Every finding on record at Cooperstown Center for Rehabilitation and Nursing

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labelled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates; (b.) controlled substances were not kept secured in a double locked cabinet; (c.) expired medications were present; and (d.) medications were left on top of medication cart unattended. This was evident for 3 out of 10 medication carts reviewed, and for 2 out of 5 medication storage rooms reviewed. This is evidenced by: The facility's Medication Administration Policy and Procedure, effective 12/2019 documented, the expiration date on the medication label must be checked prior to administering. When opening a multi-dose container, the date should be recorded on the container. During administration of medications, the medication cart would be kept closed and locked when out of sight of the medication nurse or aide. No medications were to be kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. During an observation on 4/24/2024 at 11:50 AM, Medication Cart on [NAME] unit, right side, contained the following medications with no open or expiration dates: 3 glargine insulin kwik pens; 1 vial of Humulin insulin; 1 latanoprost eye drop solution and 1 dorzol eye drop solution. The Left side of the medication cart contained the following medications with no open or expiration dates: 1 glargine insulin kwik pen; 1 vial of lispro insulin. During an observation on 4/24/2024 at 12:05 PM, a list of medications with shortened expiration dates was posted in the [NAME] Medication Room. During an observation on 4/24/2024 at 11:59 AM, Licensed Practical Nurse #6 was observed administering Oxycodone 10milligrams by mouth to Resident #116. Licensed Practical Nurse #6 stated the narcotic book was left in the medication room, and they sign out all narcotics given for the day at the end of their shift. There were 13 oxycodone 10 milligram tablets left in blister pack on the medication cart. The narcotic book locked in the medication room indicated there were 15 oxycodone 10milligram tablets still in blister pack. Licensed Practical Nurse #6 stated they gave Resident #116 one pill earlier in the day in addition to the dose just given. Licensed Practical Nurse #6 stated they did not know the facility's policy off hand for narcotic medication administration, but this system worked for them. During an observation on 4/24/2024 at 12:05 PM, the [NAME] unit Medication Room narcotic lock box on right side had only one functioning lock. The narcotic lock box was observed to have a broken lock inside while it contained multiple narcotics. Licensed Practical Nurse #6 stated they called maintenance. However, they could not recall what date maintenance was called. The medication room refrigerator contained a tuberculin purified protein derivative bottle opened on 3/01/2024. The manufacturer's label documented discard 30 days after opening. Licensed Practical Nurse #6 discarded the bottle. During an observation on 4/24/2024 at 12:20 PM, Medication Cart on [NAME] unit left side contained a narcotic book for left side assignment. The left side cart also contained a list of medications with shortened expiration dates. During an observation on 04/29/2024 at 11:50AM, Medication Storage Room on Mountain Ridge unit, right lock box had an Epinephrine pen with expiration date of 12/2023, no resident name was on the pen or bag. During an observation on 4/30/2024 at 09:42 AM, medication cart on Mountain Ridge unit was observed to have an insulin pen and a blister pack of medication laying on the top of the medication cart, unattended. Licensed Practical Nurse #3 was observed walking out of a resident's room down the hall to the medication cart. Licensed Practical Nurse #3 put away medication on the cart mumbling as they did so. During an interview on 4/24/2024 at 12:25 PM, Licensed Practical Nurse #7 stated they kept narcotic book on medication cart and each time a narcotic was given, the narcotic book was updated and reconciled. During an interview on 4/29/2024 at 11:50 AM, Licensed Practical Nurse #3 stated they were unsure what to do with the medication and did not want to just leave it out for anyone to grab before the pharmacy pick up was done. Licensed Practical Nurse #3 stated they did not know why the expired pen had not been returned to pharmacy. They stated that pharmacy pick-ups were Monday through Friday, two times per day at 2:00 PM and 10:30 PM; Saturday and Sunday, one time daily around 6:00 PM. Licensed Practical Nurse #3 removed the epinephrine pen from the lock box and placed it in the return to pharmacy bin for pharmacy pick up. During an interview on 05/01/24 at 09:25 AM, Licensed Practical Nurse #3 stated they would not normally leave medication on top of the cart unattended. They gave medication to a resident that was going out to an appointment and their catheter was leaking. They had to run and get another catheter and accidently left the medications on the cart. Licensed Practical Nurse #3 stated that the insulin pen was empty, but the blister pack was not. They stated it was wrong and that was not their typical practice. During an interview on 4/24/2024 at 12:50 PM, Director of Nursing #1 stated the facility completed a full staff medication administration training the previous month. In addition, each nurse completed competencies for medication administration upon hire and annually. During an interview on 4/26/24 at 14:00PM, Director of Nursing #1 stated the narcotic box on right side of Medication Room on [NAME] Unit had been replaced and both inside and outside locks were functioning. 10 New York Codes, Rules and Regulations 415.18(d) 48744

Based on observations, record reviews, and interviews during the recertification and abbreviated survey (Case # NY00318691), the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all residents in the facility. Specifically, call lights were not answered timely to meet the needs of residents, with multiple residents stating there were long waits for call lights, and there were 34 falls documented for the month of April 2024. This is evidenced by: The Facility Assessment, last updated 3/01/2024, documented the facility capacity was 174 residents with an average daily census range of 163-170 residents. The following two units were designated for extra staffing: [NAME]: 30 designated short term rehab beds, and Serenity Place: 35 designated beds for the dementia population on a secure unit. Staffing was based on acuity and resident needs. Record review revealed the following from 6/13/2023- 6/20/2023: On 06/13/2023 the facility census was 150: On 7:00 AM-3 PM shift, 18 Certified Nurse Aides were required but 11 Certified Nurse Aide were present. On 11:00 PM- 7:00 AM 9 Certified Nurse Aides were required but 7 Certified Nurse Aide were present. On 06/20/2023 the facility census was 155: On 7:00 AM-3 PM shift, 19 Certified Nurse Aides were required but 17 Certified Nurse Aide were present. On 7:00 AM- 3:00 PM shift, 9 Medication Nurse (Licensed Practical Nurse/Registered Nurse) were required but 8 nurses were present. On 11:00 PM- 7:00 AM 9 Certified Nurse Aides were required but 8 Certified Nurse Aide were present. Record review revealed actual staffing for 4/29/2024 - 5/02/2024 documented the following: On 4/29/2024 the facility census was 163: On 7:00 AM-3 PM shift, 20 Certified Nurse Aides were required but 18 Certified Nurse Aide were present. 10 Medication Nurse (Licensed Practical Nurse/Registered Nurse) were required but 6.6 nurses were present. On 4/30/2024 the facility census was 166: On 7:00 AM-3 PM shift, 20 Certified Nurse Aides were required but 19 Certified Nurse Aide were present. On 7:00 AM- 3:00 PM shift, 10 Medication Nurses (Licensed Practical Nurse/Registered Nurse) were required but 6 nurses were present. On 5/01/2024 the facility census was 166: On 7:00 AM-3 PM shift, 20 Certified Nurse Aides were required but 18 Certified Nurse Aide were present. On 7:00 AM- 3:00 PM shift, 10 Medication Nurses (Licensed Practical Nurse/Registered Nurse), were required but 6 nurses were present. On 3:00 PM-11:00 PM shift, 16 Certified Nurse Aides were required but 14 Certified Nurse Aide were present. On 11:00 PM- 7:00 AM shift, 10 Certified Nurse Aides were required but 9 Certified Nurse Aide were present. On 5/02/2024 the facility census was 168: On 7:00 AM-3 PM shift, 20 Certified Nurse Aides were required but 19 Certified Nurse Aide were present. On 7:00 AM- 3:00 PM shift, Medication Nurse (Licensed Practical Nurse/Registered Nurse), 10 nurses were required but 5 nurses were present. On 3:00 PM-11:00 PM shift, 20 Certified Nurse Aides were required but 16 Certified Nurse Aide were present. During an observation on 4/22/2024 at 6:50 PM on [NAME] unit, there were no staff members visible for over 20 minutes, and all residents on the floor were in bed. Residents # 116 and #132 were awake awaiting assistance. During an interview on 4/23/2024 at 9:30 AM, Resident #76 stated they waited for long periods before call light was answered. Resident #76 stated they had been waiting for over an hour for oxygen concentrator to be changed. They stated that the existing concentrator was not working properly. During an interview on 4/23/2024 at 10:30 AM, Resident #138 stated they waited a long time for staff to answer lights, especially over the weekend. However, they eventually come to assist. Resident #138 stated they were fortunate as they could do some things for themself. During an interview on 4/30/2024 at 10:46 AM, Certified Nurse Aide #7 stated they worked 16 hours a day and 6 days per week. At times there was only 1 Certified Nurse Aide overnight and only 2 Certified Nurse Aides on day shift. During an interview on 5/01/2024 at 10:00 AM, Registered Nurse #2 stated they had been assigned to the medication cart for the second day in a row. Instead of being assigned to the Serenity Place medication cart, they were assigned to [NAME] Book medication cart. Registered Nurse #2 stated Licensed Practical Nurse #8 usually worked both sides of the [NAME] unit. However, today Licensed Practical Nurse #8 refused to work alone. During an interview on 5/01/2024 at 2:50 PM, Registered Nurse #2 stated they were assigned to work a medication cart on Serenity Place. Registered Nurse #2 stated an admission had arrived and they were unable to take report for the new admission. Registered Nurse #2 was not aware Resident #146 had been discharged , and a new resident was awaiting admission. During an interview on 4/30/2024 at 10:15 AM, Licensed Practical Nurse #8 stated they were often asked to stay late and picked up shifts. Additionally, they stated they generally work a 16-hour shift. 45 percent of the time they worked alone on the rehabilitation floor. When working alone and short staffed they have to manage their time so that if a task is not completed during the day, it can be completed on the evening shift. When working short staffed, they would tell certified nurse aides to shorten resident rounds to get work done. During an interview on 5/02/2024 at 11:47 AM, Licensed Practical Nurse #9 stated they were the only nurse for both sides of one unit working on the day shift. They stated they worked alone the previous day as well. Licensed Practical Nurse #9 stated they often came in an hour early and stayed late to complete assignments. During an interview on 5/02/2024 at 12:10 PM, Registered Nurse #3 stated they usually were the only nurse for both sides on whatever unit they were assigned to. It was very busy, but since they were familiar with the residents, they were able to complete assignment if they stayed late. Registered Nurse #3 stated each Wednesday, the wound care team rounded on the residents as well as completing wound and skin assessments, and was a help because it lessened the workload for the usual floor staff. During review of facility Incident and Accident reports for April 2024, there were 34 falls documented. During an interview on 4/30/2024 at 11:02 AM, Director of Nursing #1 stated when there were staff call outs or short-staffed days, leadership came in and helped. They reached out to agency staff and ask existing staff to pick up extra shifts. They also made changes to the schedule to balance short staffed days when possible. 10 New York Codes, Rules and Regulations 415.13(a)(1)(i-iii)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and 7 of 10 kitchenettes. Specifically, food contact equipment was not being sanitized, thermometers were not calibrated, and surfaces were not clean. This is evidenced by: During observations in the main kitchen on 4/22/2024 at 6:48 PM: The concentration of quaternary ammonium compound used in the final, sanitizing rinse sink of the 3-compartment sink was 0 parts per million when measured at 70 degrees Fahrenheit, in accordance with the testing kit directions; food contact equipment was being washed during this observation. The label directions on the quaternary ammonium compound concentrate instruct that the dilution range is to be between 200 and 400 parts per million. Two food temperature thermometers were found not in calibration at 24 degrees Fahrenheit and 52 degrees Fahrenheit when tested in a standard ice-bath method. The serving line reach-down refrigerator, housekeeping room door, door to the loading dock, K-rated fire extinguisher, fire alarm pull station were soiled with food residue. Two utensil drawers by the preparation sink were broken and did not ride on their rails. During observations on 4/22/2024 at 7:37 PM: The Hollyhock Way kitchenette freezer door gasket was split and uncleanable, and the floor under refrigerator was soiled with food particles. The Gardenia Way kitchenette cabinets were soiled with food particles. The Whispering Way kitchenette floor under refrigerator was soiled with food particles. The Star Haven kitchenette bottom shelf in the refrigerator was soiled with food particles. The Emerald Way kitchenette cabinets were soiled with food particles. The [NAME] Glen kitchenette cabinets were soiled with food particles. The [NAME] Creek kitchenette freezer door gasket was split and uncleanable, and the floor under refrigerator was soiled with food particles. The Oak Creek kitchenette cabinets were soiled with food particles. During an interview on 4/22/2024 at 7:28 PM, Food Service Director #1 stated that the person washing equipment at the 3-bay sink had likely diluted the solution during their shift but would be re-educated on checking the solution to ensure it remained at the proper concentration. During an interview on 5/01/2024 at 1:17 PM, Administrator #1 stated that Food Service Director #1 had started staff education on the correct concentration of the sanitizing solution and on thermometer calibration. Administrator #1 stated that the low-boy cooler had been cleaned; one utensil drawer was repaired and the other was removed. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14

Based on record review and interviews during a recertification and abbreviated survey (Case # NY00324038), the facility did not ensure residents who were hospitalized or on therapeutic leave were allowed to return to the facility for skilled nursing or nursing facility care or services for 1 of 2 residents reviewed (Resident #165). Specifically, Resident #165 was sent to the hospital on 9/12/2023 for evaluation for behaviors. The resident was medically cleared and discharged from the emergency department. The facility refused to accept the transfer back to the facility. This is evidenced by: The facility policy and procedure titled, Discharge-Transfer/Discharge Process, dated 12/2019, documented if a resident was transferred to the hospital because the facility was unable to safely manage the resident's care at the time of transfer, the facility was expected to readmit the resident once the hospital had determined it was safe for them to return to the facility. Resident #165 was admitted with diagnoses of dementia, diffuse traumatic brain injury, and depression. There was no documented evidence of comprehensive assessment on the resident. The discharge summary dated 9/08/2023 from discharging hospital did not document any behaviors from the resident toward self or others. The Social Services progress note dated 9/11/2023 at 10:25 AM documented the resident was physically aggressive toward staff and a danger to self and others. The progress note documented the resident was to return to the hospital as they were unsafe to remain in the facility. The Physician progress note dated 9/12/2023 documented the resident was seen for aggressive behaviors. The progress note indicated the hospitalization records documented aggressive behavior in the hospital as well prior to transfer to the facility. The physician documented the resident was a danger to themselves and others due to aggressive behaviors and would be sent to the hospital. A nursing progress note dated 9/12/2023 documented the resident was exhibiting aggressive behaviors. De-escalation attempts and distraction attempts were documented as unsuccessful. The progress note documented the interdisciplinary team agreed that the resident's needs could not be met in the facility and the resident would be transferred to the hospital that discharged them. A document submitted to the New York State Health Department dated 9/19/2023 documented emergency services was called and law enforcement came to the facility. Emergency services reportedly refused to transfer the resident as there was no medically emergent need. The facility then transferred the resident to the hospital in the facility transportation vehicle with additional staff. During an interview on 4/30/2024 at 10:51 AM, Complainant #1 stated Resident #165 was not brought to the closest hospital but instead was transported to a hospital one hour away in a private vehicle. Complainant #1 stated if Resident #165 was exhibiting severe behaviors that were a threat to self or others, transporting in a private vehicle would not be appropriate. Complainant #1 stated Resident #165 did not exhibit any behaviors of that nature in the emergency room of the hospital and the medical doctor did not feel the resident was a danger to self or others. They stated the resident was medically cleared for discharge from the emergency department but when transfer to the facility was attempted, the facility refused to take the resident back. During an interview on 5/01/2024 at 10:15 AM, Director of Nursing #1 stated the facility was not aware of Resident #165's prior behaviors before they were admitted to the facility. When the resident was admitted to the facility, they began exhibiting dangerous behaviors toward staff and other residents. Director of Nursing #1 stated the resident believed they were being discharged to home and was expected to be transferred to another facility. They stated the medical provider also determined the resident was a danger to self and others, and the facility did not have the ability to have one-on-one supervision of the resident to ensure safety. Director of Nursing #1 confirmed emergency medical services would not transport the resident. They stated Resident #165 was calm when they were informed that they were leaving the facility. Director of Nursing #1 stated when the facility was informed the resident was medically cleared to be discharged from the emergency department on 9/12/2024, the facility refused to readmit the resident because they feared the resident would become agitated and dangerous if they came back to the facility. 10 New York Codes, Rules, and Regulations 415.3(h)(4)(iii)

Based on record review and interviews during a recertification and abbreviated survey (Case # NY00324855), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 resident (Resident #45) of 6 residents reviewed for abuse, neglect, and mistreatment. Specifically, for Resident #45, Certified Nurse Aide #4 did not use two staff for bed mobility as documented in Resident #45's Comprehensive Care Plan while providing care to the resident on 9/19/2023. This resulted in Resident #45 rolling out of bed onto the floor and was not reported to the New York State Department of Health. This is evidenced by: Resident #45 was admitted to the facility with diagnoses of hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), chronic obstructive pulmonary disorder (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and morbid (severe) obesity. The Minimum Data Set (an assessment tool) dated 4/01/2024, documented the resident had moderately impaired cognition, could usually understand others and be understood. The facility's policy and procedure titled Accidents and Incidents, last revised in July 2020, documented abuse allegations were reported per Federal and State Law. The facility would ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made. An interdisciplinary team would review all cases and the Administrator and Director of Nursing would determine whether the incident required reporting to outside agencies such as the Department of Health. The Comprehensive Care Plan titled, Assistance in Activities of Daily Living, dated September 2023, documented the resident was dependent on two staff members for bed mobility. The Certified Nurse Aide Kardex (Resident care card followed by Certified Nurse Aides to provide care), for September 2023, documented the resident was dependent and required two staff members for bed mobility. The facility Accident and Incident report, dated 9/19/2023 at 05:28 PM, documented Resident #45 fell out of bed and was lying on their back complaining of head and body pain. Certified Nurse Aide #4 was the only documented witness to the event. The statement by Certified Nurse Aide #4 on 9/19/2023, documented that they did not look at the resident's care Kardex before providing care. They stated that while attempting to place new sheets under the resident, the resident rolled over too far to be held and fell off the bed. During an interview on 5/01/2024 at 11:15 AM, Director of Nursing #1 stated that they and the Administrator along with the interdisciplinary team were responsible for reporting incidents to the Department of Health. They stated that all cases of abuse, whether physical or verbal, injuries, failure to follow resident care plans, and neglect, should be reported to the Department of Health. They stated that Certified Nurse Aide #4 did not follow the resident's care plan and caused the resident to fall. They stated that they did not report the incident as the resident did not have any injury from the fall. During an interview on 5/01/2023 at 12:09 PM, Registered Nurse #1 stated that Certified Nurse Aide #4 had rolled the resident in bed, and they fell . They stated Certified Nurse Aide #4 did not realize at the time that the resident required the total assistance of two staff members for bed mobility. They stated a second person should have been there to help. Registered Nurse #1 stated that all Certified Nurse Aides should review the resident's Kardex every day and before providing care. They stated that this was reported to the Director of Nursing after the resident was evaluated and sent to the emergency room . They stated that they were unsure if it was reported to the Department of Health but probably should have since Certified Nurse Aide #4 did not follow the care plan. 10 New York Codes, Rules and Regulations 483.12(c)(1)

