impairment. Resident #5 was dependent on staff for transfers and required substantial/maximal assistance (helper does more than half of the effort) for bed mobility. There was no behavior symptoms documented. Review of the Health Status Note dated signed and dated 03/20/2026 at 3:57 PM by Licensed Practical Nurse #6 documented they were informed by Resident #5's family member that the resident had reported to them they had been raped twice since being at the facility. Licensed Practical Nurse #6 documented they notified their nurse manager and the nursing supervisor. Review of the Health Status Note signed and dated 03/20/2026 at 4:39 PM by Registered Nurse Supervisor #3 documented they went to assess Resident #5 due to the allegation made by the resident's family member. They documented Resident #5 was alert to self and was unable to provide a coherent answer when questioned about the allegation. Registered Nurse Supervisor #3 documented they completed a head-to-toe assessment of Resident #5 with the Director of Nursing present and there were no injuries present. They notified the Administrator, Medical Doctor #1, and Resident #5's responsible party. Review of the accident incident reports and investigations from 03/01/2026 - 03/31/2026 provided by the Director of Nursing on 07/06/2026 revealed there were no allegations of abuse reported to the Department of Health for Resident #5. During a telephone interview on 07/13/2026 at 11:54 AM, Licensed Practical Nurse #6 stated a family member of Resident #5 had approached them and reported that resident #5 stated they had been raped at the facility, and they immediately reported the concern to Licensed Practical Nurse Manager #7. During an interview on 07/13/2026 at 1:23 PM Licensed Practical Nurse Manager #7 were made aware of Resident #5's allegation. They stated they immediately notified the Director of Nursing and had contacted Resident #5's responsible party (family member). Licensed Practical Nurse Manager #7 stated they were informed by Resident #5's responsible party that Resident #5 had made similar comments in the past at home and did not feel the allegation was valid. Licensed Practical Nurse Manager #7 stated Resident #5 had periods of confusion and could not provide a statement to them. They stated Resident #5 did not display any signs of distress and was not fearful of staff. Licensed Practical Nurse Manager stated they were not involved in the investigation process, they did not interview staff or obtain any statements. They stated the Director of Nursing was responsible for reporting abuse allegations to the Department of Health and to complete investigations. During an interview on 07/13/2026 at 11:48 AM, Registered Nurse Supervisor #3 stated there was an allegation of sexual abuse made by a family member. They stated they had immediately contacted the Director of Nursing and Medical Doctor #1. Registered Nurse Supervisor #3 stated they had completed a skin assessment on Resident #5 with the Director of Nursing, there were no injuries noted, and the resident appeared to be in no distress. They stated they were not involved any further with the investigation process. During an interview on 07/13/2026 at 1:44 PM, the Director of Nursing stated Registered Nurse Supervisor #3 notified them on 03/20/2026 that an allegation of rape was made regarding Resident #5. They stated they did not report the incident to the Department of Health because there was no evidence found to support the claim that the allegation had occurred. The Director of Nursing stated Resident #5 had cognitive impairment and most times their speech was non sensical (speech that lacks meaning, logical coherence, or reason). They stated they investigated the allegation, completed a head-to-toe assessment of the resident and nothing was found after the body check was completed. The Director of Nursing further stated based on resident's cognition, and their daughter stating the resident has history of making these statements in the past they did not investigate further. They stated there was no accident and incident report or documented investigation and had no staff and/or resident statements. During an interview on 07/13/2026 at 2:34 PM, Medical Director #1 stated they would expect the facility to investigate all allegations regardless of a resident's cognitive status to ensure nothing happened or to take further action if abuse occurred. During an interview on 07/13/2026 at 2:46 PM, the Administrator stated they were not familiar with the allegation made on 03/20/2026 and would not comment. 10 New York Code Rules and Regulations 415.4(b)(3)

Based on interview, and record review conducted during a survey the facility did not ensure that all alleged violations involving abuse were reported immediately but not later than 2-hours after the allegation was made if the events that cause the allegation involve abuse, to the Administrator of the facility and to other officials (including to the State Survey Agency) for two (Resident #5 and Resident #6) of ten residents reviewed for abuse. Specifically, allegations of physical abuse and sexual abuse were not reported to the New York State Department of Health as required. The findings include: The facility policy and procedure titled Abuse Prevention Identification Investigation Protection and Reporting dated 10/25/2025 documented the facility will provide protection for the health, welfare and rights of each resident residing in the facility. All facility staff are required to immediately report to the Administrator, Director of Nursing or designee when observed act or suspicion of abuse, mistreatment, neglect, exploitation, or misappropriation is observed or suspected. The Administrator or designee will report all alleged violations to state agencies immediately, but no later than two hours after the allegation of abuse, mistreatment; and as required to all other agencies within the required timeframe. 1.Resident #6 had diagnoses that included atrial fibrillation (irregular heartbeat), cervicalgia (neck pain), and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 03/01/2026 documented Resident #6 was cognitively intact was understood and understands. The Comprehensive Care Plan dated 02/28/2026 documented Resident #6 had limited physical mobility related to weakness and falls and required extensive assistance of one staff member for transfers and bed mobility. The Health Status Note signed and dated 02/28/2026 at 10:03 AM by Licensed Practical Nurse #5 documented they were informed by therapy staff Resident #6 reported to them a night shift aide was rough with care and tossed them around like a rag doll. Licensed Practical Nurse #5 documented they had notified their nursing supervisor of Resident #6's allegation. The Heath Status Note signed and dated 02/28/2026 at 12:08 PM by Registered Nurse Supervisor #3 documented Licensed Practical Nurse #5 notified them of Resident #6's complaint. They assessed the resident for injuries and there were no new injuries noted. Registered Nurse Supervisor #3 documented they notified Medical Doctor #1 and the Director of Nursing. Review of the Internet Quality Improvement and Evaluation System (IQIES) Complaint/Incident Investigation Report revealed the date and time of the alleged incident was 02/27/2026 at 11:00 PM. The date and time the Administrator was first made aware of the incident was 03/16/2026 at 2:30 PM and documented the allegation as physical abuse. Review of the facility Investigation Summary Form dated 03/20/2026 completed by the Director of Nursing documented the incident occurred on 02/27/2026 between 11:00 PM - 7:00AM and they were made aware of the incident on 03/16/2026 after being notified by local police that Resident #6 reported the allegation to an outpatient urgent care clinic after being discharged from the facility. The investigation summary documented Resident #6 alleged Certified Nurse Aide #6 had whipped them around like a rag doll during the night. The investigation documented that no statement was obtained from Resident #6 as they had been discharged from the facility on 03/06/2026. The investigation summary documented Certified Nurse Aide #6 was contacted and could not recall the incident or resident and provided no statement. Certified Nurse Aide #6 was terminated, and the incident was reported to the Department of Health on 03/16/2026. The facility investigation concluded that no abuse or neglect occurred. Review of the witness statement dated 03/16/2026 at 3:58 PM completed by Physical Therapist #1 revealed on 02/28/2026 they approached Resident #6 to complete their assessment. Physical Therapist #1 documented Resident #6 was unable to participate in their assessment because of feeling sore all over. They documented Resident #6 alleged their aide from the previous night was too rough on them and stated, they tossed me around like a rag doll'. Physical Therapist #1 documented they notified the unit nurse and the nursing supervisor. During a telephone interview on 07/08/2026 at 2:59 PM, Licensed Practical Nurse #5 stated if an abuse allegation was reported to them by another staff member or resident, they would have reported it immediately to their supervisor because the allegation would need to be further investigated. They stated they could not recall Resident #6 or the incident that occurred on 02/28/2026. Licensed Practical Nurse #5 stated if they documented in Resident #6's medical record that they notified the supervisor of Resident #6's complaint then that was what they did. During an interview on 07/08/2026 at 3:56 PM, Physical Therapist #1 stated on 02/28/2026 Resident #6 reported to them a male certified nurse aide was rough while providing care to them during the night shift. They stated they reported the residents' concern immediately to Licensed Practical Nurse #5 and to Registered Nurse Supervisor #3. During an interview on 07/10/2026 at 10:58 AM, Registered Nurse Supervisor #3 stated they were notified by Physical Therapist #1 on 02/28/2026 that Resident #6 reported a staff member had been rough with them during care. They stated they had assessed Resident #6 and there were no injuries found; they contacted the Director of Nursing via telephone and notified Medical Doctor #1 who was at the facility. Registered Nurse Supervisor #3 stated the Director of Nursing was responsible for reporting abuse allegations to the Department of Health. They stated all allegations of abuse were required to be reported within two hours. During an interview on 07/10/2026 at 12:00 PM the Director of Nursing stated when the detective contacted them regarding the abuse allegation on 03/16/2026 they immediately started an investigation and reported the incident to the Department of Health. The Director of Nursing stated they did not recall being made aware of Resident #6's allegation on 02/28/2026. They stated they expected staff to contact them immediately for all abuse allegations because they would need to report it to the Department of Health within two hours after the incident occurred. The Director of Nursing stated the incident was an alleged allegation of abuse and should have been reported to the Department of Health on 02/28/2026. During an interview on 07/10/2026 at 1:25 PM, the Administrator stated they expected staff to report any allegation of abuse immediately to both them and to the Director of Nursing to ensure an investigation was completed and the incident was reported to the Department of Health within the required two-hour timeframe. The Administrator stated they were unaware of the allegation made by Resident #6 on 02/28/2026, therefore it was not reported within the required time frame. During a telephone interview on 07/10/2026 at 2:43 PM, the Detective on the case stated they did not have a report on the case; they contacted the facility and closed it out. 2.Resident #5 had diagnoses that included dementia, hypertension (high blood pressure), and chronic kidney disease. The Minimum Data Set, dated [DATE] documented Resident #5 was usually understood, usually understands and had severe cognitive impairment. Resident #5 was dependent on staff for transfers and required substantial/maximal assistance (helper does more than half of the effort) for bed mobility. There was no behavior symptoms documented. The Comprehensive Care Plan dated 03/04/2026 documented Resident #5 had behaviors that included undressing, disrobing and making accusatory statements. After the allegation interventions were revised on 03/20/2026 to always include two caregivers and to provide female care providers when available. Review of the Health Status Note dated signed and dated 03/20/2026 at 3:57 PM by Licensed Practical Nurse #6 documented they were informed by Resident #5's family member that the resident had reported to them they had been raped twice since being at the facility. Licensed Practical Nurse #6 documented they notified their nurse manager and the nursing supervisor. Review of the Health Status Note signed and dated 03/20/2026 at 4:39 PM by Registered Nurse Supervisor #3 documented they went to assess Resident #5 due to the allegation made by the resident's family member. They documented Resident #5 was alert to self and was unable to provide a coherent answer when questioned about the allegation. Registered Nurse Supervisor #3 documented they completed a head-to-toe assessment of Resident #5 with the Director of Nursing present and there were no injuries present. They notified the Administrator, Medical Doctor #1, and Resident #5's responsible party. Review of the accident incident reports and investigations from 03/01/2026 - 03/31/2026 provided by the Director of Nursing on 07/06/2026 revealed there were no allegations of abuse reported to the Department of Health for Resident #5. During a telephone interview on 07/13/2026 at 11:54 AM, Licensed Practical Nurse #6 stated a family member of Resident #5 had approached them and reported that resident #5 stated they had been raped at the facility. They stated they had not heard Resident #5 make that allegation but immediately reported the concern to Licensed Practical Nurse Manager #7 because it was an allegation of abuse and needed to be reported. During an interview on 07/13/2026 at 11:48 AM, Registered Nurse Supervisor #3 stated they recalled there was an allegation made from a family member about Resident #5 being raped. They could not recall who notified them of the allegation but stated they had immediately contacted the Director of Nursing and Medical Doctor #1. Registered Nurse Supervisor #3 stated they had completed a skin assessment on Resident #5 with the Director of Nursing, there were no injuries noted, and the resident appeared to be in no distress. They stated they were not involved any further with the investigation and were unsure if the allegation was reported to the Department of Health. During an interview on 07/13/2026 at 1:23 PM Licensed Practical Nurse Manager #7 stated they became aware of Resident #5's allegation by staff but could not recall who had informed them. They stated they immediately notified the Director of Nursing and had contacted Resident #5's responsible party (family member). Licensed Practical Nurse Manager #7 stated they were informed by Resident #5's responsible party that Resident #5 had made similar comments in the past at home and did not feel the allegation was valid. Licensed Practical Nurse Manager #7 stated Resident #5 had periods of confusion and could not provide a statement to them. They stated Resident #5 did not display any signs of distress and was not fearful of staff. Licensed Practical Nurse Manager stated they were not involved in the investigation process, they did not interview staff or obtain any statements. They stated the Director of Nursing was responsible for reporting abuse allegations to the Department of Health and to complete investigations. During an interview on 07/13/2026 at 1:44 PM, the Director of Nursing stated Registered Nurse Supervisor #3 notified them on 03/20/2026 that an allegation of rape was made regarding Resident #5. They stated they did not report the incident to the Department of Health because there was no evidence found to support the claim that the allegation had occurred. The Director of Nursing stated Resident #5 had cognitive impairment and most times their speech was non sensical (speech that lacks meaning, logical coherence, or reason). They stated they investigated the allegation, completed a head-to-toe assessment of the resident and nothing was found after the body check was completed. The Director of Nursing further stated based on resident's cognition, and their daughter stating the resident has history of making these statements in the past they did not investigate further or report. The Director of Nursing stated the allegation did not rise to the level of reporting, they stated the Administrator was made aware and both agreed that this was not a reportable event at the time. During an interview on 07/13/2026 at 2:34 PM, Medical Director #1 stated they would expect the facility to follow the state regulations for reporting abuse. During an interview on 07/13/2026 at 2:46 PM, the Administrator stated they were not familiar with the allegation made on 03/20/2026 and would not comment or respond whether the allegation should have been reported because they were not aware of the incident. New York Code Rules and Regulations 415.4 (b) (2)

Based on observation, interviews and record review conducted during survey, the facility failed to ensure that a resident received adequate supervision to prevent accidents for one (Resident #1) of two residents reviewed for accidents. Specifically, at 2:59 AM on 09/22/2025, Resident #1 who had severe cognitive impairment, wore a wander/elopement alarm and was at high risk for elopement, exited the facility undetected through delayed egress equipped (security device that restricts exit by sounding an alarm and delays a door from opening for 15-30 seconds) front doors without the staff knowledge. The system was re-engaged by Certified Nurse Aide #1 who failed to visually check the surrounding areas and go outside to verify that no residents had exited the building. Resident #1 was located 30 minutes later by emergency services; seated in the roadway, wearing wet clothing and was transported to a local hospital for a medical evaluation. This resulted in no actual harm that was Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm, serious impairment, serious injury or death to Resident #1's health and safety. This was identified as past noncompliance. The findings include: The undated facility policy and procedure titled Elopement and Missing Residents, identified by the Director of Nursing as in place prior to 09/22/2025, documented that an elopement occurs when a resident successfully leaves the nursing facility undetected and unsupervised and enters harm's way. The facility must fully protect resident health and safety and create conditions that recognize resident rights and provide for a homelike environment. Resident #1 had diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side, Alzheimer's disease (progressive brain disorder that destroys memory, thinking, language and reasoning skills). The Minimum Data Set (a resident assessment tool) dated 09/05/2025 documented Resident #1 was severely cognitively impaired, sometime understands, and was sometimes understood by others. The assessment documented the resident required the daily use of a wander/elopement alarm.The Comprehensive Care Plan with a revised date of 03/11/2025 documented Resident #1 was an elopement risk, and interventions included the use of a wander guard to their left ankle. The Kardex Report (a guide used by staff to provide care) dated 09/22/2025 revealed Resident #1 was independent for transfers and ambulation with no assistive device used for distances within the facility and utilized a wander guard on their left ankle. The Wandering/Elopement Risk Assessment completed on 09/05/2025 documented Resident #1 had a history of wandering and was at a high risk to wander. The Health Status Note dated 09/22/2025 at 4:54 AM by Licensed Practical Nurse #2 (Resident #1's assigned nurse), documented Resident #1 was yelling out around 1:00 AM, was redirected and brought a sandwich and juice. Licensed Practical Nurse #2 documented Resident #1 calmed for about 30 minutes and was sitting on their bed. Ten minutes later, Resident #1 was observed walking down the hall heading towards the lobby. Licensed Practical Nurse #2 documented Resident #1 was redirected back to their room, then proceeded to walk back and forth on the unit.The facility Investigation Summary form completed by the Administrator dated 09/22/2025 documented that at 3:30 AM, emergency services contacted the facility to notify them that Resident #1 was found in the roadway, soaking wet and they had transported them to a local hospital to be evaluated. Staff statements were obtained, and surveillance footage was reviewed by the Administrator. It was determined staff statements were in concert with the surveillance footage which revealed at 2:59 AM, Resident #1 had exited the facility through the front doors sounding the alarm; and at 3:00 AM, Certified Nurse Aide #1 walked to the front door, re-engaged the lock silencing the alarm and did not verify and check to ensure no residents had wandered outside. A handwritten statement included in the facility's investigation signed by Licensed Practical Nurse #1 documented they were in the bathroom near the front door when the alarm started going off. They exited the bathroom and saw an aide (Certified Nurse Aide #1) walking away from the front door after turning off the alarm.A handwritten statement included in the facility's investigation signed by Certified Nurse Aide #2 documented they last saw Resident #1 around 2:30 AM, Resident #1 was walking back and forth on the unit and was redirected back to bed.A local police department report dated 09/22/2025 at 3:15 AM, documented that a caller reported a person was sitting in the roadway. Emergency Medical Services responded and located Resident #1, confused, soaking wet, sitting in the roadway asking for help. They appeared to have been sitting there for a while, and they were not able to answer questions. Emergency Medical Services was able to determine that Resident #1 was a resident at the facility and contacted staff, making them aware Resident #1 was being transported to the hospital to be evaluated. Observation on 07/06/2026 at 12:53 PM, revealed Resident #1 was lying in bed, appeared calm and was slow to respond. Their wander guard was visible on their left ankle.On 07/07/2026 at 9:07 AM surveyor attempted a telephone interview with Certified Nurse Aide #1 and was unsuccessful. During a telephone interview on 07/07/2026 at 9:13 AM, Nursing Supervisor Registered Nurse #1 stated they were working as one of the nursing supervisors on 09/22/2025 when they were made aware a little after 3:00 AM that Resident #1 was found by emergency services personnel outside of the facility. They stated they had been in the process of sending a different resident to the hospital, so they were not aware Resident #1 had left the building and did not hear the alarm sound. They stated following the incident, staff interviews revealed Resident #1 had been agitated, wandering towards and pushing on the front doors and staff had redirected them. Registered Nurse #1 stated they would have expected staff to have made them aware Resident #1 was agitated and wandering, or that the alarm had sounded so they could have followed the facility procedure.During a telephone interview on 07/07/2026 at 9:37 AM, Licensed Practical Nurse #1 stated they were in the bathroom near the front lobby when they heard the front door alarm sound. They stated by the time they exited the bathroom; the alarm had stopped sounding. They saw another staff member walking away from the area but did not know who the staff member was. They stated they believed the alarm issue was handled so they did not think anything of it until they were asked to fill out statements regarding Resident #1's elopement. Licensed Practical Nurse #1 stated they would have expected the staff member that heard the alarm and responded to it to check the area and surrounding areas for what could have caused the alarm to sound and report it to their supervisor. 07/07/2026 at 9:56 AM surveyor attempted a telephone interview with Certified Nurse Aide #2 (assigned aide) and was unsuccessful.During an interview on 07/07/2026 at 10:16 AM, the Director of Nursing stated on 09/22/2025, Resident #1 exited the facility through the front doors by pressing on the delayed egress handle. After 15 seconds the door unlocked, and the alarm sounded. Certified Nurse Aide #1 walked to the front lobby and put the code in to turn off the alarm and reengaged the lock but did not check the vicinity for a resident. The Director of Nursing stated staff frequently used the front door after hours because they knew the door would open after a while if you pushed on the handle with the delayed egress. Certified Nurse Aide #1 admitted to turning the alarm off on 09/22/2025 because they thought it was just another staff member going through the door. The Director of Nursing stated staff should not have been using the front door as an exit after hours. Staff should have followed the facility policy and called a Code E (possible elopement) when the alarm sounded and searched all areas for a resident. The Director of Nursing stated it was important for staff to follow facility policy when an alarm sounded because there was the potential for an accident to occur.On 07/07/2026 at 12:03 PM and 1:34 PM the surveyor attempted telephone interviews with the former Medical Director #1 but was unsuccessful.During a telephone interview on 07/07/2026 at 12:35 PM, Licensed Practical Nurse #2 (Resident #1's assigned nurse) stated Resident #1 had been actively exit-seeking on the night shift of 09/21/2025 into 09/22/2025 along with another resident. They stated they sat with the other resident and asked Certified Nurse Aide #2 to sit with Resident #1, who was near the dining room and could not be seen from one spot. They stated when the resident they were watching fell asleep, they returned to the nurses' station to finish paperwork and that was when they were made aware Resident #1 was found outside. Licensed Practical Nurse #2 stated they did not and would not have been able to hear the front door alarm sound from Unit 5 as it was too far away. During an interview on 07/07/2026 at 1:43 PM, the Administrator stated they reviewed Resident #1's elopement with the Director of Nursing, including witness statements and then the surveillance footage, which confirmed the witness statements. Resident #1 was seen on the surveillance footage heading toward the front lobby, pushing on the door and eventually exiting through the front doors. Certified Nurse Aide #1 walked toward the front lobby doors, entered a code into the alarm box, stopping the alarm and reengaged the door, and then returned to their unit. The Administrator stated Certified Nurse Aide #1 did not open the door and look for any residents in the area or outside and they should have. The Administrator stated Certified Nurse Aide #1 admitted to not checking the area after turning the alarm off, and that they did not follow facility policy. During a telephone interview on 07/07/2025 at 3:23 PM, current Medical Director #2 stated they would have expected staff to follow facility protocols when they heard an alarm sound and look for any residents in the area, not turn off the alarm. Medical Director #2 stated Resident #1 was at risk for environmental injuries, falls, or could have been hit by a car. During a telephone interview on 07/08/2026 at 11:47 AM, Licensed Practical Nurse #3 (other nursing supervisor on 9/22/25) stated they received a call from emergency services personnel notifying them that Resident #1 had been found outside in the street yelling, and was taken to the local hospital to be evaluated. They stated they immediately made Registered Nurse #1 aware and started collecting statements from all staff in the facility, which then were given to the Administrator.The following corrective actions were implemented by the facility to correct the non-compliance as of 09/25/2025. -Resident #1 was evaluated at the hospital and then by facility staff upon return for injuries, and none were noted. -Resident #1 was placed on one-to-one staff supervision on the 11:00 PM to 7:00 AM shift. -Resident #1 already had a wander guard device in place and was functional. -Facility reviewed all residents and care plans for all residents identified as a high risk for elopement.-Certified Nurse Aide #1 employment was terminated for not following facility elopement protocols. -An additional key code entry pad was installed in the foyer for staff to gain entry after hours without disengaging the lock. -Additional security cameras were installed throughout the building including the entrance. -93 % (percent) of staff had been educated about what to do when a wander alarm sounded. -Changes were made to the elopement policy regarding who was responsible for turning alarms off. This training was also presented in general orientation for new staff. -Facility conducts ongoing elopement drills and had implemented additional monitoring of residents with wander guards. -Facility conducts ongoing audits to monitor compliance with response to alarms and alerts.10 New York Code Rules and Regulations 415.12(h)(1)(2)