Based on record review and interviews during the recertification and abbreviated survey (Case #NY00324855), the facility did not ensure the resident's right to be free from neglect for 1 (Resident #45) of 6 residents reviewed for abuse and neglect. Specifically, on 9/19/2023, Certified Nurse Aide #4 did not use two staff for bed mobility as documented in Resident #45's Comprehensive Care Plan while providing care to the resident. Resident #45 rolled out of bed onto the floor. This is evidenced by: Resident #45 was admitted to the facility with diagnoses of hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), chronic obstructive pulmonary disorder (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and morbid (severe) obesity. The Minimum Data Set (an assessment tool) dated 4/01/2024, documented the resident had moderately impaired cognition, could usually understand others and be understood. The Policy and Procedure titled, Abuse, with a review date of 12/2022, documented neglect was defined as the failure of the facility, employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Additionally, the policy defined neglect as the failure to provide a resident with personal safety. The Comprehensive Care Plan titled, Assistance in Activities of Daily Living, dated September 2023, documented the resident was dependent on two staff members for bed mobility. The Certified Nursing Aide Kardex (resident care card followed by Certified Nurse Aides to provide care), for September 2023, documented the resident was dependent and required two staff members for bed mobility. Record review of the nursing progress note dated 9/19/2023 at 5:28 PM documented the nursing staff was called to the resident's room for observations after the resident fell off the bed during care. The resident was found on the floor complaining of head pain and pain all over. The resident was sent to the hospital for further evaluation. The facility Accident and Incident report, dated 9/19/2023 at 05:28 PM, documented Resident #45 fell out of bed and was lying on their back complaining of head and body pain. Certified Nurse Aide #4 was the only documented witness to the event. The statement by Certified Nurse Aide #4 on 9/19/2023 documented that they did not look at the resident's care Kardex before providing care. They stated that while they attempted to place new sheets under the resident, the resident rolled over too far to be held and fell off the bed. During an interview on 4/30/2024 at 10:09 AM, Certified Nurse Aide #5 stated each resident's bed mobility status was documented on the Kardex. If a resident was documented as requiring two staff members for bed mobility, they would have to get another staff member to assist in caring for the resident in bed; they would not attempt to perform care with need for mobility by themselves. During an interview on 5/01/2024 at 12:09 PM, Registered Nurse #1 stated that Certified Nurse Aide #4 had rolled the resident, who was in bed, and the resident fell . Certified Nurse Aide #4 did not realize at the time that the resident required two staff members to provide care moving the resident, but a second staff member should have been there to help. They stated that all Certified Nurse Aides should have reviewed the residents' Kardex every day and before providing care. Certified Nurse Aide #4 was unable to be reached for an interview. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on record review, and interviews during an abbreviated survey (Case #NY00275660), the facility did not ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 (Resident #1) of 2 residents reviewed for nursing competencies and skill sets necessary to care for residents' needs. Specifically, for Resident # 1 who had nephrostomy tubes (a tube that lets urine drain from the kidney through an opening in the skin on the back into a drainage bag) to drain each kidney, the facility was unable to provide nursing competencies that documented Registered Nurses had the skills to flush nephrostomy tubes. This was evidenced by: The Policy and Procedure titled, Competencies, dated 1/18/2023, documented facility personnel were to be competent in specific duties and tasks. Training and/or competency validations were completed on hire and annually. Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses of spinal bifida (birth defect in which a developing baby's spinal cord fails to develop properly), obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), and renal (kidney) failure. The Minimum Data Set (an assessment tool) dated 4/28/2021, documented the resident was cognitively intact, could be understood, and could understand others. The Comprehensive Care Plan for Bilateral Nephrostomy Tubes, dated 4/23/2021, documented a goal that the resident would show no sign or symptoms of urinary infection. The care plan did not document any interventions for the care of the nephrostomy tubes. The Hospital Discharge Summary, dated 4/23/2021 at 10:42 AM, documented interventional radiology inserted bilateral nephrostomy tubes on 4/15/2021. It documented Resident # 1's nephrostomy tubes were to be flushed 2-3 times a day with 10 cubic centimeters (the same unit of measurement as milliliter) of sterile saline. A Medical Doctor order, dated 4/24/2021, documented to flush nephrostomy tubes with 10 milliliters of normal saline twice a day on the day and night shift. The order documented only a Registered Nurse was to flush the nephrostomy. The April 2021 and May 2021 Treatment Administration Records documented Registered Nurse #s 3, 4, 5, and 6 flushed the residents nephrostomy tubes. An email from the facility Administrator, dated 12/13/2023 at 10:47 AM, documented they were unable to locate nursing skills competencies for 2021 for 4 Registered Nurses who had flushed the resident's nephrostomy tubes. During an interview on 12/27/2023 at 11:27 AM, the Registered Nurse Staff Educator stated they started at the facility in July 2023 and had not yet delved into what may or may not have been done for skills labs and competencies for licensed staff (Registered Nurses and Licensed Practical Nurses). They had not yet had a skills lab for nursing, but one was being planned for January 2024. During an interview on 12/27/2023 at 1:22 PM, the Director of Nursing stated they had been unable to locate any competencies for the Registered Nurses who documented they flushed Resident #1's nephrostomy tubes in April 2021 and May 2021. They stated the facility was having a nursing skills fair in January 2024. 10 New York Codes, Rules and Regulations 415.26(c)(1)(iv)

Based on record review and interviews during an abbreviated survey (Case #NY00275660), the facility did not ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, were provided by qualified persons in accordance with each resident's written plan of care for 1 (Resident #1) of 2 residents reviewed for services provided by qualified persons. Specifically, Resident #1's nephrostomy tubes (a tube that lets urine drain from the kidney through an opening in the skin on the back into a drainage bag) were flushed by Licensed Practical Nurses who were not qualified to do so within their scope of practice . This was evidenced by: The Policy and Procedure titled, Nephrostomy Tube, dated 5/2019, documented the care of a resident with a nephrostomy tube was to only be performed by a Licensed Nurse. Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses of spinal bifida (birth defect in which a developing baby's spinal cord fails to develop properly), obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), and renal (kidney) failure. The Minimum Data Set (an assessment tool), dated 4/28/2021, documented the resident was cognitively intact, could be understood, and could understand others. An email from the New York State Education Department (the entity that licenses Registered and Licensed Practical Nurses), dated 12/12/2023 at 4:35 PM, documented Registered Nurses (not Licensed Practical Nurses) may irrigate nephrostomy tubes. The Comprehensive Care Plan for Bilateral Nephrostomy Tubes, dated 4/23/2021, documented a goal that the resident would show no sign or symptoms of urinary infection. The care plan did not document any interventions for the care of the nephrostomy tubes. The Hospital Discharge Summary, dated 4/23/2021 at 10:42 AM, documented interventional radiology inserted bilateral nephrostomy tubes on 4/15/2021. It documented Resident #1's nephrostomy tubes were to be flushed 2-3 times a day with 10 cubic centimeters (the same unit of measurement as milliliter) of sterile saline. A Medical Doctor order, dated 4/24/2021, documented to flush nephrostomy tubes with 10 milliliters of normal saline twice a day on the day and night shift. The order documented only a Registered Nurse was to flush the nephrostomy tubes. The April 2021 Treatment Administration Record documented the resident's nephrostomy tubes were flushed 5 times total by Licensed Practical Nurse #s 2, 3, 4, 5, and 6. A Consult form dated 5/05/2021 at 10:27 AM, for the resident's appointment with the Nephrologist, documented to flush [nephrostomy] tubes one time a day with 10 cubic centimeters of normal saline and as needed. A Medical Doctor order dated 5/06/2021, documented only a Registered Nurse was to flush nephrostomy tubes with 10 milliliters sterile saline once a day on the day shift. A Nurses' Note dated 5/08/2021 at 11:43 AM, documented Licensed Practical Nurse #4 flushed the resident's nephrostomy tubes. The May 2021 Treatment Administration Record documented Licensed Practical Nurse #s 4,7, 8, and 9 flushed Resident #1's nephrostomy tubes 10 times total from 5/1/2021 - 5/18/2021. During an interview on 12/27/2023 at 10:30 AM, Licensed Practical Nurse #4 stated they could not recall if they had flushed Resident #1's nephrostomy tubes or not. The Licensed Practical Nurse stated they thought the order was to ensure the resident flushed their nephrostomy tubes. Licensed Practical Nurse #4 stated maybe the order was put in wrong. They stated the resident was very independent and thought maybe the resident flushed their own nephrostomy tubes. They stated they could not recall if they were trained for flushing nephrostomy tubes or not. During an interview on 12/27/2023 at 11:27 AM, Registered Nurse Staff Educator stated nephrostomy tube flushing training was only to be done by Registered Nurses. They further stated that in New York State, the flushing of nephrostomy tubes required an assessment and that the was not in the scope of practice for a Licensed Practical Nurse. Regarding Resident #1, the Registered Nurse Staff Educator stated the Licensed Practical Nurses should not have flushed their nephrostomy tubes. They stated if they had worked at the facility at the time Resident #1 resided there, they would have told the Licensed Practical Nurses they could not flush nephrostomy tubes. During an interview on 12/27/2023 at 1:22 PM, the Director of Nursing stated in New York State, Licensed Practical Nurses could not flush nephrostomy tubes. The facility's policy and procedure documented a licensed nurse had to provide care of nephrostomy tubes. They stated they sent the policy and procedure to the facility's corporate office for clarification because it needed to be changed to Registered Nurses providing the care. The Director of Nursing stated when Resident #1 resided at the facility, the Licensed Practical Nurses should not have been flushing their nephrostomy tubes. 10 New York Codes, Rules and Regulations 415.11(c)(3)(ii)

Based on interviews and facility record review during an abbreviated survey (Case #NY00317139), the facility failed to ensure each resident received adequate supervision to prevent accidents for 1(Resident #1) of 3 reviewed for elopement. Specifically, on 5/22/2023, the facility did not follow their process for elopement when Resident #1, who was moderately cognitively impaired left the building without a Leave of Absence Pass. Resident #1 was last seen by Licensed Practical Nurse #2 on 5/22/2023 approximately 3:00 PM, and identified as missing by Certified Nurse Aide (CNA) #1 on 5/22/2023 at 3:00 PM. The facility did not activate their Code Gray (missing person alert). On 5/23/2023 at 9:30 AM, Registered Nurse (RN) #1 reported to the Director of Nursing (DON) #1 that Resident #1 was missing, and a Code Gray was called. This was 18 hours after the resident was last seen. Subsequently, Resident #1 was located 120 miles away from the facility. This resulted in no actual harm with the likelihood for more than minimal harm that is Immediate Jeopardy and substandard quality of care to Resident #1's health and safety. Resident #1 Resident #1 was admitted to the facility with diagnoses of hydronephrosis with urethral stricture (a condition of excess urine accumulating in the kidney due to a blockage in one or both of the tubes that carry urine from the kidneys to the bladder), atherosclerotic heart disease (heart disease caused by plaque buildup in the arterial walls) and dementia. The Minimum Data Set (MDS, an assessment tool) dated 4/11/2023, documented the resident could be understood and could understand others. MDS documented Resident #1 required extensive 1 person assist with bed mobility, walking in the corridor, walking in room, and toilet use. Resident #2 required walker and wheelchair for mobility. The Comprehensive Care Plan (CCP) created on 1/26/2023 for Resident #1 did not address the resident's ability to go on Leave of Absence (LOA). The policy and procedure titled Elopement-Prevention dated 2/2020, documented the facility's process was for the facility to have a sign out book for all units to identify when residents left the unit with staff or visitors and conduct census/ head counts at the end and beginning of each shift to identify resident's location. The policy and procedure titled Out on Pass/LOA dated 8/2019, documented the facility honored the resident's right to temporarily leave the facility (out on pass) if they are determined by the Interdisciplinary Care (IDCP) and physician to be safe to do so. The facility also recognized the right of residents to leave the facility unescorted if they were assessed to be able to do so safely. Any Out on Pass (OOP) request would be evaluated by the Interdisciplinary Care (IDCP) team and the resident's attending physician to determine the resident's need for escort or ability to go unescorted. Based on the assessment, if the resident was safe to go out on pass, a physician order will be obtained. The facility investigation form, dated 5/25/2023, documented on 5/22/23, at approximately 3:00 PM, Resident #1 packed their belongings, and had their significant other take them home without notification to the facility staff or any warning or intent to do so. The resident was last seen by Licensed Practical Nurse (LPN) #2. The LPN #2 was walking toward their unit, which was adjacent to the unit Resident #1 resided on, to report for duty on 5/22/23, saw the resident and their significant other wheeling down hall with their belongings. LPN #2 asked the resident if they were being discharged , and they said Yes. The facility's investigation concluded Resident #1 left Against Medical Advice (AMA) with their significant other on 5/22/23 without notice. -An untimed statement written by LPN #1 on 5/23/2023, documented that LPN #1 was aware on 5/22/2023 that the resident was not in the facility. The LPN documented that RN #1 told them the resident was out on pass on 5/22/2023. LPN #1 stated they were under the impression that Resident #1 was to return back to the facility on [DATE]. -An untimed statement written by Registered Nurse (RN) #1 on 5/23/2023, documented RN #1 worked the day shift on 5/23/2023. RN #1 arrived at Resident #1's room during rounding and medication pass, they did not see the resident. RN #1 stated they went to the therapy department to check to see if the resident was there. RN #1 did not see the resident in the therapy gym. RN #1 asked the CNAs if they had seen the resident. RN #1 stated the CNAs told RN #1 no one had seen the resident, they immediately notified the Director of Nursing (DON) and a Code Gray was called. -An untimed statement written by LPN #2 on 5/23/2023, documented LPN #2 worked 3:00 PM to 11:00 PM shift on 5/22/2023. They were assigned to the unit but not assigned to the resident. LPN #2 stated the resident was in the lobby with a visitor and told LPN #2 Bye and that they were getting out and going home. -An untimed statement written by Certified Nurse Aide (CNA) #3 on 5/23/2023, documented CNA #3 and LPN #2 were walking down Resident #1's unit on 5/22/2023 when they saw Resident #1 being pushed by a visitor towards the exit. LPN #2 asked the resident if they were leaving, and Resident #1 responded Yes. CNA #3 stated LPN #2 told the resident they were going to miss them, and the resident responded, Me too. CNA #3 stated they saw Resident #1 with a jacket and their belongings on their lap. Review of physician orders revealed that there was no documented physician order for Resident #1 to go out on Leave of Absence. The facility provided no documentation of a head count at the end and beginning of each shift to identify Resident #1's location for 5/22/2023. Review of the Visitor Log for 5/22/2023 revealed that Resident #1 did not sign out for LOA. The Medication Administration Record (MAR) dated May 2023, documented on 5/22/2023, Resident #1 missed the 7:00 PM - 9:00 PM facility medication administrations of ezetimibe oral tablet 10 Milligrams (MG), that was to be given at bedtime, acetaminophen extra strength oral tablet 500 MG, which was to be given twice daily, Buspirone HCl tablet 5 MG, ordered to be given twice a day for anxiety, polyethylene glycol powder ordered for twice daily administration, and the 5:00 PM blood glucose monitoring which was to be completed three times a day every Monday for diabetes. The MAR dated May 2023, documented Resident #1 was out of the facility on 5/23/2023 for the 7:00 AM- 10:00 AM for medication administrations of acetaminophen (Also known as Tylenol), ordered to be given twice a day, Aricept Tablet 10 MG, which was to be given daily for dementia, aspirin EC, ordered to be given daily, Buspirone HCL, ordered to be given twice daily for anxiety, Lisinopril ordered to be given daily for hypertension, Metformin HCl ER tablet extended release 24 hour, which was to be given daily for diabetes, metoprolol Succinate ER, ordered to be given daily, and polyethylene glycol powder which was ordered twice daily. The Treatment Administration Record (TAR) dated May 2023, for Resident #1's nephrostomy (a procedure to drain urine from the kidney using a catheter) bag emptied (empty bag every shift, document output three times a day), was blank on 5/22/2023 at 9:00 PM. The TAR dated May 2023, documented Resident #1 was out of the facility on 5/23/2023, for the treatment to empty the nephrostomy bag at 9:00 AM, 4:00 PM, and 9:00 PM. During an interview on 6/8/2023 at 10:45 AM, LPN #1 who worked on 5/22/2023 from 3:00 PM- 7:00 AM 5/23/2023, stated that they came in at 3:00 PM on 5/22/2023 and noticed that the resident was not in their room. LPN #1 asked the nurse on duty at the time and RN #1 told them the resident was on a Leave of Absence. LPN #1 checked on resident at least 3 times that evening to see if the resident had returned to the facility. Resident #1 never returned to the facility. The LPN #1 stated on 5/23/23 between 4:30 AM and 5:00 AM, they stuck their head in the resident's room, and the resident was not there. LPN #1 stated when a resident went on leave, staff were supposed to put a note in the electronic medical record (EMR). LPN #1 stated they did not put a note in the EMR when the resident did not return to the facility, and they did not notify the DON. During an interview on 6/7/2023 at 2:47 PM, RN #1 stated they came in to work on 5/23/2023 day shift, the day after the resident went missing. No one indicated that the resident was not in their room or out on leave. RN #1 stated they realized that the resident was not in their room during their morning medication pass. The RN stated they checked the therapy gym to see if the resident was in therapy. RN #1 stated the resident was not in the therapy and notified the DON that Resident #1 was missing. During an interview on 6/8/2023 at 11:28 AM, CNA #1 stated they last saw the resident between 1:00 and 1:30 PM on 5/22/2023, when they picked up their lunch tray. When checked on the resident at 3:00 pm on 5/22/2023, and the resident was not in their room. CNA #1 told LPN #1, and LPN #1 stated Well, maybe they were in therapy. The CNA told the nurse that the resident had therapy that morning and the LPN #1 responded maybe they will come back. The CNA then went to tell Registered Nurse Supervisor (RNS) #1 at the front desk. The RNS received a phone call and told CNA #1 to wait. CNA #1 checked the sign-in/sign-out log and did not see Resident #1 had signed out. CNA#1 stated they went looking for the resident on another unit and saw LPN #2, who told CNA #1 they saw the resident being pushed down the hallway by a visitor with their stuff at 3:00 PM. CNA #1 stated they took Resident #1's dinner tray on 5/22/2023 to the resident's room and Resident #1 was not in the room. During an interview on 6/8/2023 at 12:37 PM, LPN #2 stated they saw Resident #1 at 3:00 PM on 5/22/2023 with a green bag and a visitor that was pushing the resident also with a bag. The resident told LPN #2 that they were going home, and LPN #2 wished them luck because discharges happened every day. LPN #2 stated they were not assigned to the resident or Resident #1's unit, so they were not aware if the resident was discharged or not. The LPN #2 stated when a resident was discharged , the staff were not notified of the resident discharge unless they were assigned to that resident. LPN #2 stated they did not report anyone. During an interview on 6/8/2023 at 2:35 PM, the DON stated they were not aware that the resident was missing until 5/23/2023 at 9:30 AM. Facility staff were supposed to contact the DON when the resident was not back from the leave of absence in the time frame indicated on the leave of absence form and it should have been documented in the resident's record. The DON stated no one contacted them when the resident was determined to be missing on 5/22/2023. The DON stated Resident #1 called the facility at 3:30 PM on 5/23/2023 and stated they had intentions of coming back on 5/22/23 but changed their mind because they wanted to stay home. The DON stated there was no documentation in the EMR that Resident #1 was on LOA. During an interview on 6/8/2023 at 2:58 PM, the Nursing Home Administrator (NHA) stated they learned the resident had left the facility the morning of 5/23/2023 at 9:30 AM, when RN #1 came to the morning meeting and told the DON. RN #1 told the DON that they went to the room to give Resident #1 their medications and Resident #1 was not in the room. The DON called a Code Gray, and they started an immediate search for the resident on the property when the resident couldn't be located. Resident #1 called the facility at 3:30 PM on 5/23/2023 and stated they packed all their belongings, and they were not coming back to the facility. During an interview on 6/8/2023 at 5:33 PM, Registered Nurse Supervisor (RNS) #1 stated that they did not remember anything about 5/22/2023. RNS #1 stated, they came in the next day, 5/23/2023 and were told that Resident #1 had left the facility and did not come back. RNS #1 stated they did work evening shift on 5/22/2023. They did not cover the front desk and were not aware that CNA #1 had reported the resident was missing. RNS #1 stated they did not see the Resident #1 on 5/22/2023. When a resident went on LOA, the nurses filled out the form, kept a copy and gave a copy to the front desk so that staff on the unit would know that a resident was out. Staff was supposed to document the date, time, of leave; date, and time of expected return on the LOA form every time a resident was on LOA. During a subsequent interview on 6/9/2023 at 9:59 AM, CNA #1 stated after they spoke to LPN #2 on 5/22/2023 at 3:45 PM, CNA #1 checked the sign-in/sign-out book at the front desk and the resident was never signed out. CNA #1 went back to Resident #1's unit. The CNA stated they did not follow up with RNS #1 when the resident did not return to the facility that evening of 5/22/2023 because RNS #1 ignored them when CNA #1 tried to report that Resident #1 was missing around 3:30 PM. During an interview on 6/28/2023 at 4:01 PM, the Facility Physician stated the facility notified them on 5/23/2023 that the resident left the facility without following the Leave of Absence procedures on 5/22/2023. The physician stated that they thought the resident was initially assessed for Leave of Absence but would have to check the policy to determine if the resident had to be assessed for every Leave of Absence request. The assessments would be documented in the care plan or the resident's Kardex (CNA care plan) in the resident's file; however, they would have to check the facility's policy. Nursing and Social services made the Leave of Absence determination. The physician stated they would address the medical concerns when discovered or the assessment indicated it was not safe to leave the facility. The facility physician did not believe that the resident had an issue that would prevent them from going on leave. F 689-Past Noncompliance Based on interview with the Nursing Home Administrator on 6/8/2023, the facility's corrective actions included the following effective 5/23/23, 99% of staff have been reeducated on the procedure of the: Electronic monitoring system, Elopement policy, Leave of Absence Policy and, The Visitor Policy A post-test was administered after the trainings. A Midnight Heads in Bed audit process was implemented through the EMR. An audit to review the sign-in/sign-out forms at the front at the front desk. 10 NYCRR 415.12(h)(2)

Based on record review and interviews during an abbreviated survey (Case #NY00316374), the facility did not ensure each resident's person-centered comprehensive care plan (CCP) was implemented to meet their preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for 1 (Resident #1) of 3 residents reviewed. Specifically, Resident #1's CCP for Exhibits Behavior Symptoms documented the resident was sexually inappropriate and required no male caregivers. The facility did not ensure the CCP intervention for no male caregivers was implemented. On 5/10/2023, Resident #1 alleged they had a sexual encounter with a male Certified Nurse Aide (CNA) #1, that occurred about two months ago. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of Bipolar Disorder; current mixed episode; severe; with psychotic features, anxiety disorder due to known physiological condition, and weakness. The Minimum Data Set (MDS - an assessment tool) dated 4/2/2023, documented the resident was cognitively intact. The Policy and Procedure (P&P) titled Care Plans - Comprehensive last revised 10/2019, documented the comprehensive, person-centered care plan would describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and would reflect currently recognized standards of practice for problem areas and conditions. It documented care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The CCP for Exhibits Behavior Symptoms, last revised 2/13/2023, documented the resident was sexually inappropriate along with an intervention for no male caregivers. The Visual/Bedside Kardex Report (CNA Care Card) dated 5/22/2023, documented the resident was sexually inappropriate and was to have no male caregivers. The Investigation Form dated 5/10/2023, documented Resident #1 was known to have hypersexuality and was sexually inappropriate at times. Resident #1 alleged that they had a sexual encounter with a male CNA (#1). The facility met with CNA #1, who denied the allegation and stated Resident #1 was independent with their tasks. CNA #1 stated that when the resident asked for help, they would push them in their wheelchair to the bathroom door and then stand outside the door while the resident did their own personal hygiene. During an interview on 5/16/2023 at 1:41 PM, Resident #1 stated they had a sexual encounter with CNA #1. Resident #1 stated CNA #1 was polite and would help them change their incontinence brief or change the sheets when they were wet. During an interview on 5/16/2023 at 2:35 PM, the Director of Nursing (DON) #1 stated they did not know why CNA #1 was permitted to provide care for Resident #1. DON #1 stated there should be no male staff assigned to that wing. During an interview on 5/16/2023 at 2:50 PM, Licensed Practical Nurse (LPN) #1 stated Resident #1 was independent with ADLs (activities of daily living) and was not identified as no male care givers on the unit assignment sheet. LPN #1 looked in the computer system and was able to see the intervention for no male care givers and stated the CNAs should also be able to see it. LPN #1 stated they tried to keep track of the residents who were to have no male care givers and would tell the male CNA to switch their assignment with a female CNA or would move the male CNA to another unit. During an interview on 5/16/2023 at 3:08 PM, LPN Manager (LPNM) #2 stated they were not aware that Resident #1 was to have no male care givers. LPNM #2 stated the CNA could use the kiosk (computer) on the units to see the resident's Care Card and should be looking at it before they provide care. LPNM #2 stated it was a problem that the facility had to figure out how to deal with and stated the evening nurses and supervisors need to be aware and swap out residents when they are to have no male care givers. LPNM #2 stated they did not usually have male care givers on the day shift. During an interview on 5/16/2023 at 5:05 PM, the Regional Administrator (ADMIN) #2 stated Resident #1 had accusatory behavior. ADMIN #2 stated the reason they implemented the CCP intervention for Resident #1 to have no male care givers was in large part to prevent male employees from being accused. During an interview on 5/17/2023 at 9:52 AM, CNA #1 stated they had taken care of Resident #1 many times and was not aware that Resident #1 was not supposed to have male care givers. CNA #1 stated they would look at the residents' Care Card from time to time especially if the resident was new to the facility. CNA #1 stated they have helped Resident #1 put on their incontinence brief and would change the resident's bedding when it was wet. 10 NYCRR 415.11(c)(1)

Based on record review and interviews during an abbreviated survey (Case #NY00297973) the facility did not ensure prompt efforts were made to resolve a grievance for 1 (Resident #3) of 3 residents reviewed. Specifically, for Resident #3, the facility did not ensure their grievance procedures were followed on 6/5/2022, when the resident reported they were missing $260.00 from their wallet, and it was documented that a grievance form was started. Additionally, the facility did not ensure it apprised the resident of the progress towards a resolution and maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. This is evidenced by: Resident #3: Resident #3 was admitted to the facility with diagnoses of generalized osteoarthritis, post-traumatic stress disorder (PTSD), and anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated 5/19/2022, documented the resident was cognitively intact. The Policy and Procedure (P&P) titled Grievances last revised 9/2020, documented the facility would assist residents in filing a grievance/concern form when concerns were expressed. The facility would investigate and resolve resident grievances timely to ensure residents' safety and protect residents' rights. It documented any resident may file a grievance for missing property. The Director of Social Work was the facility's Grievance Officer and was responsible for facilitating the complaint/grievance process. Upon receipt of a complaint/grievance, the corresponding department would investigate the allegation(s) and submit a written report of such findings within 7 business days. The Grievance Officer coordinated adequate and timely handling of grievances/complaints and ensured the grievances/complaints and resolutions were maintained and reviewed with administration routinely. The Administrator would review the findings with the person investigating the grievance/complaint to determine what corrective actions, if any, needed to be taken. The resident filing the grievance/complaint would be informed verbally and in writing of the findings of the investigation and the action(s) taken to correct any identified problems. It documented the facility must maintain evidence of demonstrating the results of grievances for a period of no less than 3 years from the issuance of the grievance decision. The Registered Nurse Assessment Note dated 6/5/2022 at 3:50 PM by Registered Nurse (RN) #1, documented Resident #3 and their friend stated Resident #3 was missing $260.00 from their wallet. RN #1 went to the room accompanied by the Certified Nurse Aide (CNA) and searched every drawer, pocket and corner of the resident's room and found no money. Resident #3 did not remember the last time they actually saw or touched the money and was unable to describe the bills. Resident #3 stated it was one week ago. RN #1 documented a grievance form was started and the Social Worker was to follow up. There was no documented evidence of a grievance form dated 6/5/2022, from Resident #3. Review of the Progress Notes dated 6/5/2022 through 6/30/2022, did not include documentation of notes by the Social Worker about the missing money. The Grievance Form dated 5/18/2023 by the Director of Social Work (DSW), documented a grievance from Resident #3. It documented Resident #3 stated they had spoken to previous administrators regarding missing money from last June 2022. Resident #3's named friend had sold a lawnmower for them. Resident #3 stated that a couple of days later it was missing. Resident #3 they had $300.00 and had given their friend a tip, which left them $265.00 in their wallet. -Actions taken in response to the complaint/grievance documented the Administrator (ADMIN) requested a check from the corporate office for $265.00 to reimburse Resident #3 for their money that was missing. The ADMIN signed the Grievance Form on 5/18/2023. A Staff Statement by the DSW documented a phone call was made to Resident #3's named friend on 5/18/2023 at 2:25 PM. It documented the resident's named friend sold the lawnmower for $400.00 and then brought the money to the resident. The resident gave them $40.00 for helping them sell it, which left the resident a total of $365.00 in their room. The Check Request Form dated 5/18/2023 by ADMIN, documented replacement of missing money for Resident #3. The amount of the check was for $265.00. It documented the following special instructions: grievance follow up from 6/5/2022. During an interview on 5/17/2023 at 3:56 PM, Resident #3 stated someone took $360.00 from their room, and they reported it to the nurse. Resident #3 stated they told the former Administrator and they just ignored them about the problem. Resident #3 stated they had not heard anything from the facility about the resolution of the problem. During interview on 5/18/2023, the ADMIN stated the facility would be cutting a check for $265.00 for Resident #3. The ADMIN #1 stated the resident's friend said it was $365.00 but the facility was going according to the amount the resident said it was. ADMIN #1 stated the facility did not follow through with the original grievance. ADMIN #1 stated the DSW was not working in the facility when the grievance was made, and the Social Worker no longer worked in the facility. ADMIN #1 stated they could not find a Grievance Form dated 6/5/2022. 10 NYCRR 415.3(d)(1)ii

Based on record review and interviews during an abbreviated survey (Case #NY00311601), the facility failed to ensure an alleged violation involving abuse was 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) in accordance with State law through established procedures for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure an alleged sexual interaction between the physician (MD) #1 and Resident #1 on 2/21/2023, observed by Certified Nursing Aide (CNA) #1 and reported to Licensed Practical Nurse (LPN) #1, was reported to Administration or the New York State Department of Health (NYSDOH) within 2 hours of the allegation being made. On 2/26/2023 at 10:30 AM, the alleged sexual interaction was reported to the Administrator (ADMIN) #1 but was not reported to the NYSDOH until 2/26/2023 at 10:40 PM, over 12 hours after the Administrator was notified. This resulted in no actual harm with the likelihood for more than minimal harm that is Immediate Jeopardy and substandard quality of care to resident health and safety. This was evidenced by: Resident #1: Resident #1 was readmitted to the facility, with diagnoses of bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function), schizoaffective disorder (chronic mental health condition characterized primarily by symptoms of schizophrenia, such as delusions and symptoms of a mood disorder), and anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated 1/5/2023, documented the resident was cognitively intact. The Policy and Procedure (P&P) titled Abuse last revised 1/13/2022, documented the following protocol: The shift supervisor was identified as responsible for immediate initiation of the reporting process. The ADMIN and Director of Nursing (DON) were responsible for investigation and reporting. For reporting, staff were to notify the Shift Supervisor/Charge Nurse/Manager if suspected abuse occurred. The incident was to be reported to the ADM and DON. Local law enforcement and appropriate State Agency(s) were to be notified immediately (no later than 2 hours after allegation/identification of allegation) by the Agency's designated process after identification of the alleged/suspected incident. The facility's investigation timeline titled Resident #1's Incident Timeline provided by the ADMIN on 3/1/2023 documented: - Tuesday 2/21/2023, CNA #1 made their first verbal statement to LPN #1. (written statement obtained on 2/26/23) alleged that MD #1 was doing something inappropriate and may have caused a bruise to Resident #1's breast. - Tuesday 2/21/2023, CNA #1 made their second verbal statement to LPN #1, alleging that CNA #1 saw MD #1 with their pants down in front of Resident #1, and MD #1's bottom was exposed. When MD #1 saw CNA #1 come in, MD #1 picked up their pants. MD #1 then picked up their white lab coat off the recliner and put it on. Resident #1 then begged CNA #1 to keep it quiet or they would fire the doctor and throw Resident #1 out. Resident #1 also said MD #1 always came to their room and did stuff to her. CNA #1 stated they promised not to say anything to anyone. CNA #1 then reported the incident to LPN #1. - Wednesday 2/22/2023, CNA #1's second statement, CNA #1 stated they returned to Resident #1's room on Wednesday 2/22/2023, where Resident #1 told CNA #1 that the doctor wanted to thank CNA #1 for not saying anything to anyone. - Saturday 2/25/2023 morning, LPN #2 indicated that CNA #10 reported to them that Resident #1 had a bruise on their right breast. LPN #2 tried to assess Resident #1, but they refused and only said it was consensual. Attempted a second time, but Resident #1 refused, and the resident's response was the same. At shift change, LPN #2 asked LPN #1 about the incident and LPN #1 confessed that they knew about the incident but had not told anyone. - Saturday 2/25/2023 at 3:00 PM, LPN #3 was informed by LPN #2 via phone of the incident. - Saturday 2/25/2023 at 3:00 PM, LPN #3 called law enforcement to notify them. - Sunday 2/26/2023 at 7:30 AM, LPN #3 notified their Licensed Practical Nurse Supervisor (LPNS) #6. - Sunday 2/26/2023 at 8:15 AM, LPNS #6 called the ADON (#1). - Sunday 2/26/2023 at 8:20 AM, the ADON #1 called the Regional Director of Nursing (DON) #2. - Sunday 2/26/2023 at 10:30 AM, the ADON #1 notified ADMIN #1. - Sunday 2/26/2023 at 10:36 AM, the ADMIN #1 called the MD #1 and asked them to leave the facility. - Sunday 2/26/2023 at 10:40 PM, the ADON #1 reported the incident to the NYSDOH. The facility Investigation Form dated 2/28/2023 for Resident #1, documented an allegation of sexual abuse occurred on 2/21/2023. The investigation findings documented the LPN #1 initially received report of an incident by the CNA #1 (immediately following the incident on 2/21), did not elevate to facility Administration/or report, and did not initiate an investigation. A report received from LPN #2 and LPN #3 was, they allegedly called law enforcement to report the allegation. LPN #s 2 and 3 did not report to Administration in the facility after being told of the incident on 2/25/2023 and did not initiate an internal investigation although reported to law enforcement. During an interview on 3/1/2023 at 2:43 PM, CNA #1 stated on 2/21/2023 at around 7:30 PM, CNA #1 went to the resident's room to get them ready for bed. The resident's door was closed and they knocked and entered the room. They saw Resident #1 sitting in their wheelchair and saw a man standing in between the resident's legs and was facing the resident. CNA #1 stated the man's pants were down and they could see their whole bottom. When they opened the door, the man pulled up his pants right away and then reached for the lab coat that was on the recliner. CNA #1 stated the man put their lab coat on and that was when they realized it was MD #1. CNA #1 stated they saw Resident #1 slouched in the wheelchair, their gown was pulled over their breasts, and they were exposed. Resident #1 then pulled their gown down. CNA #1 stated they were standing by the door when MD #1 walked past them and left the room, without saying a word. The CNA stated when they were done providing the evening care, they left the room and met charge nurse LPN #1 in the hallway and told LPN #1 the whole story about MD #1 and Resident #1. CNA #1 stated LPN #1 told them they would report the incident when the supervisor came to take report at the end of the shift at 11:00 PM. The CNA stated they were taught to report whatever they see to the charge nurse, whether it was a change in condition, a bruise, or a fall. During an interview on 3/1/2023 at 1:47 PM, the Regional Administrator (ADMIN) #2 stated they were involved in the facility's investigation of an allegation of sexual abuse and discussed Resident #1's Incident Timeline. ADMIN #2 stated they documented in the timeline what was reported during staff interviews. CNA #1 witnessed the incident and Resident #1 begged CNA #1 to keep it quiet or they would fire the doctor and throw them (Resident #1) out. CNA #1 reported it to LPN #1, but LPN #1 did not report it to anyone. Both CNA #1 and LPN #1 worked the evening shift and the night shift on 2/21/2023. CNA #1 made the first report to LPN #1 during the evening shift. ADMIN #2 stated when CNA #1 saw that LPN #1 had not taken any action to report or investigate the incident, CNA #1 then told LPN #1 the details of what they observed during night shift. LPN #1 did not report it to anyone. At shift change on 2/25/2023, LPN #2 asked LPN #1 about the bruise and LPN #1 confessed they knew about an incident that was reported to them, but they had not told anyone. ADMIN #2 stated LPN #2 did not report it. On 2/25/2023 at 3:00 PM, LPN #3 who was a friend of LPN #2 and was not working that day, was informed by LPN #2 via phone of the incident. ADMIN #2 stated LPN #3 then called law enforcement but did not report it to the facility. On 2/26/2023, LPN #3 notified the weekend Supervisor (LPNS #6) and the ADON #1, when they reported to work that morning. ADMIN #2 stated the ADMIN #1 called MD #1 at the facility as soon as they were made aware of the incident. ADMIN #2 stated they did not know why there was a delay in reporting the incident to the NYSDOH. During an interview on 3/2/2023 at 11:22 AM, LPN #1 stated the facility questioned them about the incident reported by CNA #1. They saw CNA #1 in the hallway on 2/21/2023 at around 8:00 PM and they told them about a sexual interaction between MD #1 and Resident #1 that occurred around 7:30 PM. LPN #1 stated they asked CNA #1 if they were sure they had seen that, and CNA #1 said yes. They did not report the incident because they did not see MD #1 and Resident #1 together and wanted to see it with their own eyes. LPN #1 stated the facility's policy for abuse reporting was if you hear or see something, you say something, because it could continue to happen. During an interview on 3/6/2023 at 2:48 PM, LPN #2 stated on 2/25/2023, CNA #10 reported Resident #1 had a bruise on their breast. LPN #2 then called the Licensed Practical Nurse Unit Manager (LPNUM #5) and was told to call LPNS #6, and they did. LPN #2 stated at change of shift, they asked LPN #1 about the bruise and LPN #1 said they were aware of the bruise and then told them about a sexual interaction between MD #1 and Resident #1 that was observed by CNA #1. LPN #2 stated they did not report what LPN #1 reported to LPN #6 but they called LPN #3 and they discussed it among themselves. They got law enforcement involved and they should have reported the incident to LPN #6 when they were made aware of it. During an interview on 3/6/2023 at 1:21 PM, LPN #3 stated on 2/25/2023, LPN #2 called and told them about a bruise on Resident #1 and that they had found out who had caused the bruise. LPN #2 told them at the end of their shift they asked the oncoming nurse LPN #1 about the bruise and was disclosed to LPN #2 that CNA #1 had walked into Resident #1's room and saw a sexual interaction between MD #1 and Resident #1. LPN #3 stated they called local law enforcement to report what LPN #2 told them. They did not call the facility because they wanted to make sure the incident was investigated. LPN #3 stated they called law enforcement and not the facility because if they let the facility know about the incident, there would be repercussions. LPN #3 then stated, They would fire me. LPN #3 stated when they reported to work on 2/26/2023 at 7:30 AM, they reported the incident to the Supervisor LPNS #6. It was the the facility's policy to immediately report allegations of abuse to the supervisor. LPN #3 stated they were terminated because they did not report the incident and left the residents unsafe. During an interview on 3/7/23 at 10:33 AM, the LPN Supervisor (LPN #6), stated on 2/25/2023 in the AM, LPN #2 reported a bruise on the resident's right breast. They arrived on the Country Meadows Unit while rounding on 2/26/2023, LPN #3 told them they knew how Resident #1 got the bruise. CNA #1 walked in on a sexual interaction between MD #1 and Resident #1 on 2/21/2023 during the 3:00 PM to 11:00 PM shift. LPN #3 told them LPN #2 called them on 2/25/2023 around 3:00 PM, to tell them LPN #1 told them that this had occurred. LPN #3 reported the incident to law enforcement and did not report it to the facility, as they were taught to do. LPN#3 should have called the facility and spoken with the ADON #1. The incident witnessed by CNA #1 should have been reported immediately to LPN #1 and then LPN #1 should have immediately reported to their supervisor. LPN #6 stated that all of what they were taught regarding abuse identification, reporting and investigating was not done by staff that knew about the alleged incident. During an interview on 3/10/2023 at 3:51 PM, ADON #1 stated they were notified about an allegation of sexual abuse on 2/26/2023 at 8:15 AM, by LPN #6 and they notified ADMIN #1 at 10:30 AM on 2/26/2023. The ADON stated they reported the allegation to the NYSDOH on 2/26/2023 at 10:40 PM; there was a delay in reporting to the NYSDOH because they were waiting to receive the okay from the corporate group to submit the report and because they were not familiar with the new reporting system. During an interview on 3/3/2023 at 12:05 PM, ADMIN #1 stated LPN #s 1, 2 and 3, were terminated for not reporting an allegation of sexual abuse. If they knew about it, they would have reported to the NYSDOH immediately and would have gotten MD #1 out of the building. During an interview on 3/3/2023 at 4:49 PM, the Corporate Educator Registered Nurse (RN) #4 stated staff were educated on abuse and neglect. RN #4 stated all nurses and staff were told to report any allegation of abuse and neglect immediately to a Nursing Supervisor. CNAs were told to report to a nurse on the unit if they witnessed or was told someone abused a resident. Staff were instructed to go to a Supervisor or Administrator about the abuse if they were concerned it was not addressed or if they thought the accused abuser had not been removed from the building. RN #4 stated everyone was aware that if an allegation of abuse occurred, they ensure the safety of the resident immediately, notify the supervisor, and start an investigation. The LPNs should have notified the Supervisor immediately, and the CNA should have notified the ADON or DON if they did not think the matter had been taken care of. During an interview on 3/13/2023 at 10:16 AM, MD #2, stated LPN #1's first move should have been to report the allegation to ADMIN #1. The ADMIN would have then called MD #1 to tell them to leave the facility and a report would have been made to the NYSDOH. During an interview on 3/13/2023 at 3:39 PM, the DON #1 stated that all staff received abuse training. DON #1 stated CNA #1 should have removed MD #1 from the Resident #1's room to protect the resident and then immediately notified the nurse about what they suspected and/or saw. DON #1 stated the nurse should have immediately reported to their Supervisor. If there was no nurse available, they should have immediately called the Supervisor. The Regional Administrator was informed of the Immediate Jeopardy and provided the Immediate Jeopardy Template on 3/3/2023. Based on the following corrective actions, the facility corrected the noncompliance as of 2/28/2023. The facility reached past noncompliance by taking sufficient corrective actions prior to the survey to both remove the immediate jeopardy and fully correct the noncompliance before survey staff entered the NH on 3/1/2023. The facility's corrective actions included the following effective 2/28/2023: -The facility removed MD #1 from the building on 2/26/2023, upon receiving report of the alleged violation of abuse. MD #1 was suspended from duty pending the outcome of the investigation and was currently not allowed to work in the facility. -As of 2/28/2023, the facility had educated 99% of staff have been educated on resident rights, abuse protocols, and timely reporting. The education provided included: prevention of abuse, neglect, and exploitation. Staff were educated that the most fundamental part of their job was to protect the residents and to accomplish this, the facility had a policy and process to follow to prevent abuse and to investigate occurrences of abuse. Abuse prevention procedures included screening; training; prevention; identification; protection; investigation; and reporting. Education on reporting included: staff must report immediately to their supervisor but were not to stop there. Staff were to report to the DON, Administrator, and the Director of Social Work. Staff were taught that it was their responsibility to ensure that any allegation, potential, or witnessed abuse was investigated immediately and that the resident(s) was protected. 10 NYCRR 415.4(b)(2)