Based on observations, interviews, and record review completed during a survey, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, a project to replace the facility's roof began and was interrupted from being completed during and due to inclement seasonal weather. The issues involved various ceiling tiles that were missing or stained throughout the facility; buckets and receptacles, and buckets and receptacles containing standing water and drain hoses from ceilings were stored in corridors and a resident room bathroom; tarps with drain hoses were hung from the corridor's ceiling assemblies; floor tiles were not level to the floor's surface, and ceiling's had missing plaster and peeling paint. This affected three (3) (Units 1/2, Unit 5, and Unit 6) of three (3) resident units and one (1) of one (1) Kitchen and one (1) of one (1) Kitchen stairway. The findings are: 1.Observations of the exterior of the building on 02/05/2026 at 8:20 AM revealed a blue tarp was covering part of the Unit 1-2 roof. Additional observations made from the Second floor Conference room on 02/05/2026 at 8:36 AM revealed a blue tarp covering part of the Unit 1-2 roof. During an interview on 02/05/2026 between 12:45 PM and 1:45 PM, the Maintenance Director stated the roof over Unit 1-2 was leaking and an outside contractor was hired to perform a total roof tear-off. They stated the outside contractor started work in December 2025 by removing the stones and the waterproof layer from the existing ballast roof. The contractors got about halfway down the 100s corridor when the weather turned, and work stopped. The contractors had not yet completed the job. The Maintenance Director stated they believed there was no written plan or schedule from the contractor for the roofing project. The Maintenance Director stated the roof over Unit 5 needed patching due to roof leaks. They stated that when water leaked in from the roof, the ceiling tiles got damaged, and each day, they assessed the condition of the ceiling tiles. Ceiling tiles that were soft and wet were replaced and ceiling tiles that were hard and dry were not replaced. During an interview on 02/05/2026 at 3:55 PM, the Administrator stated a roofing contractor was selected in October 2025 to replace the roof above the 100s corridor and 200s corridor (Unit 1- 2). The roof needed total replacement. The Administrator stated the start of the project was delayed until December 2025 due to the permit process. The decision to remove the Unit 1-2 roof in December was made because the weather at the beginning of December was not as bad as it usually was and the roofing contractor stated they could complete the work to replace the roof in three (3) weeks. The Administrator stated that the roof contractor called the Administrator a couple days before they came onsite to start work on the roof. After starting the project, the contractors paused their work due to changes in the weather, outdoor cold temperatures, wind, and snow. The Administrator stated the facility did not have a written safety schedule for the roof project and that the contractor verbally told them that the roof above the 100s corridor would take three (3) weeks to complete. Additionally, the Administrator stated they were aware of roof leaks on Unit 5 and Unit 6 since December 2025, and the facility was in the process of obtaining quotes to patch the roof in those areas. Since December, the Maintenance Director has been implementing interim measures to try to control the leaks. The roof contractor was last onsite on 02/02/2025, removed the snow from the roof on Unit 1- 2, and put a tarp over the roof. Review of the New York State Department of Health Electronic Certificate of Need System revealed the facility applied for a 'Construction Notice' with a project description of: Roof Above the Rehab Unit 1- 2 Will be removed and replaced. The project received date 12/30/2025. Review of the Construction Notice safety plan revealed the following:- A written construction schedule will be maintained, and every effort will be made to adhere to the schedule.- The construction schedule will be created in collaboration with the Construction Team (the Team) which includes our Project Manager, the contractor, the administrator, the director of nursing, and the admissions coordinator.- Changes in the construction schedule will be discussed and/or communicated to the Team by the Project Manager and/or the contractor as soon as possible to minimize any disruption to residents, families, and/or staff.- Every Possible effort will be made to minimize disruption to residents' normal routines. 2. Observation on Unit 1-2 on 02/05/2026 between 8:32 AM to 9:50 AM revealed a roof leak in Resident room [ROOM NUMBER]. Two (2) water drain hoses extended through a hole cut through the solid ceiling of the bathroom in Resident room [ROOM NUMBER]. The drain hoses directed water into a 44-gallon receptacle, which contained approximately six (6) inches of standing water, a disposal brief, a vinyl glove, and a funnel. During an interview on 02/05/2026 between 12:45 PM and 1:45 PM, the Maintenance Director stated the water leaked from the roof into the bathroom in Resident room [ROOM NUMBER] started about one (1) month ago. At that time, they attached two (2) separate funnels to the sub-ceiling above and directed drain hoses into the can below, which caught the leaks so the floor would stay dry for the residents During an interview on 02/05/2026 at 3:15 PM, Registered Nurse Unit Manager #2 stated they worked at this facility for about one (1) month, and the drain hoses and catch bucket in the bathroom of Resident room [ROOM NUMBER] were set up prior to their start at the facility. During an additional interview on 02/05/2026 at 5:00 PM, Registered Nurse Unit Manager #2 stated both residents who reside in Resident room [ROOM NUMBER] were care-planned to use the toilet with assistance, which would likely be the toilet in their room. 3a. Observations on Unit 1-2 on 02/05/2026 between 8:32 AM and 9:50 AM revealed evidence of active and inactive roof leaks as follows: -Two (2), 5-gallon buckets were stored in the corridor near Resident room [ROOM NUMBER]. Each bucket had a water drain hose that originated at the ceiling, that emptied into a bucket. -One (1), 5-gallon bucket was stored in the center of the corridor near Resident room [ROOM NUMBER], the bucket contained approximately 2 inches of standing water, and approximately one eighth of an inch of water was puddled on the floor around the bucket. -One (1), 6-foot-long by 6-foot-wide tarp suspended from the ceiling in the center of the corridor near Resident room [ROOM NUMBER]. The tarp had a water drain hose from its center that directed water into a 32-gallon receptacle. The receptacle contained approximately 6 inches of standing water. The center of the tarp was approximately 68 inches above the corridor floor. -Two (2) tarps measured approximately 10-foot-long by 4-foot-wide were suspended from the ceiling in the center of the corridor near Resident room [ROOM NUMBER]. The tarps each had a water drain hose from its center that directed water into a 32-gallon receptacle. The receptacle contained approximately six (6) inches of standing water. The center of the tarps were approximately 68 inches above the corridor floor. -Two (3), 5-gallon buckets and one (1) 1-gallon trash receptacle attached to a 1-gallon jug were stored along the right side of the corridor, between the resident lounge and exit door #2 near Resident room [ROOM NUMBER]. -Three (3), missing ceiling tiles and seven (7) sagging water-stained ceiling tiles in the corridor near Resident room [ROOM NUMBER]. -Three (3), water-stained ceiling tiles in the corridor between the Housekeeping Room and Resident room [ROOM NUMBER]. -Three (3), missing ceiling tiles and four (4) water-stained ceiling tiles in the corridor near Resident room [ROOM NUMBER]. -One (1), ceiling tile sagging in the corridor near Resident room [ROOM NUMBER]. -Two (2), water-stained ceiling tiles in the skylight perimeter in the 100s corridor. -Seven (7) water-stained ceiling tiles at the end of the 100s corridor, near Resident room [ROOM NUMBER]. -Two (2) water-stained ceiling tiles in the 200s corridor, near Resident room [ROOM NUMBER]. During an interview on 02/05/2026 at 8:50 AM, Resident #1 stated roof leaks have been present in the hallway since they were admitted to the facility during the second week of January. Resident #1 noted that buckets were being used to collect water. During an interview on 02/05/2026 at 9:05 AM, Resident #2 stated they had been at this facility for about two (2) months and stated, It has been raining in the hall ever since I got here. Resident #2 further stated on some days, they had to dodge the buckets and wet floor in the corridor. During an interview on 02/05/2026 at 2:47 PM, Resident #4 stated they had been living at this facility for about two (2) months. They stated water had leaked into the buckets in the hallway for about four (4) to six (6) weeks. During an interview on 02/05/2026 at 2:55 PM, Resident #5 stated they had been living at this facility for about one (1) month, and water had been leaking into the buckets in the hallway since they moved in. During an interview on 02/05/2026 at 3:15 PM, Registered Nurse Unit Manager #2 stated they worked at this facility for about one (1) month, and the tarps and buckets had been in the 100s corridor since then. They stated during the last month they noticed water dripping from the ceiling in the 100s hall, not heavy leaking, but the air temperatures outside had been too cold for snow and ice to melt. Registered Nurse Unit Manager #2 stated they had only observed water leaking in the corridor, not in resident rooms, except for Resident room [ROOM NUMBER]. During an interview on 02/05/2026 at 9:30 AM, Housekeeper #1 stated water leaking from the roof has been an on-going problem. They also stated water still leaked into the 100s and 200s corridors and water damage caused the floor tiles in the 200s corridor to curl up. During an interview on 02/05/2026 at 2:40 PM, Certified Nurse Aide #3 stated buckets were set up in the 100s corridor first, then about two (2) months ago the water collection tarps were added. During an interview on 02/05/2026 at 3:10 PM, Certified Nurse Aide #4 stated the tarps were installed on the ceiling in the 100s corridor sometime around January 1st, 2026. 3b. Observation on Unit 5 on 02/05/2026 between 9:58 AM and 10:40 AM revealed evidence of active and inactive roof leaks as follows: - One (1), 5-gallon bucket located at the angled area outside of the Therapy room. The bucket contained approximately 1-inch of standing water.-Two (2), 4-foot-long by 2-foot-wide ceiling tiles had been moved on top of other ceiling tiles resulting in a 4-foot-long by 2-foot-wide opening in the ceiling assembly in Resident room [ROOM NUMBER].-Two (2), water-stained ceiling tiles and one (1) missing ceiling tile in Resident room [ROOM NUMBER], with a nearby 5-gallon bucket.- One (1), 6-foot-long by 4-foot-wide tarp was suspended from the ceiling near Resident room [ROOM NUMBER]. The tarp had a water drain hose from the center that directed water into a 5-gallon bucket located on the right side of the corridor. The bucket contained approximately two (2) inches of standing water.-Five (5), water-stained ceiling tiles in the corridor near Resident room [ROOM NUMBER]-One (1), water-stained ceiling tile in Resident room [ROOM NUMBER]-Seven (7), water-stained ceiling tiles in the corridor near Resident room [ROOM NUMBER]-One (1), water-stained ceiling tile in Resident room [ROOM NUMBER], with an area of wall damage below that measured 5 inches wide by 5 feet high.-One (1) drain hose originating from the ceiling in the corridor near Resident room [ROOM NUMBER]. The drain hose directed water into a 5-gallon bucket located on the right side of the corridor.-Three (3), 5-gallon buckets near Resident room [ROOM NUMBER]. One (1) drain hose was directed into one (1) of the 5-gallon buckets.-One (1), 4-foot-long by 3-foot-wide piece of linoleum that was formed into a U-shape was wedged into the corridor ceiling tile grid near Resident room [ROOM NUMBER] above the three (3) 5-gallon buckets along the right side of the corridor. A 1-foot-long by 3-foot-wide section of the piece of linoleum was hanging below the corridor ceiling grid directed toward the buckets near Resident room [ROOM NUMBER]. During an interview on 02/05/2026 at 10:20 AM, Certified Nurse Aide #1 stated they had worked at the facility since November 2025 and the roof leaks on Unit 5 had been happening since they started. Certified Nurse Aide #1 stated the roof on Unit 5 leaked when it rained outside and when snow from the roof melted. They added, when it leaks, it leaks bad.During an interview on 02/05/2026 at 1:35 PM, the Maintenance Director stated they set up the ceiling tarp outside of Resident room [ROOM NUMBER] about two (2) months ago to catch water leaking from the roof.During an interview on 02/05/2026 at 1:40 PM, the Maintenance Director stated they set up a contraption to collect the leaking water inside and outside of Resident room [ROOM NUMBER] about two (2) months ago. They stated they placed a bed pan with a drain above the ceiling tiles at the entry of Resident room [ROOM NUMBER] to catch the leaks, then a sheet of vinyl was placed to direct the water to the buckets in the corridor outside of Resident room [ROOM NUMBER]. They stated it was the best they could do to minimize resident impact while waiting for roof repairs.3c. Observation on Unit 6 on 02/05/2026 between 10:40 AM and 11:05 AM revealed evidence of active and inactive roof leaks as follows:-Two (2), water-stained ceiling tiles in Resident room [ROOM NUMBER]-Two (2), water-stained ceiling tiles and one (1) sagging ceiling tile in the corridor near Resident room [ROOM NUMBER]-Seven (7), water-stained ceiling tiles in the corridor between Resident Rooms #607 and #612-Three (3), water-stained ceiling tiles in the Resident LoungeDuring an interview on 02/05/2026 at 11:00 AM, Licensed Practical Nurse #1 stated that water leaked from the roof in the hallway outside of Resident room [ROOM NUMBER] when it rained and when snow melted. They further stated water leaked from the sagging ceiling tile in the hallway outside of Resident room [ROOM NUMBER], but that was the only active leak on Unit 6.During an interview on 02/05/2026 at 11:00 AM, Registered Nurse Unit Manager #1 stated there was one (1) active leak from the roof on Unit 6 and it came from outside of Resident room [ROOM NUMBER]. They stated it leaked when the ice above thawed, or it rained. The individual ceiling tiles that were water-stained elsewhere on Unit 6 were from previous leaks and were not active.During an interview on 02/05/2026 between 12:45 PM and 1:45 PM, the Maintenance Director stated collection tarps were installed from the ceiling in the 100s corridor about one (1) month ago and the tarps and buckets near Resident Rooms #524 and #536 in the 500s corridor were set up about two (2) months ago.During an interview on 02/05/2026 at 4:40 PM, the Director of Nursing stated they first saw the buckets collecting roof leaks in the 100s corridor around September 2025. The Director of Nursing stated around mid-December 2025, contractors stripped the top layer of the roof over the 100s corridor, which made the situation worse, and the ceiling tarps were added at that time. Some ceiling tiles may be stained but do not have an active water leak. There have been short periods of time when a ceiling tile was missing, but they would notify the Maintenance Director, and the ceiling tiles would always be replaced. The Director of Nursing stated they were not aware of any active water leaks in resident rooms, but they were aware of the water leak in the bathroom of Resident room [ROOM NUMBER].4. Observation in the Kitchen on 02/05/2026 between 12:10 PM and 12:28 PM revealed evidence of active and inactive roof leaks as follows:- About one-third of a 2-foot-long by 2-foot-wide ceiling tile was broken and missing in the Large Kitchen Ancillary Room, with an active water drip onto the floor.-One (1), 2-foot-long by 2-foot-wide ceiling tile was missing above the dishwash machine.-One (1), water collection tarp was suspended from the ceiling above the three-bay sink, with a drain hose from the center of the tarp, directed into the three-bay sink-The Kitchen stairway ceiling had an area of fallen plaster that measured 6 feet long by 5 feet wide, with the wire mesh exposed-The solid ceiling in the Kitchen's rear stock hallway had an area of peeled paint that measured 4-feet long by 3-feet wideDuring an interview on 02/05/2026 at 12:23 PM, Dietary Aide #1 stated the tarp was installed in the Kitchen ceiling a few weeks ago because water was leaking from the roof. Dietary Aide #1 also stated water leaked from the ceiling of the Kitchen stairway when it rained and the ceiling damage in the stairway was made worse every time the stairway door slammed shut.During an interview on 02/05/2026 at 12:30 PM, the Food Service Director stated there was a slow drip from the roof in the Large Kitchen Ancillary Room, which caused the ceiling tile damage. They stated the drip comes and goes, but it was a constant problem about six (6) months ago, it was repaired and had started to drip again. The Food Service Director also stated the dishwash machine was repaired recently and the ceiling tile above it needed to be put back into place. Additionally, they stated the ceiling tarp above the three-bay sink was put up about two (2) months ago on a rainy day, and if it rains or the snow on the roof above the Kitchen melts, it will leak into the tarp. The Food Service Director stated a roof leak also caused ceiling damage in the Kitchen stairway, and that started about six (6) months ago. They stated the solid ceiling in the rear stock hallway had a water leak only one (1) time, which was within 24 hours of the leak above the three-bay sink, which caused the paint to peel, but it had not leaked since.10 New York Code Rules Regulations 415.29

Based on interview and record review the facility did not follow the required transfer or discharge process for three (3) of three (3) residents (Residents #3, #4, and #5) reviewed for Transfer or Discharge Process. Specifically, the facility did not notify the residents and the residents' representatives in writing and did not send a copy of the notice to the representative of the Office of the State Long-Term Care Ombudsman at least 30 days before the resident was transferred or discharged . The findings are:The policy and procedure titled Discharge Plan - Discharge Instructions revised 12/03/2025 documented it was to provide each resident that had an anticipated discharge date with the necessary information and connections to outside services to ensure the safest discharge. It documented that each department was to interview the resident and continuing care provider prior to the anticipated discharge to assess continued care needs as well as develop a plan designed to ensure the resident's needs will be met after discharge.1.Resident #3 had diagnoses that included dementia, type II diabetes mellitus, and depression. The Minimum Data Set (a resident assessment tool) dated 10/13/2025 documented Resident #3 was always understood, always understands, and was cognitively intact. The Minimum Data Set indicated there was no active discharge plan. A progress note by Social Worker #1 dated 11/17/2025 at 2:56 PM, documented that Social Worker #1 spoke with Resident #3's representative early last week and made them aware that the facility was planning to laterally discharge Resident #3 to another facility with a more secure lock down unit. It further stated that the resident and representative were both made aware that the resident would be transferring to the first facility with an open bed. This was the only note entered by Social Worker #1 regarding any discharge planning for Resident #3. 2.Resident #4 had diagnoses that included dementia, bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity levels), and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 09/12/2025 documented Resident #4 was always understood, always understands, and was cognitively intact. Resident #4 was discharged on 11/14/2025 and the discharge notice was completed and dated 11/13/2025 by Social Worker #1. The signature line for the resident was blank. 3.Resident #5 had diagnoses that included polyneuropathy (a condition where multiple peripheral nerves outside the brain or spinal cord are damaged causing wide-spread symptoms like numbness, tingling, weakness, and burning pain), bipolar disorder, and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 10/16/2025 documented Resident #5 was usually understood, always understands, and was moderately cognitively impaired. A progress note by Social Worker #1 marked as a late entry and effective 11/17/2025 at 9:09 AM that documented the writer notified this resident of discharge and gave them the discharge notice and summary upon discharge. Resident #5 was discharged on 11/14/2025 and subsequently re-admitted on [DATE] after filing an appeal. Their discharge notice was completed and dated 11/13/2025 by Social Worker #1 and the signature line indicated Verbal Consent where Resident #5's signature was required.During an interview on 01/07/2026 at 9:10 AM, Social Worker #1 stated that Resident #3 had been discharged because they required a more secure unit, due to their dementia diagnosis and because they had been wandering throughout the facility. When asked for documentation of Resident #3's wandering behaviors, Social Worker #1 searched through the facility's electronic medical records system and was unable to locate any recent documentation, or recent wandering /elopement assessments. Social Worker #1 state they did not know why Section Q of Resident #3's minimum data set, completed on 10/13/2025 indicated there was no active discharge planning for this resident. Social Worker #1 then stated that someone must have told them Resident #3 was at risk for elopement due to wandering but was unable to remember who that someone was.Social Worker #1 stated they believed they spoke with Resident #3's representative on 11/11/2025 to inform them that Resident #3 would be discharged to another facility. They gave the representative time to research two facilities with lock-down units and the representative got back to them either the following day or the day after with their choice. The representative requested Social Worker #1 call them prior to the move to ensure they would be able to be at the facility to assist Resident #3 with the move. Social Worker #1 stated they did not call the representative prior to the move and only spoke with Resident #3 on 11/13/2025 to inform them that they were going to be moving, stating the resident was pretty okay with the move. Social Worker #1 stated that the aides on the unit packed Resident #3's belongings and that after the move, the resident's representative left a message for Social Worker #1 stating they had filed a complaint as they were not notified of the timing of Resident #3's move and had not received a written Transfer/Discharge notice. Social Worker #1 stated they left a message back to the representative apologizing on 11/17/2025 but never connected with Resident #3's representative. They stated, I sent a Transfer/Discharge notice to the Ombudsman and we discharged two other residents to that same facility as Resident #3 on the same date as Resident #3 (11/14/2025). Social Worker #3 printed the email sent to the Ombudsman program notifying them of the discharges. The email was dated 11/18/2025 at 9:41 AM and stated: Attached are discharge transfer notices. I will update more frequently going forward. Thanks. Social Worker #1 furnished a copy of the notice they stated they gave to Resident #3. It was dated 11/13/2025, documented that it was necessary for the resident's welfare and their needs could not be met at this facility - lateral transfer to secure locked unit in another Skilled Nursing Facility. The line to be signed by the resident or representative was blank and Social Worker #1 signed the signature line for the social worker, both lines were dated 11/13/2025.During a follow-up interview on 01/07/2026 at 10:42 AM, Social Worker #1 stated the nutritional section of the IDT Discharge instructions dated 11/14/2025 for Resident #3 were not completed because the facility nutritionist was working part-time and likely didn't know about the discharge. He stated he had not spoken with the nutritionist about these discharges.During an interview on 01/07/2026 at 11:54 AM, the Administrator stated that if a resident was agreeable to a move, they did not need to give a transfer/discharge notice 30 days prior to the discharge and if a resident was responsible for themselves, family would not need to be notified of a transfer. The Administrator stated that the discharge summary was to be initiated by the social worker and all other disciplines/departments would receive a notice to complete their parts. The Administrator stated they expected all parts of the discharge summary in the electronic system to be completed, including the nutrition part. The Administrator stated that on 11/14/2025 three residents (Resident #3, Resident #4, and Resident #5) were transferred to the same other facility, and one filed an appeal, and this facility ended up having to take Resident #5 back, after they lost the appeal. The Administrator stated they were aware there was an issue with sending transfer and discharge notices to the Ombudsman and had since re-trained Social Worker #1 regarding this. They stated that they expected a discharge plan to be in place, prior to a resident being transferred or discharged . The Administrator stated they would only issue a 30-day Transfer/Discharge notice to a resident who was discontent with leaving the facility.During an interview on 01/07/2026 at 1:55 PM, the facility's Ombudsman (Ombudsman #1) stated they had not been receiving discharge notices from the facility when they were made aware of the move of four of this facility's residents on 11/14/2025 to the other facility. They were the Ombudsman at the other facility as well, and received calls over the weekend, prior to 11/17/2025 from family members of residents who were moved and from the receiving facility stating that the residents were unhappy about the move. They started their day on 11/17/2025 at this facility and met with Social Worker #1 and the Administrator to inform them they had not received transfer/discharge notices for any residents since they had received one notice in July 2025. Social Worker #1 told them this recent move of the four residents had been poorly planned. Ombudsman #1 stated that residents considered for transfer/discharge and their representative should be given a written notice 30 days prior to the transfer/discharge and Ombudsman #1 should receive a copy of that notice on the same day as the resident and representative. They stated they gave the most updated Transfer/Discharge Notice form to Social Worker #1 and the Administrator and set their expectations for future notifications with Social Worker #1 and the Administrator during their meeting on 11/17/2025. They stated the forms they received for transfers and discharges that took place prior to 11/17/2025 were an outdated form that did not meet the current regulatory requirements for the written notices. Ombudsman #4 stated the facility moved a total of four residents to the other facility on 11/14/2025.During an interview on 01/07/2026 at 3:31 PM, Resident #5 stated that the facility did not tell them they were moving. They stated staff came into their room in the morning on the day of the move, packed them up and moved them. Resident #5 stated they had to beg to get back to this facility and they did not like it at the facility they had been moved to.10 NYCCR 415.3(i)(1) (i-vii)

Based on interview and record review conducted during an Abbreviated survey (Complaint #2693403), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (1) (Resident #1) of three (3) residents reviewed for physician orders. Specifically, Resident #1 had an order for compression for leg edema (swelling caused by excess fluid accumulation) that was not entered into the electronic medical record or implemented.The finding is: The policy titled Physician Notification dated 12/10/2024 documented that nurses are to record any new orders in the resident's medical record. The policy titled Physician Verbal and Telephone Orders documented that all new orders including admission orders are to be confirmed by medical staff via phone or during medical rounds. Resident #1 was admitted to the facility with diagnoses including heart failure, heart disease, and was cognitively impaired. The comprehensive care plan dated 10/08/2025 documented that Resident #1 was at the facility for short term rehabilitation and had altered cardiovascular status including hypertension (high blood pressure), coronary artery disease (disease that affects the main arteries leading to the heart), and atrial fibrillation (an irregular heartbeat). Review of nursing Progress Notes dated 09/17/2025 to 10/8/2025 revealed:-On 09/17/2025 at 4:23 PM, Resident #1's legs were elevated to reduce edema (swelling caused by excess fluid). -On 09/17/2025 at 7:47 PM, the resident's legs were elevated to tolerance and some swelling was noticed.-On 09/18/2025 at 10:10 PM, the resident's lower legs were elevated to tolerance with some swelling noted.-On 09/25/2025 at 8:30 PM, the resident's legs appeared more swollen than usual. An order for Lasix (medication used to treat excess fluid) was given for three days to reduce the swelling and they would be seen by the house doctor.There were no new orders for compression of any type documented for Resident #1 Review of the medical provider progress note dated 09/29/2025, the Physician Assistant documented that they ordered compression to be added to Resident #1's treatment. Review of physician orders dated 09/16/2025 to 10/09/2025 revealed that there were no orders for any kind of compression stockings, ace wraps, or other form of compression for Resident #1. Review of the Treatment Administration Record dated from 9/17/2025 to 10/07/2025 revealed there were no treatments for any type of compression for edema for Resident #1. During a telephone interview on 01/06/2026 at 12:00 PM with Licensed Practical Nurse #1, they stated that they are supposed to clarify any orders from the Physician Assistant. They stated that the Unit Manager or the Registered Nurse Supervisor are the nurses who would take the order from the Physician Assistant. They stated that if the Unit Manager is not available then the Registered Nurse Supervisor is to take care of new orders. During a telephone interview on 01/06/2026 at 12:40 PM with the former License Practical Nurse Unit Manager #2, they stated that they would often not see new orders as the providers would not give them the orders directly. They stated that they might not see new orders for a resident for a few days. They stated they did not review the provider's note and were not aware the physician assistant ordered compression for Resident #1's legs. During an interview on 01/07/2026 at 10:01 AM, the Director of Nursing stated that they expect their Unit Managers to put in new orders for residents. They stated that they would expect the Unit Manager to get a clarification for any new orders and to put new orders in by the end of the day. They stated this order should have been implemented for the resident. During an interview on 01/07/2026 at 10:38 AM, the Administrator stated that they would expect the Unit Manager or the interdisciplinary team to have the orders clarified. They stated that the orders should have been entered within 24 hours. During a telephone interview on 01/07/2026 at 11:46 AM with the former Registered Nurse Supervisor #1, that stated that the Physician Assistant would leave the new orders for residents and not give them to the Unit Manager. They stated they expect new orders to be put in right away. They stated that the new orders should be put in by the Unit Manager and, if the Unit Manager is not available, then the Registered Nurse Supervisor should put the new orders in. They stated that yes, these new orders should have been put in. During a telephone interview on 01/08/2026 at 7:46 AM with the former Physician Assistant stated that they would expect the order to be entered for the resident as soon as possible. They stated that if there were any problems with the order, a nurse should have clarified the order. They stated the order should have put in for compression. They stated that they wanted ace wraps for the resident, and they should have written that. They stated that at the time, providers could not put in their own orders with the facility's electronic medical record. They stated they did not communicate the order for compression to the nursing staff. 10 NYCRR 415.12

Based on observation, interview and record review conducted during a Complaint investigation (#NY00372469) the facility did not have evidence that all alleged violations of misappropriation were thoroughly investigated, that the results of all investigations were reported to the state agency within 5 working days of the incident, and that corrective actions were taken for the verified alleged violation for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the facility did not complete an investigation of an alleged theft of Resident #1's credit card, did not report the results within 5 working days of the incident, and did not take corrective actions when the allegation was verified. In addition, the facility did not ensure their policy for abuse investigation and reporting was current. The finding is:The policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated [DATE] documented misappropriation of resident property included theft, unauthorized use or removal of a resident's personal property including but not limited to money, and other possessions and articles belonging to the resident regardless of monetary value. Facilities must document that the allegations are thoroughly investigated, including any incident that is not consistent with routine operation of the facility or routine care of the resident. The supervisor who has been informed of the allegation is to complete the initial investigation report and forward a copy to the Administrator. Resident #1 had diagnoses including chronic obstructive pulmonary disease, atrial fibrillation (irregular heart rate), and general anxiety disorder. The Minimum Data Set (a resident assessment tool) dated [DATE] documented the resident had moderately impaired cognition. Review of the comprehensive care plan dated [DATE] revealed Resident #1 was independent for meeting their emotional, intellectual, physical, and social needs. There was no documentation that addressed safekeeping of the resident's personal items. The ACTS (Aspen Complaints/Incidents Tracking System) Complaint/Investigation Report dated [DATE] documented the former Director of Nursing submitted a report on [DATE] at 4:42 PM that Resident #1's daughter reported the resident's credit card had unknown charges. The resident had found their wallet on the floor and noted their card was missing. The resident's daughter called the police and filed a report. The investigation was ongoing, the former Director of Nursing and Human Resources staff went to review video surveillance at the police station and identified a Certified Nurse Aide #1 with an unidentified male. The Certified Nurse Aide had been removed from the schedule within the last two (2) weeks because their certification expired prior to the resident's daughter reporting this incident. The report documented there was reasonable cause to believe that abuse, neglect or mistreatment occurred.The Police Report dated [DATE] at 12:51 PM documented the officer responded to the facility for complaint of a stolen credit card and driver's license. Resident #1 believed they were taken by a staff member, but did not see who took their property. They did not have any visitors and had only seen staff members enter their room between [DATE] and [DATE] when they believed the items were taken. Resident #1 last knew they had their credit card in their possession on [DATE] at 6:00 PM, when they returned from having dinner with their daughter. They found their wallet on the floor of their room on [DATE] around 6:00 PM and when they picked it up, the noticed their driver's license and credit card were removed. Resident #1 contacted their daughter, who contacted the bank to let them know of the theft and to cancel the credit card. The fraudulent charges were noted on [DATE] at apparel stores for a total loss of $1,041.41. The offender was identified as Certified Nurse Aide #1. During an observation and interview on [DATE] at 11:40 AM, Resident #1 was lying in their bed, watching television. Resident #1 stated their credit/bank card was stolen, sometime over this past winter. They stated they didn't know who took it, but it was probably someone who worked at the facility, someone who knew where their things were and their routine. Resident #1 stated it was taken from their room; it was in their wallet located in their purse. The resident stated they had a drawer with a lock, but they never received a key for it, and they would have used the drawer if they had a key. During an interview on [DATE] at 3:39 PM, the interim Director of Nursing stated they could not find an accident and incident report regarding the stolen credit card and the Administrator didn't have anything either. During an interview on [DATE] at 11:40 AM, the Interim Director of Nursing stated they would have expected an incident report to be completed regarding the missing credit card. The former Director of Nursing should have been the one to complete it. The investigation should have included statements from the resident and roommate, any witnesses like Certified Nurse Aides, Unit Manager. The Director of Nursing should have notified the Administrator about the situation and should have called the police. During a telephone interview on [DATE] at 12:23 PM, Certified Nurse Aide #1 stated they started working at the facility in January. Certified Nurse Aide #1 stated on February 3rd or 4th (2025), Human Resources contacted them and said their certification had lapsed and they had to leave. Certified Nurse Aide #1 stated nobody from the facility contacted them about this credit card situation and they found out when the police showed up at their house sometime after February 20th (2025). During an interview on [DATE] at 1:10 PM, the Administrator stated this stolen credit card incident did not sound familiar to them. They stated credit card theft was considered misappropriation if it was founded. The Administrator stated everything was an allegation until it was proved or disproved, they did not know if this situation was proven, and they should have known. They stated they expected the former Director of Nursing (who submitted the report) to have notified them of this situation and they did not know if a 5-day report was done. The Administrator stated they asked the Social Worker to see if they had anything in their files, but the current Social Worker did not work at the facility when this incident was reported. They stated they were currently looking for any information they had on this and at that point, the Department of Health had more information than they did. The Administrator stated an incident report should have been done; the prior Director of Nursing (who reported this incident) left the end of February, and a lot of stuff was done without their knowledge. The Administrator stated they were going to go through the process, see if the police were called and if other steps were taken back then. The Administrator stated they will probably call [NAME] to see if they could get a copy of what was initially reported. The Administrator stated they would start from scratch, have the Social Worker see Resident #1, and see if the police were able to get them restitution. b. The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, with a handwritten date of 01/2025 documented the facility prohibits abuse, neglect, mistreatment, and misappropriations of resident property. The policy did not document written procedures that included identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses, and others who may have knowledge of the allegations; protection of the alleged victim during and after the investigation; immediately reporting all alleged violations to the Administrator, state agency and all other required agencies within specified timeframes. During an interview on [DATE] at 11:40 AM, the interim Director of Nursing stated they could not find a more current policy in their files. They stated they knew the policies were outdated, but they had only started working in the facility since the beginning of August and became in the interim Director of Nursing as of [DATE]. During an interview on [DATE] at 1:10 PM, the Administrator stated the only thing not included in their policy was the 2-hour reporting requirement. They started doing policy revisions in the month of July but have been focused on hiring staff. During further interview on [DATE] at 3:35 PM, the Administrator provided another copy of the facility abuse policy that had a handwritten date of 1/2025 and stated this policy was reviewed as part of a plan of correction from their recertification survey when they were cited for background check issues. On [DATE] at 11:36 AM, the Administrator stated a lot of the facility policies were outdated and that they had been focused on staffing first as a priority.10 NYCRR 415.4(b)(3)