Based on observation, manufacturer's directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, the automatic dishwashing machine (dish machine) was not operating within the manufacturer's specifications, the concentration of chemical sanitizing rinse (QAC) utilized in the three-compartment sink was less than that required by the manufacturer, and equipment and serving areas (9 of 9 kitchenettes) required cleaning or equipment repairs. This is evidenced as follows: The kitchen and unit kitchenettes were inspected on 02/28/2022 at 11:16 AM. During the inspection of the kitchen, the concentration of QAC used in the sanitizing rinse sink of the 3-compartment sink was found to be 150 ppm when measured at 73 degrees Fahrenheit (F); the manufacturer's label directions stated the concentration is to be between 200 ppm and 400 ppm when the solution is measured between 65 F and 75 F. When checked, the automatic dishwashing machine final rinse was 125 F; the automatic dishwashing machine information data plate states that the minimal final rinse water temperature is to be 180 F. The table fan, stove drip pans, top of dishwashing machine, K-fire extinguisher were soiled with food particles. During the inspection of the unit kitchenettes called Hollyhock Way, Gardenia Court, Willow Creek, Oaks Creek, Serenity Place, Emerald Way, [NAME] Glen, Eagle Rock, and Sleeping Lion; microwave ovens, freezer door gaskets, cabinetry, and floors under refrigerators were soiled with food particles or dirt. In the Gardenia Court kitchenette, the back piece of the cabinet below the steam table was detached and falling off. In the Hollyhock kitchenette, one cupboard door was loose and did not seat and close. In the Serenity Place kitchenette, the countertop had large cracks. In the Willow Creek kitchenette, the sink faucet was leaking and did not shut off when tested . During an interview on 02/28/2022 at 1:43 PM, the Food Service Director stated that the vendor will be contacted to adjust the dishwashing machine final rinse temperature; the chemical supply vendor will be contacted to adjust the concentration of QAC; and the kitchenettes will be thoroughly cleaned, and maintenance will be notified of the necessary repairs. During an interview on 03/03/2022 at 12:34 PM, the Administrator stated that a new dishwashing machine will be purchased, the chemical used in the 3-compartment sink will be adjusted, and the items found in the kitchen and on the kitchenettes will be repaired and/or cleaned. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-1.112, 14-1.113, 14-1.180

Based on record review and interview during the recertification survey dated 2/28/2022 through 3/8/2022, the facility did not ensure medical records on each resident were complete and accurately documented for 6 (Residents #s 36,42,57,104,113, and 512) of 33 residents reviewed. Specifically, for Resident #36 the facility did not ensure documentation of the resident's condition or follow-up upon return from the emergency room , for Resident #42 the facility did not ensure documentation for the resident's transfer out of bed (oob) was accurately reflected when the resident did not get oob; for Resident #57, the facility did not ensure documentation reflected the resident's ongoing reports of diarrhea or the need for an antidiarrheal being administered on four out of eight days in March 2022, for Resident #104, the facility did not ensure the administration of narcotic pain medication that was administered on an as needed basis (PRN) to the resident who reported pain level of 7 out of 10 was consistently documented, for Resident #113, the facility did not ensure Certified Nurse Aides (CNAs) consistently documented the care they provided to Resident #113, and the amount of fluids and food consumed on every shift and for Resident #512, the facility did not ensure the resident's medication administrator record did not include an x or NA when a respiratory evaluation was ordered. This was evidenced by: The facility policy titled, Charting and Documentation, last revised 1/2020, documented All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Resident #36 Resident #36 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 1/4/2022 documented the resident had no cognitive impairment, could understand others, and could be understood. A Progress Note dated 02/10/2022 at 10:30 AM written by RN #1, documents the resident fell , striking head on bedside table resulting in lacerations to head and right elbow and pain in chest. Medical in and assessed. Transferred by emergency medical services to the hospital emergency department (ED). There were no Nursing Progress Notes documented in the electronic medical record from 02/10/2022 until 02/24/2022, when it was documented, the resident was positive for COVID-19. There was no documentation of the resident's return to the facility from the ED and there were no assessments of the resident's condition and/or injuries following the ED visit. During an interview on 03/08/2022 at 10:21 AM, RN #1 stated they were not in the facility when the resident returned. They would expect to see documentation of wound monitoring, neurological checks, and a full re-admission assessment upon this resident's return from the hospital. RN #1 was able to provide documentation of neurological checks but no other documentation of the resident's condition upon return to the facility. During an interview on 03/08/2022 at 01:51 PM, the Director of Nursing (DON) stated, there should have been a progress note documenting the resident's return from the hospital, what the new orders were, that neuro checks were being done, and the residents wounds should have been monitored. If the resident was discharged from facility a re-admission assessment should have been done. Resident #512 Resident #512 was readmitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 1/25/22, documented the resident was cognitively intact, could understand others and could usually make self-understood. A MD order dated 2/22/22, documented the resident was to have a complete vital sign with oxygen saturation, lung sounds, and symptom check to be completed every day and evening shift for Respiratory Documentation for fourteen days. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, on 3/4/22, 3/5/22 and 3/6/22 on the day shift an x was documented for monitoring Resident #512 for chills, headache, lung sounds, respirations and a sore throat and vital signs. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/8/22 at 8:44 AM, Licensed Practical Nurse Unit Manager (LPNU) #2 stated staff an NA or x should not be used when documenting on the MAR. LPNUM #2 stated they were unsure what NA or x meant as these were not acceptable abbreviations for Respiratory Monitoring or vital signs. LPNUM #2 stated they were responsible for ensuring staff were documented accurately and completely, however the daily reports that were reviewed only indicated documentation being completed, not the accuracy of documentation. During an interview on 3/8/22 at 9:43 AM, the Director of Nursing (DON) stated the unit managers were responsible for monitoring documentation for both accuracy and completeness. Resident #113: Resident #113 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 12/14/2021, documented the resident had moderately impaired cognition, could usually understand others and could make self understood. The Documentation Survey Report (used by staff to document care provided) for Resident #113 dated from 01/01/2022 through 01/31/2022 did not include documentation of the care provided on the: 7:00 AM to 3:00 PM shift on 02/24/2022, 02/25/2022. 3:00 PM to 11:00 PM shift on 02/20/2022. 11:00 PM to 7:00 AM shift on 02/01/2022, 02/09/2022, 02/12/2022, 02/13/2022. The documentation of the amount of fluids consumed and the percentage of meals eaten for Resident #113 dated from 01/01/2022 through 02/28/2022 did not include documentation of the fluids and food consumed on the: 7:00 AM to 3:00 PM shift on 01/01/2022, 01/11/2022, 01/20/2022, 02/24/2022, 02/09/2022, 02/24/2022, and 02/25/2022. 3:00 PM to 11:00 PM shift on 01/21/2022, 01/24/2022, 01/27/2022, 01/28/2022, and 02/20/2022. During an interview on 03/07/2022 at 03:21 PM the Licensed Practical Nurse Unit Manager (LPNUM) stated we were working on documentation, unfortunately we were so strict that some staff documented before they even did their work. We were still having a problem with blanks on the CNA documentation. During an interview on 03/08/2022 at 10:56 AM the Director of Nursing (DON) stated blanks in the medical record was an issue with CNA documentation. Documentation and leaving the blanks is part of the staff education. 10NYCRR 415.22 (a)(1-4)

Based on observations, record review, and interviews during a recertification survey dated 2/28/2022 through 3/8/2022, the facility did not ensure that there were no more than 14 hours between a substantial evening meal and breakfast the following day, except, when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Specifically, the facility did not ensure a nourishing bedtime snack was provided when there was a greater than 14-hour time span between the evening meal and breakfast. This was evidenced by: A review of the document titled, Mealtimes undated, documented the meal times were approximate to when the trays/meals would arrive in the designated dining areas: Breakfast: Cart Country Meadows (CM) Left #1: 7:40 AM Cart CM Right #2: 7:48 AM Cart [NAME] (WB) Left #3: 7:56 AM Cart WB Right #4: 8:04 AM Cart Mountain Ridge (MR) Left #9: 8:12 AM Cart MR Right #10: 8:20 AM Cart Rolling Hills (RH) Left #7: 8:28 AM Cart RH Right #8: 8:36 AM Cart Serenity Place (SP) Left #5: 8:45 AM Cart SP Right #6: 8:53 AM Dinner: Cart CM Left #1: 4:38 PM Cart CM Right #2: 4:46 PM Cart WB Left #3: 4:54 PM Cart WB Right #4: 5:02 PM Cart MR Left #9: 5:10 PM Cart MR Right #10: 5:18 PM Cart RH Left #7: 5:26 PM Cart RH Right #8: 5:34 PM Cart SP Left #5: 5:42 PM Cart SP Right #6: 5:50 PM The mealtimes for each of the designated dining areas included a lapse of 14-hours 58 minutes and 15-hours and five minutes between the evening and breakfast meals. During a Resident Council interview on 3/1/22 at 2:55 PM, two (2) of five (5) residents in attendance stated snacks are not offered and often not available. Resident #159 stated they occasionally have a box of crackers available if any snack was available. Resident #24 stated they were not offered snacks in the facility. During an interview on 3/3/22 at 1:02 PM, the Director of Food Service (DFS) stated the kitchen staff fills a snack cabinet every other day with chips and cookies for the residents to have upon request. The DFS stated if the resident wanted a late-night snack, they could request it, and stated the kitchen did not prepare evening snacks for the residents regularly. The DFS stated they were unaware of the regulation that when there was more then 14 hours between a substantial evening meal and breakfast the following day, a nourishing snack would be served to the residents. During an interview on 3/8/22 at 8:42 AM, the Administrator stated they were not aware a nourishing snack was not being provided to the residents or that there was greater than 14 hours between dinner and breakfast the next day on each unit. 10 NYCRR 415.14(h)

Based on observations, interviews and record review during the recertification survey, the facility did not ensure provision of sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility did not ensure the desired staffing levels for Licensed Practical Nurses (LPNs), as documented in the Facility Assessment, were met 9 of 9 calendar days from 2/27/2022 to 3/7/2022 and Certified Nursing Assistants (CNAs), as documented in the Facility Assessment, were met for 9 out of 9 calendar days from 2/27/2022 to 3/7/2022. This is evidenced by: The Facility assessment dated [DATE]; rev. 03/1/2022 documented Staffing Plan; See Attached. On 3/7/2022 at 2:40 PM, the Administrator provided an undated document and stated the document was the current Facility Assessment Staffing Plan. The undated Staffing Plan documented the desired number of Licensed Practical Nurses (LPNs) in a 24-hour period was 21. The staffing plan documented the desired number of Certified Nursing Assistants (CNAs) in a 24-hour period was 46. The facility assessment documented the minimum number of License Practical Nurses (LPNs) on the 7:00 AM-3:00 PM shift (Days) was 10, on the 3:00 PM-11:00 PM shift (Evenings) was 6, and on the 11:00 PM- 7:00 AM shift (Nights) was 5, with a total of 21 LPNs in a 24-hour period. A review of Staffing Sheets dated 2/27/2022 - 3/7/2022 documented in a 24-hour period: 2/27/2022- 19 LPNs (Days - 8, Evenings - 6, and Nights - 5) 2/28/2022- 19 LPNs (Days - 8, Evenings - 6, and Nights - 5) 3/1/2022- 20 LPNs (Days - 8, Evenings - 6, and Nights - 5) 3/2/2022- 20 LPNs (Days - 9, Evenings - 6, and Nights - 5) 3/3/2022- 19.7 LPNs (Days - 8.7, Evenings - 6, and Nights-5) 3/4/2022- 17 LPNs (Days - 6, Evenings - 6, and Nights - 5) 3/5/2022- 17 LPNs (Days - 4, Evenings - 5, and Nights - 5) 3/6/2022- 17 LPNs (Days - 6, Evenings - 6, and Nights - 5) 3/7/2022- 19.5 LPNs (Days - 8.5, Evenings - 6, and Nights-5) The facility staffing plan documented the minimum number of Certified Nursing Assistants (CNAs) on the 7:00 AM-3:00 PM shift (Days) was 20, on the 3:00 PM-11:00 PM shift (Evenings) was 16, and on the 11:00 PM- 7:00 AM shift (Nights) was 10, with a total of 46 CNAs in a 24-hour period. A review of Staffing Sheets dated 2/27/2022 - 3/7/2022 documented in a 24-hour period: 2/27/2022- 35 CNAs (Days - 12, Evenings - 14, and Nights - 9) 2/28/2022- 35 CNAs (Days - 12, Evenings - 14, and Nights - 9) 3/1/2022- 40 CNAs (Days - 12, Evenings - 18, and Nights - 10) 3/2/2022-35.5 CNAs (Days - 10.5, Evenings -15, and Nights -10) 3/3/2022- 39 CNAs (Days - 17, Evenings - 14, and Nights - 8) 3/4/2022-42.5 CNAs (Days - 16.5, Evenings -17, and Nights - 9) 3/5/2022- 44 CNAs (Days - 14, Evenings - 20, and Nights - 9) 3/6/2022- 39 CNAs (Days - 13, Evenings - 17, and Nights - 9) 3/7/2022- 38.5 CNAs (Days - 13.5, Evenings - 15, and Nights - 10) During an interview on 3/8/2022 at 1:28 PM, the Staffing Coordinator stated they were told that for each of the 5 units the minimum staffing levels per shift were 7:00 AM -3:00 PM; 2 LPNs and 3-4 CNAs; 3:00 PM-11:00 PM 1 LPN and 3 CNAs; and 11:00 PM-7:00 AM 1 LPN and 2 CNAs. The Staffing Coordinator stated the facility has contracts with multiple staffing agencies and are able to obtain some supplemental staff from them, primarily for the evenings and night shifts, however the obtaining staff for the day shift remains challenging. The facility offers weekday shift and weekend shifts bonuses of $250.00 for LPNs and $150.00 for CNAs per shift as needed. The Staffing Coordinator also stated the Director of Nursing (DON), and the Administrator were made aware when staffing minimums were not met. On 3/8/2022 at 2:06 PM the Director of Nursing (DON) stated they need a minimum of 3 CNAs per unit on the day shift to provide resident care, the goal is 4 CNAs however the LPNs and Unit Managers assist with resident care as needed. The DON stated they were aware that the minimum staffing levels were not always met. The facility has implemented a bonus program that includes sign on bonuses, referral bonuses, and even shift bonuses to try to get more staff. The facility also works with local schools with LPN students and CNA students completing clinical's in the facility and have hired new staff upon their graduation. The facility provides housing and transportation to the traveling staff, as well as provided free bus passes to employees to assist them to get to and from work. The Corporates own traveling staffing agency provides contracted staff, the contracts are usually for 3 months at a time, the DON stated they are working with the agency to stagger the dates of the contracts to avoid large turn overs at one time, and to orient the new contacted staff to the facility before the previous contracted staff leave. The DON stated the facility is still taking admissions, the DON and ADON review all referrals for the acuity and level of care needed and if they do not feel the facility can provide the care, they decline the admission. During an interview on 03/01/2022 at 01:20 PM, Licensed Practical Nurse Unit Manager (LPNUM) #5 stated there were two CNAs on the day shift yesterday, they did the best they could. There were 35 residents on the unit, when there were 2 CNAs, they would be assigned to 17-18 residents and when there were 3 CNAs they would have 11-12 residents. During an interview on 03/03/2022 at 11:14 AM, CNA #5 stated when there was only two CNAs, we cared for the residents that needed less assistance first, then started with the other residents. When there were only two CNAs on the day shift, a CNA would be assigned to care for up to 20 residents. During an interview on 3/8/22 at 2:07 PM the Administrator stated they are aware they are working short with bare bones staffing, they have tried everything possible to get staff in locally and from out of state. The facility offers housing, transportation, and sign on bonuses. The Administrator stated the facilities priority is that the residents are taken care of. On 3/8/2022 at 3:57 PM, the Administrator stated the minimum staffing plan provided on 3/7/2022 was incorrect and provided another undated document and stated it was the correct minimum staffing plan. 10NYCRR415.13(a)(1)(i-iii)

Based on observations, record review and interview, during a recertification survey dated 2/28/2022 through 3/8/2022, the facility did not ensure that comprehensive person-centered care plans (CCP) were developed and implemented for each resident consistent with the resident rights set forth that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for five (5) (Resident #'s 57, 85, 89, 367 and #512) of thirty three (33) residents reviewed. Specifically, for Resident #57, the facility did not ensure a care plan was developed to address the resident's frequent diarrhea; for Resident #85, did not ensure a care plan was developed for the resident's use of anticoagulant therapy and increased risks of bleeding; for Resident #89, the facility did not ensure a care plan was developed to address the resident's anxiety and associated behaviors or the use of antianxiety and antidepressant medications; for Resident #367, did not ensure care plans were developed to address the resident's need for two person caregivers at all times as indicated in the facility's investigation of the resident's accusation of staff abuse; for Resident #512, the facility did not ensure a care plan was developed for a resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: The facility's policy and procedure (P&P) titled Care Plans- Comprehensive revised 10/19, documented the care plan would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. It documented the care plan would incorporate identified problem areas and risk factors associated with problems areas. Additionally, it would identify the professional services that are responsible for each level of care. Resident #85: Resident #85 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 1/28/2022, documented the had a significant cognitive impairment. The Comprehensive Care Plan (CCP) did not include a care plan to address the resident's daily use of an anticoagulant (a blood thinner used to prevent and treat blood clots in blood vessels). The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/8/2022 at 8:59 AM, Licensed Practical Nurse Unit Manager (LPNUM) #2 stated care plans were developed by a Registered Nurse (RN) at the facility. LPNUM #2 stated it was their responsibility to ensure CCP's were accurate, up to date and included resident specific information. LPNUM #2 stated the Unit Managers have to provide resident care including COVID swabs and blood draws due to the lack of staff to provide resident care, therefore they were unable to complete all managerial duties due to staffing. LPNUM #2 stated Resident #86 should have a CCP in place for deep vein [CONDITION(S)] risk and anticoagulation therapy and did not. During an interview on 3/8/22 at 9:32 AM, the Director of Nursing (DON) stated the Unit Managers were expected to ensure all CCP's included resident specific information to care for the residents on their units. The DON stated they were previously aware that the Unit Managers were unable to complete all tasks and responsibilities due to staffing and the facility continued to work with the Unit Managers on ways to complete their duties such as reviewing CCPs. Resident #89: Resident #89 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 10/20/2021, documented the resident had moderately impaired cognition, could usually understand others and could usually be understood. An Order Summary Report documented, [MEDICATION(S)] (antidepressant medication) 20 mg every day was ordered on 10/11/21 and [MEDICATION(S)] (antianxiety medication) 0.5mg every day at bedtime was ordered on 1/30/2022. A Progress Note dated 1/30/2022 documented the resident is hallucinating, combative, and agitated. Physician aware and ordered [MEDICATION(S)]. The Medication Administration Records (MAR's) dated February 2022, documented [MEDICATION(S)] and [MEDICATION(S)] continued to be administered each day as ordered. There was no Comprehensive Care Plan (CCP) to address the resident's anxiety and associated behaviors or the use of antianxiety and antidepressant medications. During an interview on 03/08/22 at 10:16 AM, RN #1 reviewed the resident's electronic medical record (EMR) and stated there was no CCP for anxiety behaviors, antianxiety medications, or antidepressant medications and there should be. RN #1 stated they must have missed it. Resident #367: Resident #367 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 4/6/2020, documented the resident had a significant cognitive impairment. The Comprehensive Care Plan (CCP) did not include a care plan to address the resident's accusatory behaviors or the need for two caregivers at all times. A facility investigation dated 4/21/2020 documented Resident #367 accused a staff member took their call bell and unplugged it and the resident reported they were treated roughly. Following the completion of the facility's investigation, the resident's accusations were unfounded, and the resident would have a care plan in place for two people (one being the nurse of the unit) for care during the night shift. During an interview on 3/7/2022 at 11:07 AM, the DON stated the resident should have a care plan for behaviors prior to and certainly after the incident on 4/21/20. The DON stated Resident #367 should have had a care plan in place for two person caregivers for assistance as per the investigation summary and did not. The DON stated it was the responsibility of the DON to ensure staff were updating the care plan and this one was missed by them. 10NYCRR415.11(c)(1)