Based on observation, interview, and record review during a Complaint investigation (#NY00372469), the facility did not ensure a resident's right to be free from misappropriation of resident property for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1's bank/credit card was reported missing and had fraudulent charges made by a staff member. The finding is:The policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 01/20/2025 documented misappropriation of resident property included theft, unauthorized use or removal of a resident's personal property including but not limited to money, and other possessions and articles belonging to the resident regardless of monetary value. Resident #1 had diagnoses including chronic obstructive pulmonary disease, atrial fibrillation (irregular heart rate), and general anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 02/21/2025 documented the resident had moderately impaired cognition. Review of the comprehensive care plan dated 01/07/2022 revealed Resident #1 was independent for meeting their emotional, intellectual, physical, and social needs. There was no documentation that addressed safekeeping of the resident's personal items. The ACTS (Aspen Complaints/Incidents Tracking System) Complaint/Investigation Report dated 02/19/2025 documented the former Director of Nursing submitted a report on 02/18/2025 at 4:42 PM that Resident #1's daughter reported the resident's credit card had unknown charges. The resident had found their wallet on the floor and noted their card was missing. The resident's daughter called the police and filed a report. The investigation was ongoing; the former Director of Nursing and Human Resources staff went to review video surveillance at the police station and identified a Certified Nurse Aide #1 with an unidentified male. The report documented there was reasonable cause to believe that abuse, neglect or mistreatment occurred.The Police Report dated 02/07/2025 at 12:51 PM documented the officer responded to the facility for complaint of a stolen credit card and driver's license. Resident #1 believed they were taken by a staff member but did not see who took their property. They did not have any visitors and had only seen staff members enter their room between 02/02/2025 and 02/04/2025 when they believed the items were taken. Resident #1 last knew they had their credit card in their possession on 02/02/2025 at 6:00 PM, when they returned from having dinner with their daughter. They found their wallet on the floor of their room on 02/04/2025 around 6:00 PM and when they picked it up, the noticed their driver's license and credit card were removed. Resident #1 contacted their daughter, who contacted the bank to let them know of the theft and to cancel the credit card. The fraudulent charges were noted on 02/04/2025 at apparel stores for a total loss of $1,041.41. The offender was identified as Certified Nurse Aide #1. During an observation and interview on 09/08/2025 at 11:40 AM, Resident #1 was lying in their bed, watching television. Resident #1 stated their credit/bank card was stolen, sometime over this past winter. They stated they didn't know who took it, but it was probably someone who worked at the facility, someone who knew where their things were and their routine. Resident #1 stated it was taken from their room; it was in their wallet located in their purse. The resident stated they had a drawer with a lock, but they never received a key for it, and they would have used the drawer if they had a key. The resident's purse was observed attached to their rolling walker next to their bed. During an interview on 09/09/2025 at 11:40 AM, the Interim Director of Nursing stated they considered stealing a credit card a misappropriation of resident's items which was a form of abuse. They stated this was the resident's home and that some people lose sight of that.During a telephone interview on 09/09/2025 at 12:23 PM, Certified Nurse Aide #1 stated they started working at the facility in January. They stated when they left work either on 02/03/2025 or 02/04/2025 a coworker asked them for a ride home. The coworker asked Certified Nurse Aide #1 to drive them to a clothing store because they needed something to wear for a funeral. Certified Nurse Aide #1 stated the coworker told them their clothing size and gave them a credit card to use in the store. Certified Nurse Aide #1 stated they didn't look at the name on the credit card and they wouldn't have known it was a resident's name if they had looked because they only worked at the facility a short time and didn't know everyone's name yet. Certified Nurse Aide #1 stated nobody from the facility contacted them about this and they found out when the police showed up at their house sometime after February 20th (2025). Certified Nurse Aide #1 denied taking the credit card and stated they had a lawyer, and their court date was soon. During an interview on 09/09/2025 at 1:10 PM, the Administrator stated this stolen credit card incident did not sound familiar to them. They stated credit card theft was considered misappropriation if it was founded. The Administrator stated everything was an allegation until it was proved or disproved, they did not know if this situation was proven, and they should have known. They stated they expected the former Director of Nursing (who submitted the report) to have notified them of this situation. The Administrator stated they asked the Social Worker to see if they had anything in their files, but the current social worker did not work at the facility when this incident was reported. They stated they were currently looking for any information they had on this and at that point, the Department of Health had more information than they did. The Administrator stated the prior Director of Nursing (who reported this incident) left the end of February. The Administrator stated they didn't have enough information to say if the resident's right to be free from misappropriation was maintained. 10 NYCRR 415.4(b)

Based on observation, interview, and record review during a Complaint investigation (Complaint #NY00374344- 635063) the facility did not ensure physician orders for the resident's immediate care were in place on admission for one (1) (Resident #7) of three (3) residents reviewed for admission orders. Specifically, Resident #7 was re-admitted to the facility on [DATE] and their admission medication orders were not entered into the electronic medical record and implemented until 09/10/2025.The finding is:The policy and procedure titled Electronic Physician Orders (Create, Confirm, Processing Orders) dated 08/28/2024, documented Admission/readmission orders for the care of a resident are received from a Licensed Physician/Nurse Practitioner/Physician Assistant upon admission/readmission of a resident to the facility. Orders will either be entered into the electronic medical record system by the nurse/pharmacist following confirmation from the Practitioner or directly entered by the medical provider. The nurse/pharmacist will communicate with the ordering provider when the data entry process is complete to alert the provider to electronically sign.Resident #7 had diagnoses that included schizophrenia, anxiety disorder, and hypertension. The Minimum Data Set (a resident assessment tool) dated 09/08/2025 documented an entry tracking record and was still in progress with no resident additional information.The comprehensive care plan documented there was a care plan focus initiated on 07/05/2019 for alteration in cardiac status related to hypertension, hyperlipidemia, obesity, and edema. Additionally, potential for alteration in mood was initiated on 07/05/2019 related to depression, schizophrenia, and bipolar disorder. Interventions included to administer medications as ordered and to monitor for side effects and effectiveness. The base line care plan was not provided.Review of the hospital Discharge summary dated [DATE] documented Resident #7's discharge medications: acetaminophen (Tylenol) 650 milligrams by mouth every four hours as needed; amlodipine (blood pressure medication) 7.5 milligrams by mouth every day; aripiprazole (antipsychotic medication) 30 milligrams by mouth every day; aspirin 81milligrams by mouth every day; bisacodyl suppository (laxative)10 milligrams rectally every day as needed; Vitamin D-3 (supplement) 25 micrograms two tablets by mouth every day; cholestyramine 4 gram packet by mouth every day; clonazepam (anti-anxiety medication) 0.5 milligrams by mouth every day; Vitamin B-12 (supplement) 500 micrograms by mouth every day; dicyclomine (medication used to treat irritable bowel syndrome) 20 milligrams by mouth four times a day; famotidine (medication used to treat heartburn) 20 milligrams by mouth every day; finasteride (medication for enlarged prostate gland) 5 milligrams by mouth every day; furosemide (diuretic) 20 milligrams two tablets by mouth every day; loperamide (used to treat diarrhea) 2 milligrams by mouth every two hours as needed; losartan (blood pressure medication) 25 milligrams by mouth every day; melatonin (supplement for sleep) 5 milligrams by mouth every day at bedtime; metoprolol succinate (blood pressure medication)100 milligrams by mouth every day; oxcarbazepine (seizure medication) 300 milligrams by mouth every day; oxybutynin (bladder medication) 300 milligrams by mouth twice a day; artificial tears 1.4(%) percent ophthalmic eye drops to both eyes twice a day; simvastatin (cholesterol medication) 20 milligrams by mouth every day at bedtime; tamsulosin (medication for enlarged prostate gland) 0.8 milligrams by mouth every day at bedtime; tolterodine (bladder medication) 4 milligrams by mouth every day; and trazadone (antidepressant) 100 milligrams by mouth every day at bedtime.Review of the Health Status Note dated 09/09/2025 at 10:15 AM entered as late entry by Licensed Practical Nurse Unit Manager #1, documented Resident #7 returned to the facility on [DATE] at 15:04 PM (3:04 PM), they were alert and oriented to self and surroundings, and made their needs known. Licensed Practical Nurse Unit Manager #1 further documented discharge instructions were clear, recommended medication changes and were given to the provider for further review.Review of the Telephone/Verbal Order Signature Details report dated 09/01/2025 - 09/30/2025 revealed Resident #7's medication orders were not entered into the electronic medical record until 09/10/2025 and were electronically signed by the medical providers on 09/10/2025 at 11:44 AM, 12:22 PM, 12:28 PM, 3:14 PM and 4:19 PM.Review of the Medication Administration Record dated 09/01/25 - 09/30/2025 documented Resident #7 had not receive any medications until 09/10/2025.During an observation and interview on 09/10/2025 at 9:10 AM, Resident #7 was observed sitting up at the side of their bed, appeared well-kempt and in no distress. Resident #7 stated they had returned from the hospital on Monday 09/08/2025 sometime in the evening, they received their morning medications from the hospital prior to being re-admitted but had not receive any further medications after they arrived at the facility. Resident #7 stated they asked their nurse yesterday for their medication but never received anything. They stated they took several medications and were concerned about missing their blood pressure medication.During an observation on 09/10/2025 at 9:25 AM, Licensed Practical Nurse #3 entered Resident #7's room and informed them there were no medication orders listed in the computer and would have to wait until orders were entered before they could administer medications to them.During an interview on 09/10/2025 at 9:40 AM, Licensed Practical Nurse #3, stated Resident #7 had re-admitted back to the facility on [DATE] and were unsure why their medication orders were not entered into the computer. Licensed Practical Nurse #3 pulled up the electronic medication administration record (EMAR) on their computer and stated Resident #7 did not appear on their computer screen. They stated they were familiar with Resident #7, knew they took several medications during the day, and had not worked since Resident #7 was re-admitted to the facility. Licensed Practical Nurse #3 stated they had just informed their Director of Nursing and the Medical Director that Resident #7's admission orders had not been entered into the electronic medical record.During an interview on 09/10/25 at 10:12 AM, Licensed Practical Nurse Unit Manager #1 stated they had worked the evening shift (3:00 PM - 11:00PM) on 09/08/2025 as both the supervisor and medication nurse on another unit. Licensed Practical Nurse Unit Manager #1 stated they were not aware Resident #7 had been readmitted until later that evening on 09/08/2025, they completed the quick admit into the electronic medical record which consisted of entering Resident #7 status in the computer as returned from hospital and the time of arrival. Licensed Practical Nurse Unit Manager #1 stated they saw batch orders listed for Resident #7 and assumed they were their complete set of orders and had been activated. At this time, Licensed Practical Nurse Unit Manager #1 pulled up Resident #7's electronic medical record and noted under the order tab 23 orders remained listed in the que and were not activated. They stated the orders in the que appeared to be only the batch orders and did not contain any medications listed from the hospital discharge summary. Licensed Practical Nurse Unit Manager #1 stated on 09/09/2025 they had Physician Assistant #1 review Resident #7's hospital discharge summary and clarified orders but they had not entered any orders from the discharge summary into the electronic medical record after being reviewed by Physician Assistant #1. During an interview on 09/10/2025 at 10:37 AM, the Director of Nursing stated they had just been made aware by the Medical Director that Resident #7 did not have admission orders entered into their electronic medical record and had received no medications since their readmission on [DATE]. The Director of Nursing stated depending on the time of admission it was the responsibility of either the unit manager or the nursing supervisor to enter admission orders from the discharge summary into the electronic medical record and notify the on-call provider to review, confirm and sign all orders. The Director of Nursing stated they would expect admission orders to be entered into the electronic medical record on the day of admission to ensure medications were received and administered timely and avoid any delays or adverse effects. The Director of Nursing stated Resident #7's admission orders should have been entered into the electronic medical record by the nursing supervisor on 09/08/2025.During a telephone interview on 09/10/2025 at 12:24 PM, Licensed Practical Nurse #2 stated they worked on 09/09/2025 from 7:00 AM until 7:00 PM and did not remember administering any medications to Resident #7. They stated other staff members had informed them Resident #7 had just returned from the hospital and their electronic medical record did not show any medications were due to be administered. They stated the Unit Manager or Nursing Supervisor were responsible for completing admission orders. Licensed Practical Nurse #2 stated if a resident was due for a medication or treatment their name would show up in the electronic medication administration record (EMAR) and would be either yellow meaning a medication was due or red indicating a medication was overdue. Licensed Practical Nurse #2 stated they were not familiar with Resident #7's routine medications, and they did not request any medications during their shift. They stated they just assumed no medications were due to be administered during their shift for Resident #7.During an interview on 09/10/2025 at 11:08 AM, Physician Assistant #1 stated the nursing staff would notify them when a new admission arrived at the facility to confirm and sign admission orders after they had been entered into the electronic medical record. They stated they were the on-call provider on 09/08/2025 and were not notified to review admission orders for Resident #7 upon readmission. Physician Assistant #1 stated on 09/09/2025 they had reviewed Resident #7's hospital discharge summary with Licensed Practical Nurse Unit Manager #1 but no orders had been electronically sent to them to be confirmed and signed. They stated they had just been made aware that Resident #7's admission orders had not been entered into the electronic medical record and they had not received their medications. Physician Assistant #1 stated Resident #7's missed doses of medications were not medically dangerous but could have exacerbated their anxiety symptoms. They stated the delay in entering admission orders into the electronic medical record was unacceptable.During a telephone interview on 09/10/2025 at 11:28 AM, the Medical Director stated they expected the nursing staff to notify them or the on-call provider when an admission arrived, they would review and electronically sign admission orders after they had been entered by nursing staff. The Medical Director stated they had just been notified Resident #7 readmitted to the facility on [DATE] and their admission orders had not been entered into the electronic medical record. They stated they would expect admission orders be entered into the electronic medical record on the same day of admission to ensure timely administration.10 NYCRR 415.11

Based on observation, interview and record review conducted during the Recertification survey completed on 12/6/24, the facility did not ensure a Quality Assurance and Performance Improvement program (QAPI) developed, implemented, monitored, maintained effective systems, and used feedback to develop an appropriate plan of action to correct identified deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the facility did not maintain effective systems to maintain compliance and had repeated deficiencies from the previous Recertification Survey 4/21/23 and Post Survey Revisit 7/12/23. In addition to identified systematic problems regarding grievances and functional/usable bathtubs. The findings are: Repeated Citations Refer to the following citations cited 4/21/23: F 584 Safe/Clean/Comfortable/Home Like Environment F 656 Develop/Implement Comprehensive Care Plan F 677 ADL (activities of daily living) Care Provided for Dependent Residents F 812 Food Procurement, Store/Prepare/Serve Sanitary F 880 Infection Prevention and Control F867 Quality Assurance and Performance Improvement Activities (7/12/23). Additionally, Refer to F 585 Resident Rights/Grievances Refer to F 561 Resident Rights/Self-determination. Review of the policy and procedure titled Quality Assurance/Performance Improvement revised 8/16, documented the facility will conduct quality assurance/improvement and assessment committee meeting at least quarterly to identify area of service that are non-complaint, or with potential for improvement. The facility will ensure that there is an effective, facility-wide performance improvement program to evaluate resident care and performance of the organization. The policy documented that the facility would have an ongoing plan, consistent with available community and facility resources, to provide or make available services that meet the medically related needs of its residents. Review of an undated facility document titled Quality Assurance Improvement Plan, provided by the Administrator during the entrance conference process documented that a dashboard for individual performance improvement projects were used to communicate progress and outcomes of individual QAPI (Quality Assurance Improvement Plan) projects. The QAPI (Quality Assurance Improvement Plan) lead is responsible for maintaining documentation of the minutes of all meetings. The plan documented that the QAPI (Quality Assurance Improvement) committee monitors progress to ensure that interventions or actions were implemented and effective in making and sustaining improvements. Once the performance improvement program goals have been met, it will be placed on a permanent tracking log for ongoing measurement to assure the performance improvement project doesn't get forgotten. Review of Recertification Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date of 4/21/23 revealed the facility was cited for the following: -F 656 the lack of development of comprehensive care plans for residents. The facilities corrective action plan included that the Assistant Director of Nursing would report monthly to the QAPI committee to determine if any further process changes or approaches were needed. This would happen for three months or longer depending on compliance outcomes. -F 677 the lack of chin hair removal and long fingernails. The facilities corrective action plan included the floor charge nurse along with the Assistant Director of Nursing would report their finding for three months and corrective action will be taken as necessary by the QAPI committee. -F 812 foods unlabeled/outdated in the refrigerators. The facilities corrective action plan included the Food Service Director along with the QAPI committee will submit weekly audit findings for three months or until problems were resolved. -F 584 the facility did not ensure that housekeeping and maintenance services were adequate to maintain a sanitary, orderly, and comfortable interior. The facilities corrective action plan included the audit results will be reported to the Quality Assurance and Performance Improvement committee for monthly for three months and the frequency of on-going audits will be determined based on the audit results. - F 880 issues involved transmission-based precautions and adequate hand hygiene. The facilities corrective action plan included audit results would be reported to the Quality Assurance and Performance Improvement committee monthly for three months and frequency of on-going audits will be determined based on the audit results. Review of Post Recertification Survey Revisit Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date of 7/12/23 revealed the facility was cited for the following (includes but not limited to): -F 812 the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service. System implemented to ensure continued compliance included: the administrator will meet with the Director of Food Service and Director of Maintenance daily to review any kitchen/food service-related repairs and assign priority tasks. Audits will be performed by the Director of Food service daily for 1 month then weekly for 2 months. The Consultant will also conduct random onsite audits of the above areas for three months and report findings to the QA&A Committee. Frequency of on-going audits will be determined by the Committee based on audit results. -F 867 the Quality Assurance and Performance Improvement Committee the facility did not institute and follow corrective actions that were to put in place to ensure that the following deficiencies would not reoccur. An audit tool was to be developed to track completion of all audits; audits will be submitted to the administrator/designee for review weekly for 12 months to ensure compliance; Audit results will be reported to the QA&A Committee monthly. Frequency of on-going audits will be determined by the Committee based on the results; the Consultant will also conduct random onsite audits of the cited areas for three months and attend the meeting monthly for 3 months. Review of the Quality Assurance and Performance Improvement Meeting Minutes dated 10/25/23 documented that all staff were educated and aware of the importance of a clean and sanitized kitchen and weekly plan of correction audits were ongoing. The meeting minutes documented that infection control, quality assurance and discharge records were reported upon at the meeting. The minutes did not include if the plan was effective. Review of the Quality Assurance/Performance Improvement Meeting Agenda date 10/16/24 documented that infection prevention and control, dietary, environmental services, plant operations and medical record review were reported upon at the meeting. The minutes did not include if the plan was effective. During the QAPI/Quality Assessment and Assurance (QAA) interview on 12/6/24 at 2:25 PM with the Administrator and Director of Nursing, the Administrator stated they could not provide any further documents (QAPI items- meeting agendas, minutes, meeting attendance records or PIP's (performance improvement projects) from the previous Administration other then what was presented (10/25/23, 1/24/24 and 2/28/24). They stated they became the Administrator of record in August 2024 and since they started the committee had conducted a PIP (performance improvement project) on Enhanced Barrier Precautions. The Administrator stated there was continued noncompliance with infection control practices and their performance improvement project was ineffective. The Director of Nursing stated their PIP (performance improvement project) for nail care and facial hair removal remained ineffective as noncompliance continues. The Director of Nursing stated the facility no longer had a Nurse Educator or an Assistant Director of Nursing and there was great turnover of the staff. This made it hard to continue to audit and educate the new staff. The Director of Nursing stated their PIP (performance improvement project) for developing comprehensive care plans was ineffective and the entire care process needed to be revised. The Administrator added there was a lack of staffing resources (employees) available in the facility making it difficult to keep the comprehensive care plans up to date. The Director of Nursing stated the PIP (performance improvement project) for outdated and unlabeled food in the kitchen was ineffective because of continued issues identified. The Director of Nursing stated that there had been a massive staff turnover in the kitchen and education needed to provide to those new staff members. The Administrator stated even though the plan of correction phase was over from previous surveys; constant/or at least as needed auditing and oversite needed to be continued. The Administrator stated new employees needed to be audited and educated on previous deficiencies issue to ensure the same errors/issues are not occurring over and over. The Administrator stated they felt there was sufficient staff to provide efficient and quality of care to the residents, however the facility lacked regional staff oversight and support at a higher level and the day-to-day support of the extra corporate managerial support was lacking. 2a. During an interview on 12/5/24 at 4:51 PM, the Director of Nursing stated the facility did not have functioning bathtubs in the shower rooms on the resident units and the bathtubs in the private rooms were too low and would pose as a safety hazard for residents. They stated the facility should have a functioning tub and believed the last functioning tub in the facility broke approximately 2 years ago. During an interview on 12/5/24 at 5:00 PM, the Administrator stated they were not aware the facility did not have a functioning bathtub. b. During an interview on 12/6/24 at 2:25 PM, the Administrator stated Social Worker terminated their employment at the facility (12/2/24). During an interview on 12/6/24 at 4:18 PM, the Administrator stated they didn't have a specific Grievance Officer and the Social Worker would be responsible for grievances. During an interview on 12/6/24 at 2:25 PM, the Administrator stated Social Worker terminated their employment at the facility (12/2/24). During an interview on 12/6/24 at 4:40 PM, the Director of Nursing stated the facility did not have a grievance policy and procedure. During an interview on 12/6/24 at 5:26 PM, the Administrator stated resident grievances were not being reviewed and process was not being followed. 10 NYCRR 415.27 (c)(1)(2)(3)(iv)

Based on observation, interview and record review conducted during a Standard survey, completed on 12/6/24, the facility did not ensure information on how to file a grievance or complaint was available to the residents and that they had an established grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights. Specifically, Resident Council was unaware of the process and policy on how to file a grievance or a compliant. The facility did not have a policy to ensure prompt resolution of all grievances regarding resident rights that included all required information. The findings are: During a Resident Council meeting on 12/3/24 at 10:30 AM, 7 of 7 Resident Council attendees stated they did not know how to file a grievance or who acted as the Grievance Officer. The residents stated the facility does not always respond to concerns voiced (staffing concerns, and customer service issues). This involved Resident's #17, 34, 36, 61, 70, 82 and 96. During an interview on 12/6/24 at 11:18 AM, Activities Department Director stated they were not aware if the facility had of a Grievance Officer. They stated when concerns, grievances were expressed during Resident Council meetings, they believed the Social Worker addressed them. They stated some concerns go to a specific department or the Administrator. They stated they weren't aware of a grievance policy or where the grievance forms were kept. During an interview on 12/6/24 at 1:45 PM, the Director of Nursing stated it was important for residents to know how to file a grievance. They stated residents always need to be advocated for, so they feel comfortable while in the facility and that their concerns were addressed. The Director of Nursing stated blank grievance forms were kept at the receptionist desk and maintained by the Social Worker. During an interview on 12/6/24 at 2:25 PM, the Administrator stated Social Worker terminated their employment at the facility (12/2/24). During an interview on 12/6/24 at 3:01 PM, the Receptionist stated they had not had any blank grievance forms available in a long time. They stated no families or residents had asked for a form but they should have them available if needed. During an interview on 12/6/24 at 4:18 PM, the Administrator stated they didn't have a specific Grievance Officer and the Social Worker would be responsible for grievances. They stated grievance forms should be available at the reception so anybody can have access to them. The Administrator stated grievances provide a paper trail and allows for facility follow up. The Administrator stated grievances should be reviewed during morning meeting and they should have ensured grievances were followed up on. Additionally, they stated they hadn't changed the grievance process. During an interview on 12/6/24 at 4:40 PM, the Director of Nursing stated the facility did not have a grievance policy and procedure. During an interview on 12/6/24 at 5:26 PM, the Administrator provided a grievance binder that included filed grievance forms. Review of grievance forms within the binder revealed there was no department head follow up or signatures. The Administrator stated grievances were not being reviewed and process was not being followed. 10 NYCRR 415.3 (d)(1)(i)