Based on observation, record review and interviews during a recertification survey dated 2/28/2022 through 3/8/2022, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases, infections and COVID-19. Specifically, for 1 (Serenity Place) of 5 units, the facility did not ensure contact and droplet precautions were maintained when Resident #55, who tested positive for COVID-19, was not socially distanced from residents who did not test positive for COVID-19 and for Resident #42, the facility did not ensure infection control practices were maintained during the disposal of soiled linen following incontinence care. Finding #1: Resident #55 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 10/9/21, documented the resident had severely impaired cognition, could usually understand others and could make self understood. The Policy and Procedure (P&P) titled COVID-19 Outbreak Management dated 5/21/21, documented contact and droplet precautions should be initiated upon a positive test result and residents should wear a facemask or a cloth face covering to contain secretions when out of their rooms. The P&P titled Isolation Precautions dated 12/19, documented staff should limit the movement of the resident under droplet precautions from the room to essential purposes only. The Comprehensive Care Plan (CCP) titled Resident is at risk for cross infection related to actual COVID-19 revised 3/1/22 documented interventions to maintain contact and droplet precautions and to provide a facemask to resident while out of room or out on an appointment. A document titled Lab Order dated 2/24/22 documented the result of the polymerase chain reaction (PCR) test for COVID-19 as positive for specimen collected 2/22/22. During an observation on 2/28/22 at 1:59 PM and 2:10 PM, Resident #55 was sitting at a table with 2 other residents. All residents were unmasked and within arm's reach of each other. During an observation on 2/28/22 at 2:11 PM, Licensed Practical Nurse (LPN) #1 came into the area with another resident. LPN #1 did not redirect or move Resident #55. During an observation on 2/28/22 at 2:13 PM, LPN #3 encouraged Resident #55 to return to their room. Resident #55 remained sitting. Residents sitting next to Resident #55 remained withinin arm's reach of Resident #55. No staff offered or attempted to move them. During an observation on 2/28/22 at 2:22 PM, LPN #3 offered to walk Resident #55 to the end of the hall. Resident #55 said Why? and swung an open hand at LPN #3. No attempt observed to move other residents. During an interview on 2/28/22 at 2:02 PM, Certified Nursing Assistant (CNA) #1 stated they knew to put on a gown when on the unit but weren't sure why Resident #55 shouldn't be with others. During an interview on 2/28/22 at 2:04 PM, LPN #3 stated Resident #55 shouldn't be at a table with other residents. The staff had tried to keep Resident #55 away from other residents but Resident #55 has behaviors. During an interview on 2/28/22 at 2:40 PM, LPN #1 stated residents with COVID-19 are supposed to be isolated in their rooms on quarantine but due to this being a dementia unit there is a lot of redirection trying to get residents to stay in their rooms and most have choking precautions so they can't eat in their rooms alone. LPN #1 stated a resident with COVID-19 should be seated at least six feet apart from other residents. A lot of the residents have places they are used to sitting and redirection can be hard. Resident #55 sometimes has a mind of their own. We were all attempting to reseat the others and they were not willing to be reseated. During an interview on 3/1/22 at 9:19 AM, CNA #2 stated they were told Resident #55 tested positive for COVID-19 and liked to come out of their room. CNA #2 stated they have Resident #55 wear a mask and redirect them away from people as much as possible. During an interview on 3/1/22 at 9:37 AM, CNA #8 stated they wear PPE on the unit because there is a resident with COVID-19. That resident should be kept away from others as much as possible. During an interview on 3/1/22 at 9:39 AM, LPN #1 stated they try to educate Resident #55 on COVID-19, but the resident has dementia. They monitor Resident #55, but it is Resident #55's right not to wear a mask. LPN #1 stated they weren't there when residents sat down to eat and didn't try to move Resident #55 or their tablemates. During an interview on 3/1/22 at 9:47 AM, LPN #3 stated they try and keep Resident #55 in their room and away from other residents and encourage them wear a mask if they do come out of their room. Resident #55 shouldn't have been at that table with the other residents. Another resident at the table was recently COVID19 recovered. LPN #3 stated they asked the other resident to move but they said no, they didn't want to. The staff are instructed to keep them as separate as they can. LPN #3 stated they would expect attempts to separate the residents. During an interview on 3/1/22 at 12:30 PM, the Director of Nursing (DON) stated they expected residents with COVID-19 to be kept as separated as possible from other residents. In addition they would not expect a resident with COVID-19 to be seated at a table with other residents to eat a meal without staff attempts to move them. Finding #2: The facility did not ensure infection control practices were maintained during the handling and disposal of soiled linen following incontinence care. Resident #42 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 1/9/22 documented the resident was without cognitive impairment, could understand and was understood. Additionally, the MDS documented the resident was always incontinent of stool. During an observation on 3/2/22 at 11:08AM, Certified Nurse Assistant (CNA) #2 was providing care for Resident #42 in their room. CNA #2 was observed picking up several items from the resident's floor, placing a washcloth with a moderate amount of brown liquid in their left hand and disposable items that contained thick brown liquid in their right hand. CNA #2 exited Resident #42's room, walked down the hall, passed Resident # 11, who was self-propelling in a wheelchair within 3 feet of CNA #2's left hand. CNA #2 continued to walk down the hall and entered a room labeled bathing spa and discarded these items in a soiled linen basket. During an interview on 3/2/22 at 11:09 AM, CNA #2 stated staff should place soiled items into a garbage bag and not on the floor. CNA #2 stated items should then be carried out of the room in a garbage bag to the soiled linen closet. CNA #2 stated their practice was unsanitary, however they regularly throw soiled linen items on the floor when providing incontinence care to residents. CNA #2 stated they carried the soiled linens out of the resident's room in their hands, because there was not a garbage bag available in the resident's room to use. During an interview on 3/2/22 at 11:17 AM, Licensed Practical Nurse Unit Manager (LPNUM) #2 stated staff should not throw soiled items on the floor when providing incontinence care to residents. LPNUM #2 stated linen carts are frequently in the hall, and if a linen cart was not in the hall outside of the resident's room, staff should place the soiled linens in a bag and carry the soiled items in the bag to the soiled linen room. During an interview on 3/2/22 at 3:00 PM, the Director of Nursing stated they were made aware of CNA #2's handling of soiled linen by LPNUM #2 and CNA #2 was educated on proper soiled linen handling. 10 NYCRR 415.19(b)(1) 10 NYCRR 415.19(c)

Based on observation, record review, and staff interview during the recertification survey dated 2/28/2022 through 3/8/2022, the facility did not maintain a pest-free environment and an effective pest control program. Specifically, the facility did not maintain an adequate pest control program as evidenced by multiple sightings of rodent droppings. This is evidenced as follows: During observations on 02/28/2022 at 11:16 AM, rodent droppings were found in the cabinets below the tray line counters in the Oak Creek and Willow Creek kitchenette on the [NAME] pod, the Gardenia Court kitchenette on the Country Meadows pod, the [NAME] Glen kitchenette on the Rolling Hills pod, and the Serenity Place pod main kitchenette. Record review of the facility pest-control sighting logs (dated from April 2021 through February 2022) on 02/28/2022 documented staff last reported rodent activity on the [NAME] pod in May 2021 but not at any other time since. Staff did not report evidence of rodent activity on the Country Meadows pod, Rolling Hills pod, or the Serenity Place pod. Record review of the pest-control service reports on 03/02/2022 documented that facility kitchenettes were not specifically treated for rodents on the [NAME] Book pod, Country Meadows pod, Rolling Hills pod, or the Serenity Place pod since June 2021. During an interview on 02/28/2022 at 1:43 PM, the Food Service Director stated that the kitchenette cabinets will be cleaned. During an interview on 03/03/2022 at 12:40 PM, the Administrator stated that the expectation is that staff should be completing the sighting logs of evidence of rodent droppings, the kitchenette cabinets will be cleaned, and the exterminator will be notified. 10 NYCRR 415.29(j)(5)

Based on observation and staff interview during the recertification survey dated 2/28/2022 through 3/8/2022, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure that on four (4) of 4 resident units observed, the walls, ceilings, and floors were clean and/or in good repair. This is evidenced as follows: During observations on 03/04/2022 at 10:05 AM, the floor linoleum was separating forming a gap revealing the subfloor in resident rooms #A221, #A227, #A255, #A279, #B136, #D103, #D130, #D179, #D259, and Salon/Barber room #C208A. The floor was soiled with ground-in dirt in resident rooms #A255, #B102, and #D130 and the corridors next to walls on the [NAME] Glen unit, Country Meadows unit, and [NAME] unit. The carpeted wainscoting below the handrails were soiled on the Mountain Ridge unit, Rolling Hills unit, and Country Meadows unit. The washer/dryer closet were heavily soiled with lint on the [NAME] Glen unit, Rolling Hills, unit, and Gardenia Way unit. Dead flies were found in the ceiling light fixtures on the Rolling Hills unit and Country Meadows unit. During an interview on 03/04/2022 at 11:13 AM, the Director of Environmental Services stated that the carpeted wainscoting needs to be cleaned and the floors need to be stripped and waxed but hasn't had the manpower. The washer/dryer closets and light fixtures will be cleaned. During an interview on 03/04/2022 at 2:57 PM, the Director of Maintenance stated that the separating linoleum will be repaired, and Maintenance will work with Housekeeping to clean the washer/dryer closets. During an interview on 03/04/2022 at 3:21 PM, the Director of Nursing stated that by working with the Administrator, Director of Housekeeping, and Director of Maintenance, the cleaning and floor repair items will be addressed. 483.10(i)(3); 10 NYCRR 415.5(h)(4)

Surveyor: ELLIOTT, MELISSA J. Based on record review and staff interviews during an abbreviated survey (Case # NY 683) the facility did not ensure that one (Resident #1) of four residents reviewed received treatment and care in accordance with professional standards of practice. Specifically, for Resident #1, with poorly controlled Type 1, Diabetes Mellitus, the facility did not ensure the resident received insulin, as documented on the hospital discharge summary, from 7/6/17 through 7/8/17, resulting in a hospital admission for high blood sugar. Additionally, upon readmission to the facility on [DATE], the facility did not ensure a physicians order for insulin was administered timely for a high blood sugar on 7/20/17, resulting in a hospitalization for high blood sugar. This is evidenced by: The American Diabetes Association target range for normal blood glucose level is 80 to 130. Resident #1: The resident was admitted to the facility on [DATE] at 1:30 pm, with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have modified independence with cognitive ability. It also assessed the resident as able to be understood and able to understand others. Finding #1: The facility did not ensure the resident received insulin as documented on the hospital discharge summary, from 7/6/17 through 7/8/17, resulting in a hospital admission for high blood sugar. Review of the Hospital Discharge Summary dated 07/05/17, documented the [DIAGNOSES REDACTED]. The hospital discharge summary, pages 1 through 3 included the initials of Nurse Practitioner (NP) #1 and the date of 07/06/17. Review of the Hospital Patient Transfer Report dated and received by the facility on 07/06/17, documented that on 07/02/17, the resident had an elevated blood glucose. The resident received 10 units of [MEDICATION NAME] and the blood glucose remained elevated. Review of the Hospital physician progress notes [REDACTED]. The assessment dated [DATE], documented to continue [MEDICATION NAME] and [MEDICATION NAME] Insulin. Review of the hospital's MAR indicated [REDACTED]. Review of the facility's 24-hour report documented the resident arrived at the facility on 07/06/17 at 1:30 pm. Review of the electronic Medication Administration Record [REDACTED]. Review of a nursing progress note dated 07/08/17 at 1:12 pm, written by RN #1, documented the resident's spouse requested to meet with RN #1 because he was upset that the LPN (Licensed Practical Nurse) did not know that his wife was a diabetic. The husband requested blood sugar testing before they left for [MEDICAL TREATMENT]. The blood sugar was checked and read high. It documented the husband did not understand why there were no standing orders to check blood sugars and that the husband stated he would bring the resident to the hospital for [MEDICAL CONDITION]. Review of the facility Investigational Summary (undated) documented Registered Nurse Unit Manager (RNUM) #2 and NP #1 did not question why there were no insulin orders. Review of Hospital Discharge Summary Notes documented the resident was admitted to the hospital on [DATE], with the [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary dated 07/19/17, documented the resident was admitted to the Intensive Care Unit on 07/08/17, in DKA, after not receiving insulin while at the rehabilitation facility. Finding #2: The facility did not ensure that a physicians order for insulin was administered timely on 7/20/17, resulting in the resident's transfer to the hospital for a high blood sugar. Review of a nurse progress note dated 07/19/17 at 3:58 pm, documented the resident was readmitted to the facility. Review of Discharge Summary dated 7/19/17 documented the resident's glucose levels had been particularly difficult to control while in the hospital. It documented to resume 8 units of [MEDICATION NAME] daily in the evening. The hospital discharge summary and medication list documented they were reviewed by NP #1 on 7/19/17. Review of physician order's dated 07/19/17 at 5:31 pm, documented [MEDICATION NAME] Insulin 6 units SQ 3 times daily before meals, Humalog Insulin 12 units SQ as a one time order (entered at 5:56 pm), and [MEDICATION NAME] Insulin 6 units one time dose (entered at 6:06 pm). The physician orders did not include documentation of an order for [REDACTED].>Review of a progress note dated 07/19/17 at 8:12 pm, written by RNUM #1, documented the resident's blood sugar result was 546 and 576 at approximately 5:00 pm. The resident received Humalog Insulin 12 units SQ per physician's order and an hour later the resident's blood sugar was 474. An additional physician's order for [MEDICATION NAME] Insulin 6 units SQ was obtained. One hour later, the resident's blood sugar result was 369. Review of a progress note dated 07/20/17 at 7:24 am, written by RNUM #1, documented the residents blood sugar was 516. RNUM #1 documented she directed LPN #2 to contact the provider for instructions. Review of a physician's order dated 07/20/17 at 7:44 am, written by LPN #2 documented a physician order to administer Humalog Insulin 10 units SQ three times daily before meals. Review of the EMAR dated July 2017, documented the resident received one dose of Humalog Insulin 15 units SQ administered at 10:30 am, on 07/20/17. Review of a progress note dated 07/20/17 at 10:42 am, written by RNUM #1, documented the resident was leaving for Hospital due to nausea and a blood glucose too high to register on the glucometer. Interviews: During interviews with the Director of Nursing (DON): On 07/25/17, at 1:30 pm, the DON stated the Director of Admissions emails the hospital clinical information and PRI packet to the admission group. The DON stated, a thorough review of the admission and medication reconciliation was not done for Resident #1, on 7/6/17. The DON stated she expected the registered nurses to complete a comprehensive review of admission paperwork and clarify any discrepancies with a physician. On 8/9/17 at 11:33 am, the DON stated she would have expected the [MEDICATION NAME] to have been continued as the hospital had recommended on the discharge summary of 07/19/17. During an interview with NP #1 on 07/25/17 at 1:50 pm, NP #1 stated she generally reviews the discharge summary and the discharge medication list. She stated she does not read the actual hospital MAR's for last dose received and does not review the hospital admission packet, but the packet is placed in the file cabinet on the unit. NP #1 stated she did not see the insulin orders on the discharge summary and did not read the actual summary. Additionally, she stated that the resident not receiving insulin coverage contributed to the resident's [DIAGNOSES REDACTED]. During an interview on 07/25/17, at 2:00 pm, with LPN #2, LPN #2 stated at the beginning of day shift on 7/20/17, she was notified by Registered Nurse Unit Manager (RNUM) #1 that the resident had a blood sugar reading of 516 and for her to notify the provider. She received instructions back from the provider to increase the amount of [MEDICATION NAME] Insulin to give with meals. She stated she advised RNUM #1 of the orders received and wrote the telephone order. LPN #2 stated she entered the order into the computer system. She stated that at 10:20 am, RNUM #2 requested she obtained another blood sugar on the resident and the first and second blood sugar readings read high. RNUM #2 advised LPN #2 that the resident had not received her morning insulin. LPN #2 then received an order from NP #1, (who was present) to give 15 units of Humalog insulin at that time. During an interview with the Director of Admissions on 07/26/17 at 9:30 am, she stated that she received the hospital clinical information and the PRI and sent the information to the MDS Coordinator for review. After the admission was approved, she sent all the received information to the facility admission group, which included the DON, Pharmacy, and all RNUM's. She stated that the discharge summary was emailed from the hospital to the facility at 1:18 pm, on 7/6/17. She stated the resident's discharge summary was transmitted to the facility prior to the resident arriving to the facility on [DATE]. During an interview with RNUM #1 on 07/26/17, at 2:30 pm, RNUM #1 stated that on 07/19/17, the resident's blood sugar was checked and found to be elevated. NP #1 was contacted for orders. RNUM #1 stated that on 07/20/17 at 7:24 am, the resident's blood sugar result was 516. She stated she directed LPN #2 to contact the provider and take care of it. She stated she went to do other things and attend morning report. She stated, she was not aware the resident had not received insulin at the time it was ordered by the physician on 07/20/17. During an interview with the Administrator on 07/27/17 at 1:40 pm, he stated he would have expected the RN to ensure the insulin was administered timely. During an interview on 07/31/17 at 10:20 am, the Medical Director stated he expected the admitting RN to review all admission information received and provide accurate medical information to the provider. He stated, that if NP #1 initialed and dated the hospital discharge summary, he would expect her to have read the discharge summary and reviewed the hospital admission packet information. He stated he would have expected blood sugar monitoring and insulin's to have been ordered. Additionally, he stated that he would have expected the increased insulin ordered on [DATE] at 7:44 am, to be administered within 30 minutes and for the resident to have been re-assessed by nursing. On 08/01/17 at 11:54 am, he stated that nursing staff should have reviewed the PRI, medical consults, the hospital MAR indicated [REDACTED]. During an interview on 8/9/17 at 9:38 am, Physician #1 stated that [MEDICATION NAME] is administered to Type 1 Diabetic patients to maintain a continuous coverage of insulin. He stated that he would not have discontinued the [MEDICATION NAME]. 10NYCRR415.12

Based on record review, interview, and observation during an abbreviated survey (Case # NY 322), the facility did not ensure 1 (Resident #3) of 4 residents had the right to be free from abuse. Specifically, for Resident #3, the facility did not ensure the resident was not physically restrained during incontinence care, resulting in bruising to the resident's forearms and toes. This is evidenced by: Resident #3: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have moderately impaired cognition. It assessed the resident as usually able to be understood and able to understand others. Review of the facility's investigation for an incident dated 6/27/17 at 11:25 am, documented the resident was observed by facility staff to have a discolored area on her pants as she was ambulating in the halls. At 11:30 am, Registered Nurse Unit Manager (RNUM) #1, Certified Nurse Aide (CNA) #1, and CNA #2 attempted to provide incontinence care. The resident became physically combative and resistive to care delivery from staff. The RNUM restrained (held) the resident's hands to prevent the resident from swinging at staff during care delivery. The RNUM also placed her feet on top of the resident's feet to prevent the resident from kicking the staff. Facility staff continued to provide incontinence care and once the resident was sitting, staff was able to complete incontinence care. On 6/28/17 at 5:30 pm, RNUM #1 notified the responsible party. It also documented the investigation was initiated on 6/29/17, when the family observed bruising to the resident's right forearm. It documented that the Medical Provider and the Assistant Director of Nursing (ADON) were notified on 6/29/17 at 3:47 pm. The facility investigation documented that the facility began discussion regarding the incident on 07/03/17. It documented that abuse/neglect/mistreatment were not ruled out. Review of a progress note by RNUM #1 dated 6/27/17 at 11:45 am, documented the resident required a 3 staff assist (including RNUM #1) to toilet and change after an episode of bowel incontinence care due to increased behaviors. Review of a progress note written by Registered Nurse (RN) #1 dated 6/29/17 at 2:44 pm, documented the RN was called to assess a bruise on the resident's right forearm. Review of the progress notes did not include an assessment of the bruise. Review of a progress note written by RN #1 dated 6/30/17 at 1:16 pm, documented resident was assessed for additional bruising on her first and second toes which demonstrated bruising which was deep the resident's bruise was deep purple underneath nail beds and to the first joint of toes, bilaterally. Review of the Comprehensive Care Plan (CCP) dated 12/21/16, documented the resident became agitated with perineal care and could become combative. It documented that the resident was a modest person with the recommendation to re-approach the resident for care delivery. During an interview on 7/26/17 at 11:35 am, CNA #1 stated RNUM #1 placed her full hands around Resident #3's bilateral wrists and forearms. CNA #1 stated that when RNUM #1 grabbed both arms of the resident's arms, the resident started to kick at RNUM #1. RNUM #1 put both her feet on the resident's toes to prevent her from kicking her. She stated, RNUM #1 verbally instructed the CNA's to provide the incontinence care. She stated, she observed the resident physically trying to pull away from RNUM #1's physical hold and would have fallen, if CNA #2 had not been behind her. She stated, the event lasted about 15 minutes and she did not report the event. CNA #1 stated, on 6/28/17 she discussed her concerns with RNUM #1 and was told the actions were not inappropriate because she wasn't trying to hurt the resident. Additionally, she stated that RNUM #1 told her that the Director of Nursing (DON) was aware and understood the situation. CNA #1 stated she received a phone call on 6/29/17, from the DON, who stated the family was upset about the resident's bruises. The DON stated she had not been aware of the incident. During an interview on 7/26/17 at 12:20 pm, Social Worker (SW) #1 stated the family of Resident #3 had observed bruises on her forearm area, on 6/29/17. The SW stated that she reported the family's observation to the DON and ADON. Additionally, she stated she was not aware of the alleged incident on 6/27/17, prior to the notification regarding bruises. During an interview on 7/26/17 at 12:30 pm, CNA #2 stated that on 6/27/17, she was positioned behind the resident, that CNA #1 was on the left side of the resident and RNUM #1 was in front of the resident providing incontinence care. She stated the resident was hitting and kicking, so she was focused on removing the soiled clothing. She stated, the resident kept leaning on CNA #2 with her body weight and if she hadn't been there, the resident would have fallen. A couple days later, CNA #2 observed a bluish-green bruise approximately a little larger than a half-dollar coin on the resident's left forearm. She stated, she reported this observation to the Licensed Practical Nurse (LPN). CNA #2 stated the DON asked her to write a statement. Additionally, she stated RNUM #1 did not work on the unit for 2 weeks, but then began to work on another unit. On 7/26/17 at 2:00 pm, the DON stated she would have expected the initiation of an Incident and Accident Investigation and family notification at the time of the event. During an interview on 7/26/17 at 2:30 pm, RNUM #1 stated, she redirected the resident to her room because the resident was incontinent of a bowel movement and had been ambulating in the unit hall. She stated, she remained in the resident's room while incontinence care was provided by herself, CNA#1, and CNA #2. RNUM #1 stated the resident was punching and kicking at staff and she held the resident's hand's and held her feet down to prevent the resident from punching and kicking the staff. RNUM #1 stated, she was worried about the resident being clean and her skin breaking down. Additionally, she stated she did not call the family after the event, but did call the Nurse Practitioner on duty. During an interview on 7/31/17 at 10:20 am, the Medical Director stated he would have expected the RN to have attempted to re-approach the resident when she was calm. He stated, that he would have expected the RN to discuss the resident's behaviors with the family and medical providers for additional potential interventions. He also stated for a RN to hold a resident by the forearms and place her feet on a resident's toes to prevent movement is abuse. 10NYCRR415.4(b)(1)(i)