Based on interview, and record review conducted during the Standard Survey completed on 12/6/24, the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for six (Residents #10, #25, #36, #41, #43, and #65) of 28 residents reviewed for care planning. Specifically, Resident #10 did not have a care plan developed for skin integrity and had pressure ulcers; Resident #25 did not have a care plan developed for dentures; Residents #36 and #41 did not have a care plan developed for an alleged resident-to-resident altercation; Resident #43 did not have a care plan developed for skin care and incision care with treatments ordered, depression, cardiac, vision, dry nasal passages and supplements with medications ordered, and discharge planning; and Resident #65 did not have a care plan developed for bowel incontinence, safety, falls, and psychoactive medication use. The findings include: The policy and procedure titled Comprehensive Care Planning & Baseline with a revision date of 6/2021 documented a Care Plan will be individualized for each resident using a person-centered approach. The Comprehensive Care Plan will include measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs that are identified from admission assessments, the comprehensive assessment and application of the Care Area Assessment. Additional problems, strengths or needs identified by the Interdisciplinary Team will be included in the Comprehensive Care Plan. The Comprehensive Care Plan will be completed no later than seven days following completion of the admission comprehensive assessment. The care plan must be individualized for each individual. All disciplines are responsible for reviewing the plan of care and documenting goals, interventions, monitoring notes and updating as needed. Chronic active diagnoses and acute changes in condition will be card planned by the appropriate discipline in a timely manner. 1. Resident #10 had diagnoses including multiple sclerosis (a disease where the immune system effects the protective covering of nerves), diabetes mellitus type 2, and pressure ulcers of the sacrum (area at the base of the tailbone) and ischium (area of the lower buttocks). The Minimum Data Set, dated dated dated [DATE], documented Resident #10 was cognitively intact, understood and understands. The assessment tool documented that Resident #10 had one stage III (wound that involves full thickness loss of tissue) pressure ulcer and one unstageable (full thickness skin and tissue loss where the depth of the wound is hidden by eschar [dead tissue] and slough [yellow/white soft, stringy, thick substance]) pressure ulcer upon admission. The comprehensive care plan, initiated on 11/4/24, documented Resident #10 had pressure ulcers on their left ischium and coccyx related to multiple sclerosis, diabetes mellitus and limited mobility. There were no care plan interventions developed for the pressure ulcers until 12/4/24. Review of the Wound Evaluation and Management Summary noted dated 11/25/24, the Wound Consultant documented that Resident #10 had chronic wounds on their sacrum and left ischium with history of osteomyelitis (a serious bone infection). It was documented that Resident #10 had a stage IV (full thickness skin and tissue loss that exposes bone, muscle, tendon, ligament, or cartilage) pressure ulcer to their sacrum and left ischium with moderate serous drainage (clear/yellow drainage from a wound). During an interview on 12/6/24 at 12:41 PM, the Director of Nursing stated that they added care plan interventions on 12/4/24 to Resident #10's comprehensive care plan for pressure ulcers after the surveyor requested a copy of the care plan. The Director of Nursing stated they added the care plan interventions because the care plan did not have any and they felt Resident #10 needed them. 2.Resident #25 had diagnoses including unspecified dementia, stroke, and lower back pain. The Minimum Data Set (a resident assessment tool) dated 10/17/24, documented Resident #25 was moderately cognitively impaired, and always understood and understands. Resident #25 required partial/moderate assistance with oral hygiene. The comprehensive care plan last revised 10/25/24, documented Resident #25 had an ADL self-care performance deficit related to muscle weakness, and limited physical mobility related to weakness. The care plan also documented the resident had oral/dental health issues related to poor oral hygiene, and to provide mouth care as per ADL personal hygiene. There was no documentation that the resident had dentures or how to care for them. Review of the Closet Care Plan (used by staff to guide care) updated on 11/25/24, revealed the area labeled personal care had blank boxes where upper and lower dentures should have been checked and there were no instructions for denture care. During an interview on 12/5/24 at 8:58 AM, Licensed Practical Nurse #1 stated that if a resident wore dentures, it should be documented on their care plan, so the staff knew to clean them. During an interview on 12/5/24 at 9:24 AM, Unit Manager, Licensed Practical Nurse #2 stated that the care plan should reflect if a resident wore dentures so the certified nurse aides would know to clean them. They stated it was important for dentures to be removed at night and soaked for proper hygiene, because bacteria could grow underneath them. They were not aware that Resident #25's dentures were not documented on their care plan. Unit Manager, licensed Practical Nurse # 2 stated that care plans had not been updated recently. They stated that care plans should be reviewed, at least annually if not quarterly, by the entire interdisciplinary team and involve the resident and/or their family. They stated they only worked in the facility for a few weeks, so they had not updated care plans yet. During an interview on 12/6/24 at 10:52 AM, the Director of Nursing stated that nursing care plans should be reviewed/updated quarterly, by the unit managers and the interdisciplinary team. Dentures should be documented on the care plan, so staff know to properly clean them. 3. Resident #36 had diagnoses including diabetes mellitus type 2, chronic obstructive pulmonary disease, and bipolar disorder. The Minimum Data Set, dated dated dated [DATE], documented Resident #36 was cognitively intact, and always understood and understands. The assessment tool documented that the resident did not have any behaviors. Resident #41 had diagnoses including diabetes mellitus type 2, end stage renal disease, and bipolar disorder. The Minimum Data Set, dated dated dated [DATE], documented Resident #41 was cognitively intact, and always understood and understands. The assessment tool documented that the resident did not have any behaviors. Review of a facility investigation summary dated 7/11/24, the Former Administrator documented that on 7/11/24 Resident #36 alleged that Resident #41 rolled up to them in their wheelchair in the lobby area of the facility. Resident #36 alleged that they told Resident #41 you are supposed to stay away from me (due to a previous allegation's intervention) and Resident #41 responded by hitting them in the arm. Resident #36 had no injuries and Resident #41 denied the accusation. The investigation documented the interventions included that both residents were re-educated and reminded to stay away from each other. The comprehensive care plan, date initiated 2/6/24, documented Resident #36 had impaired self-care skills related to muscle weakness. Interventions included that resident was independent with personal powered wheelchair. The care plan documented that Resident #36 had potential for alteration in mood related to diagnosis of bipolar, manipulation with staff and had accusatory behavior at times. There was no care plan development for the allegation of a resident-to-resident interaction including interventions to keep away from Resident #41. The comprehensive care plan, date initiated 9/16/22, documented Resident #41 had limited self-care skills related to weakness. Interventions included that Resident #41 was independent with standard wheelchair. The care plan documented that Resident #41 had a behavior problem related to non-compliance and poor safety awareness as they had a history of refusing therapies, medication, treatments, and care. There was no care plan development for the allegation of a resident-to-resident interaction with intervention to keep away from Resident #36. During a telephone interview on 12/5/24 at 1:26 PM, Previous Unit Manager, Licensed Practical Nurse #3 stated that they did not witness nor had knowledge about the alleged resident to resident incident that occurred on 7/11/24 between Resident #36 and Resident #41. Licensed Practical Nurse #3 stated that development and revision of a resident's comprehensive care plan was the responsibility of the unit manager along with the Director of Nursing. Licensed Practical Nurse #3 stated that prior to end of their employment at the facility, they were behind on their development and revisions of the comprehensive care planning because they would have to work as a floor nurse two to three times a week and did not have a working computer. Licensed Practical Nurse #3 stated that Residents #36 and #41 should have had the alleged resident to resident altercations with interventions added to their comprehensive care plans. During an interview on 12/6/24 at 12:41 PM, the Director of Nursing stated that Licensed Practical Nurse #3 would have been responsible for care plan development and was unsure why they did not develop a comprehensive care plan with interventions for the alleged resident to resident altercation between Resident #36 and #41 on 7/11/24. The Director of Nursing stated they would have expected a care plan to be developed and it was important so staff would know how to take care and maintain the safety of both residents. 4. Resident #43 had diagnoses including major depressive disorder, ileostomy, and gastro-esophageal reflux disease. The Minimum Data Set, dated dated dated [DATE] documented the resident was understood, understands, was cognitively intact and had active diagnoses including hypertension, wound infection, hyponatremia (define), hyperlipidemia (define), cerebrovascular accident, malnutrition, depression, and respiratory disorder. Physician order recap report for Resident #43 dated 10/1/24 through 12/31/24 documented the following: -Clean abdominal incision with normal saline pat dry cover with dry clean dressing -Nystatin- Triamcinolone external cream around abdominal incision for skin irritation -Atorvastatin Calcium 20 mg every day for Hyperlipidemia (elevated fat levels in the blood) -Azelastine HCL nasal solution 1 spray in each nostril two times a day for dry nasal passages -Claritin 10 mg daily for allergies -Vitamin B 12 500 micrograms twice a day as supplement -Vitamin D 25 micrograms twice a day as supplement -Gen Teal Tears Moderate Ophthalmic solution 0.3% 1 drop each eye for dry eyes -Isosorbide Mononitrate extended release 30 milligrams every day for angina (chest pain) -Magnesium Oxide 800 milligrams every day for supplement -Metamucil fiber oral packet every day for supplement -Olanzapine 10 milligrams at bedtime for behavior -Omeprazole 20 milligrams every day for gastro-esophageal reflux -PreserVision Multi vitamin every day for supplement -Sennosides-Docusate Sodium 8.6-50 milligram twice a day for constipation -Sertraline Hydrochloride 100 milligrams every day for depression -Silodosin 1 capsule every day for benign prostatic hyperplasia (enlarged prostate gland) -Sodium Chloride 1 Gram four times a day for supplement The comprehensive care plan for Resident #43 dated 10/24/24 identified as current by the Director of Nursing did not have care plan focus areas, goals or interventions for the diagnoses, medications and treatments identified in the physician orders above. In addition, there were no documented focus, goals or interventions for skin integrity, oral care, urinary incontinence, Enhanced Barrier Precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities), and discharge planning. During an interview on 10/6/24 at 10:42 AM, Nursing Supervisor/Unit Manager Licensed Practical Nurse #5 stated the comprehensive care plan for Resident #43 should have been completed by November 7, 2024, and they were responsible to ensure the comprehensive care plan was completed to include diagnoses, medications, treatments, skin integrity, incontinence care, oral care, enhanced barrier precautions, advanced directives and discharge planning for continuity of nursing care and it wasn't done. During an interview on 12/6/24 at 12:11 PM, the Director of Nursing stated the comprehensive care plan for Resident #43 should have been developed by the 14th day after admission (11/7/24) and there was no care plan development with goals and interventions for the diagnoses, medications and treatments identified in the physician orders above. The Director of Nursing stated there were no documented focus, goals or interventions for skin integrity, oral care, urinary incontinence, enhanced barrier precautions, advanced directives and discharge planning and there should have been. The Director of Nursing stated they would have expected Unit Manager Licensed Practical Nurse #5 to have developed the comprehensive care plan by 11/7/24, and updated it as needed with changes. 5. Resident #65 had diagnoses that included dementia, protein-calorie malnutrition, and macular degeneration left eye (loss of the central field of vision because of deposits of the retina). The Minimum Data Set, dated dated dated [DATE] documented Resident #65 had severe cognitive impairment, was sometimes understood, and sometimes understands. Resident #65 was occasionally incontinent of urine and bowel, had a fall with major injury since admission, and was administered high-risk (antianxiety, antidepressant and opioid) medications. The comprehensive care plan for Resident #65, date initiated 7/3/24, identified as current by the Director of Nursing, did not have care plan focus areas, goals or interventions for bladder incontinence and falls until 12/4/24. There were no documented focus, goals or interventions for skin integrity, oral care, bowel incontinence, preferences, advanced directives, diagnoses, medications, and discharge planning. The closet care plan last updated on 10/2/24, documented the resident needed extensive assist of one person for toileting on the commode or bathroom, had an incontinence/toileting schedule, briefs were not indicated. No safety or behavior monitoring was indicated. During an interview on 12/6/24 at 9:13 AM, Certified Nurse Aide #7 stated they weren't responsible for changing or updating the residents care plans. They stated therapy and nursing were responsible. During an interview on 12/6/24 at 9:56 AM, Licensed Practical Nurse #7 stated a resident's care plan was important, so staff knew how to care for the residents. They stated the unit nurse manager was responsible to complete. During an interview on 12/6/24 at 10:18 AM, Unit 5 Nurse Manager, Licensed Practical Nurse #2 stated the interdisciplinary team collectively build a resident's comprehensive care plan. They stated assessments in the electronic record that are in red indicate that they were incomplete/overdue and there hadn't been a care plan meeting for residents since they started at the facility in November. They stated there was no structure or schedule to inform them when the resident's care plans were due for completion and review. Licensed Practical Nurse #2 reviewed Resident #65's care plan and stated that it was incomplete, outdated, or overdue. During an interview on 12/6/24 at 1:45 PM, the Director of Nursing stated every single discipline was responsible to complete the resident's comprehensive care plan within 14 days of admission and should be reviewed and updated as needed. They stated the interdisciplinary team should meet and review the comprehensive care plan at least on a quarterly basis. The Director of Nursing stated the unit managers were responsible for completing the nursing sections of the comprehensive care plan. The Director of Nursing reviewed Resident #65's care plan and stated their care plan was absolutely incomplete and wasn't aware until 12/4/24. The Director of Nursing stated they updated Resident #65's care plan on 12/4/24 after they discovered it wasn't completed. They documented that they added bladder incontinence and falls to Resident #65's care plan on 12/4/24. The Director of Nursing stated it was important that the comprehensive care plan was completed, updated timely for the entire interdisciplinary team to see, so quality of care, continuation of care and safety can be provided to the residents. 10NYCRR 415.11(c)(1)

Based on observation, interview and record review conducted during the standard survey, completed on 12/6/24, the facility did not ensure that residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for two (Residents #10 and #25) of six residents reviewed. Specifically, Resident #25 had visible food residue in their top and bottom dentures on multiple observations; Resident #10 had visible chin hair and long nails with brown debris underneath on multiple observations. The findings are: The policy and procedure titled ADL Care Guidelines dated 10/2021, documented care givers will review the resident's nursing care instructions at the beginning of each shift to assure that care is given according to the individual's plan of care. It also documented that the resident will be assisted with oral hygiene as appropriate, and dentures will be removed nightly and placed in a labeled denture cup with a cleaning tablet. The ADL policy documented female residents with excessive facial hair will be shaved at least weekly, if indicated and routine hand care will be done with bath and as needed. Fingernails should be cleaned underneath, and shaped. The policy and procedure titled Fingernail and Toenail Care, dated 7/3/2012, documented resident's fingernails would be monitored during their weekly skin assessments or on bath days. 1. Resident #25 had diagnoses including unspecified dementia, stroke, and lower back pain. The Minimum Data Set (a resident assessment tool), dated 10/17/24, documented Resident #25 was moderately cognitively impaired, and always understood and understands. Resident #25 required partial/moderate assistance with oral hygiene, and partial/moderate assistance with transfers out of bed to their wheelchair. Review of Resident #25's dental consult, dated 2/8/24, revealed they had a full upper denture and a partial lower denture, with a note staff to assist patient with daily cleaning of dentures, nightly and as needed. The comprehensive care plan last revised 10/25/24, documented Resident #25 had an ADL self-care performance deficit related to muscle weakness, and limited physical mobility related to weakness. The care plan also documented the resident had oral/dental health issues related to poor oral hygiene, and to provide mouth care as per ADL personal hygiene. There was no documentation that the resident had dentures or how to care for them. Review of the Closet Care Plan (used by staff to guide care) updated on 11/25/24, revealed the area labeled personal care had blank boxes where upper and lower dentures should have been checked and there were no instructions for denture care. Review of the Certified Nurse Aide task documentation for Resident #25 revealed from 12/3/24-12/5/24 oral hygiene was documented as Not Applicable. During an observation and interview on 12/2/24 at 9:22 AM, Resident #25 was in bed, there was visible food debris in both their upper and lower dentures. Resident #25 stated staff did not clean their dentures very often and could not recall the last time they were removed and cleaned. During observations and interviews, on 12/4/24 at 8:28 AM and 12/5/24 at 8:53 AM, Resident #25 had visible food debris in both their upper and lower dentures. They stated staff had not remove them to soak them. During an interview on 12/5/24 at 8:58 AM, Licensed Practical Nurse #1 stated that if a resident wore dentures, it should be documented on their care plan, so the staff knew to clean them. During an interview on 12/5/24 at 9:24 AM, Unit Manager, Licensed Practical Nurse #2 stated that the care plan should reflect if a resident wore dentures so the certified nurse aides would know to clean them. They stated it was important for dentures to be removed at night and soaked for proper hygiene, because bacteria could grow underneath them. They were not aware that Resident #25's dentures were not documented on their care plan. During an interview on 12/5/24 at 10:54 AM, Certified Nurse Aide #2 stated they looked at a resident's care plan to determine what type of oral care a resident needed. Certified Nurse Aide #2 stated that resident's dentures should be removed at night and placed in a denture cup to be sanitized. It was important for good hygiene and for their dignity to have clean teeth. They stated they did morning care on resident #25 that morning and they did not remove their dentures. Certified Nurse Aide #2 stated they could not recall the last time Resident #25's dentures were cleaned; they were in their mouth whenever they did the resident's morning care. During an interview on 12/6/24 at 10:52 AM, the Director of Nursing stated that nursing care plans should be updated by the unit managers. Dentures should be documented on the care plan, so staff know to properly clean them. They expected Certified Nurse Aides to remove residents' dentures every night to soak them because it was important for good hygiene and dignity. 2. Resident #10 had diagnoses including multiple sclerosis (a disease where the immune system effects the protective covering of nerves), diabetes mellitus type 2, and pressure ulcer (injury to the skin and tissues from prolong pressure to the area) of the sacrum (area at the base of the tailbone) and ischium (area of the lower buttocks). The Minimum Data Set, dated dated dated [DATE], documented Resident #10 was cognitively intact, understood and understands. Resident #10 required supervision/touching assistance with hygiene, and substantial/maximal assistance with bathing. The comprehensive care plan initiated on 11/4/24, documented Resident #10 had an ADL self-care performance deficit related to muscle weakness. Interventions included the resident was independent/set up for grooming and extensive assist of one for bathing. During observations on 12/2/24 at 12:43 PM and 12/3/24 at 11:11 AM, Resident #10 was observed to be lying in bed wearing their own personal night gown. Resident #10 was observed have long fingernails with brown debris underneath and 1/2 inch long white chin hairs. During an observation and interview on 12/4/24 at 9:42 AM, Resident #10 was observed to continue to have long nails with brown debris and chin hairs. Resident #10 stated they minded having long chin hairs and would like the staff to help remove them and they would also like to have their fingernails cut. Resident #10 added they would like to have their hands and nails cleaned but staff do not give them anything to wash them with. Resident #10 stated they were new to the facility and still were getting used to the ways staff did things. During an observation on 12/4/24 at 10:13 AM, Certified Nurse Aide #8 and #9 performed morning care for Resident #10 by washing, rinsing, and drying the resident's neck, underneath their breasts and armpits, peri area and buttocks. Resident #10 was dressed in their personal gown and was not gotten out of bed. Certified Nurse Aide #8 and #9 did not wash nor offer to clean Resident #10's hands and nails or assist with removal of their chin hair. During an interview and observation on 12/6/24 at 10:29 AM, Resident #10 was observed to continue to have long nails with brown debris and chin hairs. Resident #10 stated that no staff members had offered to cut and clean their nails or assist them with chin hair removal during the week. During an interview on 12/4/24 at 1:30 PM, Certified Nurse Aide #8 stated that they did not perform nail care to Resident #10 and that they usually were not responsible to provide nail care to residents. They stated they did not know who was responsible to provide nail care. Certified Nurse Aide #8 stated that they did not notice the debris under Resident #10's nails and should have looked at their hands during care. They stated they did not offer Resident #10 to wash their hands and they should have. Certified Nurse Aide #8 stated the Activities Department usually was the department that would shave and/or cut a resident's hair. Certified Nurse Aide #8 stated they also did not offer to assist Resident #10 with chin hair removal and probably should have. Certified Nurse Aide #10 stated it was important to offer a resident to wash their hands because they touched everything, and it was an everyday activity. They stated it was important to remove chin hair because it was an everyday appearance to make a resident more presentable. During an interview on 12/4/24 at 1:59 PM, Certified Nurse Aide #9 stated when they performed morning care to a resident, they washed everything including a resident's hands and nails. Certified Nurse Aide #9 stated they did not offer Resident #10 hand washing, nail care and chin hair removal because they were only helping Certified Nurse Aide #8. Certified Nurse Aide #9 stated they should have placed Resident #10's hands in water and offered the resident a razor/shaver. During an interview on 12/5/24 at 12:16 PM, Licensed Practical Nurse #10 stated that the Certified Nurse Aides were responsible to perform nail care on a resident's shower day unless the resident was a diabetic. They stated that residents should be offered hand hygiene every day; prior to and after they eat; and when they used the bathroom. They stated that Resident #10 should have been offered hand hygiene and chin hair removal during morning care for infection control and dignity issues. During an interview on 12/6/24 at 12:41 PM, the Director of Nursing stated that morning care for a resident consisted of washing a resident from head to toe, including washing their hands. They stated nail care should be completed by the nursing staff and offered to the residents whenever their nails were long, or debris was noted for infection control and hygiene issues. The Director of Nursing stated the Certified Nurse Aides should also be offering/performing chin hair removal/shaving when needed due to dignity and respect for the resident. During an interview on 12/6/24 at 1:47 PM, Certified Nurse Aide #4 stated they were responsible for care on Resident #10 on 12/6/24. They stated they knew they should perform or offer nail care to Resident #10 every day during morning care, but they did not. Certified Nurse Aide #4 stated they had performed chin hair removal on Resident #10 last week but did not assist or offer today or at all this week. Certified Nurse Aide #4 stated they usually were the staff member that shaved the residents on the unit, and they have the other Certified Nurse Aides do the nail care. 10NYCRR 415.12 (a)(3)

Based on observation, interview, and record review conducted during a Standard survey completed 12/6/24, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues with foods being either unlabeled or outdated in the refrigerator. The findings are: The undated facility policy and procedure titled Food Storage Refrigerator/ Freezer documented purpose is to ensure foods are stored properly to minimize spoilage and contamination, and to ensure taste and quality of food. All refrigerated foods should be labeled/ dated and discarded after three (3) days. The facility policy and procedure titled Food Safety Requirements Policy - use and storage of food and beverage brought in for resident's food procurement dated 11/2017 documented the policy is to provide safe and sanitary storage, handling, and consumption of all food. This includes the storage, preparation, distribution, and serving food in accordance with professional standards for food safety. The food service supervisors, cooks, dietary aides, or any persons who are in the kitchen working with any type of food, are responsible for adhering to the food safety requirements. During an observation of the main kitchen on 12/2/24 at 8:51 AM revealed the reach in refrigerator labeled #6 across from the walk-in refrigerator had nine plastic containers revealing the following: -3/4 quart of mixed fruit was not labeled or dated and had black debris floating on the mixed fruit and on the inside sides of the container. -1/4 quart of sliced pears was not labeled or dated and had green/grey debris on the pears. -1 1/2 quarts of chopped peaches were not labeled and marked with a date of 11/11. -1 1/2 quarts of chopped peaches were not labeled and marked with a date of 9/24/24. -2 quarts of chopped pears were not labeled or dated. -1/4 quart of chopped peaches were not labeled or dated. -1/2 pitcher of unidentifiable brown liquid was not labeled or dated. -1/4 pitcher of unidentifiable yellow liquid was not labeled or dated. -2 1/2 quarts of orange pudding like consistency was not labeled or dated. During an interview on 12/2/24 at 9:16 AM, dietary [NAME] #1 stated all food items should be labeled and dated when opened and disposed of after 3 days. They stated all the items identified must be disposed of as they do not know when they were placed in the refrigerator. They stated they believe the black floating debris in the mixed fruit and green/grey debris on the pears is mold and must have been in the refrigerator greater than 3 days. During an interview on 12/2/24 at 9:32 AM, the Dietary Department Director stated all opened food items are to be labeled and dated and disposed of after 3 days from opening. They stated the dietary aides are responsible to date and label the items, although they are ultimately responsible to ensure the staff are following the facility's policies and procedures, and regulations. They stated they believe the black debris and green/grey debris identified in the containers was mold and would have been opened greater than 3 days.They stated this is for food safety to prevent contamination and molding. 10 NYCRR 415.14(h) 14-1.43(e)

Based on observation, interview and record review conducted during a Standard survey completed 12/6/24, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections, for two (Resident #10 and #43) of four residents reviewed for enhanced barrier precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities) during care. Specifically, Resident #10 had chronic pressure ulcers (injury to the skin and tissues from prolong pressure to the area) and the Certified Nurse Aides did not wear proper personal protective equipment during morning care. Additionally, Resident #42 had an ileostomy (a surgical operation in which a piece of the intestine is diverted to an opening in the stomach wall) and the nurse did not wear proper personal protective equipment during care. The findings are: Review of the policy and procedure titled Enhanced Barrier Precautions dated 4/2024 documented that residents in nursing homes are at increased risk of becoming colonized and developing infection with multi-drug resistant organisms, especially those with risk factors like indwelling medical devices or wounds. It is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of the organisms. The policy documented that enhanced barrier precautions involve gown and gloves use during high-contact resident care activities for residents who were at increased risk of multi-drug resistance acquisition. High contact resident activities include dressing, bathing, providing hygiene, device care or use, and wound care. 1. Resident #10 had diagnoses including multiple sclerosis (a disease where the immune system effects the protective covering of nerves), diabetes, and pressure ulcers of the sacrum (area at the base of the tailbone) and ischium (area of the lower buttocks). The Minimum Data Set (a resident assessment tool) dated 11/11/24, documented Resident #10 was cognitively intact, understood and understands. Resident #10 required substantial/maximal assistance with bathing and had one stage 3 (wound that involves full thickness loss of tissue) pressure ulcer and one unstageable (full thickness skin and tissue loss where the depth of the wound is hidden by eschar [dead tissue] and slough [yellow/white soft, stringy, thick substance]) pressure ulcer. The comprehensive care plan revised on 12/4/24, documented Resident #10 had pressure ulcers related to multiple sclerosis, diabetes mellitus and limited mobility. Interventions included to administer treatments and medications and to follow facility policies/protocols for prevention/treatment of skin breakdown. There was nothing in the care plan about Enhanced Barrier Precautions. Review of the Wound Evaluation and Management Summary noted dated 11/25/24, the Wound Consultant documented that Resident #10 had chronic wounds on their sacrum and left ischium with history of osteomyelitis (a serious bone infection). It was documented that Resident #10 had a stage IV (full thickness skin and tissue loss that exposes bone, muscle, tendon, ligament, or cartilage) pressure ulcer to their sacrum and left ischium with moderate serous drainage (clear/yellow drainage from a wound). During an observation on 12/2/24 at 12:43 PM, Resident #10 was noted to have a precaution sign on the door indicating stop, staff to wear gloves and gown during care. A plastic bin was observed to be outside the resident door in the hallway filled with gowns and masks. During an observation on 12/4/24 at 10:13 AM, precaution signage remained on the door and the plastic bin was now located inside the door entrance to the right-hand side. Certified Nurse Aide #8 and #9 performed morning care to Resident #10 by washing, rinsing, and drying the resident's neck, underneath their breast and armpits, peri area and buttocks. Resident #10 was observed to have open areas to their sacrum and left ischium that were not covered with any dressings. Certified Nurse Aide #8 and #9 did not wear gowns during the morning care observation. During a wound care observation on 12/4/24 at 10:42 AM, immediately following the completion of morning care, Licensed Practical Nurse #10 donned a gown prior to initiating the care. Resident #10's left ischium wound was noted to be moist with area of slough in the wound bed. Serosanguinous drainage (watery drainage mixed with blood from a wound) was noted on the gauze pad as the wound was cleansed with wound cleaner and prior to the application of the ordered ointment the wound began to actively bleed. During an interview on 12/4/24 at 1:30 PM, Certified Nurse Aide #8 observed the precaution signage on Resident #10's door and stated they did not pay attention to the signage on the door. They stated they should have worn a gown during morning care. Certified Nurse Aide #8 stated Resident #10 had a wound and because they did not wear a gown, they did not protect themselves from possible germs. During an interview on 12/4/24 at 1:59 PM, Certified Nurse Aide #9 observed the precaution signage on Resident #10's door and stated the sign meant that they were to wear a gown when providing care to Resident #10. They stated that themselves and Certified Nurse Aide #8 did not wear gowns during morning care for Resident #10 because they were not used to being observed performing their duties and they both were nervous being observed. Certified Nurse Aide #9 stated the purpose of wearing gowns for residents that were on enhanced barrier precautions was for infection control reasons. During an interview on 12/5/24 at 12:16 PM, Licensed Practical Nurse #10 stated enhance barrier precautions were when any type of care was given to a resident that had a wound and the area was exposed. Licensed Practical Nurse #10 stated that Resident #10 had chronic pressure ulcers. They stated that at any point during care Resident #10's dressing could come off and that it often did. Licensed Practical Nurse #10 stated staff needed to wear a gown when providing care to Resident #10 because the area could become infected at any time. 2. Resident #43 had diagnoses including major depressive disorder, ileostomy, and gastro-esophageal reflux disease. The Minimum Data Set (a resident assessment tool) dated 10/28/24 documented the resident was understood, understands, was cognitively intact. The comprehensive care plan for Resident #43 dated 10/24/24 identified as current by the Director of Nursing, did not have a focus area, goals or interventions for enhanced barrier precautions. Observation on 12/2/24 at 11:10 AM, revealed signage on Resident #43's room door for precautions with directions to don a face mask, gloves, and a gown. There was a multi-pocket storage container hanging on Resident #43's door with gowns, gloves, masks, and face shields available. There was a bin located outside Resident #43's doorway in the hallway with additional personal protective equipment including masks, gloves, and gowns. During an observation and interview on 12/4/24 at 9:42 AM, Licensed Practical Nurse #9 donned gloves and a mask and performed changing Resident #43's ileostomy bag/flange, they did not wear a gown. Licensed Practical Nurse #9 stated Resident #43 was on Enhanced Barrier Precautions because of the ileostomy. They stated they applied gloves and a mask and should have also donned a gown before changing the ileostomy flange, for infection control, and they stated they have no excuse why they didn't, just that they had forgotten to put on a gown. During an interview on 12/6/24 at 10:42 AM, Nursing Supervisor/Unit Manager Licensed Practical Nurse #5 stated Resident #43 was on Enhanced Barrier Precautions because they had an ileostomy and would have expected Licensed Practical Nurse #9 to have donned gloves, mask and a gown prior to changing Resident #43's ileostomy bag/flange for infection control purposes to protect the resident. During an interview on 12/6/24 at 8:59 AM, the Infection Preventionist stated Enhance Barrier Precautions were used for residents that had any invasive device and/or opening such as wounds or ostomies/colostomies. They stated the purpose of Enhance Barrier Precautions was to shield the care giver from bacteria and to protect the resident from introduction of bacteria. The Infection Preventionist stated personal protective equipment (gloves and gowns) needed to be worn during any direct contact with the resident such as dressing, bathing, or care to the area. They stated they would have expected the nurse to wear a gown when preforming colostomy/ostomy care and would have expected the Certified Nurse Aides to wear a gown when performing morning care to a resident with an open wound. During an interview on 12/6/24 at 12:11 PM, the Director of Nursing stated Resident #43 was on Enhanced Barrier Precautions for the ileostomy and would have expected Licensed Practical Nurse #9 to have donned a gown in addition to the gloves and mask prior to changing the ileostomy bag/flange for infection control purposes. During a further interview at 12:41 PM, the Director of Nursing stated that gowns and gloves were to be worn during any type of care or transfers when a resident had any skin wounds. They stated they were familiar with Resident #10 and Certified Nurse Aides absolutely should have worn gowns during morning care. The Director of Nursing stated the purpose for Enhanced Barrier Precautions was the resident could have an infection without one knowing. They stated that wearing gowns not only protected the resident from possible infection but also the staff from possible infection. 10NYCRR 415.19(a)(2)

Based on observations, record review and interviews during a Standard survey completed 12/6/24, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight for one (Resident #65) of two residents reviewed. Specifically, Resident #65 had a significant weight loss and there was a lack of meal and nourishment acceptance being documented or recorded. In addition, the medical provider was not made aware of the significant weight loss. The finding is: 1. Resident #65 had diagnoses that included dementia, protein-calorie malnutrition, and macular degeneration left eye (loss of the central field of vision because of deposits of the retina). The Minimum Data Set, dated dated dated [DATE] documented Resident #65 had severe cognitive impairment, required supervision/touch assist for eating, weight was 105 pounds and weight loss marked no or unknown. Additionally, Resident #65 was on a therapeutic diet. During breakfast and lunch meal observations on 12/5/24 at 9:11 AM and 12:53 PM, Resident #65 was sitting in the unit dining room with meal. Meal ticket on tray it was noted alert- extensive assist feeding. No staff present at table to provide assist during meal. Staff that were present were observed assisting other residents in the unit dining room. Meal ticket did not indicate what supplements they were to receive. Shake was observed on breakfast tray and boost was present on lunch tray. The Order Summary Report dated 12/6/24 documented No Added Salt diet, Regular texture, thin consistency with start date 7/3/24. Obtain admission weight and height, one time only for admission. Review of the Medical Orders for Life Sustaining Treatment (MOLST) last updated 9/18/24, revealed Resident #65 had a do not attempt resuscitation, do not intubate, send to hospital order when medically necessary. There were limited medical interventions which included no feeding tube, administer intravenous fluids, and use antibiotics to treat infections. The comprehensive care plan for Resident #65 initiated on 7/3/24 identified as current by the Director of Nursing, documented the resident had potential for nutritional risk related to body mass index 19.6, dietary restrictions secondary diagnosis of hypertension (high blood pressure), leaves greater than 25 percent of some meals uneaten at times. Dated 8/20/24 significant weight loss and 11/8/24 weight loss trend noted. Goal was to maintain adequate nutritional status as evidenced by maintaining weight within 1-5 pounds of current weight. Interventions included monitor meal consumption records, monitor weights as per policy, provide and serve supplements: shake at lunch and dinner, monitor acceptance and effects. On 8/29/24 shake was changed to Boost plus, on 9/20/24 shake added at breakfast and on 11/8/24 magic cup added every lunch. Report significant weight losses to medical doctor and interdisciplinary care team for input. Additionally, Resident #65 had limited self-care skills related to weakness, required extensive assist for feeding. Review of the Closet Care Plan last revised on 10/2/24 documented eating as extensive assist of 1 on unit. Review of the Weights and Vitals Summary dated 12/6/24 revealed the following weights and weight status: -7/2/24 admission weight was 114 pounds. -8/20/24 weight was 107 pounds. -9/13/24 weight was 105 pounds which showed a change/loss of 7.9 percent or 9 pounds since 7/2/24. -10/7/24 weight was 103 pounds which showed a change/loss of 9.6 percent or 11 pounds since 7/2/24. -11/11/24 weight was 100.5 pounds which showed a change/loss of 11.8 percent or 13.5 pounds since 7/2/24. -12/6/24 weight 98 pounds which showed a change/loss of 14 percent or 16 pounds since 7/2/24. Review of the Initial Nutrition Assessment completed by the Dietary Technician dated 7/3/24, revealed admission weight on 7/2/24 was 114 pounds with a body mass index of 19.6. Diet order of No Added Salt regular consistency thin liquids provides 1600-1700 kilocalories, 65-75 grams protein and 1200 milliliters fluids. Shakes at lunch and dinner provided 600 kilocalories, 22 grams protein and 360 millimeters of fluids. Estimated needs were 1554-1813 kilocalories, 51.8-62.2 grams of protein and 1544 milliliters of fluid per day. Actual intake for solids, liquids, and supplements to be monitored. Review of the dietary progress note dated 8/29/24 revealed weights reviewed, 8/20/24 weight was 107 pounds indicating a significant loss from previous weight. Intake of meals 26-100 percent. Shake provided at lunch and dinner with acceptance generally greater than 50 percent. Shake was changed to Boost plus for increased kilocalories. Monitor acceptance and effects. Review of the dietary progress note dated 9/20/24 revealed weights reviewed, 9/13/24 weight was 105 pounds indicating a 2-pound loss from previous weight. Intake of meals 26-100 percent. Supplements provided, acceptance 25-100 percent. Shake was added at breakfast for increased kilocalorie, monitor acceptance and effects. Review of the Quarterly Nutrition assessment dated [DATE] completed by the Dietitian revealed documented weight on 9/13/24 was 105 pounds with no significant weight change noted. Current diet and supplements provided met residents estimated needs. Intake was fair to good. Meal plan supplemented with Boost plus twice daily and shake daily. Weight indicates some decline since admission. Review of the dietary progress note dated 11/11/24 revealed weights reviewed, 11/8/24 weight 100.5 pounds with weight loss trend noted. Intake of meals usually 26-75 percent. Supplements provided with meals, acceptance generally 100 percent. Magic cup added daily to lunch for increased kilocalorie, monitor acceptance and effects. Review of the undated Nutrition-Amount Eaten 30 day look back revealed out of 90 meals only 20 were documented for meal intakes. Review of the undated Nutrition-Supplement for Breakfast: Boost plus, Lunch: Boost Plus, Dinner: Boost Plus 30 days look back revealed out of 30 days only 13 days were documented and out of 90 supplement opportunities only 25 were documented. Review of all the departments progress notes dated between 9/2/24- 12/6/24 revealed no evidence that the medical provider or the resident representative were notified of Resident #65's significant weight loss. Review of the medical provider notes dated 9/18/24, 9/19/24, 10/24/24, and 11/15/24 revealed no evidence of notification of weight loss. 9/19/24, 10/24, and 11/15/24 documented review of systems, denied weight loss. Review of the Speech Screening dated 7/4/24 revealed swallowing regular consistency with thin liquids within functional limits. Review of Occupational Therapy Screen dated 10/14/24 revealed recommendation to Nursing for feeding was extensive assist with minimal help. During an interview on 12/2/24 between 12:12 PM-12:28 PM Resident #65's family member stated they felt the resident had lost weight. Resident #65's family member stated the resident needs assistance to eat due to confusion and impaired vision. They stated they weren't sure that the resident was receiving the required help and they had expressed this before to nursing. During an interview on 12/5/24 at 1:44 PM, Licensed Practical Nurse #4 stated they should be made aware of weight loss so they can monitor for adequate meal intake. They stated if weight loss was indicated on the 24-hour nurse report they would ask the Certified Nurse Aides what the resident consumed so it could be documented in the progress notes. Licensed Practical Nurse #4 stated the Certified Nurse Aides are responsible for documenting acceptance percentages of meals in the electronic medical record. Licensed Practical Nurse #4 stated they were not aware that Resident #65 had a weight loss. During an interview on 12/6/24 at 10:18 AM, Unit 500 Manager, Licensed Practical Nurse #2 stated the Dietitian enters weights in the electronic medical record, tracks resident's weights and alerts the Unit Managers of weight changes. They stated they were not aware Resident #65 had a weight loss and should have been notified so nursing follow up could be completed. They stated if a meal ticket indicates extensive assist, resident requires assistance with set up and eating to ensure the resident is consuming food properly. During an interview on 12/6/24 at 11:35 AM, Nurse Practitioner #1 stated they had not been informed of Resident #65's weight loss since admission. They stated if they were made aware of weight concerns, they would have document it and followed up. They stated they would expect to be notified of weight changes so it can be discussed with family, weights can be monitored more closely, medication can be reviewed, and determination can be made if it's a decline in disease process. During an interview on 12/6/24 at 12:11 PM, the Dietary Technician stated that residents' weights are reviewed every month, as needed or per medical order. They stated when weight loss is noted they see the resident, make necessary changes such as adding supplements, updating preferences, making a referral to occupational therapy and/or speech, and discuss with interdisciplinary team the need for an appetite stimulant. The Dietary Technician stated weight loss is discussed during morning meeting with the interdisciplinary team and the medical provider would be updated by them or the Dietitian. They stated they update the medical provider by placing something like a note in the medical providers book on the units. The Dietary Technician stated after the medical provider makes recommendations nursing reports the recommendations/orders to them. The Dietary Technician stated there probably wouldn't be any documentation on them notifying the medical provider of weight loss. They stated they did not have a good reason and that it would be documented from now on. Upon reviewing Resident #65's electronic medical record the Dietary Technician stated Resident #65 had a weight loss and did not believe the medical provider was notified. They stated they would consider an 11.84 percent weight loss in 4 months a significant weight loss and that a medical provider should have been updated. The Dietary Technician stated it was important to monitor residents' weights for their overall well-being, determine if their MOLST needs to be updated and if the medical provider needs to be involved. Additionally, the Dietary Technician stated Resident #65's weights should have been monitored more frequently due to their weight trending down. During a telephone interview on 12/6/24 at 12:29 PM, the Dietitian stated supplement and meal acceptance is based on observation and what is placed in the electronic medical record. They stated the documentation of acceptance is inconsistent and lacking. The Dietitian stated they are not able to get a clear picture of the residents' acceptance of supplements and meals based on the information given. The Dietitian stated the medical provider and nursing should be notified of significant weight loss or when weight loss can't be explained immediately, so various interventions such as labs, medication changes, referrals can be done. They stated Resident #65's weight loss was significant and should have been reported by them or the Dietary Technician. During an interview on 12/6/24 at 1:45 PM, the Director of Nursing stated that the certified nurse aides and nurses are responsible to ensure supplements are being administered and recorded. The Director of Nursing stated they expected percentages to be documented so that nursing and dietary could review acceptance. They stated supplements are an important means of nutrition and they are important for calorie intake, maintaining resident's weights, hydration, and skin. The Director of Nursing stated a medical provider should be notified of weight loss immediately by dietary or the unit manager. During a telephone interview on 12/6/24 at 2:23 PM, Medical Doctor #1 stated they would expect to be notified of weight loss as soon as it is noticed so interventions can be implemented. They stated they were not made aware of any weight loss for Resident #65. They stated if Resident #65 were having frequent loose stools this could contribute to weight loss and malnutrition. They stated Resident #65 could be lactose intolerant and that dietary should be involved. 10 NYCRR 415.12(i)(1)

Based on observation, interview, and record review conducted during the Standard survey completed 12/6/24 the facility did not ensure that residents with an indwelling foley catheter (tube inserted into the bladder to drain urine) received the appropriate care for one (Resident #45) of two residents reviewed. Specifically, staff did not maintain proper infection control practices for a resident with a foley catheter. The finding is: The policy and procedure titled Indwelling Catheter Care dated 2/2019, documented to keep the drainage tubing/catheter junction closed. Ensure the catheter is properly secured to upper thigh with securement device. 1. Resident #45 had diagnoses that included obstructive and reflux uropathy (obstruction in urinary tract), history of urinary infections and dementia. The Minimum Data Set (a resident assessment tool) dated 11/20/24 documented Resident #45 had moderate cognitive impairment, required substantial/max assistance with toileting and had an indwelling urinary catheter. The Clinical Physicians Orders dated 11/14/24 through 12/5/24 documented to flush foley with 30 milliliters of normal saline every day and as needed, and document foley output every shift. There were no other catheter care orders. The comprehensive care plan initiated 11/15/24 documented Resident #45 had an activities of daily living self-care performance deficit related to weakness. Interventions included extensive assist was required for toileting, bedpan use and foley care. The Kardex provided as of 12/6/24, documented Resident #45 required extensive assist was required for toileting, bedpan use and foley care. The Kardex posted in the resident's room on 12/5/24 during the observation did not indicate Resident #45 had a foley catheter. During an observation on 12/2/24 at 11:15 AM, Resident #45 was in bed. The foley catheter bag was attached to the bedframe and the bottom of the urinary drainage bag was directly on the floor; the spigot (spout used to empty urine from the collection bag) was not secured and was also touching the floor. The urinary drainage bag was dated 11/18/24 and the catheter tubing and bag contained yellow urine. During an observation on 12/5/24 at 9:18 AM, Resident #45 was in bed and the urinary drainage bag was attached to the bed frame, the catheter tubing and urine collection bag was on the floor. The urinary drainage bag was dated 11/18/24 and the catheter tubing contained cloudy yellow urine with mucous shreds. During an observation and interview on 12/5/24 at 1:04 PM to 1:21 PM, Certified Nurse Aide #5 placed the urinary collection bag spigot inside an undated urinal to empty urine from the collection bag. After draining the urine from the bag, they tapped the inside of the urinal with the spigot several times, clamped the spigot and then reconnected the spigot to the urinary drainage bag without sanitizing it. Resident #45's foley catheter was not secured to the securement device (leg strap) on the residents left thigh. Certified Nurse Aide #5 stated the securement device should be used so the resident's urine can flow better. They stated they should have wiped the spigot with an alcohol pad after emptying the drainage bag for infection control purposes. They stated they didn't have any alcohol pads and it slipped their mind to clean the spigot. Additionally, they stated they could have gotten alcohol pads from the clean utility room or from the nurse. During an interview on 12/5/24 at 1:44 PM, Licensed Practical Nurse #4 stated the spigot should be drained over a graduate, cleaned with alcohol to remove bacteria and germs for infection control purposes. During an interview on 12/5/24 at 2:00 PM, Unit 500 Manager Licensed Practical Nurse #2 stated an alcohol wipe should be utilized after draining urine from spigot to ensure nothing yucky was being left behind for infection control purposes. During an interview on 12/6/24 at 8:59 AM, the Infection Preventionist stated the process for emptying a foley catheter would be to perform hand hygiene, wear gloves, pull the spigot out of its holder, cleanse the spigot with an alcohol swab, empty the bag contents into a cylinder or urinal, cleanse the spigot again with an alcohol swab and replace into the holder. The Infection Preventionist stated they would expect the nursing staff to be careful not to hit the insides of the urinal/graduate with the spigot. The urinary drainage bag spigot should never be out of its holder laying on the floor nor should the foley drainage bag and tubing ever be laying directly on the floor because it could introduce bacteria into the bladder. During an interview on 12/6/24 at 9:56 AM, Licensed Practical Nurse #7 stated the foley catheter bag and tubing should not be touching or on the floor. The foley drainage bag should be replaced if it had been on the floor. Additionally, they stated the catheter drainage bag should be dated and changed every month or as needed. During an interview on 12/6/24 at 10:18 PM, Unit 500 Manager Licensed Practical Nurse #2 stated they expected foley catheter drainage bags and tubing to be kept off the floor for infection control purposes. It was the nursing teams responsibility to ensure catheter drainage bag and tubing weren't on the floor. During an interview on 12/6/24 at 1:45 PM, the Director of Nursing stated they expected foley catheter drainage bags and tubing to be kept off the floor. They stated the spigot should not touch the graduate and should be cleaned, disinfected after use for infection control purposes. 10 NYCRR 415.12(d)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 12/6/24, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #30) of one resident reviewed for positioning and mobility. Specifically, the staff did not ensure that Resident #30's left and right palm guards (assistive device that positions the fingers away from the palm) were worn as recommended by occupational therapy. In addition, there was inconsistent documentation that range of motion exercises were provided to the resident per their care plan. The finding is: The policy and procedure titled Range of Motion and Ambulation revised 9/15/2020, documented that every effort would be made to ensure that residents do not lose range of motion, ability to walk or activities of daily living abilities unless the loss is unavoidable. Certified nursing assistants are expected to assist with range of motion in accordance with the care plan and document that range of motion has been provided prior to the end of their shift in the electronic medical record. The policy and procedure titled Splint revised on 10/19/2015, documented that physical therapy/occupational therapy will determine the need of splint for the resident. Nursing, resident, and family members as indicated will be instructed in the wearing schedule and would be written on the plan of care/care guide. Resident #30 had diagnoses which included cerebral vascular accident- (stroke), dysphasia (impairment of speech and verbal comprehension), and muscle weakness. The Minimum Data Set (a resident assessment tool) dated 11/26/24, documented Resident #30 had severe cognitive impairment, was rarely/never understood, and rarely/never understands. The Minimum Data Set documented Resident #30 had upper extremity functional limitation in range of motion on one side. The comprehensive care plan dated 12/13/17, documented that Resident #30 had limited mobility and was on a restorative nursing program. The program included assistive active range of motion (exercises performed by resident with some help from staff) to bilateral (both) lowers extremities and passive range of motion (exercises performed on the resident by nursing staff) to bilateral upper extremities three times weekly on Mondays, Wednesdays, and Fridays. Resident #30 wore right and left palm guards as tolerated except for range of motion, hygiene, meals and when asleep. Review of the Occupational Therapy Discharge Summary dated 9/20/24 documented nursing caregivers were instructed on the restorative nursing program which included bilateral upper extremities passive range of motion. The splinting/orthotic schedule was reviewed with nursing staff to preserve Resident #30's current level of function. During intermittent observations on 12/2/24 at 3:27 PM, Resident #30's right hand was curled into a fist. The left hand was gripping the wheelchair seat, there were no palm guards in the resident's hands. On 12/4/24 at 9:16 AM, 3:54 PM, and 12/5/24 at 10:48 AM there were no palm guards in Resident #30's left or right hand. Review of the Order Audit Report dated 12/5/24 revealed an active standing physicians order dated 11/30/22 for right and left palm guards to be worn except for range of motion, hygiene, and while asleep. The Medication Administration Record dated 12/1/24-12/31/24 documented right and left palm guards were to be worn except for range of motion, hygiene and while asleep. There were no start or end dates and there were no staff initials that documented the palm guards were worn. There was an x documented from 12/1/24-12/31/24. Review of the Documentation Survey Reports for 9/2024,10/2024,11/2024 and 12/2024 revealed Resident #30 was on a restorative nursing program for upper extremity and lower extremity range of motion three times weekly on Mondays, Wednesdays, and Fridays. There were multiple blanks where the range of motion wasn't documented as completed. During observation and interview on 12/5/24 at 1:48 PM, Certified Nursing Assistant #5 stated that palm guards prevented worsening contractures (loss of joint mobility) and verified Resident #30 had no palm guards in their hands per the care plan. They checked Resident#30's room, and the palm guards were missing. They never realized that Resident #30 did not have them on this morning. Rolled up wash cloths should have been used for Resident #30 to hold onto until the palm guards were located. Certified Nursing Assistant #5 stated the night shift was responsible for dressing Resident #30 and they got the resident out of bed. Certified nursing assistant's provided range of motion with morning care or when they go back to bed in the afternoon. Documentation was completed after the task was provided or by the end of the shift. During an interview on 12/5/24 at 10:23 AM, Certified Nursing Assistant #6 stated Resident #30 tolerated the palm guards when they wore them. Certified nursing assistants were responsible to provide range of motion and the blanks in the documentation indicated range of motion was not done. During an interview on 12/5/24 at 2:06 PM, Licensed Practical Nurse #1 stated that Resident #30 should wear right and left palm guards. Licensed Practical Nurse #1 observed the resident and stated they were not wearing their palm guards. Licensed Practical Nurse #1 checked the residents care plan and stated the resident was care planned to wear the palm guards at all times except for range of motion, hygiene, meals and while sleeping. Licensed Practical Nurse #1 stated palm guards prevented contractures and skin potential breakdown. Certified nursing assistants were responsible to ensure residents had their devices when they were gotten up for the day. Certified Nursing Assistant #5 should have checked the care plan and Licensed Practical Nurse #1 would have expected to be notified if the palm guards were missing. During an interview on 12/5/24 at 2:30 PM, Licensed Practical Nurse #2, Unit Manager stated Certified Nursing Assistant #5 should have read the care plan and communicated to Licensed Practical Nurse #1 the palm guards were not in Resident #30's room. Licensed Practical Nurse #1 should have informed them, and they would have notified therapy to replace the palm guards. Licensed Practical Nurse #2, Unit Manager stated there was no process of monitoring documentation for range of motion and it was a team effort. During an interview on 12/6/24 at 10:36 AM the Director of Therapy #1 stated Resident #30's palm guards were recommended by occupational therapy and updated on the care plan. Certified Nursing Assistant #5 should have made sure the palm guards were on after reading Resident #30's care plan. Nurses were responsible to ensure that the certified nursing assistants put on the palm guards, performed range of motion, and completed the documentation. The blanks on the Documentation Survey Report indicated uncertainty that range of motion was being done as recommended. Palm guards were important because they prevented further contractures for Resident #30. During an interview on 12/6/24 at 2:10 PM, the Director of Nursing stated they expected that Resident #30 would wear the palm guards if they are care planned and Certified Nursing Assistant #5 should have put them on. The Unit Manager, Licensed Practical Nurses and all staff were responsible to make sure the resident's care plan was followed. The palm guards were a standing physician's order on the medication administration record which alerted the nurses to ensure the certified nursing assistants had put them on but did not have to sign for the palm guards. Range of motion exercises were expected to be done with morning care and documented when completed in the electronic medical record by the assigned certified nursing assistants. If the resident was unavailable or refused, they would expect the resident to be reapproached later. During an interview on 12/6/24 at 2:05 PM, the Administrator stated it was important to ensure that the residents care plan was being followed. 10NYCRR 415.12(e)(2)

Based on observations, interviews, and record review conducted during the Standard survey completed on 12/6/24, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for one (Resident #64) of one resident reviewed. Specifically, Resident #64 was not provided with a tub bath per their preference as the facility did not have a functioning tub. The finding is: The policy and procedure titled Comprehensive Care Planning & Baseline dated 6/2021, documented a care plan will be individualized for each resident using a person-centered approach. Your Rights as a Nursing Home Resident in New York State dated 2022 documented, you have the right to self-determination includes but not limited to; be offered choices and allowed to make decisions important to you and receive services with reasonable accommodations for individual needs and preferences. The policy and procedure titled Tub Maintenance undated documented, repairs if needed are completed. If repair cannot be made, then this is communicated to maintenance department who calls in outside service company to make repair. The Maintenance Director will obtain necessary quote(s)for repair and the Administrator will be notified of quote and any scheduled repairs. Resident #64 had diagnoses including malignant neoplasm of prostate, diabetes mellitus type 2, and osteoarthritis. The Minimum Data Set (a resident assessment tool) dated 10/24/24, documented Resident #64 was moderately cognitively impaired. The Activity Interview for Daily and Activity Preferences form dated 7/23/24 for Resident #64 documented very Important to choose between a tub bath, shower, bed bath or sponge bath and preferred a tub bath. During an interview on 12/3/24 at 10:20 AM, Resident #64 stated they used to take tub baths at home and would prefer a tub bath, but the facility doesn't have a working tub, and stated they think it's been broken for a long time. During an interview on 12/4/24 at 10:09 AM, Resident #64's Primary Contact (family) stated Resident #64 always took baths at home and Resident #64 had informed them they would prefer a tub bath at the facility. During an interview on 12/4/24 at 10:51 AM, the Activities Department Director #1 stated they had interviewed Resident #64 upon readmission and completed the Activity Interview for Daily and Activity Preferences form based on the residents answers. They would expect the Nursing Department to meet the Resident's preferences and they stated they did not know the facility did not have a functioning tub. Observation on 12/3/24 at 10:12 AM Unit 6's bathtub had red bags covering it that were held in place by straps. The tub was unable to be utilized. Observations on 12/5/24 between 11:03 AM and 11:20 AM revealed the following: - Unit 2's bathtub had dark brown debris in the base of the tub with a chair and other equipment stored in the tub. - Unit 1 did not have a bathtub available. - Unit 5's bathtub had dried white and dark brown debris in the base of the tub. During an interview on 12/5/24 at 9:37 AM, [NAME] #1 stated they clean Unit 6 shower room and they believe the tub had not functioned for over two years. During an interview on 12/5/24 at 9:47, Certified Nurse Aide #3 stated Unit 6's tub had been broken for over a year and doesn't know if there were any functioning tubs in the facility. During an interview on 12/5/24 at 9:52 AM, Certified Nurse Aide #4 stated Resident #64 had not asked for a tub bath and they had not offered a tub bath because there were no functioning bath tubs in the facility. At 9:53 AM Certified Nurse Aide #4 asked Resident #64 what their preference was for bathing and Resident #64 stated they preferred a tub bath but know they can't have one because there were not any functioning tubs in the facility. During an interview on 12/5/24 at 1:11 PM, the Environmental Department Director stated there were no functioning tubs on the units in the shower rooms, but there were some tubs in the private rooms that work. They stated they do not know what was specifically wrong with each of the shower room tubs and had reported the concern to the previous Administrator. The Environmental Department Director stated the facility should have a functioning bath tub for resident's who prefer a bath and suggested Resident #64 may be able to use a private room tub for their preferences, if one was available. During a telephone interview on 12/5/24 at 1:46 PM, previous Unit Manager Licensed Practical Nurse #3 stated they were not aware Resident #64 preferred a bath, but they would not be able to meet the resident's preference because the facility doesn't have a functioning tub. During an interview on 12/5/24 at 3:38 PM, the Therapy Department Director stated Resident #64 does not have the physical mobility to utilize one of the private room tubs, because the tub was too low and would be a safety concern. They stated choosing a bath verses a shower was a resident's right of preference and the facility should have a functioning tub. During an interview on 12/5/24 at 4:51 PM, the Director of Nursing stated the facility did not have functioning bathtubs in the shower rooms and the bathtubs in the private rooms were too low and would pose as a safety hazard for Resident #64. They stated the facility should have a functioning bathtub for any resident that had a preference to use it. They stated they believed the last functioning bathtub in the facility broke approximately 2 years ago. During an interview on 12/5/24 at 5:00 PM, the Administrator stated they have been the Administrator since August 2024 and didn't know the facility didn't have a functioning bathtub and would have expected the Environment Department Director to have informed them. They stated it was important for all residents to have choices and bathing preferences and the facility was unable to accommodate Resident #64's preferences. 10 NYCRR 415.5 (b)(3)