Surveyor: Raymond, Kendra J. Based on record reviews and staff interview during an abbreviated survey (Case #NY 746), it was determined that each resident did not receive adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed. Specifically, for Resident #1, the facility did not ensure the resident received a mechanical soft texture diet due to difficulty chewing from 12/23/16 through 7/27/17. The resident was unable to swallow food or fluids, and was hospitalized for [REDACTED]. Resident #1: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. It assessed the resident as understood and usually able to understand. The Facility Computerized Diet Manual (undated) for Mechanically Altered Foods documented that meat should be moistened ground or tender cooked meat with gravy or sauce for Mechanically Soft Textured Food. Review of Physician order's dated 08/04/16 through 07/26/17 documented a Regular Texture Diet. The Nutrition Comprehensive Care Plan (CCP) dated 08/10/2016, documented the resident had chewing and swallowing problems, required a mechanically altered diet, and was able to feed self independently. Review of the facility computerized diet program documented a Mechanical Soft Texture Diet on 8/11/16. Review of a Kardex (used by aides to provide care to the resident) documented the resident's diet as Mechanical Soft Texture, effective 08/11/16, and as independent with eating abilities after setup help only from staff. Review of a Speech Therapy progress note dated 08/11/16, documented the resident was evaluated due to difficulty chewing and a Mechanical Soft Texture diet was recommended. Review of dietary progress notes dated 09/28/16, at 1:31 pm, documented the resident was receiving a Mechanical Soft Texture Diet per Speech Therapy recommendations and a Mechanical Soft Texture Diet order was requested. Review of the facility computerized diet program documented a Regular Texture Diet on 12/23/16. The Swallowing Function CCP dated 01/21/17, documented to monitor the resident for signs or symptoms of alteration in swallowing. The Dental CCP dated 01/22/17, documented the resident was on a regular texture diet. Review of nurse progress notes: 07/25/17 at 7:33 am - LPN (Licensed Practical Nurse) #4 documented the resident vomited undigested food. 07/25/17 at 8:45 am - RNUM (Registered Nurse Unit Manager) #3 documented she received physician orders to administer 2 liters of intravenous fluids, obtain vital signs each shift for 2 days, and to add Zofran (prevents vomiting) 4 mg orally every 8 hours for 2 days. 07/25/17 at 11:07 pm - LPN #5 documented the resident refused dinner after several attempts. 07/26/17 at 7:06 am - RNUM #3 documented the resident complained of nausea. 07/26/17 at 2:17 pm - RNUM #3 documented the resident reported she was having difficulty swallowing for the past day, had a coughing episode when eating and spit up her cream cheese and toast, that she continued on a regular diet with thin liquids, and a speech evaluation was indicated and ordered. 07/26/17 at 2:50 pm - RNUM #3 documented she received a physician's order to discontinue the intravenous fluids. 07/26/17 at 2:51 pm - LPN #6 documented the resident refused breakfast that am due to not feeling well. 07/27/17 at 4:15 am - LPN #4 documented the resident had difficulty swallowing her regular diet and was given yogurt and potatoes that she tolerated well. Additionally, she documented she crushed the resident's medications and put them in yogurt. 07/27/17 at 12:05 pm - RNUM #3 documented the resident was displaying shortness of breath, abnormal lung sounds, nausea, and vomiting since 07/25/17 and that the symptoms had gotten worse. Additionally, she documented the resident had lung sounds that included rales, rhonchi, and crackles with a pain level of 9 out of 10, was unable to swallow, and had grayish colored skin. Review of speech therapy progress note dated 07/27/17 at 12:17 pm, documented moderate to severe crackles were observed post swallow followed by a rumbling with a high-pitched squeal. Approximately 3 minutes after swallowing, the resident was observed expelling the same amount of liquid previously swallowed. The resident's diet was recommended to be changed to pureed texture with thin liquids due to the resident's risk for choking on emesis of foods and a compromised airway. Review of Nurse Practitioner (NP) #1's progress note dated 07/25/17, documented the resident had nausea and vomiting since 07/24/17. Review of NP #1's progress note dated 07/26/17, documented the resident had tracheal congestion and had a coughing episode with food. Review of NP #2's progress note dated 07/27/17, documented the resident was unable to tolerate anything orally and had been regurgitating (vomiting) liquids and solids shortly after she swallowed them. It documented that once oral intake reached a certain point in her esophagus everything came back up. The NP documented the resident stated she felt short of breath and when the lungs were assessed there was a loud coarse crepitus (grating, crackling, or popping) sound identified between the breast area of the resident and posteriorly the lungs had rales and rhonchi. The assessment and plan was documented as intractable vomiting of unknown origin, respiratory distress and the resident was transferred to the hospital (named) for evaluation. Review of hospital (named) history and physical dated 07/27/17, documented an admitting [DIAGNOSES REDACTED]. The EGD findings documented esophageal (throat) meat impaction stacked up, relieved with multiple extractions, until the airway was clear. The future diet recommendations documented limited to very moist finely ground foods. During an interview on 08/07/17 at 11:15 am, Speech Therapist #1 stated that she was made aware of the resident vomiting all food and fluids on 07/26/17 by RNUM #3. She stated that during her evaluation she assessed that no oral input was going down the resident's throat and a high pitched whine sound was heard near her Hyoid (between the chin and thyroid). During an interview on 08/08/17 at 9:20 am, NP #2 stated that the Speech Therapist came to her with the speech evaluation results and NP #2 went in to assess the resident. She stated that the resident was observed with dyspnea (shortness of breath) and the NP was concerned the resident had pneumonia (respiratory infection). During an interview on 08/8/17 at 10:00 am, LPN #4, stated the resident had difficulty swallowing the evening meal of 07/26/17. She stated that the resident had stated she didn't feel like the medication was going down her throat, that's why LPN #4 crushed the pills. During an interview on 08/08/17 at 1:40 pm, Certified Nurse Aide (CNA) #4 stated the resident ate in her room, there were no specific interventions or safety precautions for her during meal times, and that there was no supervision required for her meal intake. She stated that the resident meal tickets were verified to match the actual meal served at the time of delivery. During an interview on 8/9/17 at 8:35 am, CNA #5 stated the resident received her meal trays in her room and ate independently in her room. She stated the resident was on a regular diet and staff would cut up her meat, if needed. She stated that on 7/27/17 during lunch time, she walked into the resident's room and the resident had asked for a cream cheese sandwich for lunch and the resident was holding her chest in between her breast area. CNA #5 stated, the resident said she thought she had food caught and the CNA asked the resident to spit out any food in her mouth. CNA #5 stated the resident then took a sip of water and the water immediately came right back out of her mouth. During an interview on 08/09/17 at 10:05 am, the Assistant Director of Nursing (ADON) stated that the inconsistency of the documented diet texture from the Kardex, CCP, and physician order's should have been identified and questioned by RN's or the Dietician. Additionally, she stated that she would have downgraded the resident's diet when a speech therapy evaluation was indicated and that the physician's order for the Speech Therapy evaluation was capable of being approved by a medical provider the same day it was indicated. During an interview on 08/09/17, at 11:33 am, the DON stated that resident's on altered textured diets are supervised with meals in the dining room and the Kardex should have been reviewed when the care plan was reviewed, at least every 4 months. During an interview on 08/09/17 at 11:38 am, the dietary technician stated that a change in a resident's diet does require a physician's order. She also stated that when a change in diet is recommended by the speech therapist, the dietary department institutes the recommended change before the physician signs the order, because it usually takes two days to get an order approved. She stated that she reviewed the resident's CCP usually every 4 months, but she used the current physician's orders to compare with the current CCP. During an interview on 8/22/17 at 10:45 am, with the physician, the physician stated the process for dietary orders is that the Speech Therapist receives an order for [REDACTED]. Nursing is responsible for calling the physician or provider to obtain a telephone order for the recommended diet or obtains a written order when/if the physician is in the facility. The physician stated orders are renewed on the computer in real time and that every order previously changed shows up as current on the computer. The physician stated that because there was no physician order for [REDACTED]. 10NYCRR415.12(h)(1)