Based on observations, interviews, and record reviews conducted during an Abbreviated Partial Extended survey (Complaint #NY00345600), the facility failed to provide an environment free of accident hazards and adequate supervision to prevent elopement for seven (Resident #1, #2, #3, #4, #5, #6, and #7) of seven residents reviewed. Specifically, on 6/18/2024 at 4:30 AM, staff returned Resident #1 to the facility after they were found outside. The facility failed to initiate safety interventions after Resident #1 eloped to prevent recurrence. Subsequently, at 6:30 AM facility staff were unable to locate Resident #1 and local authorities were called. Resident #1 was returned to the facility at 4:00 PM by their Health Care Proxy. Additionally, windows in resident rooms of those identified at risk for elopement did not have adequate safety devices to prevent the window from being fully opened. This involved Resident's #1, #2, #3, #4, #5, #6, and #7. This resulted in the likelihood for harm that is immediate jeopardy and substandard quality of care to Resident #1's health and safety and had the potential to affect seven residents in the facility identified as being an elopement risk. The findings include, but are not limited to: The policy and procedure titled Elopement/Missing Resident dated 2/2016 documented any resident identified as a risk for elopement will be reassessed monthly. Plant Operations will provide maintenance and monitor preventive maintenance schedules for elopement prevention devices. Exit seeking behavior may include but not be limited to history of elopement, opening doors to the outside, making statements referencing leaving the facility, seeking to find someone/something outside of facility, noncompliance with facility protocols. The policy and procedure documented upon the return of a missing resident; the resident would be placed on every 15 minutes visual checks for the first 24 hours following the incident. Documentation would include modification to the comprehensive and closet care plan. 1. Resident #1 had diagnoses which included dementia, Alzheimer's disease, and alcohol abuse. The Minimum Data Set (a resident assessment tool) dated 5/24/2024 documented Resident #1 was cognitively intact, usually understands and was usually understood by others. The comprehensive care plan dated 3/21/2024 documented Resident #1 was at risk for elopement related to a history of elopement. Interventions included to monitor the wander alert device every shift. Resident #1 had impaired cognitive function/dementia and impaired thought processes related to Alzheimer's. Interventions included to communicate with the resident and caregivers regarding resident's capabilities and needs. The Wandering/ Elopement Risk Assessments dated 11/16/2023, 2/16/2024, 5/16/2024 and 6/18/2024 documented Resident #1 was at low risk for wandering and elopement. The Kardex (guide used by staff to provide care) dated 6/21/2024 documented Resident #1 was independent with all activities of daily living and to monitor the wander alert device on their right ankle every shift. The facility was unable to provide a Kardex that was in effect on the day of the resident's elopement. Review of the Nursing Progress Notes revealed the following: -6/18/2024 at 4:18 AM, Nursing Supervisor Registered Nurse #1 documented that Resident #1 was found outside of the building by Certified Nurse Aide #1. Nursing Supervisor Registered Nurse #1 documented they went to assist Resident #1 back into the facility. The resident was very angry and verbally abusive as they were brought back inside the building. Nursing Supervisor Registered Nurse #1 documented they encouraged unit staff to keep an eye on the resident and Licensed Practical Nurse #1 stated they would put Resident #1 on 15-minute checks. At 6:50 AM, Nursing Supervisor Registered Nurse #1 documented Licensed Practical Nurse #1 notified them Resident #1 was not in their room. A total building check and a vehicle search was started. The Director of Nursing, the Assistant Director of Nursing and emergency services were notified. -6/18/2024 at 7:22 AM, Licensed Practical Nurse #1 documented at 4:25 AM they were informed that Resident #1 was found outside of the building and was escorted back into the building to their room. The note documented Resident #1 did not want to return to the facility. Education was provided, and Resident #1 agreed to stay. At 6:40 AM Licensed Practical Nurse #1 went to Resident #1's room to administer medications and Resident #1 was not there. The resident was unable to be located within the building and the surrounding grounds. -6/18/2024 at 4:50 PM, the Director of Nursing documented that Resident #1 returned to the facility via their Health Care Proxy's car. The note documented Resident #1 had stated they were jimmying their window for a few days, released the window stopper and climbed out of the window. There was no documented evidence that 15-minute checks were completed. According to the National Oceanic and Atmospheric Administration weather service, the local weather on 6/18/2024 from 6:00 AM-4:00 PM was between 73 degrees Fahrenheit and 92 degrees Fahrenheit, with a heat index between 79 degrees Fahrenheit and 101 degrees Fahrenheit. Heat advisory and poor air qualities were in effect. During an interview on 6/20/2024 at 8:34 AM, Resident #1 stated they no longer wanted to stay at the facility. They stated at 4:00 AM they climbed out of their bedroom window but not long after they were brought back inside by staff. Resident #1 stated when no one was watching, they climbed out of their window a second time. The resident stated they waited on a bench until it was day light, then took a bus to the area of a local hospital. Resident #1 stated they had walked around until they got into a stranger's car and was dropped off at their Health Care Proxy's house. Resident #1 stated it was hot, and they needed to rest every 15-20 minutes. The resident stated they were sore from all the walking and had fallen but did not hurt themselves. During a telephone interview on 6/20/2024 at 10:53 AM, Certified Nurse Aide #1 stated they were on their break on 6/18/2024 around 4:30 AM when they saw Resident #1 walking up the hill on the parking lot side of the building with a pillowcase filled with their own belongings. Certified Nurse Aide #1 stated along with Nursing Supervisor Registered Nurse #1 they brought Resident #1 back into the building. Certified Nurse Aide #1 stated they went back to their own unit to work and did not see Resident #1 after that. Certified Nurse Aide #1 stated Resident #1 had a previous history of exit seeking behaviors when they were on Unit 1 (Rehab Unit). During a telephone interview on 6/20/2024 at 11:32 AM, Certified Nurse Aide #2 stated they were responsible for Resident #1 from 10:00 PM to 6:00 AM on 6/17/2024 - 6/18/2024. Certified Nurse Aide #2 stated they were never notified Resident #1 had eloped at 4:30 AM until the Director of Nursing telephoned them just a bit ago on 6/20/2024. Certified Nurse Aide #2 stated the last time they saw Resident #1 was on 6/17/2024 about 10:30 PM. They stated they were never given instructions that Resident #1 was to be on 15-minute visual checks. During a telephone interview on 6/20/2024 at 11:34 AM, Licensed Practical Nurse #1 stated on 6/18/2024 at 4:30 AM they were alerted by a staff member that Resident #1 was outside and was escorted back into the building. Licensed Practical Nurse #1 stated about 20 minutes after Resident #1 was returned to their room they spoke with Nursing Supervisor Registered Nurse #1 about starting 15-minute checks. Licensed Practical Nurse #1 stated they did not instruct staff working on the unit to do 15-minute checks and they did not do 15-minute checks. Licensed Practical Nurse #1 stated about 6:25 AM they went to Resident #1's room to administer medications and the resident was not in their room. Licensed Practical Nurse #1 stated Resident #1 had a history of exit seeking behaviors. During a telephone interview on 6/20/2024 at 12:07 PM, Nursing Supervisor Registered Nurse #1 stated on 6/18/2024 at 4:30 AM Resident #1 was found outside and was brought back into the facility. Nursing Supervisor Registered Nurse #1 stated they discussed the elopement with Licensed Practical Nurse #1. Licensed Practical Nurse #1 stated they would put Resident #1 on 15-minute checks. Nursing Supervisor Registered Nurse #1 stated they did not notify Certified Nurse Aide #2 (assigned aide) that Resident #1 had eloped. Nursing Supervisor Registered Nurse #1 stated they left the unit and did not return until around 6:45 AM when they were notified Resident #1 was not in their room. Nursing Supervisor Registered Nurse #1 stated they did not ensure the 15-minutes checks were completed. Nursing Supervisor Registered Nurse #1 stated Resident #1 had a history of exit seeking behavior and verbalized desires to leave the facility. During a telephone interview on 6/22/2024 at 12:29 PM, Certified Nurse Aide #3 stated they were responsible for Resident #1 on 6/18/2024 from 6:00 AM - 2:00 PM. They stated when they started their shift, they were not instructed to complete 15-minute checks on Resident #1 and a search for the resident was already in progress. During a telephone interview on 6/20/2024 at 3:49 PM, Resident #1's Health Care Proxy stated they had received a telephone call from a concerned citizen that they had found Resident #1 walking around the area by a local hospital, and that they had the resident in their vehicle. The concerned citizen drove Resident #1 to the Health Care Proxy's house. The Health Care Proxy stated they eventually returned Resident #1 back to the facility which was about a 25-minute drive away. During a telephone interview on 6/21/2024 at 8:24 AM, Certified Nurse Aide #4 (second certified nurse aide scheduled on the resident's unit) stated they received a telephone call from Certified Nurse Aide #1 that Resident #1 was outside of the building. Certified Nurse Aide #4 stated around 5:00 AM was the last time they saw Resident #1. Certified Nurse Aide #4 stated they did not notify Certified Nurse Aide #2 that Resident #1 had eloped and was unsure if the unit nurse did. They stated they were not instructed to complete 15-minute checks on Resident #1. During an interview on 6/21/2024 at 9:18 AM, the Director of Nursing stated the facility did not have a specific policy for 15-minute checks and window safety. The Director of Nursing stated Licensed Practical Nurse #1 never implemented the checks or any other safety interventions and they had no evidence the checks were completed after Resident #1's 4:30 AM elopement. They stated Resident #1 was returned to the facility unharmed, but potential outcomes could have been drug seeking, serious injury or death. During a telephone interview on 6/21/2024 at 9:52 AM, Medical Director #1 stated Resident #1 should have been kept under close surveillance after their 6/18/2024 elopement at 4:30 AM. Medical Director #1 stated the nursing home population was more at risk for heat related injuries due to their medications and general medical condition. The Medical Director stated the resident's elopements could have resulted in serious harm, injury, or even death. During an interview on 6/21/2024 at 10:22 AM, the Administrator stated after Resident #1 eloped on 6/18/2024 at 4:30 AM, 15-minutes checks should have been put into place, and staff should have been instructed to complete them. 2. Review of an undated document titled Travels club elopement, handwritten by the Director of Nursing, documented that Residents #1, #2, #3, #4, #5, #6, and #7 were at risk for elopement. Resident #1 had diagnoses which included dementia, Alzheimer's disease, and alcohol abuse. The Minimum Data Set, dated dated dated [DATE] documented Resident #1 was cognitively intact, usually understands and was usually understood by others. An interview and observation of Resident #1's room on 6/20/2024 at 9:30 AM revealed the room contained two windows that were double-hung style. The window on the left was screwed shut on the top and bottom, had a screw in the vertical track on the left, and had a plastic window stop that was screwed into the vertical track on the right. The window on the right had a window-mounted air conditioning unit which was screwed to the bottom of the lower sash and was braced by two pieces of wood that were screwed into the windowsill. The Maintenance Director stated at the time of the Resident #1's elopement on 6/18/2024, there was no window-mounted air conditioning unit in the room. During an observation and interview on 6/20/2024 at 10:00 AM, the Maintenance Director stated prior to Resident #1's elopements on 6/18/2024, Resident #1's windows were secured the same as a typical resident room window. The room next door to Resident #1's room was used as an example. Both windows were equipped with a snap-on plastic window stop in one of two vertical tracks. They could be removed by hand without the use of a tool. With the window stops removed, the bottom window sash could be lifted to open an area that was 27 and one-half inches wide by 22 inches high by turning the center sash latch. Regardless of the presence of the plastic window stop, the top window sash could be lowered to an open area that was similar in dimension by clasping the top sash latch. A window screen was present in the bottom half of the window and could be lifted without any additional effort. The plastic window stop measured 15 inches long by one and a half inches wide and snapped into the vertical window track. The Maintenance Director stated clinical staff decided the elopement risk level for each resident and they would have to let maintenance staff know if the windows in those rooms needed more security. They stated they were not informed about Resident #1's elopement risk status until after the elopements on 6/18/2024. Observations from the exterior of the building on 6/20/2024 at 9:45 AM and 4:00 PM revealed Resident #1's window was located within a fully fenced-in courtyard with a community gated entrance. The fence was approximately five feet tall. The bottom of the window had an exterior sill and the vertical distance from the sill to the ground below was 33 inches. Resident #2 had diagnoses which included dementia, depression, and anxiety. The Minimum Data Set, dated dated dated [DATE] documented Resident #2 had severe cognitive impairment. The comprehensive care plan dated 6/20/2024 documented Resident #2 was at risk for elopement related to a history of wandering. An interview and observation of Resident #2's room conducted on 6/20/2024 at 12:15 PM revealed the room contained two windows that were double-hung style. The window on the right had a plastic window stop in one of two vertical tracks that could be removed by hand without the use of a tool. With the window stop removed, the bottom window sash could be lifted to an area that was 34 inches wide by 22 inches high. The window on the left had a plastic window stop in one of two vertical tracks that was screwed in, and when the bottom sash was lifted, it opened six inches high. Regardless of the presence of the plastic window stop, if the top sash latch was clasped, the top window sash of both windows could be lowered to open an area that was 34 inches wide by 21 inches high by clasping the top sash latch. A window screen was present in the bottom half of the window and could be lifted without any additional effort. The Maintenance Director stated they were unaware of which residents were identified as an elopement risk. They stated if they were made aware that a resident was an elopement risk, they would add extra security measures to that resident's window, such as screwing in the stoppers, or adding a screw to the bottom or top of the window. Resident #3 had diagnoses including dementia, hypertension, and atherosclerotic heart disease (hardening of the arteries). The Minimum Data Set, dated dated dated [DATE] documented the resident had severe cognitive impairment. The comprehensive care plan dated 1/29/2024 documented Resident #3 was at risk for elopement related to attempts to leave the facility unattended and had impaired safety awareness. Observation of Resident #3's room on 6/20/2024 at 12:55 PM revealed the room contained two windows that were a double-hung style. The window on the left had a plastic window stop in one of two vertical tracks. The window stop could be removed out of the track, by hand without the use of a tool. With the window stop removed, the bottom window could be lifted to an area that was 28 inches wide by 21 inches high. The window on the right had a plastic window stop in one of two vertical tracks that was screwed in, and when the bottom sash was lifted, it opened six inches high. Regardless of the presence of the plastic window stop, if the top sash latch was clasped, the top window sash of both windows could be lowered to open an area that was 28 inches wide by 22 inches high. A window screen that was present in the bottom half of the window and could be lifted without any additional effort. During an interview on 6/20/2024 at 1:50 PM, the Maintenance Director stated some plastic window stops could be removed from the window track with fingers, but some were harder to remove, and they needed to use a tool to pry them out. During an interview and observation on 6/20/2024 at 5:50 PM, Licensed Practical Nurse #3 Unit Manager stated windows should only open six inches. They stated if a resident was an elopement risk, the window stoppers should be drilled in. Licensed Practical Nurse #3 Unit Manager stated if a window was able to be opened from the top down even with the window stopper in place was a safety risk. They stated if nursing staff saw a window stop on the window, it was considered alright, but if nursing staff noticed a window stop was missing, they would notify the maintenance staff. During an interview and observation on 6/20/2024 at 6:25 PM, the Director of Nursing stated all resident room windows needed stoppers and should only open six inches high. After Resident #1 eloped from the facility, all resident windows were checked by staff for the presence of window stoppers. At this time, the snap-on plastic window stop from the resident room next to Resident #1's room was shown to the Director of Nursing. The Director of Nursing stated they did not know the window stops could pop out that easily, and stated they needed to be secured. The Director of Nursing stated they were unaware the top windowpane opened from the top down, and something was needed to prevent the windows from opening. During an interview on 6/21/2024 at 9:23 AM, the Administrator stated in response to the elopement a window audit was completed on 6/18/2024 by Licensed Practical Nurse #3 Unit Manager, Licensed Practical Nurse #4 Unit Manager, and the Director of Activities. They checked to see if the windows opened greater than six inches from the bottom up. The Administrator stated the words stopper in place or a checkmark on the 6/18/2024 audit meant that plastic window stops were in place. Window stops were not checked for secureness or looseness during the audit. 10NYCRR 415.12(h)(1)(2)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED ON 12/18/14 AND 8/20/15. Based on observation, interview and record review conducted during a Complaint investigation (Complaints #NY 851, NY 853 and NY 501) conducted during an Extended survey completed on 6/8/16, the facility did not ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individuals clinical condition demonstrates that they were unavoidable and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Three (Residents #38,135, 214) of four residents reviewed for pressure sores had issues. Specifically, Resident #214 that entered the facility on 5/3/16 with a Stage 2 ulcer on the left great toe lacked initial and on-going Registered Professional Nurse (RN) assessments including staging and measurements. In addition, the resident's toes which were documented to be bleeding and abraded with 2-3+ [MEDICAL CONDITION] (swelling caused by excess fluid accumulation) to both lower extremities (BLE) following an incident on 5/6/16 lacked initial and on-going RN assessments of the BLE and feet. On 5/17/16 the resident was first noted to have a suspected deep tissue injury (DTI) and a ruptured blister on the right heel and a blister to the left heel and admitted to the hospital with [REDACTED]. This resulted in actual harm that is not immediate jeopardy. In addition, Resident #38 admitted with a Stage 2 pressure ulcer on the left 2nd toe with osteo[DIAGNOSES REDACTED] (bone infection) lacked an RN assessment and weekly monitoring including staging and measurements. Also, there was lack of an RN assessment for the initiation of a treatment and on-going monitoring of reddened buttocks. Residents #135 lacked planned weekly skin checks and the Certified Nurse Aide (CNA) did not inform the nurse of new open areas (two Stage 2 pressure ulcers) on the buttocks that were painful during cleansing and the application of a barrier cream. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #214 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was on [MEDICATION NAME] therapy (anticoagulant medication-prevents blood from clotting) for A-fib. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/30/16 revealed the resident was cognitively intact. Review of the hospital discharge Transfer Summary dated 5/2/16 revealed the resident had dime sized ulcer on the left great toe that was stable with white slough (soft, moist, dead tissue may be white, tan, green or yellow) and BLE [MEDICAL CONDITION]. Review of the Admission Nursing assessment dated [DATE] signed by RN #5 revealed the resident had no skin issues except for several scratches on the upper back. There was no documentation regarding the left toe ulcer. Review of the Interim Care Plan dated 5/3/16 revealed the resident had no impaired skin integrity on admission. There was no documentation regarding the left toe ulcer. Review of the CNA Closet Care Plan dated 5/3/16 revealed the resident was to receive routine skin care and was on bruising/bleeding precautions. Review of a Nurse Practitioner (NP) Acute Visit Note dated 5/4/16 revealed the resident had 2 + BLE [MEDICAL CONDITION] and the skin had no wounds or breakdown. There was no documentation regarding the left toe ulcer. Review of the Physician's Admit Visit Note dated 5/6/16 revealed that the resident had a Stage 2 ulceration on the left great toe. The note further documented that the resident was following with Podiatry, to continue local wound care as ordered, and if the wound appears to worsen, the wound care nurse would evaluate him. Review of admission Physician's Orders and Verbal Physician's Orders dated 5/3/16 through 5/6/16 revealed no orders for Podiatry service or for a treatment to the left great toe. Review of an Accident/Incident Report (A&I) dated 5/6/16 at 7:00 PM signed by a Licensed Practical Nurse (LPN) revealed the resident was self-ambulating to the bathroom and small abrasions were noted to the resident's toes on the left and right feet. The resident toileted self and did not wait for assistance, the resident is on [MEDICATION NAME] therapy and has BLE [MEDICAL CONDITION]. The toes were extremely [MEDICAL CONDITION] and ecchymotic (purplish patch caused by blood under skin) and the resident came to the facility with this condition. The resident's daughter noted blood on the resident's toes and called staff into the room. The areas were cleansed with normal saline (NS) and wound wash and left open to air. The Supervisor assessed the resident. Further review of the A&I revealed a form entitled Supervisor's Investigation of Event and Interventions signed on 5/6/16 by LPN #7 Unit Manager (UM) revealed that the resident was able to give an account of the events and stated, I bumped them, they hurt, my feet are swollen. LPN #7 UM documented both feet 2-3 + [MEDICAL CONDITION] 2nd toes on feet swollen. Abrasion areas noted. Resident on [MEDICATION NAME] (diuretic medication-promotes excretion of urine) 80 mg (milligrams) BID (twice a day) and blood thinners. Resident denies complaints of pain at present. Review of Progress Notes revealed no documentation of an RN assessment of the resident's BLE after the incident of 5/6/16. Review of the Physician's Acute Visit Note dated 5/9/16 revealed the reason for the visit was lower extremity [MEDICAL CONDITION] and bleeding from foot ulcer. The Physician documented that the resident developed significant bleeding from his foot ulceration over the weekend. He noted that currently the bleeding has stopped and resident stated that he feels he is doing well. The note documents that the resident has a chronic left great toe ulceration without any active bleeding at this time. Review of a Physician's Verbal Order dated 5/9/16 revealed an order for [REDACTED]. Review of the Bathing Documentation Sheets revealed the resident was bathed on 5/7/16 with a note written by LPN #8 that the 11:00 PM - 7:00 AM shift nurse did the skin check. The document is not signed by the nurse that performed the skin check. The 5/14/16 entry revealed CNA #5's signature that the bath was done, however there is no nurse signature that the skin check was done. Review of the Treatment Administration Record (TAR) revealed instructions with an order date of 5/9 to apply TEDS in the morning and take off at bedtime. All daytime entries on the TAR are complete with initials by nursing staff from 5/10/16 through 5/17/16. The 5/17/16 entry was circled indicating that the resident refused TEDS on that date. All evening shift entries are complete with initials by nursing staff from 5/10/16 through 5/16/16, except the 5/13/16 entry was blank on the form. Further review of Progress Notes from 5/3/16 through 5/17/16 revealed no documentation of initial RN and on-going assessments of the resident's left great toe ulcer. Review of a First Skin Alert dated 5/17/16 written by RN #4 Rehab Unit Manager revealed that the resident's skin to BLE was assessed. The lateral aspect of the right heel was noted with a 3.5 centimeter (cm) x (by) 4.5 cm ruptured blister, the skin was red and moist, with remnants of skin remain (loose hanging). The right medial heel was noted with a 2 cm x 4.5 cm reabsorbing blister. The left heel was noted with a 2 cm x 4.5 cm reabsorbing blister, the skin was discolored however intact. The document revealed that the reabsorbing blister would be treated with Skin Prep (topical application that toughens skin and enhances adherence of dressing). Review of Physician's Verbal Order dated 5/17/16 revealed orders for a wound consult for bilateral heel ulcers. Skin Prep to right heel medial blister and left heel blister topically BID. Cleanse right heel lateral blister with wound cleanser, pat dry, apply TAO (triple antibiotic ointment) topically BID, apply DCD (dry clean dressing) and wrap with Kerlix. Review of an RN Progress Note dated 5/17/16 at 10:40 PM revealed the resident was noted with increased weakness while being toileted and had to be lowered to the floor. The LLE (left lower extremity) was reddened, warm to the touch and developing blisters on the shin and ankle. The resident's family was concerned and requested the resident be transferred to the hospital for evaluation. The NP was notified and ordered transfer to the hospital. The resident was admitted with a [DIAGNOSES REDACTED]. Review of the hospital History and Physical (H&P) exam dated 5/17/16 completed by the Physician Assistant (PA) and Physician revealed the resident was admitted to the hospital with [REDACTED]. The H&P exam revealed the resident was admitted with right and left heel ulcers. The heels were being elevated off the bed and a wound consult was placed. Review of a hospital record entitled Documentation: Pressure Ulcer dated 5/18/16 completed by an RN documented the following: Skin care referral to assess multiple areas. Found heels with ulcers from pressure present on admission. Right heel with fluid filled blister purplish in color. Will call DTI at present. Recommend Skin Prep and float using pillows or booties as directed. Left heel with evolved DTI and partial thickness red base or Stage 2 at present. Wound care as directed by the Podiatrist. Float and use booties as directed. Staff to assess at least every shift for prevention with booties. Review of a hospital Podiatry Consultation dated 5/18/16 revealed, the resident presented with bilateral grade 2 pressure ulcers on both heels with intact skin on the left and open skin on the right. The right heel has a firm black eschar with a significant open wound posteriorly with no active evidence of infection; the other heel has an intact pressure wound, it is still questionable whether this may open up and become a worse problem. The plan is to offload the heels with heel offloading boots and to continue antibiotics. AlgiSite (dressing that forms a soft gel that absorbs when it comes into contact with wound exudate (drainage) was prescribed for the right heel wound. Review of the facility Policy and Procedure entitled Skin Care Team last revised in January 2016 revealed to provide a skin care team composed of the Charge Nurse and wound consultant. The ADON (Assistant Director of Nursing) or designee and staff nurses will be included as necessary. Procedure #2 revealed the charge nurse for the unit will ensure that a current list of all residents with skin issues will be submitted to the ADON and wound consultant as necessary. During interview on 6/3/16 at approximately 10:00 AM, CNA #5 stated that per the Bathing Documentation Sheet, she bathed the resident on 5/14/16. CNA #5 stated that she performed the bath early on 5/14/16 between 6:00 AM and 7:00 AM. CNA #5 notified the night nurse that the resident needed a skin check. CNA #5 stated that she could not remember which nurse she told as there are many agency nurses working at the facility on the night shift. CNA #5 stated that she does not know if the nurse performed the skin check. CNA #5 stated that she does not recall seeing any skin issues on the resident's feet or heels during the bath. During an interview on 6/6/16 at approximately 3:00 PM, RN #5 that completed the Admission Nursing Assessment stated she did not see a pressure sore on the resident's left great toe on 5/3/16. After reviewing the TAR for May 2016 RN #5 stated that she initialed the TAR that she removed the resident's TEDS on 5/10/16, 5/11/16, 5/12/16, 5/14/16 and 5/15/16 at bedtime. RN #5 stated that when she removed the resident's TEDS she pulled them off and did not look at the resident's feet or heels. RN #5 stated she was not aware of any skin issues on the resident's feet. During an interview on 6/6/16 at approximately 11:45 AM, RN #4 Rehab Unit Manager stated she was not aware of any skin issues on the resident's feet or heels until the day of the resident's discharge to the hospital on [DATE]. RN #4 Rehab Unit Manager stated that neither the Physician, nurses nor CNAs, informed her at any time during the resident's stay of any skin issues until 5/17/16 when she was informed of the resident's heel blisters. On 5/17/16 RN #4 Rehab Unit Manager assessed the blisters and then treatments including a wound consult were ordered. During an interview on 6/6/16 at 12:00 PM, LPN #8 stated according to the May 2016 TAR she initialed that she applied the resident's TEDS on 5/16/16 in the morning. LPN #8 stated she was not aware of any skin issues. During an interview on 6/6/16 at approximately 12:00 PM, LPN #4 reviewed the May 2016 TAR and stated that she circled her initials on 5/17/16 in the morning that the resident refused the TEDS on that day. The resident told her they were too painful. LPN #4 stated that prior to 5/17/16 she had informed RN #4 Rehab Unit Manager of the resident's heel blisters but LPN #4 could not recall the date. During an interview on 6/6/16 at approximately 12:15 PM, the ADON stated that she heads the skin care team and did not receive a First Skin Alert of any skin issues regarding the resident until 5/17/16, the day the resident was sent to the hospital. The ADON stated that the only way a resident would have been put on skin rounds is for her to receive a First Skin Alert. The ADON stated that the procedure for staff on the unit, including RNs, LPNs and CNAs, is to inform the Unit Manager of a skin issue. The Unit Manager is then supposed to send a First Skin Alert to the ADON so the resident can be put on skin rounds. During an interview on 6/7/16 at approximately 12:00 PM, the Physician stated that she was not working at the facility during the time frame that resident was there. The Physician stated that it is her expectation that nursing staff perform skin monitoring and RN assessments of all residents with pressure sores and other skin issues. During an interview on 6/6/16 at approximately 2:30 PM, Resident #214 stated that while at the facility there were a few times when the nurses left his TEDS on for 2 days without removing them but he could not remember the dates. He stated that sometimes they took the TEDS off at night. Resident #214 stated that he thinks the TEDS were the wrong size because they were very uncomfortable. In summary, the resident was admitted to the facility on [DATE] with a Stage 2 pressure ulcer on the left great toe that was not noted during the RN's assessment on 5/3/16. On 5/6/16 the Physician noted the Stage 2 on the left great toe and documented Podiatry to follow. The Physician did not write orders for a treatment or a Podiatry consult. On 5/6/16 the resident sustained [REDACTED]. In addition, CNAs that bathed the resident and nursing that either applied or removed the TEDS did not note or report the resident's altered skin conditions including to the ADON to be placed on weekly skin rounds. 2. Resident #135 has [DIAGNOSES REDACTED]. The resident requires extensive staff assistance for toilet use and personal hygiene, and is always continent of bowel and bladder. The resident is at risk for pressure ulcers, has one, not staged, with usual precautions. Review of CNA Closet Care Plan revealed the resident requires extensive staff assistance for lower extremity personal care and requires toileting in the bathroom every two to three hours. Review of Physician ' s Orders dated 4/4/16 revealed an order to apply Inzo (zinc oxide) barrier cream to coccyx (tail bone) and buttocks every shift for superficial areas. Review of the Care Plan Detail dated 5/31/16 revealed the resident has a care focus of potential for impaired skin integrity related to immobility and has bladder incontinence at times related to immobility with goals to keep the skin free from skin breakdown related to incontinence at times and brief use with planned interventions of toileting the resident every 2-3 hours. Review of Progress Notes from 4/1/16 through 6/3/16 revealed no documentation that the resident has any skin issues and there are no Progress Notes entered after 5/21/16 when the record was reviewed on 6/3/16 at 1:00 PM. Review of the Bathing Documentation Sheets on 6/3/16 revealed that the resident's skin was intact on 5/5/16, 5/19/16, and 5/26/16. There was no skin check sheet for the resident on 6/2/16. Observation of morning care on 6/3/16 at approximately 7:10 AM revealed when CNA #2 wiped along the natal cleft (the groove between the buttocks) the resident had two open skin excoriations along each side of the buttock adjacent to the natal cleft with the surrounding skin very reddened. The resident moaned and stated it's very painful, when CNA #2 cleansed the area. CNA #2 then applied Remedy Zinc Protective Paste (barrier cream) over the reddened and open areas of the resident's buttocks and again the resident moaned and stated, my butt is really sore. During an interview on 6/3/16 at 1:06 PM, LPN #1 Desk Nurse stated that after the resident receives their shower, the LPN assigned to the resident is responsible to check the resident's skin to see if it is intact. During an interview on 6/3/16 at approximately 1:30 PM, LPN #3 stated that the CNAs will perform a bath and tell her if there are any skin issues and she documents the finding in the treatment book; she does not inspect the skin. LPN #3 stated she did not do a skin check for the resident on 6/2/16. In addition, LPN #3 stated that CNA #2 did not tell her that the resident had any problems today. During an interview on 6/3/16 at approximately 1:45 PM, CNA #2 stated that she did not report the resident's skin issues or buttock pain to LPN #3. Observation of the resident on 6/3/16 at approximately 2:00 PM with RN #1 revealed that the resident was toileted and when wiping the resident's buttocks, the resident stated, why is it so sore? RN #1 stated during the observation that the resident had two Stage 2 open areas on the buttocks which were new. Review of the RN Progress Note dated 6/3/16 at 3:04 PM revealed the resident had a Stage 2 on the left buttock measuring 1 cm x 1 cm round, the right buttock appears excoriated, both areas are red and blanchable, the buttocks were cleansed and zinc oxide was applied. A new order was obtained for the buttocks to cleanse with wound cleanser, and apply zinc oxide with responsible party and NP notification. 3. Resident #38 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact and is understood and understands. Review of the CNA Closet Care Plan revised 2/9/16 revealed the resident was independent with bathing, dressing, grooming, and bed mobility. Instructions included to turn and position every two hours and use a positioning wedge in bed. Wheelchair with personal cushion. The resident is independent with toileting needs. Review of a Progress Note dated 1/11/16 revealed the resident was admitted to the facility at 6:40 PM. Review of a Progress Note dated 1/12/16 at 1:44 PM written by an agency nurse revealed the following; the skin evaluation revealed a 1 cm in length x 1 cm in width wound to left second toe, area noted to have a scant amount of serous (pale yellow, transparent body fluid) drainage. Review of an undated and unsigned nursing Admission and Readmission Assessment revealed a Stage 2 pressure ulcer to the left toe that measured 1.0 cm in length, 1.0 cm in width, and 0 cm depth. During an interview on 6/7/16 at 10:01 AM, the ADON stated that the agency nurse who wrote the Progress Note and the admission skin assessment on 1/12/16 is an LPN. Review of January 2016 Physician's Orders revealed on 1/12 to cleanse left foot 2nd toe with NS, pat dry and apply TAO. On 1/17 to apply zinc cream to buttocks BID and as needed with incontinent care for redness. On 1/29 turn and position every 2 hours in bed. Review of the Physician's Admit Visit Note dated 1/15/16 revealed there is a 1 cm x 2 cm lesion on his left 2nd toe with a dressing in place. Further review of Progress Notes dated 1/17/16 through 2/12/16 revealed no documentation of an RN assessment of the left 2nd toe pressure ulcer or of the resident's reddened buttocks. Review of the Skilled Charting dated 1/18/16 through 2/8/16 revealed no documented RN assessments of the left 2nd toe pressure ulcer or of the resident's reddened buttocks. Additional review of Physician Visit Notes and the NP Visit Notes dated 1/18/16 through 2/12/16 revealed no documented assessments of the residents left 2nd toe pressure ulcer or the reddened buttocks. Review of Infectious Disease Consult dated 2/2/16 revealed left toe wound getting smaller, moderate redness no drainage, continue with IV antibiotic and treatment. During an interview on 6/6/16 at 12:05 PM, the ADON stated that there is no documentation that weekly skin checks were done. During an interview on 6/6/16 at 1:52 PM, RN #4 Rehab Unit Manager stated that a full skin assessment is supposed to be completed on admission, then a pressure ulcer or wound would be followed and monitored weekly. If the pressure ulcer or wound is not getting better we would have the NP make an assessment and probably would order a wound consult if the NP felt it was necessary. RN #4 Rehab Unit Manager stated there are no weekly skin check sheets, and there are no weekly pressure ulcer or wound monitoring sheets for Resident #38. During an interview 6/6/16 at 2:16 PM the ADON stated that usually the RN on the Unit or myself is responsible for monitoring pressure ulcers and wounds. If the ulcer was documented on admission as pressure. The ulcer should have been monitored and tracked weekly. The ADON stated she was not aware the resident had a pressure ulcer and she was not tracking the ulcer. Additionally the ADON would expect that if an RN wrote an order to initiate a treatment to the buttocks she would have expected the RN to have documented an assessment. The ADON stated, we could infer from the order that the redness might be related to incontinence because it says to apply twice daily and as needed with incontinence care. But ideally there still needs to be an assessment. 415.12(c)(2)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 441) completed on [DATE], the facility did not ensure that the resident had a right to formulate an Advance Directive. One (Resident #1) of five residents reviewed for Advance Directives was a full code status per the MOLST (Medical Orders for Life Sustaining Treatment) form in the resident's Medical Record. On [DATE] the resident was observed by nursing staff to stop breathing and was not provided cardiopulmonary resuscitation (CPR). The resident's Advance Directive of a full code status was not honored by the nursing staff. The resident expired in the facility. This resulted in actual harm that is not immediate jeopardy. The findings are: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary dated [DATE] revealed the resident returned to the nursing home on [DATE] after a hospital admission in the Intensive Care Unit from [DATE] through [DATE] where she recieved intravenous antibiotics for pneumonia, and was intubated due to acute [MEDICAL CONDITION]. Review of a Progress Note dated [DATE] at 9:34 PM written by Licensed Practical Nurse (LPN) #2 revealed that the resident returned to the facility at approximately 2:00 PM via stretcher ambulance. Oxygen (O2) was applied at 3L (liters) via nasal cannula, the resident was alert with some anxiety. Blood pressure (BP- normal ,[DATE]) ,[DATE], pulse 88 (P-average ,[DATE]), respirations 22 (R-average ,[DATE]), temperature 99.1 degrees (T-normal 98.6), pulse oximetry (the amount of O2 in the blood-normal ,[DATE]%) (percent) was 94.5 % on O2. The day shift Supervisor Registered Nurse (RN) RN #2 was made aware by the secretary that the resident had returned. Review of a Progress Note dated [DATE] at 4:18 PM written by RN #2 revealed RN #2 assessed the resident and noted the abdomen to be very rigid and grossly distended in a supine (upright) position. Diminished bowel sounds were noted and the resident was very restless. BP ,[DATE], T 99.2 degrees, P 95, R 24, pulse oximetry was 94% on 3L of O2. A call was placed to the Physician and awaiting a response. Review of a written statement signed by agency LPN #1 dated [DATE] revealed that on [DATE] when arriving on Unit 5 she checked the resident and noted that the resident had a firm extended abdomen with negative bowel sounds. At this time the resident was free from chest pain, shortness of breath and did not appear to be in acute distress. LPN #1 informed RN #2 of her findings and that the resident should be evaluated in the emergency room (ER). RN #2 instructed LPN #1 to notify the Physician of her findings for further instructions before sending the resident to the ER. LPN #1 contacted the Physician and was told by the Physician to call the managed care provider for further instructions. LPN #1 documented that while at the Nurse's Station she heard a loud sound from the resident's room. LPN #1 and RN #2 proceeded to the room and found the resident on the floor. The resident stated that she fell out of bed while attempting to reposition herself. The resident was evaluated for injuries by RN #2 and the resident was lifted back to bed by staff with a Hoyer lift. Per the statement LPN #1 returned to the Nurse's Station and called the managed care Nurse Practitioner (NP) and received orders for a stat (immediate) flat plate x-ray of the abdomen and was told the NP would be in to assess the resident that evening. LPN #1 contacted the x-ray company who arrived at the facility at 7:15 PM. At that time the resident was alert and talking when the x-ray technician went to the room to complete the test. The x-ray technician was in the room approximately eight minutes when the technician notified LPN #4 that there was something wrong with the resident. LPN #4 went to the resident's room. LPN #1 stated that she was called to the resident's room by LPN #4. LPN #1 stated that on the way to the room she instructed the CNA to grab the resident's chart, to call 911 and call the evening shift Supervisor RN #1. LPN #1 stated that upon arriving in the room at approximately 7:25 PM the resident appeared to be taking last breaths. LPN #1 stepped out of the room to take the chart from the CNA to check code status and to check if 911 was called. The CNA told LPN #1 that she was told by RN #1 to wait to call 911. LPN #1 took the chart from the CNA and stepped back into the resident's room. LPN #1 checked the chart in hand and found to be DNR. RN #1 arrived and checked the resident's BP with no pulse noted. LPN #1's statement revealed that the NP arrived at the resident's room at approximately 7:30 PM and was notified of the resident's passing. LPN #1 stated that at approximately 7:35 PM while at the Nurse's Station when looking at the chart to get contact information she realized it was the incorrect chart. LPN #1 notified RN #1 that the information that was given in the room was incorrect and the resident was a full code. RN #1 determined that it would not be appropriate to begin a code after the resident had already passed away and instructed LPN #1 that a code was not necessary and would be ineffective because of the amount of time that had lapsed before the code would have started. LPN #1's statement revealed that she believed a code should be started regardless of the time that had passed and 911 should be called. RN #1 disagreed with LPN #1 and declined the code. Review of a Progress Note dated [DATE] at 7:38 PM written by RN #1 revealed he was summoned to the resident's room. Resident was without respirations. RN #1 documented that he spoke to a staff nurse regarding DNR status. He was unable to get a BP or apical pulse. The resident had expired. RN #1 documented that he was met by the NP who came to the facility to further assess the resident. RN #1 documented that he received the order to release the body to the funeral home. During an interview on [DATE] at 11:30 AM, the NP stated that on [DATE] LPN #1 called the Physician first about the resident's abdominal distention. The Physician instructed LPN #1 to call the NP. The NP stated that she received the call from LPN #1 between 6:30 to 6:45 PM informing her of the resident's abdominal distention and decreased bowel sounds. The NP stated that she ordered a stat abdominal flat plate x-ray and told LPN #1 she would be in to see the resident. The NP stated that she arrived in the resident's room at 7:30 PM. She said that the x-ray technician, 2 LPNs (LPNs #1 and LPN #4) and RN #1 were in the room at the time. The NP stated that the resident had expired and all staff in the room believed the resident was a DNR. The NP stated that she did not look at the Medical Record in the room. The NP stated that staff discovered the resident was a full code status at approximately 7:35 PM and that starting CPR at that point would have been futile. During an interview on [DATE] at 3:00 PM, RN #1 stated that on [DATE] he was working as a Team Leader on another unit when he was called to the resident's room. He stated that he arrived at the resident's room at approximately 7:30 PM. LPN #1 located in the resident's room told him that the resident was a DNR. RN #1 stated that he assessed the resident and she had passed away. He said the resident had no vital signs, was ashen, not breathing and the resident's abdomen was very distended. RN #1 stated that immediately after he got to the room the NP entered the room and declared that the resident had expired. RN #1 stated that approximately 10 minutes later while at the Nurse's Station, LPN #1 told him that there was a mistake and the resident was a full code. RN #1 stated that the NP was also at the Nurse's Station and stated that there is nothing that they will do for her now, they would not even paddle her. RN #1 stated that based on the NP's input he told LPN #1 that they would not begin CPR since the resident had expired. RN #1 stated that it is facility policy to review the Medical Record to determine a resident's code status. RN #1 stated that since this incident the resident's code status is also put on the certified nurse aide (CNA) Closet Care Plan. During a telephone interview on [DATE] at approximately 1:00 PM, LPN #1 stated that she is an agency nurse and was contracted by the facility to work the nursing desk to complete resident admissions and Physician orders. LPN #1 stated that she worked on Unit 1 from 12:00 PM to 8:00 PM on [DATE] when she was called to Unit 5 at approximately 4:00 PM to check the resident. LPN #1 stated that she checked the resident and noted the resident's abdomen to be very distended with decreased bowel sounds. LPN #1 informed RN #2 and called the Physician. When the Physician returned the call LPN #1 informed him of the situation and said that she thought the resident should be evaluated in the ER. LPN #1 stated that the Physician instructed her to call the managed care NP. LPN #1 stated that she called the NP between 6:30 PM and 6:45 PM. The NP gave a verbal order for an abdominal flat plate x-ray and stated that she would be in to see the resident. LPN #1 stated that at approximately 7:20 PM she was called to the resident's room by LPN #4 stating that the resident was unresponsive. LPN #1 stated that on her way to the room she instructed a CNA to get the resident's chart, call 911 and call RN #1. LPN #1 stated that she arrived at the resident's room and the resident appeared to taking her last breaths. LPN #1 stated that she took the chart given to her by the CNA, flipped to the Advance Directive section of the chart to look at the MOLST form. LPN #1 stated that she did not look at the name on the chart. LPN #1 stated that the MOLST form she was looking at stated DNR. LPN #1 stated that RN #1 arrived in the room and she informed him that resident was a DNR. RN #1 assessed the resident and then the NP arrived in the room and said the resident had expired. LPN #1 stated that none of the other staff in the room looked at the Medical Record. LPN #1 stated that approximately five minutes later at the Nurse's Station when reviewing the record she realized she had the wrong Medical Record. She checked the correct record and noted the resident was a full code. LPN #1 stated that she informed RN #1 of the resident's full code status and he stated that they would not do CPR as the resident had already expired. LPN #1 stated that she did not agree with the decision. During an interview on [DATE] at 2:30 PM, LPN #4 stated that on [DATE] the resident was not feeling well and her abdomen was distended. LPN #1 stated that RN #2 assessed the resident and LPN #1 called the Physician and the NP. LPN #4 stated that the x-ray technician was in the resident's room, came out and stated that the resident was acting strange. LPN #4 stated that she and LPN #1 went to the resident's room to check on her. She stated that LPN #1 looked at the Medical Record and stated the resident is a DNR. RN #1 came to the room, assessed resident and said there were no signs of life. The NP then entered the room and said that the resident had expired. LPN #4 stated that she later learned that the resident was a full code. LPN #4 stated that to determine a resident's code status you are supposed to check the Medical Record or the Closet Care Plan. During an interview on [DATE] at approximately 2:45 PM, the RN Director of Nursing (DON) stated that in order to determine a resident's code status staff are supposed to check the Advance Directive section in the Medical Record. The DON stated that the resident's code status is also located on the Closet Care Plan. During a telephone interview on [DATE] at 10:00 AM, the Physician stated that on [DATE] he received a call from nursing staff regarding the resident's distended abdomen and request to send the resident to the ER. The Physician stated that he instructed the nurse to call the managed care NP because they are the primary care providers and want to be notified before a resident is sent to the hospital. The Physician stated that the managed care staff will often do their own assessment before making any decisions. The Physician stated that his expectation is that a resident's Advance Directive would be followed by the nursing home staff. 413.3(e)(1)(ii)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 996) completed on 2/29/16, the facility did not ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. One (Resident #12) of six residents reviewed for quality of care involved the resident that required PEG (percutaneous endoscopic gastrostomy-a flexible feeding tube placed through the abdominal wall into the stomach for nutrition, fluids and medications) tube feedings and ordered to be NPO (nothing by mouth), received an oral liquid tray two times on 10/24/15. The resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #12 has [DIAGNOSES REDACTED]. Review of a facility investigation dated 10/26/15 revealed that the resident was on tube feedings, was NPO and had not been receiving trays since his admission to the facility on [DATE]. The investigation revealed that on 10/24/15 the resident received a breakfast and lunch tray with regular liquids; 4 ounces (oz.) of orange juice, 8 oz of 2% (percent) milk and 8 oz. of coffee but no solid food. Per the investigation the dietary staff questioned the resident's meal ticket and the Dietary Supervisor made a judgement call to serve the beverages as she thought it might be for oral gratification. Review of the Food Service Supervisor's (FSS) signed statement dated 10/26/15 revealed the following: On Friday, Oct. 23, 2015 I may have inadvertently reassigned the resident into tray line rotation while assigning the five new admits that had arrived that prior day. On Saturday, Oct. 24, 2015 while on tray line I did see that he was a tube feed receiving drinks. I did not realize nor question my judgement at the time that he was not supposed to have a tray, because currently we have two residents who are tube feeds who receive full meals for oral gratification. On this particular day I was the cook, the Supervisor, and was handling the Fall Festival activity. I do recognize the seriousness of this situation. Review of the Meal Acceptance Sheet (included in the facility investigation) for the week ending 10/24/15 documented that the resident consumed 600 cc (cubic centimeters) at breakfast on 10/24/15. The facility's investigation including statements from the nurses and certified nurse aides (CNAs) that worked the day shift on the unit on 10/24/15, did not determine who passed the breakfast and lunch tray with the liquids to the resident. The investigation revealed that the resident was sent to the hospital on [DATE] and admitted with a [DIAGNOSES REDACTED]. Review of a Physician/ Prescriber verbal order form dated 10/9/15 revealed that the resident was NPO with PEG tube feeding. Review of the resident's undated Closet Care Plan revealed the resident was NPO with GT (gastrostomy tube) feeds at 50 cc per hour. Review of a Progress Note dated 10/24/15 at 3:10 PM written by an Registered Nurse (RN) revealed that at 1:45 PM the resident's family member complained that the resident is NPO status but was given an oral diet for lunch. The resident was complaining of cold, chills, shortness of breath, nausea, vomiting and not feeling well. The RN documented in the note that upon assessment the resident's temperature was 104 degrees (normal 98.6), blood pressure 126/ 62 (BP-normal 120/80), heart rate 115-120 (average 80) and pulse oximetry (the amount of oxygen in the blood-normal 90-100%) (percent) was 85% on room air. The pulse oximetry was 95% on 4 liters of oxygen. The lungs were clear in the upper lobes and diminished in lower bases. Level of consciousness was WNL (within normal limits) and color was pink. The Physician was notified with a new order to send the resident to the hospital to rule out aspiration pneumonia. Review of the Hospital history and physical examination [REDACTED]. The Food Service Director (FSD) stated during an interview on 2/22/16 at 10:00 AM that the FSS on duty on 10/24/15 was the person that printed the ticket for the tray to go to the resident. The FSS knew the resident was NPO but thought the resident was receiving liquids for oral gratification. The FSD stated that it is not apparent why the resident's name was in the system. She stated that in practice the nursing staff has to either call down for a tray if a new diet order is received and written communication has to follow. She stated that the FSS was questioned by dietary staff when the tray was being assembled but she made the decision to send the tray anyway. The FSD stated that the FSS was terminated from her job and the Dietary Department is now using a different tray ticket software. Interview with the Registered Dietitian (RD) on 2/23/16 at 2:00 PM revealed the only staff allowed to print tray tickets are the two FSSs, the Diet Technician and the RD. All diet orders must be ordered by the Physician. If the order is requested via telephone, the nurse must call it to Dietary and follow it with written communication. If a new order is called to Dietary, the FSS must verify the order before sending a tray. The RD reported that the Dietary Department is using new software to print tray tickets that is easier to manipulate. The Physician stated during a telephone interview on 2/29/16 at approximately 10:00 AM that the resident was ordered on NPO status and it is his expectation that a resident who is NPO would not be given liquids to consume. 415.12