Based on record review and staff interview during the recertification survey and abbreviated survey (Case #NY 512), the facility failed to ensure all residents were free from abuse, neglect or mistreatment for 3 (Resident #'s 23, 58 and #172) of 14 residents reviewed for abuse and/or neglect. Specifically, the facility failed to provide required care and services for Resident #23 who was dependent on staff for assistance with care planned Activities of Daily Living (ADL's). On 5/29/16, facility staff did not provide assistance with this resident's ADL's including turning and positioning, incontinence care, food and hydration, and did not attempt to administer medications on the day shift. Also, did not provide turning and positioning, and incontinence care on the evening and night shifts, and did not perform neurological checks on the night shift. Facility staff, including licensed staff members were aware that the resident did not receive care, and did not intervene to prevent neglect. This resulted in immediate jeopardy to resident health or safety and substandard quality of care for Resident #23, and had the potential to affect all residents in the facility. Additionally, for Resident #58 the facility was aware of multiple allegations regarding Certified Nursing Assistant (CNA) #2's mistreatment of [REDACTED]. Also, for Resident #172, the facility did not provide timely care and services after the resident complained to licensed staff on three occasions from 5/18/16 through 5/20/16, that staff had pulled on, or mishandled her arm, and subsequent complaints of pain for which she was medicated eight times during this time period. The resident was sent to the hospital on [DATE] at 9:30 am, where she had surgery for [REDACTED]. The facility's undated Policy and Procedure (P&P) for Abuse documented that it was the responsibility of all staff, as well as licensed personnel whether employed by the facility or not, to prevent occurrences of abuse, mistreatment and neglect. Staff were to identify, correct and intervene where abuse may occur, and report alleged violations and sustained incidents to appropriate authorities. Additionally, residents were to be protected from harm during an investigation. The Reasonable Cause definition included the statement Upon review of circumstances there is sufficient evidence for a prudent person to believe that physical abuse, neglect or mistreatment has occurred. An example of reasonable cause is a statement, the presence of a physical condition which is inconsistent with the history or course of treatment of [REDACTED]. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm or mental anguish. The neglect definition also included the failure to provide nutrition, medication, sanitary clothing and ADL's. Resident #23: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to be cognitively intact, was able to make herself understood and was able to understand others. She was also assessed to require the total assist of two staff for transfers, and extensive assistance of two staff for bed mobility. The Comprehensive Care Plan (CCP) for Urinary and Bowel Incontinence dated 2/26/16, documented the resident was incontinent of bowel and bladder and was dependent on staff for assistance with Activities of Daily Living (ADL's). Interventions included: the skin was to be kept clean and dry, and staff were to provide tilting assistance. The CCP for ADL's dated 2/26/16, documented staff were to assist in bed mobility, and utilize the sit-to-stand mechanical lift for transfers. The CCP for Nutritional Status dated 5/4/16, documented the resident required adaptive devices at meals including a lip plate,an anti-slip mat and a scoop bowl with suction, was on a mechanically altered diet and was able to feed herself independently. A Video Recording provided by the facility, provided an unobstructed, continuous view of this resident from 5/28/16 (Friday) at 1:05 PM, until 5/30/16 (Monday) at 6:15 am, a total of 41 hours. During that time span, the resident was in a reclining chair in the living room area, and wore the same gown. The video revealed this resident was provided incontinence care on 5/29/16 at 12:43 am, and was not provided incontinence care again until 5/30/16 at 6:15 am, a total of 29 hours. Day Shift: The undated Certified Nursing Assistant (CNA) Instruction sheet (used by staff to know what care the resident required) documented the resident was totally dependent on two staff with a mechanical lift for transfers, extensive assistance of one person for bed mobility, supervision and setup help for eating. The Resident CNA Documentation History Detail form (used by staff to document what care had been provided) dated 5/29/16, documented that from 7:00 am to 3:00 pm (day shift) the resident was not toileted, was not assisted with bed mobility, CNA care was not provided, assistance with eating was not provided, safety measures were not performed, skin checks were not performed, and the resident was not transferred. The Medication Administration Record [REDACTED]. Licensed Practical Nurse (LPN) #6 documented that none of the medications were given to the resident because she was asleep. A Nurses Note dated 5/29/16 at 2:49 pm, documented the resident slept most of the day shift, and the resident hit staff during attempts to give care. The supervisor was aware of the behavior. The note was signed by LPN #6. In a statement provided to the Director of Nursing (DON) dated 6/1/16, CNA #14 stated that on the 5/29/16 day shift, this resident was rude and snappy when staff approached her, and she upset the other residents. She stated the resident did not eat or drink, was not moved or repositioned and was not changed for incontinence care for the entire day shift. She figured since she didn't drink she didn't urinate. Attempts to contact LPN #6 on 6/2/16 and 6/3/16 were unsuccessful. During an interview on 6/2/16 at 3:55 pm, CNA #14 stated that when she came to work on the unit on the 5/29/16 day shift, the resident was asleep in a reclining chair in the living room/dining room (LR/DR). She told the LPN (#6) working with her that shift, that the resident was sound asleep (so morning care could not be done) and LPN #6 told her it was fine, leave her be today. She stated she did no care for the resident for the entire shift: the resident was not washed, was not changed after being incontinent, her skin was not checked, and the resident was not offered food or fluid. She also stated LPN #6 did not give the resident her medications. After lunch, she reported to a male Registered Nurse Supervisor (RNS) that she had not given care to the resident, but the RNS did not say anything about it. She stated she did not offer the resident food or drink because if she ate or drank she would be incontinent, and would have to be changed. CNA #14 stated she did not give care to the resident because she did not want to wake her up because she would be agitated and disrupt the other residents. Review of the facility's Video Recording from 5/29/16 at 7:00 am until 3:00 pm, revealed the resident was not offered and did not receive care including repositioning, incontinence care, food or hydration. In addition, the video revealed that LPN #6 made no attempt to wake and/or offer the resident her medications on the day shift. There was no evidence that the resident was aggressive toward staff. Evening Shift: In a statement provided to the Director of Nursing (DON) dated 6/1/16 at 5:15 pm, LPN #7 stated that on the 5/29/16 evening shift, this resident was provided incontinence care at least once, she cooperated with neurological checks, and ate dinner in the reclining chair. The resident slept soundly until 6:00 pm and had dinner, was changed for incontinence care at 7:00 pm, and was returned to the recliner. She was awake for a little while during the shift, and she was doing OK. She was not yelling or complaining. The only thing the Certified Nursing Assistant's (CNA's) told him was that she was better tonight. In a statement provided to the DON dated 5/31/16, CNA #15 stated when she arrived to work on the 5/29/16 evening shift, she attempted to provide care for the resident, but she was very abusive. She was kicking the (mechanical) lift, swinging at staff and swearing. None of the above activities appeared on the video recording. Review of the facility's Video Recording from 5/29/16 at 3:00 pm until 11:00 pm, revealed the resident was not offered and did not receive care including repositioning or incontinence care. There was no evidence that CNA #15 attempted to give care to the resident, or that the resident was kicking or swinging at staff. At 5:15 pm, the dinner meal was placed on the overbed table in front of the resident, and the resident was left in a reclined position. At 6:19 pm, a staff member raised the back of the recliner, without repositioning the resident, and set up the resident's meal tray. The resident began to eat and drink. At 6:29 pm, the LPN leaned toward the resident after going to the medication cart, and at 6:34 pm, a staff member removed the resident's meal plate and utensils. At 6:45 pm, with the back of the recliner still in the upward position, the resident slightly repositioned herself. At 7:01 pm, a staff member laid the back of the recliner down again, and did not reposition the resident. Night Shift: The undated Certified Nursing Assistant (CNA) Instruction sheet (used by staff to know what care the resident required) documented the resident was totally dependent on two staff with a mechanical lift for transfers, extensive assistance of one person for bed mobility, supervision and setup help for eating. A Neurological Check Sheet dated 5/27/16, 5/28/16 and 5/29/16 documented the resident fell on [DATE] at 2:45 am, and required neurological (neuro) checks. Neurological checks included pupil equality and reaction, blood pressure, alertness and orientation, cooperativeness, speech, pulse, respirations, and presence of emesis (vomiting) or [MEDICAL CONDITION]. On 5/28/16 at 3:15 am and 5:15 am, and again on 5/29/16 at 1:15 am and 5:15 am, LPN #5 documented that the neurological checks were completed. The Resident CNA Documentation History Detail form dated 5/29/16, documented that from 11:00 pm to 7:00 am (night shift) the resident was not toileted and the resident was incontinent of urine, was not assisted with bed mobility, the resident resisted care, CNA care was provided, safety measures and skin checks were performed, the skin was intact, and the resident was not transferred. A Nurses Progress Note dated 5/30/16 at 6:24 am, documented the resident had no behaviors through the shift, and slept in the recliner at her request. Neuro checks were completed and were within normal limits. A Nurses Progress Note dated 5/30/16 at 6:25 am, documented the note was a correction and that the resident refused to wear her rook boots (a protective boot used for wound care) throughout the shift. A Skin Assessment Tracking form dated 5/31/16, documented the resident had a 4 centimeter (cm) by 2cm wound to the right buttock. The wound bed was pink with minimal drainage and was staged as a moisture/sheering wound. In a Staff Statement dated 6/1/16, CNA #13 stated when she arrived to work for the night shift for 5/29/16 into 5/30/16, the evening shift Licensed Practical Nurse (LPN) #7 and CNA #15 informed her this resident was terrible throughout the weekend, and had been shoving her overbed tray, hitting and yelling at everyone. She was finally settled in her chair, and the LPN said She was given her meds (medications) and should be out for a long time. Both LPN #7 and CNA #15 said they would not disturb the resident unless she woke. The resident was breathing heavily throughout the night. She informed LPN #5, who said they would monitor the resident, but do not disturb her. In a statement provided to the Director of Nursing dated 6/3/16 at 11:45 am, CNA #16 stated when she arrived to work on 5/30/16, she took the resident to her room to clean her. The resident's lift sheet was soaked and the resident had body odor. When she cleaned the resident, she saw a red, raw open area on the resident's buttock that had not been there on Friday. She also stated the resident had the same clothing on that she was wearing Friday. During an interview on 6/2/16 at 7:10 am, CNA #13 stated that on the night shift on 5/29/16, the evening shift CNA (#15) told her the resident had acted out all weekend. The evening shift Licensed Practical Nurse (LPN #4) told her to leave the resident alone overnight, because if she woke the resident she would just get the other residents going, because she was disruptive and nobody liked her. When CNA #13 came on shift, the resident was in the living room/dining room (LR/DR) in a reclining chair. CNA #13 stated she approached the resident, but the resident got nasty with her so she told LPN #5 (this was not on the video recording). LPN #5 told the CNA to keep an eye on her and just leave her alone. She stated she was supposed to check and change the resident three times overnight, but she did not do that, although the resident was known to be incontinent of both bowel and bladder. She reported to LPN #5 a few times throughout the shift that the resident had not received care. CNA #13 stated she did not give care to the resident, because she did not want to wake the resident because she was disruptive and would upset the other residents - nobody likes her. During an interview on 6/2/16 at 7:47 am, LPN #5 stated she performed neurological checks on this resident on 5/28/16 at 3:15 am and 5:15 am, and again on 5/29/16 at 1:15 am and 5:15 am. During the night shift of 5/29 into 5/30, she repositioned the resident each time she did neurological checks. She also stated she saw CNA #13 reposition the resident and checked to see if she had been incontinent at the beginning of the shift, approximately 11:30 pm on 5/28/16. LPN #5 then reviewed the Neurological Check Sheets for 5/27/16, 5/28/16 and 5/29/16 and stated the documentation and her initials meant she had completed the neurological checks. During an interview on 6/2/16 at 8:15 am, LPN #5 again reviewed the Neurological Check Sheets for 5/27/16, 5/28/16 and 5/29/16 and stated she did not do the neurological checks on 5/28/16 at 3:15 am and 5:15 am, or on 5/29/16 at 1:15 am and 5:15 am. She also stated she did not reposition the resident on the 5/29/16 night shift, because the resident was very difficult and disruptive to the staff and other residents and she did not want to wake her up. She also stated she documented on 5/30/16 at 6:24 am, that the resident had slept in the recliner at her request, but she had not asked the resident and the resident did not ask to sleep in the recliner. She stated this resident was very difficult, and waking her or disrupting her would have made her be disruptive to the staff and the residents for the rest of the shift. Review of the facility's Video Recording from 5/29/16 at 11:00 pm until 6:15 am on 5/30/16, revealed the resident was not offered and did not receive care including repositioning or incontinence care. Additionally, there was no evidence on the video recording that LPN #5 performed neurological checks on this resident. On 5/30/16 at 6:15 am, a day shift CNA removed the resident from the recliner and took her out of camera view. Additional Interviews: During an interview on 6/1/16 at 11:00 am, the Director of Nursing (DON) stated she had received written statements alleging this resident had been neglected over the previous weekend, and she was going to report it to the New York State Department of Health (DOH). During an interview on 6/2/16 at 10:00 am, the DON stated that in her investigation Certified Nursing Assistant (CNA) #14 told her she did not wake the resident on the 5/29/16 day shift and did not give care to the resident that entire shift. CNA #14 said that if the resident did not drink, she would not urinate, and she did not want to wake the resident because the resident is rude and nasty. The CNA also told her Licensed Practical Nurse (LPN) #6 did not give the resident her medications, because the resident was asleep. The DON stated LPN #6 should have attempted to wake the resident before holding the medications. On the evening shift, the resident slept until 6:00 pm, then was given food and drink, neurological checks were completed and at 7:00 pm incontinence care was given. When the night shift arrived, LPN #4 and LPN #5 told CNA #13 not to wake the resident, and that the resident got all her meds and should be out for a long time. CNA #13 told the DON she had approached the resident at approximately 11:30 pm or 11:45 pm, and the resident yelled at her, so she did not give care to the resident for the entire night shift. When the day shift staff arrived on the morning of 5/30/16, LPN #5 told CNA #17 the resident had received incontinence care on the night shift. CNA #16 reported that the resident was in her chair and was soaked in urine. She also stated the resident had two open areas on her right buttock, that were discovered on 5/31/16, and both appeared to be from moisture and shearing. During an interview on 6/2/16 at 2:59 pm, Registered Nurse Manager (RNM) #2 stated when she arrived for work on the morning of 5/31/16, written staff statements had been slid under her door from CNA #'s 16 and 17. They wrote that the resident was in the same clothes and chair since Friday and was soaked in urine. They said they could smell the resident from down the hallway. She stated she immediately reported this to the DON. She then assessed the resident and noted a wound on her right buttock which appeared to be from moisture or shearing. She stated this was a new wound. The RNM reviewed the resident record and stated there was no documentation that Registered Nurse Supervisor (RNS) #1 had assessed the resident on 5/30/16. During an interview on 6/2/16 at 3:45 pm, RNS #1 stated that mid-morning on 5/30/16, CNA #16 told her that when she started her shift that day, this resident was exactly where she was on Friday (5/27), and was wearing the same clothes, and was soaked with urine. CNA #17 reported that CNA #14 did no care for this resident on the day shift on 5/29/16. At approximately 11:00 am, CNA #14 told the RNS that she had not provided care to this resident on the 5/29 day shift, because she did not want to wake the resident because of her behaviors. She stated CNA #'s 14 and 17 wrote statements, and the RNS put them under the door of Registered Nurse Manager (RNM) #2, so she could see it when she came in on 5/31/16, and reported the allegations to the evening RNS (#2). In the morning of 5/31/16, she reported the allegations to the Director of Nursing (DON) and the Administrator. The RNS stated she recognized this as potential neglect, but did not remove CNA #14 from care, because she did not know what to do with this information. She stated she knew the Policy and Procedure (P&P) for Abuse because she wrote it, and knew to start an investigation, but did not immediately notify the DON, because she did not know what to do. RNS #1 also stated she did not write a nurses note about the wound she saw when she assessed the resident, because it was possibly the result of neglect, but did not know how to put that information in the medical record without writing that this was neglect. An undated Staff Statement signed by RNS #1, documented that on 5/30/16 at 11:30 am (a Monday), CNA #16 asked her to assess this resident because she had not been touched and was in the same clothes, in the same chair since the previous Friday. CNA #16 reported that the night shift said they had recently provided incontinence care, but when they got the resident out of bed that morning (5/30) the resident was soiled through several layers. CNA #17 also reported that CNA #14 had provided no care to this resident on the day shift of 5/29/16. RNS #1 spoke with the 5/29/16 day shift CNA (#14) who openly admitted she didn't do care because the resident was sleeping and she thought care was done by the previous shift since the resident was already dressed and in a chair. The RNS then assessed the resident and found an open area on the right buttock that appeared to be caused by moisture although the RNS did not know if the area was old or new. During an interview on 6/3/16 at 8:46 am, the Nurse Practitioner (NP) stated this resident had an intermittent history of behaviors along with a [DIAGNOSES REDACTED]. Resident #58: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have long and short term memory problems, with severely impaired decision making skills. The facility investigation into an incident with Resident #58 which occurred on 4/3/16 and was reported to the DOH (Department of Health) Hotline on 4/7/16, was provided to the (DOH) Surveyor on 5/31/16. The investigation consisted of 5 staff member interviews, resident records, and accused Certified Nurse Aide (CNA's) personnel records. There was no documented evidence of a summary of the investigation. A request from the DOH Surveyor to the Director of Nursing (DON) for a written summary of the investigation, was provided to the DOH Surveyor on 6/2/16. The facility Summary of Findings regarding the incident dated 4/3/16, documented the time of occurrence 7:30 pm, and was reported to Administration on 4/6/16. CNA #1 reported on 4/6/16 that on 4/3/16 she witnessed CNA #2 grab Resident #58 by the hair, jerk her head back and to look her in the eyes saying we are not gonna have any f--king (expletive) problems tonight because I am too tired and I don't have time. She then turned to CNA #1 and said it doesn't leave a mark and what you see here stays here. They finished getting the resident ready for bed. The incident was reported after CNA #1 spoke with another CNA about it. CNA #2 denied the allegation, she was suspended and then terminated. Licensed Practical Nurse (LPN) #1 who usually worked with CNA #2, stated CNA #2 was often loud and gruff with residents, but he had never seen any signs of resident abuse. He stated he spoke to CNA #2 once about her approach, and she told him I'm military and I'm a little gruff. LPN #1 stated that CNA #1 came to him on 4/6/16 and stated you will be mad at me, but I need to tell you what happened and she proceeded to report the occurrence. The facility interviewed CNA's #'s 1, 3, 4, 5, 6, 7, 8, and #9 as they had worked with CNA #2. None reported witnessing any verbal or physical abuse (there was no written evidence of interviews for CNA #'s 4, 5, 6, 7, 8, and #9). The RN Nurse Manager and the Director of Nursing (DON) counseled CNA #1 about the requirements for reporting abuse, noting she is to stop and report immediately. She stated she was afraid of repercussions from CNA #2, but reported the incident because she felt so bad. Resident Event Investigation Staff Statements for five staff member included in the facility investigation were: 1. CNA #1 was in Resident #58's room getting her ready for bed. CNA #2 swore at the resident saying you better f---ing (expletive) behave tonight I do not have the time or energy. CNA #2 pulled the residents hair back so she could look her in the eye. CNA #2 told CNA#1 that pulling hair did not leave marks. CNA#2 also said, what you see or hear here stays here. 2. CNA #2 stated she and CNA #1 did this resident's care, and Resident #58 raised her hand and I told her to put it down. CNA#2 finished her care and put her to bed, and stated she only went in to help with care. 3. CNA #3 reported that she was not working on 4/3/16, but when she worked on 4/6/16, she was told about the incident when she was feeding other residents. She was told that CNA #2 pulled Resident #58's hair and said that there will be no problems. 4. LPN #1 documented that he was approached by CNA #1 on 4/6/16, over an issue on Sunday 4/3/16. CNA#1 told him that while toileting Resident #58, CNA #2 pulled the resident's hair and told her that she was to behave tonight. CNA #1 also told LPN#1 that CNA #2 told her what happens in the room stays in the room, and not to worry it won't leave a mark. CNA #1 also stated that CNA #6 was also in room while this was going on. 5. A written statement dated 4/7/16, and identified as a telephone interview with LPN #1, documented a few instances including: CNA#2 being loud with residents and often gruff and stern. CNA#2 lied about feeding residents, and instead put their food in the refrigerator. LPN#1 also talked with the supervisor about watching CNA#2. CNA#2 had been spoken to before, but she stated I'm military and I'm a little gruff. The Facility Investigation included an Office of Attorney General, Medicaid Fraud Control Unit Deposition. The deposition was written by CNA #1 and documented, I have worked on the dementia unit since I started. On 4/3/16, I was working the 3-11 shift (evening). At about 7:30 pm on this day, I was in Resident #58's room with CNA #2 and CNA #6 (who was orienting) getting the resident ready for bed, we were all in the bathroom, I pulled the resident's pants and brief down and we placed her on the toilet. As the resident was on the toilet CNA #2 grabbed the resident by the hair on top of her head to look the resident in the eyes and say we are not gonna have any f---ing (expletive) problems tonight because I'm too tired and I don't have time. CNA #2 then looked at me and CNA #6 and said it doesn't leave a mark, and what you see here stays here. CNA #6 then left the room and I think it was because she was upset about what CNA #2 just did to the resident. I helped CNA #2 finish getting the resident ready for bed and then left the room. I worked with CNA #2 the rest of the shift and didn't see any other issues with her care. I reported the incident on 4/6/16 to LPN #1. I talked to another CNA #10 and decided it should have been reported. During an interview on 6/1/16 at 1:55 pm CNA #1 stated the incident she reported on 4/6/16, happened a few days before (4/3/16). CNA #1 stated she was kinda scared, because of the way CNA #2 would react. CNA #2's demeanor showed she was angry. Nurses would tell her not to yell at the residents. CNA #1 stated she received inservice on abuse, she could remember that reports of abuse should be made within 24 or 48 hours. CNA #1 stated that Resident #58 can be abusive to staff with biting and kicking. On 4/3/16, CNA #1 asked for help with Resident #58 and CNA #2 and CNA #6 (orientee) came into the room. CNA #1 and CNA #2 stood Resident #58 up and pulled down her pants and set her on the toilet. CNA #2 immediately grabbed Resident #58 hair, pulled her head back and said in her face, were not going to have any f---ing problems tonight, I'm not going to do this. CNA #2 then looked at CNA #1 and CNA #6 and said, what you see here stays here and it does not leave a mark. Resident got mad and started to swat. Both CNA #1 and CNA #2 stayed in room and gave care together, no further problems. CNA #1 stated that prior to the incident the RNM had told CNA #1 that they were looking into CNA #2 and what is going on, because so many residents were getting bruises. During an interview on 6/2/16 at 1:10 pm, CNA #2 stated Resident #58 was not her resident on the night in question (4/3/16). CNA #2 was asked by CNA #1 to help because Resident #58 was combative. There was another CNA present but CNA #2 could not remember her name. CNA #2 could not remember whether she helped to put the resident to bed or on the toilet. CNA #2 stated she will walk out of resident rooms sometimes because of frustration, but never takes it out on the residents. CNA #2 never had a nurse correct her about her verbal behavior toward the residents. There had been no talk of her resident being bruised, and CNA #2 has no history of failure to follow care plan. During an interview on 6/2/16 at 2:30 pm, the Registered Nurse Manager (RNM) #1 stated she became aware of the incident of 4/3/16, with Resident #58 from the evening shift CNA's. The Registered Nurse Supervisor (RNS) started the investigation and the RNM assessed Resident #58's scalp for injury. RNM #1 stated she had spoken to CNA #2 a couple weeks prior to the incident, after the Unit Clerk reported to her that she overheard CNA #2 speaking to Resident #48 in a loud tone. RNM #1 told CNA #2 about her tone of voice being inappropriate and explained the proper way. RNM #1 did not put the conversation in writing. RNM #1 also stated that CNA #2 had reported that there were bruises to her own residents. RNM #1 stated she collected statements from staff in regards to the bruises. RNM #1 could not remember who the residents with the bruises were or exactly how many, she stated there was possibly two residents. RNM #1 stated she reported to the DON that it seemed strange that CNA #2 was the one coming up with the bruises. RNM stated she was not aware of the doll being grabbed from Resident #58 by CNA #2, that was written in the statement of CNA #6 (see below). During an interview on 6/2/16 at 3:00 pm Unit Clerk #1 (UC #1) stated she sits at the nursing station across from Resident #48's room. The UC #1 could not recall the date, but stated that Resident #48 had a hospital gown on that appeared disheveled. CNA #2 approached Resident #48 and said to him let me take that off you, lets go in your room. Resident #48 stated don't let her take me in the room, she's mean to me. UC #1 stated that CNA #2 then took Resident #48 into his room and while in the room the UC #1 heard CNA #2 say stop being so dramatic, I'm not hurting you. CNA #2 then opened the door and Resident #58 came out of his room. UC #1 then reported this to the RNM. During an interview on 6/2/16 at 3:50 pm CNA #10 stated she had been concerned about the way CNA #2 talked to the residents. CNA # 10 had heard CNA #2 speaking to Resident #48 in Spanish and in a [MEDICATION NAME] manner, when CNA #10 asked CNA #2 what she had said to the Resident #48, CNA #2 said she told the resident to shut up. CNA #10 also witnessed CNA #2 yelling at Resident #43. CNA #10 stated she reported to the Registered Nurse Manager (RNM) that she did not like the way CNA #2 treated the residents. During an interview on 6/2/16 at 3:55 pm, LPN #3 stated that CNA #2 did not speak nicely to the residents, she was short and yelled at them. LPN #3 tried to talk to CNA #2 about the way she treated residents, and CNA #2 did not want to hear it. LPN #3 did report the behavior of CNA #2 to the RNM. During an interview on 6/2/16 at 11:20 am, CNA #6 stated I know CNA #1 said I was in the room on 4/3/16 with Resident #58, but I was not. CNA #6 stated I wasn't in the room when the hair pulling occurred. CNA #6 stated when she first started working at the facility she was observing care with CNA #2. CNA #6 was in Resident #58 room with CNA #2 and the Resident, with the door closed. The Resident (#58) had dolls in her arm and she was not cooperating with CNA #2 giving care. CNA #6 witnessed CNA #2 grab the doll from the resident's arms

Based on record review and staff interview during a recertification survey and abbrieviated survey (Case #NY 512), the facility failed to administer the facility in a manner to enable it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, for Resident #23 facility staff failed to implement the Policy & Procedure to prevent neglect and to protect residents during an investigation of allegations of neglect. This resulted in Immediate Jeopardy to resident health and safety for Resident #23, with the potential to affect all residents in the facility. Additionally, facility administration did not ensure a Licensed Practical Nurse (LPN) assigned as a Unit Manager, did not create, initiate or alter nursing care goals, or establish nursing care plans for 3 (Resident #s 104, 135 and 136) of 5 residents reviewed on the LPN Unit Manager's unit. This was evidenced by Resident #23: Refer to F 224 - Staff treatment of [REDACTED]. Refer to F 226 - Staff treatment of [REDACTED]. During an interview on 6/2/16 at 3:45 pm, Registered Nurse Supervisor (RNS) #1 stated that mid-morning on 5/30/16, Certified Nursing Assistant (CNA) #16 told her that when she started her shift that day, this resident was exactly where she was on Friday (5/27/16), was wearing the same clothes, and was soaked with urine. CNA #17 reported that CNA #14 did no care for this resident on the day shift on 5/29/16. At approximately 11:00 am, CNA #14 told the RNS that she had not provided care to this resident on the 5/29/16 day shift, because she did not want to wake the resident because of her behaviors. She stated CNA #'s 14 and 17 wrote statements, and the RNS put them under the door of Registered Nurse Manager (RNM) #2, so she could see it when she came in on 5/31/16, and reported the allegations to the evening RNS (#2). In the morning of 5/31/16, she reported the allegations to the Director of Nursing (DON) and the Administrator. The RNS stated she recognized this a potential neglect, but did not remove CNA #14, from care because she did not know what to do with this information. She stated she knew the Policy and Procedure (P&P) for Abuse because she wrote it, and knew to start an investigation, but did not immediately notify the DON, because she did not know what to do. RNS #1 also stated she did not write a nurses note about the wound she saw when she assessed the resident, because it was possibly the result of neglect, but did not know how to put that information in the medical record without writing that this was neglect. During an interview on 6/1/16 at 11:00 am, the DON stated that on 5/31/16, she received written statements alleging this resident had been neglected over the previous weekend. The Administrator was notified when she found out about it. During an interview on 6/2/16 at 10:00 am, the DON stated that in her investigation CNA #14 told her she did not wake the resident on the 5/29/16 day shift and did not give care to the resident that entire shift. CNA #14 said that if the resident did not drink, she would not urinate, and she did not want to wake the resident because the resident is rude and nasty. The CNA also told her Licensed Practical Nurse (LPN) #6 did not give the resident her medications because the resident was asleep. The DON stated LPN #6 should have attempted to wake the resident before holding the medications. On the evening shift, the resident slept until 6:00 pm, then was given food and drink, neurological checks were completed and at 7:00 pm incontinence care was given. When the night shift arrived, LPN #4 and LPN #5 told CNA #13 not to wake the resident, and that the resident got all her meds (medications) and should be out for a long time. CNA #13 told the DON she had approached the resident at approximately 11:30 pm or 11:45 pm, and the resident yelled at her, so she did not give care to the resident for the entire night shift. When the day shift staff arrived on the morning of 5/30/16, LPN #5 told CNA #17 the resident had received incontinence care on the night shift. CNA #16 reported that the resident was in her chair and was soaked in urine. She also stated the resident had two open areas on her right buttock that were discovered on 5/31/16, and both appeared to be from moisture and shearing. During an interview on 6/3/16 at 7:52 am, the DON stated that CNA #13 had not been suspended during the course of her investigation into allegations of neglect of this resident on 5/29/16. She stated she was not finished with her investigation and should have suspended this CNA. After reviewing her notes, the DON stated she had forgotten to suspend CNA #13. Finding: New York State Education Law §6902, New York law does not include nursing [DIAGNOSES REDACTED]. Thus, Licensed Practical Nurses in New York State do not have assessment privileges; they may not interpret patient clinical data or act independently on such data; they may not triage, they may not create, initiate, or alter nursing care goals or establish nursing care plans. Source: http://www.op.nysed.gov/prof/nurse/nursebroch.htm) Resident #104: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Resident Record revealed the resident was able to understand and had clear speech. Review of the Comprehensive Care Plan's (CCP's) revealed the following nursing care plans were created, initiated or nursing care goals were altered by the Licensed Practical Nurse (LPN) Unit Manager: Communication, Skin Integrity, Dental Care, Pressure Ulcer Risk, Pain, Vision and Urinary and Bowel Incontinence. Resident #135: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, was usually able to understand others, and was usually able to make herself understood. Review of the Comprehensive Care Plan's (CCP's) revealed the following nursing care plans were created, initiated or nursing care goals were altered by the Licensed Practical Nurse (LPN) Unit Manager: Skin Integrity, Behaviors/Mood State/Cognition, Elopement, Vision, Communication, Activities of Daily Living, Urinary and Bowel Incontinence, Falls, Pressure Ulcer Risk, Pain and Actual Pressure Ulcer. There was no documented evidence of a Registered Nurse signature on these CCP's. Resident #136: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, was able to understand others, and was able to make herself understood. Review of the Comprehensive Care Plan (CCP) revealed the following nursing care plans were created, initiated or nursing care goals were altered by the Licensed Practical Nurse (LPN) Unit Manager: Visual Function, Communication, Urinary and Bowel Incontinence, Skin Integrity, Elopement, Hypertension, Resident Smoking, [MEDICAL CONDITION] Medications, Pain. There was no documented evidence of a Registered Nurse signature on these CCP's. Interviews: During an interview on 6/1/16 at 1:30 pm, the Director of Nursing (DON) stated the Licensed Practical Nurse (LPN) Unit Manager was not supposed to create or initiate care plans, and that her doing so was outside her scope of practice. The LPN Unit Manager was supposed to tell RNS #1 when she needed a care plan, and RNS #1 was supposed to oversee the care planning for that unit. During an interview on 6/2/16 at 10:51 am, Registered Nurse Supervisor (RNS) #1 stated the LPN Manager was not supposed to create or initiate nursing care plans, or alter nursing care goals. She reviewed the CCP's of Resident #'s 104, 135 and 136 and stated these care plans were initiated and altered by the LPN Manager. She stated there was no one particular Registered Nurse (RN) responsible for reviewing the care plans on the LPN Manager's unit, but she was supposed to get an RN to review and sign the care plans. During an interview on 6/2/16 at 12:35 pm, the LPN Manager stated the RNs normally initiate care plans on her unit. She stated that when the new electronic record was implemented at the facility, she put the care plans in and they were supposed to be reviewed and signed by an RN. She stated she had notified an RN in the facility a few weeks ago but the RN still had not reviewed the care plans. During an interview on 6/2/16 at 12:40 pm, the Administrator stated LPN's were not supposed to initiate care plans or alter nursing care goals, and in doing so the LPN was [MEDICATION NAME] outside her scope of practice. 10 NYCRR 415.26