Based on observation, record review and staff interview conducted during an Abbreviated survey (complaint #NY 123) completed on 1/24/11, the facility did not ensure that each resident receives the necessary care and services to attain and maintain the highest practicable physical, mental and psychological well being in accordance with the plan of care. One (Resident #1) of five residents reviewed for quality of care related to wounds had an issue involving the lack of monitoring and assessment of a wound by a registered professional nurse (RN) and a delay in requesting medical evaluation of the wound as the wound declined. Resident #1 developed a right lower leg skin tear on 11/28/10. There was no RN assessment of the skin tear wound on 11/28/10 and there was no Physician order for [REDACTED]. This resulted in actual harm that was not immediate jeopardy. The finding is: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of an "Occurrence Report" dated 11/28/10 revealed that a Certified Nurse Aide (CNA #1) noted a "scab" on the resident's leg (not identified) while doing care and notified the Licensed Practical Nurse (LPN) Team Leader. Further review of the "Occurrence Report" revealed the report was not signed by the nurse who initiated the report nor by the Nurse Manager (NM). There was no documentation on the Report that the supervisor, the physician or family was notified. Further review of the Report revealed that there was no documentation that the Director of Nursing (DON), Medical Director (MD) or Administrator reviewed the report. The Administrator stated during an interview on 1/12/11 at approximately 2:00 PM that the 11/28/10 "Occurrence Report" was not properly completed by the day shift LPN who left the report to be completed by the evening shift LPN, who also did not complete the report. The Administrator further stated that the "Occurrence Report" was not properly followed up on by the Registered Nurse (RN) Clinical Nurse Manager (CNM), as the report did not go through the proper channels to the DON. During a telephone interview on 1/24/11 at 2:30 PM, LPN #1 stated that she over-heard CNA #1 tell another LPN Team Leader about the resident's skin tear on 11/28/10 on the day shift. LPN #1 stated that she started to fill out the accident (Occurrence) Report in an effort to help the LPN (LPN #4) whose team Resident #1 was on. LPN #1 explained that she gave the accident report to the evening shift LPN (LPN #2) to finish. LPN #2 stated during a telephone interview on 1/24/11 at approximately 1:00 PM that he works full time evenings on Unit 6. LPN #2 stated he was informed of the skin tear on Resident #1's right leg during shift report on 11/28/10 and was given the accident report. LPN #2 stated that he followed up on the skin tear by calling the Nurse Practitioner (NP #2) and obtaining an order for [REDACTED]. LPN #2 further stated that he did not recall if he completed the Occurrence Report. The DON stated during a telephone interview on 1/24/11 at approximately 2:00 PM that it is the RN CNM's responsibility to ensure that the Occurrence Report is complete and to send the report through the proper channels to the DON. The "24 Hour Report" sheet dated 11/28/10 documented that Resident #1 had a right lower leg skin tear that was cleansed with normal saline and triple antibiotic ointment and a dry clean dressing were applied. Review of "Interdisciplinary Notes" and "24 Hour Reports" from 11/28/10 through 12/1/10 revealed no documentation that the right lower leg skin tear was assessed by an RN. Review of Treatment Administration Records (TARs) for 11/10 and 12/10 revealed documentation that the treatment to the right lower leg consisted of cleansing the skin tear with normal saline and applying a triple antibiotic ointment and dry clean dressing twice a day from 11/28/10 to 12/28/10. Review of Physician's Orders for the time period of 11/28/10 through 12/28/10 revealed there were no orders for this treatment. Review of a facility policy and procedure entitled "Wound Management and Treatment Policy" dated 2/15/05 revealed a procedure for "Skin Assessment and Documentation" which stated that all skin impairments and [MEDICAL CONDITION] should be noted and these may include but are not limited to the following: - scars/[MEDICAL CONDITION], - rash, - ecchymosis (purplish patch caused by blood under the skin), - incisions, - diabetic neuropathic ulcers ([MEDICAL CONDITION] usually related to sensory loss in the lower extremities), - arterial ulcer, - [MEDICAL CONDITION] ulcer (stasis ulcer), - excoriation, - pressure ulcers (Stage 1 to 4, unstageable), - lacerations, - burns, - graft/donor sites, - skin tears, - suspected deep tissue injury. The policy states that the following will occur for a patient with a new wound: - An RN will complete initial wound assessment by end of shift and document in the medical record. - A treatment order and interventions, will be obtained and implemented prior to the end of the shift. - A prevention plan of care will be designed and implemented, to prevent additional wounds or worsening of the wound, prior to the end of the shift. - The Interdisciplinary Team (IDT) will be notified of the new wound through IDT communication and complete assessments as needed per discipline specific policy. Review of a "Wound/Skin Routing Form" initiated and signed by the RN CNM dated 12/2/10 revealed the right lower leg wound was originally a skin tear and on 12/2/10 the area surrounding the tissue was red. The Routing Form was sent to Dietary, Physical Therapy, Occupational Therapy and the Wound Specialist. Additional review of the Wound/Skin Routing Form revealed the following: - The size of the wound was 4 centimeters (cm) by 2.5 cm with a red base and serosanguineous (blood and serum drainage) drainage. - A call was placed to the Nurse Practitioner (NP) and an order was received to start [MEDICATION NAME] (antibiotic) 150 milligrams (mg) three times a day. - On 12/6/10, the dietary department's plan was to provide increased supplements. - On 12/8/10, the Physical Therapy (PT) and Occupational Therapy (OT) departments were aware of the area and were in agreement with the treatment. Review of an "Interdisciplinary Note" written by the RN CNM dated 12/27/10 at 6:00 PM revealed that the NP was notified that the wound presented with serosanguineous drainage and increased size and depth. The RN CNM documented that the NP requested that a Wound Consultant see the wound and that an email was sent to the Wound Consultant. Review of an "Interdisciplinary Note" written by the RN CNM dated 12/28/10 revealed PT Wound Consultant to see, please see new order-"resident displays no evidence of pain, as assessment and treatment done". Review of an "MD order form" dated 12/29/10 revealed an order to cleanse the wound on the right lower leg with Wound Cleanser, pat dry, apply Skin Prep (topical application that "toughens" skin and enhances the adherence of a dressing) to the area around the wound and apply a "Tender Wet" (a moist absorbent dressing) dressing to cover the entire wound bed and cover the area with an "ABD" (abdominal pad - thick, absorbent dressing) pad. The treatment was ordered to be done every day and as necessary. Additional review of the 12/2/10 "Wound/Skin Routing Form revealed on 12/30/10, the PT Certified Wound Consultant (CWC) assessed the right leg wound and documented that the wound was a large area with an exposed tendon, the wound was infected and had 100% black, brown slough (soft, moist, dead tissue may be white, yellow, tan or green). The PT CWC recommended antibiotics per the physician and a new Rx (treatment) as per orders to help in debridement" (removal of dead tissue and/or foreign matter in the wound). Review of Wound/Skin Routing Forms and 24 Hour Reports from 12/3/10 to 1/2/11 revealed no documented evidence that the condition of the right lower leg wound, including measurement of size, was assessed by an RN on a weekly basis. An "Interdisciplinary Note" written by the RN CNM dated 1/3/11 documented that the NP was in to assess the wound and was in agreement with the treatment order. The RN CNM documented that the (right leg wound) measured "9 cm by 4 cm with 25 percent (%) dark and 50% yellow base". The RN CNM stated during an interview on 1/12/11 at approximately 1:00 PM that she could not find a Physician order for [REDACTED]. The RN CNM explained that she notified the NP of the wound condition in late December and that the NP requested that a wound specialist see the wound. The RN CNM also stated that she assessed the wound in early January but did not have any other assessments of the wound. The RN CNM stated that she is responsible for doing weekly wound assessments on the unit but did not have an answer as to why she did not do wound assessments on Resident #1 between 12/2/10 and 1/3/11. The DON stated during an interview on 1/18/11 at approximately 10:00 AM that the RN CNM on each unit is responsible for conducting weekly wound assessments and documenting in the nurse's notes or on the "Wound Skin Detail Report". The DON further stated that the RN CNM admitted to the DON that she did not do weekly wound assessments on Resident #1. The PT CWC stated during an interview on 1/18/11 that she was notified of the right lower leg wound on 12/29/10 by the RN Nurse Manager. The PT CWC stated that she assessed the right leg wound on 12/29/10 and suggested a new treatment including a "Tender-Wet" dressing which the RN Nurse Manager obtained an order for [REDACTED].#1 if she had known about the area, however she was not aware of the area until 12/29/10. The PT CWC stated that although she did the wound assessment on 12/29/10 she did not document the assessment on the "Wound/Skin Routing Form" until 12/30/10. Observation of the wound treatment on 1/12/11 at approximately 11:00 AM revealed the LPN Treatment Nurse provided the wound treatment using a "Tender-Wet" dressing according to the physician orders. The wound on the back of the lower right leg was approximately 12 cm in length and 5-6 cm in width. The wound bed was yellow in color with what appeared to be a tendon visible. There was a slight amount of serosanguineous drainage on the old dressing. The resident tolerated the treatment well and had her eyes closed throughout most of the treatment. Review of a monthly "Visit" Note written by NP #1 on 1/4/11 documented that the resident was seen for a monthly visit and to evaluate the wound on the posterior aspect of the calf. The NP documented that the patient had a posterior calf wound that "started as a skin tear" which "apparently" progressed. The NP also documented that the wound measured approximately 9 cm by 5 cm with yellow slough in the center; there was no tunneling (passage way of tissue destruction under the surface); and pinkish red healthy looking skin on the exterior edges. The NP documented that the wound did not appear to be infected. In addition, the NP documented that the plan was to continue with the current treatment and that the wound care team was seeing the patient weekly. NP #1 stated during a telephone interview on 1/18/11 that she assessed the right leg wound for the first time as per her note of 1/4/11. The NP stated that this was the first time the wound was brought to her attention by nursing staff. NP #1 further stated that her on-call logs show that the on-call NP #3 was called on 12/30/10 by a facility nurse regarding a request for a treatment order for the right calf which included a "Tender-Wet" dressing and that the on-call NP gave the order for the treatment. Review of an "Acute Visit" note written by the Physician dated 1/7/11 revealed the physician saw the resident to evaluate the right leg sore "which is worsening significantly". The Physician documented the resident denied any pain but since getting a skin tear on her lateral posterior right leg about a month ago, "has had significant decline" and the tendon was now visible. The Physician documented that the right leg lesion was approximately 12 cm by 5 cm in its largest area and there was no sign of infection and no significant drainage. The Physician further documented that the wound is likely not pressure related but looks like a hematoma (collection of blood under the skin) that has eroded. The Physician also documented that the resident is not "likely to heal" this, but (he) will follow the recommendations of the skin team. The Physician stated during a telephone interview on 1/12/11 at approximately 12:00 PM that he assessed the wound on 1/7/11 per his note. The Physician stated that he does not recall being made aware of the wound prior to his visit on 1/7/11 and he agreed that there was a lack of documentation regarding the wound. The Physician stated that the [MEDICATION NAME] (blood flow) to that area of the (resident's) leg is poor. Review of Nursing Interdisciplinary notes written by LPNs dated 12/4/10 to 12/26/10 revealed the following: - 12/4/10 at 11:48 AM - "right lower leg healing; No c/o (complaints of) s/s (signs and symptoms) pain". - 12/13/10 at 10:47 AM - "RLE (right lower extremity) dressing changed with scant amount bleeding noted. - 12/15/10 at 1:18 PM - "dressing changed to RLE with scant amount brownish drainage. Area dark in color. No s/s c/o pain". - 12/17/10 at 3:41 PM - Medium amount of yellow/bloody drainage noted to right lower leg". - 12/18/10 at 12:33 PM - "RLE remains darkened". - 12/20/10 at 3:24 PM - "Medium amount of yellow drainage noted to right lower leg". - 12/25/10 at 3:03 PM - Large amount of yellow/bloody drainage noted from right lower leg. Tylenol 650 mg (milligram) tab for increased pain with positive effect". LPN #3 stated during a telephone interview on 1/19/11 at approximately 2:45 PM, that she frequently performed the residents dressing changes during 11/10 on the day shift. LPN #3 stated that she noted that the wound was getting worse and passed the information to the RN CNM. LPN #2 stated during a telephone interview on 1/24/11 at approximately 1:00 PM that he performed the treatment to the resident's right leg frequently on the evening shift and stated that he informed the RN CNM a couple times that the area did not appear to be improving. Review of the "Resident Care Plan" last updated on 1/4/11 revealed a "problem" dated 11/28/10 that the resident had a skin tear "(2 cm x .5 cm)" with an approach to monitor positioning, a treatment of [REDACTED]. Further review revealed a "problem" dated 12/2/10 which stated "wound (4 x 2.5)". A care plan notation dated 1/4/11 revealed a goal that the resident would be free from complications such as pain and infection related to a full thickness wound on the right lower extremity with an approach to do a weekly assessment of the wound. Review of the medical record, including Physician and NP progress notes, revealed that the NP made visits to the resident on the following dates: 11/16/10 (monthly visit), 11/23/10 (acute visit), 12/20/10 (monthly visit), and 1/4/11 (monthly visit). The right leg was not evaluated by the NP until the visit of 1/4/11. The Physician made visits to the resident on 12/21/10 (interval visit) and 1/7/11 (acute visit). The Physician did not assess the right leg until the visit on 1/7/11. In summary, review of "Interdisciplinary Notes", "Wound/Skin Detail Reports" and "24 Hour Reports" from 11/28/10 to 12/29/10 revealed there was no initial assessment of the resident's right lower extremity (RLE) skin tear by an RN when the wound was first discovered on 11/28/10 and there were no weekly skin assessments from 12/2/10 when the RN CNM measured the wound as 4 cm by 2.5 centimeters until 12/29/10 when the PT CWC assessed the wound. The PT CWC documented the 12/29/10 assessment on 12/30/10 and described the wound as a large area with an exposed tendon, infected with 100% black brownish slough. A treatment change was initiated on 12/29/10 via a verbal order. There were no Physician's Orders for the wound treatment that was provided from 11/28/10 to 12/28/10. In addition, review of the medical record revealed there were multiple visits by medical staff in 11/10 and 12/10, including the NP and Physician, however there was no documented evidence that nursing staff requested medical staff to evaluate the wound prior to 1/4/11. 415.12

Based on observation, record review, and staff interview conducted during an Abbreviated survey (complaint # NY 922) completed 10/28/10, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #1) of six residents reviewed for quality of care did not receive necessary care and services. Resident #1 had issues involving the lack of a complete assessment and ongoing tracking of reddened, excoriated skin at the insertion site of a PEG (percutaneous endoscopic gastrostomy - feeding tube inserted into the stomach) tube by a registered professional nurse; lack of a facility policy specific to the care and monitoring of a PEG tube site; and lack of timely notification of the Physician/Nurse Practitioner of a change in condition of the PEG tube site. There was a delay scheduling a surgical consult; delay changing the PEG tube per the physician's orders [REDACTED]. This resulted in actual harm for Resident #1 that is not immediate jeopardy. The findings are: 1. Resident #1 was initially admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set) dated 8/18/10 revealed the resident has moderately impaired cognitive skills, is usually understood and usually understands. The CCP (comprehensive care plan) dated 9/1/10 documented a problem dated 2/22/10" related to [DEVICE] (gastrostomy tube/ PEG tube) site irritation with some bleeding" with an approach to "assess skin for redness q (every) shift". Review of an Order Management Sheet dated 3/11/10 and physician's orders [REDACTED]. Review of Treatment Administration Records (TARs) dated 3/12/10 through 9/7/10 revealed the Medline antifungal powder treatment was applied to the [DEVICE] site daily as ordered. Review of TARs dated 6/1/10 through 8/31/10 revealed an entry for nursing staff to monitor the [DEVICE] site every shift, document drainage, color, odor and to check the skin. Additional review of the TARs revealed the [DEVICE] site was monitored every shift as planned, however, there was no documentation of the actual appearance of the insertion site. Review of a facility Policy and Procedure (P+P) entitled Wound Management and Treatment dated 6/09 revealed skin assessments and documentation are to be done on all wounds and [MEDICAL CONDITION]. The policy documented that these may include but are not limited to rashes and excoriations, that clinicians will assess and document appearance at each treatment session and record measurements weekly including weekly documentation of the type of wound/ characteristics. Interview with the DON on 9/29/10 at approximately 1:15 PM revealed there was no facility P&P related to the care and monitoring of PEG tube sites. The DON stated the condition of the PEG tube site should have been monitored weekly. During an interview on 9/28/10 at approximately 11:00 AM, skin/wound sheets for Resident #1 were requested from the Director of Nursing (DON), LPN (Licensed Practical Nurse ) #1 and RN #2, who is the Certified Wound Clinician and the Sub Acute Unit Clinical Nurse Manager. During the interview, it was learned that the skin surrounding the [DEVICE] insertion site was not being "tracked" since it was not a pressure sore or a wound. The nurses explained that weekly skin checks are done on each resident's bath day and anything noticed would be documented on a Weekly Skin Assessment Sheet. Review of Weekly Skin Assessment Sheets revealed there were four skin assessments documented regarding Resident #1's PEG site from 6/1/10 to 9/22/10. The Weekly Skin Assessment Sheets revealed the following: - 6/18/10 - LPN #3 documented that the abdomen ([DEVICE]) site was excoriated. There was no measurement of the excoriated area. - 9/3/10 - the "red area remains on abdomen at PEG tube site." - 9/10/10 - LPN #3 documented the PEG tube site was reddened and excoriated. - 9/17/10 - the area at the PEG tube site remains reddened. There was no documentation of a complete assessment of the area. Interview with the DON on 9/28/10 at 11:00 AM, confirmed these were the only dates the [DEVICE] area was evaluated on the Weekly Skin Assessment Sheets. Review of Interdisciplinary Notes dated 6/1/10 through 9/22/10 revealed no evidence that the PEG site was assessed every shift as planned. Additional review of Interdisciplinary Notes written by LPNs dated 6/5/10 to 6/10/10 revealed documentation there was tan drainage from the site and the resident complained that the [DEVICE] was "painful". Review of an Interdisciplinary Note dated 7/6/10 at 2:26 PM revealed LPN #2 documented that the PEG site remained reddened with excoriation and that the site was stable and "no worse". Review of Interdisciplinary Notes and Weekly Skin Assessment Sheets revealed no documented evidence that an RN assessed the condition of the [DEVICE] insertion site from 6/5/10 to 7/6/10. Review of an Interval Visit Note written on 7/9/10 by the NP (Nurse Practitioner) revealed the resident's skin was documented as having no rash, no open areas, and no pruritis (itching). Under Physical Examination of the abdomen the NP documented that the resident had a PEG tube site, bowel sounds were present and the abdomen was non tender. Review of an Interdisciplinary Note written by LPN #2 dated 7/13/10 at 2:24 PM revealed the PEG site had watery drainage after flushing, with a small amount of old bloody drainage on the dressing. An Interdisciplinary Note written by LPN #2 dated 7/16/10 at 2:45 PM documented that the PEG site was reddened and was "no worse" with some "dark blackish" drainage. There was no documented evidence that an RN assessed the [DEVICE] site. Review of Interdisciplinary Notes written by LPNs dated 7/17/10 through 8/13/10 revealed the [DEVICE] site remained reddened and had tan/brown drainage at the site. Additional review of the Interdisciplinary Notes revealed no documented evidence that the [DEVICE] site was monitored every shift as planned, that the skin at the insertion site was assessed by an RN or that the Physician/NP was notified regarding the continued redness and drainage at the site. Review of an Acute Visit Note written by the NP dated 8/13/10 revealed the resident had no rash, no open areas, and no pruritis. The Physical Exam revealed the abdomen was soft, non tender, with bowel sounds in all 4 quadrants and a [DEVICE]. During an interview on 11/3/10 at approximately 3:50 PM, the NP stated she saw the patient for constipation on 7/9/10 and for dysphagia on 8/13/10. The NP stated that if the notes for these visits reveal that bowel sounds were present, then she knows she listened. The NP further stated that she may have done it through the resident's gown if nursing had not informed her there was an issue with the [DEVICE] site and/or skin integrity of the abdomen. Review of Interdisciplinary Notes written by LPNs dated 8/20/10 to 8/26/10 revealed the [DEVICE] site was reddened and had a small amount of brownish drainage. Review of an Acute Visit Note written by the NP dated 8/26/10 revealed nursing staff asked the NP to see the resident because the resident had "quite a severe rash surrounding the PEG tube". The NP documented that "the PEG tube is leaking biliary drainage" and that the drainage was "excoriating the area". The NP documented a probable remedy was to put in a larger PEG tube with a bigger bulb or a Foley with a large balloon to prevent leaking around the skin. When interviewed on 11/3/10 at 3:50 PM, the NP stated nursing staff first made her aware of the condition of the [DEVICE] site on 8/26/10 and she then saw the resident. Review of an MD Order Form dated 8/26/10 revealed the NP wrote orders for a: - [DEVICE] with larger balloon to be placed due to leaking around [DEVICE] (No specific PEG size was ordered) - Compound a one pound jar of [MEDICATION NAME] cream with 2.5% [MEDICATION NAME] cream to be applied around the PEG site, and to cleanse with wound cleaner twice daily. Review of an MD Order Form dated 8/27/10 revealed the Attending Physician provided a clarification order to change the PEG tube to a 20 Fr (french - diameter size of a catheter) with a 30 cc (cubic centimeter) bulb on 8/28/10 during the 7:00 AM to 3:00 PM shift. Review of the TARs and Interdisciplinary Notes dated from 8/27/10 revealed no documented evidence that the PEG tube was changed until 9/6/10, 9 days after the order was given. Review of Interdisciplinary Notes dated 8/28/10 through 9/6/10 revealed no evidence the Physician or NP was notified that the PEG tube was not changed. During an interview on 10/27/10 at 2:40 PM, LPN #1, who was the Acting Unit Manager, stated that the NP order did not initially have the right size tube, so clarification of the order was obtained on 8/27/10. LPN #1 stated that LPNs are not allowed to replace or reinsert PEG tubes so she mentioned it to the two RN Unit Managers but "they have their own units to run, would get busy and were unable to get to it". LPN #1 stated she did not put this on report or inform the RN Supervisors. Review of the TAR dated 8/10 revealed no evidence the [MEDICATION NAME]/ [MEDICATION NAME] Cream was applied to the PEG site as ordered on [DATE]. Review of the 9/10 TAR revealed both the [MEDICATION NAME]/ [MEDICATION NAME] Cream and the Medline antifungal treatment were documented as provided from 9/1/10 to 9/7/10. Interview with LPN #1 (Acting Unit Manager) on 10/27/10 at 2:40 PM revealed the Medline antifungal powder should have been discontinued. Review of Interdisciplinary Notes written by LPNs dated 8/28/10 through 9/4/10 revealed the [DEVICE] continued to leak, the insertion site was excoriated and there was dark brown and black drainage from the site. An Interdisciplinary Note, written by RN #3, who is a Nursing Supervisor, on 9/6/10 at 3:40 PM revealed RN #3 replaced the [DEVICE]. RN #3 documented "Stomach contents continue to leak around stoma site" and the stoma site is very red and excoriated". RN #3 documented "Skin Nurse notified to evaluate skin". Review of Interdisciplinary Notes and wound documentation dated 9/6/10 through 9/19/10 revealed no documented evidence the RN Skin Nurse assessed the [DEVICE] insertion site. During an interview on 9/29/10 at 12:30 PM, RN #2 (the Wound Clinician) stated he did not receive a Decubitus (wound ulcer) Alert Routing Form which is used for requesting a wound consultation and did not assess the [DEVICE] site until 9/20/10. During an interview on 9/30/10 at 10:30 AM, RN #3 who documented on 9/6/10 that she changed the [DEVICE] and requested the Skin Nurse to see the resident, revealed she did not fill out a Decubitus Alert Routing Form. RN #3 explained that RN #2 was working as the Unit Manager on his unit and she personally went and discussed Resident #1's [DEVICE] site with him. RN #3 stated she only works per diem at the facility but once she saw the abdominal area, even though there was a treatment in place, she knew it had to be addressed. RN #3 stated she believed the drainage could have been "bile with a foul odor". Review of an MD Order Form dated 9/7/10 revealed a treatment change to cleanse the PEG tube site with wound cleanser, pat dry, apply [MEDICATION NAME] (a gel like dressing that promotes healing) dressing and change every 3 days and PRN (as needed) and to apply zinc oxide to the area surrounding the peg tube every shift and PRN. Review of physician's orders [REDACTED]. Review of an Interdisciplinary Note written by LPN #1 (who was the Acting Unit Manager since 5/10) dated 9/9/10 at 11:53 AM revealed that the resident's Health Care Agent had called and informed her that she spoke with a Surgeon and he thinks it may be time for a replacement and that she would prefer that the resident be returned to the hospital where the tube was originally inserted. An Interdisciplinary Note dated 9/10/10 at 5:30 PM documented that the Health Care Agent called LPN #1 and informed her that she attempted to speak with a Surgeon at the hospital where the tube was initially inserted, but was told it had to be done by referral. LPN #1 also explained a possible option was the use of an "Eakin" seal (a [MEDICATION NAME] barrier that forms a gel to prevent skin damage). The Health Care Agent was in agreement with [MEDICATION NAME] if it would work. During an interview on 9/28/10 at 1:05 PM, RN #2 (the Wound Nurse Clinician) stated that samples of [MEDICATION NAME] were delivered to the facility on [DATE], 6 days after the seal was discussed with the Health Care Agent, as an alternative to surgery. RN #2 stated that [MEDICATION NAME] was not delivered with instructions so he had to research how to use and apply the seal. RN #2 stated that when he went to initiate the use of [MEDICATION NAME] on 9/20/10 (10 days after the discussion with the Health Care Agent), it was determined that [MEDICATION NAME] could not be used. RN #2 stated that 9/20/10 was the first time he actually saw the condition of the [DEVICE] site. Additional review of Interdisciplinary Notes revealed: - On 9/8/10 at 2:24 PM, LPN #2 documented there was a "gross" amount of "fresh bleeding from GT site" with many large clots. - On 9/8/10 at 8:18 PM, the MD was in to see the resident and assessed the PEG tube site. PEG tube site "continues to drain large" amounts of "bloody drainage from site" and the MD "witnessed this". The MD then spoke with the Health Care Agent (HCP #1) regarding reinsertion of the [DEVICE]. - On 9/12/10, the 11:00 PM to 7:00 AM shift LPN (#12) documented Resident #1 was able to make her needs known that her abdomen was tender to touch, dark brown drainage was noted on the previous dressing and that a voicemail message was left for the MD regarding the dark brown drainage. - On 9/13/10, the 3:00 PM to 11:00 PM shift LPN (#11) documented Resident #1 complained of abdominal pain and was medicated with Tylenol and the "area very excoriated". - On 9/14/10, LPN #13 documented the [DEVICE] site was "extremely excoriated" with a moderate amount of blackish/brown drainage on the dressing. - On 9/14/10 at 7:40 AM, LPN #4 documented that the site was very excoriated with a large amount of dark brownish, bloody drainage and that the resident was medicated for c/o abdominal pain. - On 9/14/10 at 2:20 PM, LPN #2 documented "[DEVICE] site very excoriated" with dark drainage from site and a "towel" was applied. During an interview on 9/29/10 at 1:20 PM, LPN #2 stated she applied an actual bath towel over the dressing because it would not stop leaking. The LPN stated she did not report the leaking to the Nursing Supervisor because "everyone knew" and [MEDICATION NAME] was on order. - From 9/15/10 through 9/18/10 there was continued documentation that the [DEVICE] site was excoriated. - On 9/18/10 at 5:59 AM, LPN #8 documented that the "[DEVICE] site was bright red and excoriated" with "substantial" amounts of yellow drainage observed coming out of the "opening around the actual [DEVICE]". - On 9/18/10 at 9:57 PM, LPN #3 documented that the resident's "abdomen is very excoriated and painful". Review of an Interdisciplinary Note written by LPN #3 dated 9/19/10 at 10:20 PM revealed that the resident's "[DEVICE] is very excoriated and painful" and "bile like liquid" continues to "pour out of it onto the skin". Review of an Interdisciplinary Note written by LPN #5 dated 9/20/10 at 3:47 PM revealed "resident [DEVICE] site noted to be bleeding and was raw", she called the supervisor who helped her with the bandage and the feed was turned off. Review of a Request for Skin/Wound Consultation Sheet completed by RN #2 (the Certified Nurse Clinician) dated 9/20/10 revealed the excoriated area around the PEG tube measured 6 cm to 7.5 cm in circumference around the umbilicus with [MEDICATION NAME] (outer layer of the skin) erosion present and brown green [MEDICAL CONDITION] drainage continued from the PEG insertion site with 12.5 cm of external PEG exposed. RN #2 consulted with the Attending MD, notified him of the assessment; suggested a change in treatment for [REDACTED]. RN #2 documented that he called for the surgical consult himself. There is no documented evidence that an Interdisciplinary Note was written by nursing until the following day 9/21/10 at 11:10 AM when RN #4 called the Attending Physician who stated he is "awaiting guidance from family" related to the Surgeon. RN #4 called the Medical Director and discussed the current status at which time he gave the following orders: CBC (complete blood count), CMP (comprehensive metabolic panel) STAT (now), stop feed, place IV (intravenous) Clysis (infusion of fluid usually subcutaneously for therapeutic purpose) .45 NS (normal saline), and check daily BMP (basic metabolic profile). An Interdisciplinary Note dated 9/21/10 at 5:19 PM documented that the Medical Director was called with laboratory results including an increased WBC (white blood cell) of 21 (normal 4.0 to 10.5), BUN (blood urea nitrogen) 108 (normal 5 to 31) and NA (sodium) 128 (normal 133 to 147). New orders were received to obtain a CBC and CMP in the morning and start [MEDICATION NAME] (antibiotic) 1 gram IM (intramuscular) x 3 days. Review of Interdisciplinary Notes dated 9/21/10 at 11:05 AM through 9/22/10 at 7:00 AM revealed that multiple attempts were made to contact Health Care Agent #1 for 13 hours without attempting to utilize the alternate Health Care Agent. Interview on 9/30/10 at approximately 10:00 AM, with RN #6 who worked as the Nursing Supervisor on 9/21/10 starting at 6:00 PM, revealed that the alternate Health Care Agent was in the facility, but was not approached regarding a care decision for the resident. Review of an Interdisciplinary Note dated 9/22/10 at 7:26 AM revealed Resident #1 was sent to the hospital via ambulance at 12:00 AM and admitted to the hospital. During an interview on 9/29/10 at 3:30 PM, the Attending Physician stated he did not know when Resident #1's PEG site started leaking or when the skin became impaired, and that he could not tell "from memory". The Physician stated he was aware of the condition of the PEG site for approximately two weeks prior to the resident's transfer to the hospital. When asked why the Health Care Agent was told to arrange a surgical evaluation, the Physician stated because she wanted to do it. When asked why on 9/10/10, when he was informed by LPN #1 that the Health Care Agent was unable to arrange the evaluation, there was no follow up, the Physician replied no and stated he was not informed by LPN #1. When asked why from 9/8/10 from discussion with Health Care Agent until nursing had him see the resident he did not follow up, the Physician abruptly stood, said he didn't know and exited the room. Interview with the DON on 9/29/10 at approximately 3:45 PM revealed she was called to Resident #1's room by LPN #5 on 9/20/10. The DON explained that LPN #5 does not usually work on the resident's unit, but when LPN #5 saw the condition of the resident's abdomen she called the Supervisor and the DON. The DON stated she was not aware of the severity of the [DEVICE] site. The DON stated morning report and the 24 Hour Reports mentioned some redness or excoriation but nothing like the condition it was in or she would have intervened before it had reached that point. The DON stated that the Attending Physician happened to be in the facility at that time and she personally went and brought him down to the resident's room to look at the condition of the abdomen and PEG site. Review of the ED (emergency department) Triage Sheet dated 9/22/10 at 12:31 AM revealed the reason for the visit was abnormal labs and the leaking [DEVICE] with a chief complaint of abdominal pain. Review of an ED MD Note dated 9/22/10 at 1:28 AM revealed the resident's abdomen was distended with no bowel sounds. The Physician documented there were extensive excoriations and [DIAGNOSES REDACTED] surrounding the [DEVICE]. Review of a hospital Skin Care Note dated 9/23/10 revealed there was an extensive area of moisture associated skin damage, [DIAGNOSES REDACTED], fungal rash and denuded (loss of the outer surface of the skin due to exposure to drainage) areas around the [DEVICE] and extending to the flank areas. Review of GI (gastrointestinal) Progress Notes dated 9/23/10 revealed extensive erythemus (redness), excoriation with induration (abnormal hard spot) and likely fungal component surrounding [DEVICE] insertion site which itself appears "eroded" and that a new [DEVICE] site was not indicated at this time due to active [MEDICAL CONDITION] (inflammation of tissue under the skin). Review of the hospital Transfer Summary dated 10/1/10 revealed the primary discharge [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. inch by 4 inch gauze dressing) every shift. Observation of the resident's abdomen on 10/27/10 at approximately 10:00 AM revealed a dressing was in place over the PEG tube site that was dated 10/26/10, 3:00 PM to 11:00 PM, with initials. Review of the TAR dated 10/10 revealed there was no documentation that the PEG site dressing has changed during the 11:00 PM to 7:00 AM shift, from 10/26/10 to 10/27/10. When interviewed on 10/27/10, RN #4 (the Clinical Nurse Manager) stated that the PEG tube dressing was initialed by the 3:00 PM to 11:00 PM Nurse last evening on 10/26/10 and that the treatment was not done on the 11:00 PM to 7:00 AM shift per the physician's orders [REDACTED]. During an interview on 10/28/10 at 9:45 AM, LPN #14 stated she meant to do the treatment but got busy and forgot. LPN #14 stated that she did not notify the Supervisor or the relief shift. 415.12