Based on interview and record review during a recertification survey and an abbrieviated survey (Case #s NY 882 and #NY 512), the facility failed to ensure the development and implementation of written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for 2 (Resident #23 and 58) of 14 residents reviewed for abuse/neglect. Specifically, the facility's Policy and Procedure (P&P) did not include interventions for protecting residents from potential further neglect during an investigation. On 5/30/16, Certified Nursing Assistants (CNA's) notified the Registered Nurse Supervisor (RNS) that Resident #23 did not receive care on the day and night shifts on 5/29/16. The RNS did not recognize her responsibility to identify neglect (failure to provide goods and services)) and did not immediately intervene when 2 CNA's gave her statements that the resident did not receive care, did not immediately notify Administration, and did not ensure one of the involved CNA's was removed from resident care to protect residents from potential harm. Additionally, the Director of Nursing upon notification of the allegation of neglect failed to remove one of the involved CNA's (CNA#13) from resident care to protect residents from potential harm during the investigation. This resulted in immediate jeopardy to resident health or safety and substandard quality of care for Resident #23, and had the potential to affect all residents in the facility. Additionally, the facility did not protect Resident #58 from abuse when facility staff did not adequately investigate and address multiple allegations regarding CNA #2's treatment of [REDACTED].#2 was observed pulling Resident #58's head back by her hair and verbally threatened her using foul language. Facility staff that witnessed this incident did not intervene to prevent further abuse by reporting this incident when it occurred to Administration. This was evidenced by: The undated P&P for Abuse documented it was the responsibility of all staff, as well as licensed personnel whether employed by the facility or not, to prevent occurrences of abuse, mistreatment and neglect. Staff were to identify, correct and intervene where abuse may occur, and report alleged violations and sustained incidents to appropriate authorities. Additionally, residents were to be protected from harm during an investigation. The Reasonable Cause definition included the statement Upon review of circumstances there is sufficient evidence for a prudent person to believe that physical abuse, neglect or mistreatment has occurred. An example of reasonable cause is a statement, the presence of a physical condition which is inconsistent with the history or course of treatment of [REDACTED]. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm or mental anguish. The Neglect definition also included the failure to provide nutrition, medication, sanitary clothing and ADL's. The undated Policy and Procedure (P&P) for Incident and Accident Reports documented that abuse, mistreatment or neglect be reported to administration as soon as possible. Resident #23: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have severely impaired cognition, was able to make herself understood and was able to understand others. She was also assessed to require the total assist of two staff for transfers, and extensive assistance of two staff for bed mobility. Refer to F Tag 224 for additional information regarding Resident #23. An undated Staff Statement signed by Registered Nurse Supervisor (RNS) #1, documented that on 5/30/16 at 11:30 am (a Monday), Certified Nursing Assistant (CNA) #16 asked her to assess this resident because she had not been touched and was in the same clothes, in the same chair since the previous Friday. CNA #16 reported that the night shift said they had recently provided incontinence care, but when they got the resident out of the chair that morning (5/30) the resident was soiled through several layers. CNA #17 also reported that CNA #14 had provided no care to this resident on the day shift of 5/29/16. RNS #1 spoke with the 5/29/16 day shift CNA (#14) who openly admitted she didn't do care because the resident was sleeping and she thought care was done by the previous shift since the resident was already dressed and in a chair. RNS #1 then assessed the resident and found an open area that appeared to be caused by moisture although RNS #1 did not know if the area was old or new. During an interview on 6/2/16 at 3:45 pm, RNS #1 stated that mid-morning on 5/30/16, CNA #16 told her that when she started her shift that day, this resident was exactly where she was on Friday (5/27/16), and was wearing the same clothes, and was soaked with urine. CNA #17 reported that CNA #14 did no care for this resident on the day shift on 5/29/16. At approximately 11:00 am, CNA #14 told RNS #1 that she had not provided care to this resident on the 5/29/16 day shift because she did not want to wake the resident because of her behaviors. She stated CNA #s 14 and 17 wrote statements, and the RNS (#1) put them under the door of Registered Nurse Manager (RNM) #2, so she could see it when she came in on 5/31/16, and reported the allegations to the evening RNS (#2). In the morning of 5/31/16, she reported the allegations to the Director of Nursing (DON) and the Administrator. RNS #1 stated she recognized this as a potential neglect, but did not remove CNA #14 from care because she did not know what to do with this information. She stated she knew the P&P for Abuse because she wrote it, and knew to start an investigation, but did not immediately notify the DON because she did not know what to do. RNS #1 also stated she did not write a nurses note about the wound she saw when she assessed the resident, because it was possibly the result of neglect, but did not know how to put that information in the medical record without writing that this was neglect. During an interview on 6/3/16 at 5:05 pm, RNS #2 stated that on 5/30/16 at the change of shift from day shift into evening shift, RNS #1 told him there was an allegation of neglect regarding staff and Resident #23. He stated he thought the matter had been handled and passed the information on to the night RNS (RNS #3). During an interview on 6/2/16 at 2:59 pm, RNM #2 stated when she arrived for work on the morning of 5/31/16 (a Tuesday), written staff statements had been slid under her door from CNA #s 16 and 17. They wrote that the resident was in the same clothes and chair since Friday and was soaked in urine. They said they could smell the resident from down the hallway. She stated she immediately reported this to the DON. She stated she then assessed the resident and noted a wound on her right buttock which appeared to be from moisture or shearing. She stated this was a new wound. RNM #2 reviewed the resident record and stated there was no documentation that RNS #1 had assessed the resident on 5/30/16. During an interview on 6/1/16 at 11:00 am, the DON stated on 5/31/16 she received written statements alleging this resident had been neglected over the previous weekend. The Administrator was notified when she found out about it. A record of the Time Card for CNA #13 revealed she worked the following dates and times: from 9:59 pm on 5/29/16 unitl 6:56 am on 5/30/16. From 10:03 pm on 5/30/16 until 7:00 am on 5/31/16. From 9:57 pm on 5/31/16 unitl 7:04 am on 6/1/16. From 9:55 pm on 6/1/16 until 7:29 am on 6/2/16. From 9:54 pm on 6/2/16 until 7:00 am on 6/3/16. During an interview on 6/3/16 at 6:10 am, CNA #13 stated she had worked night shift on 5/29, 30 and 5/31/2016, and 6/1 and 6/2/2016. She stated that she had not been suspended after the allegations related to this resident on 5/29/16. During an interview on 6/3/16 at 7:52 am, the DON stated that CNA #13 had not been suspended during the course of her investigation into allegations of neglect of this resident on 5/29/16. She stated she was not finished with her investigation and should have suspended the CNA. After reviewing her notes, the DON stated she had forgotten to suspend CNA #13. During an interview on 6/3/16 at 8:46 am, the Nurse Practitioner (NP) stated this resident had an intermittent history of behaviors along with a [DIAGNOSES REDACTED]. Resident #58: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have long and short term memory problems, with severely impaired decision making skills. The facility investigation into an incident with Resident #58 which occurred on 4/3/16 and was reported to the DOH (Department of Health) Hotline on 4/7/16, was provided to the (DOH) Surveyor on 5/31/16. The investigation consisted of 5 staff member interviews, resident records, and accused Certified Nurse Aide (CNA's) personnel records. There was no documented evidence of a summary of the investigation. A request from the DOH Surveyor to the Director of Nursing (DON) for a written summary of the investigation, was provided to the DOH Surveyor on 6/2/16. The facility Summary of findings regarding the incident dated 4/3/16, documented the time of occurrence 7:30 pm, and was reported to Administration on 4/6/16. CNA #1 reported on 4/6/16 that on 4/3/16 she witnessed CNA #2 grab Resident #58 by the hair, jerk her head back and to look her in the eyes saying we are not gonna have any f--king (expletive) problems tonight because I am too tired and I don't have time. She then turned to CNA #1 and said it doesn't leave a mark and what you see here stays here. They finished getting the resident ready for bed. The incident was reported after CNA #1 spoke with another CNA about it. CNA #2 denied the allegation, she was suspended and then terminated. The facility Summary of Findings regarding the incident dated 4/3/16, documented the time of occurrence 7:30 pm, and was reported to Administration on 4/6/16. CNA #1 reported on 4/6/16 that on 4/3/16 she witnessed CNA #2 grab Resident #58 by the hair, jerk her head back and to look her in the eyes saying we are not gonna have any f--king (expletive) problems tonight because I am too tired and I don't have time. She then turned to CNA #1 and said it doesn't leave a mark and what you see here stays here. They finished getting the resident ready for bed. The incident was reported after CNA #1 spoke with another CNA about it. CNA #2 denied the allegation, she was suspended and then terminated. Licensed Practical Nurse (LPN) #1 who usually worked with CNA #2, stated CNA #2 was often loud and gruff with residents, but he had never seen any signs of resident abuse. He stated he spoke to CNA #2 once about her approach, and she told him I'm military and I'm a little gruff. LPN #1 stated that CNA #1 came to him on 4/6/16 and stated you will be mad at me, but I need to tell you what happened and she proceeded to report the occurrence. The facility interviewed CNA's #'s 1, 3, 4, 5, 6, 7, 8, and #9 as they had worked with CNA #2. None reported witnessing any verbal or physical abuse (there was no written evidence of interviews for CNA #'s 4, 5, 6, 7, 8, and #9). The RN Nurse Manager and the Director of Nursing (DON) counseled CNA #1 about the requirements for reporting abuse, noting she is to stop and report immediately. She stated she was afraid of repercussions from CNA #2, but reported the incident because she felt so bad. Resident Event Investigation Staff Statements for five staff member included in the facility investigation were: 1. CNA #1 was in Resident #58's room getting her ready for bed. CNA #2 swore at the resident saying you better f---ing (expletive) behave tonight I do not have the time or energy. CNA #2 pulled the residents hair back so she could look her in the eye. CNA #2 told CNA#1 that pulling hair did not leave marks. CNA#2 also said, what you see or hear here stays here. 2. CNA #2 stated she and CNA #1 did this resident's care, and Resident #58 raised her hand and I told her to put it down. CNA#2 finished her care and put her to bed, and stated she only went in to help with care. 3. CNA #3 reported that she was not working on 4/3/16, but when she worked on 4/6/16, she was told about the incident when she was feeding other residents. She was told that CNA #2 pulled Resident #58's hair and said that there will be no problems. 4. LPN #1 documented that he was approached by CNA #1 on 4/6/16, over an issue on Sunday 4/3/16. CNA#1 told him that while toileting Resident #58, CNA #2 pulled the resident's hair and told her that she was to behave tonight. CNA #1 also told LPN#1 that CNA #2 told her what happens in the room stays in the room, and not to worry it won't leave a mark. CNA #1 also stated that CNA #6 was also in room while this was going on. 5. A written statement dated 4/7/16, and identified as a telephone interview with LPN #1, documented a few instances including: CNA #2 being loud with residents and often gruff and stern. CNA#2 lied about feeding residents, and instead put their food in the refrigerator. LPN#1 also talked with the supervisor about watching CNA #2. CNA #2 had been spoken to before, but she stated I'm military and I'm a little gruff. The Facility Investigation included an Office of Attorney General, Medicaid Fraud Control Unit Deposition. The deposition was written by CNA #1 and documented, I have worked on the dementia unit since I started. On 4/3/16, I was working the 3-11 shift (evening). At about 7:30 pm on this day, I was in Resident #58's room with CNA #2 and CNA #6 (who was orienting) getting the resident ready for bed, we were all in the bathroom, I pulled the resident's pants and brief down and we placed her on the toilet. As the resident was on the toilet CNA #2 grabbed the resident by the hair on top of her head to look the resident in the eyes and say we are not gonna have any f---ing (expletive) problems tonight because I'm too tired and I don't have time. CNA #2 then looked at me and CNA #6 and said it doesn't leave a mark, and what you see here stays here. CNA #6 then left the room and I think it was because she was upset about what CNA #2 just did to the resident. I helped CNA #2 finish getting the resident ready for bed and then left the room. I worked with CNA #2 the rest of the shift and didn't see any other issues with her care. I reported the incident on 4/6/16 to LPN #1. I talked to another CNA #10 and decided it should have been reported. During an interview on 6/1/16 at 1:55 pm CNA #1 stated the incident she reported on 4/6/16, happened a few days before (4/3/16). CNA #1 stated she was kinda scared, because of the way CNA #2 would react. CNA #2's demeanor showed she was angry. Nurses would tell her not to yell at the residents. CNA #1 stated she received inservice on abuse, she could remember that reports of abuse should be made within 24 or 48 hours. CNA #1 stated that Resident #58 can be abusive to staff with biting and kicking. On 4/3/16, CNA #1 asked for help with Resident #58 and CNA #2 and CNA #6 (orientee) came into the room. CNA #1 and CNA #2 stood Resident #58 up and pulled down her pants and set her on the toilet. CNA #2 immediately grabbed Resident #58 hair, pulled her head back and said in her face, were not going to have any f---ing problems tonight, I'm not going to do this. CNA #2 then looked at CNA #1 and CNA #6 and said, what you see here stays here and it does not leave a mark. Resident got mad and started to swat. Both CNA #1 and CNA #2 stayed in room and gave care together, no further problems. CNA #1 stated that prior to the incident the RNM had told CNA #1 that they were looking into CNA #2 and what is going on, because so many residents were getting bruises. During an interview on 6/2/16 at 1:10 pm, CNA #2 stated Resident #58 was not her resident on the night in question (4/3/16). CNA #2 was asked by CNA #1 to help because Resident #58 was combative. There was another CNA present but CNA #2 could not remember her name. CNA #2 could not remember whether she helped to put the resident to bed or on the toilet. CNA #2 stated she will walk out of resident rooms sometimes because of frustration, but never takes it out on the residents. CNA #2 never had a nurse correct her about her verbal behavior toward the residents. There had been no talk of her resident being bruised, and CNA #2 has no history failure to follow care plan. CNA #2 stated she had tossed Resident #58's doll on the bed, but not rough. During an interview on 6/2/16 at 2:30 pm, the Registered Nurse Manager (RNM) #1 stated she became aware of the incident of 4/3/16, with Resident #58 from the evening shift CNAs. The Registered Nurse Supervisor (RNS) started the investigation and the RNM assessed Resident #58's scalp for injury. RNM #1 stated she had spoken to CNA #2 a couple weeks prior to the incident, after the Unit Clerk reported to her that she overheard CNA #2 speaking to Resident #48 in a loud tone. RNM #1 told CNA #2 about her tone of voice being inappropriate and explained the proper way. RNM #1 did not put the conversation in writing. RNM #1 also stated that CNA #2 had reported that there were bruises to her own residents. RNM #1 stated she collected statements from staff in regards to the bruises. RNM #1 could not remember who the residents with the bruises were or exactly how many, she stated there was possibly two residents. RNM #1 stated she reported to the DON that it seemed strange that CNA #2 was the one coming up with the bruises. RNM stated she was not aware of the doll being grabbed from Resident #58 by CNA #2, that was written in the statement of CNA #6 (see below). During an interview on 6/2/16 at 3:00 pm Unit Clerk #1 (UC #1) stated she sits at the nursing station across from Resident #48's room. The UC #1 could not recall the date, but stated that Resident #48 had a hospital gown on that appeared disheveled. CNA #2 approached Resident #48 and said to him let me take that off you, lets go in your room. Resident #48 stated don't let her take me in the room, she's mean to me. UC #1 stated that CNA #2 then took Resident #48 into his room and while in the room the UC #1 heard CNA #2 say stop being so dramatic, I'm not hurting you. CNA #2 then opened the door and Resident #58 came out of his room. UC #1 then reported this to the RNM. During an interview on 6/2/16 at 3:50 pm CNA #10 stated she had been concerned about the way CNA #2 talked to the residents. CNA # 10 had heard CNA #2 speaking to Resident #48 in Spanish and in a [MEDICATION NAME] manner, when CNA #10 asked CNA #2 what she had said to the Resident #48, CNA #2 said she told the resident to shut up. CNA #10 also witnessed CNA #2 yelling at Resident #43. CNA #10 stated she reported to the Registered Nurse Manager (RNM) that she did not like the way CNA #2 treated the residents. During an interview on 6/2/16 at 3:55 pm, LPN #3 stated that CNA #2 did not speak nicely to the residents, she was short and yelled at them. LPN #3 tried to talk to CNA #2 about the way she treated residents, and CNA #2 did not want to hear it. LPN #3 did report the behavior of CNA #2 to the RNM. During an interview on 6/2/16 at 11:20 am, CNA #6 stated I know CNA #1 said I was in the room on 4/3/16 with Resident #58, but I was not. CNA #6 stated I wasn't in the room when the hair pulling occurred. CNA #6 stated when she first started working at the facility she was observing care with CNA #2. CNA #6 was in Resident #58 room with CNA #2 and the Resident, with the door closed. The Resident (#58) had dolls in her arm and she was not cooperating with CNA #2 giving care. CNA #6 witnessed CNA #2 grab the doll from the resident's arms and threw it across the room. CNA #6 stated that CNA #2 said to her what you learn in school is not what you will see. CNA #6 stated that CNA #2 was cold and mean to the residents. CNA #6 did not report CNA #2's behavior to anyone. During an interview on 6/3/16 at 8:50 am, the Registered Nurse Inservice Coordinator (RNIC) stated that a Power Point Abuse training was done for employees in September 2015, all employees who missed the initial inservice had viewed the Power Point inservice and completed a post test. RNIC stated that in January 2016 there was an incident of abuse, maybe a resident to resident, but could not remember the circumstance. A facility wide inservice was done with all staff in January 2016 to review abuse reporting. During an interview on 6/3/16 at 7:50 am, the DON stated that abuse education was done with CNA #1 following the report of the 4/3/16 incident with CNA #2. The case was considered completed. The DON did remember talking about the bruises on the residents assigned to this CNA and asked the RNM to look into it. DON could not remember the residents involved. The DON stated the RNM did tell her of the UC #1 report during the investigation for the 4/3/16 incident, DON was not aware of the UC #1 report prior to the 4/3/16 incident. DON was not aware of any other reports from staff members in regards to CNA #2's behavior towards the residents. DON stated there was an abuse in January that resulted in abuse inservice for all staff being done, DON stated she could not remember the incident or resident involved. 10 NYCRR 415.4(b)

Based on medical record review and staff interviews, during a standard recertification survey it was determined that the facility Quality Assurance (QA) Program did not have a process that readily identified issues that had the potential to cause serious harm to residents. It was determined the facility failed to have an effective system in place to ensure critical medications were administered to all residents as ordered by the physician. The lack of an effective system resulted in fourteen (14) out of twenty-six (26) residents not receiving significant necessary medications. This resulted in Immediate Jeopardy to the health and safety of the Residents. This is evidenced by: Interviews conducted with the nursing supervisors, the Director of Nursing, the contract pharmacy pharmacist, the Medical Director and the Nursing Home Administrator reveal that they were unaware of the medication omissions until it was brought to their attention by the DOH survey team. The Medical Director stated he would have expected to be notified of any medication omissions. Refer to F 333-Scope and Severity-L. During an interview on 7/22/15 at 1:30 pm the DON stated they were looking into the problem with medication omissions and noted the medication computer system has a keystroke for reorder of medications and the keystroke was not operational. All nurses will be re-educated to order medications using the sticker system, and will be made aware that the reorder keystroke in the computer is not functional. During an interview on 7/22/15 at 3:00 pm the Medical Director stated he expects to be notified by phone or in writing in the communication log when a medication is not given as ordered. He encourages staff to call and let the medical staff make decisions so nursing staff will not be accountable for problems. During an interview on 7/23/15 at 11:35 the Administrator stated that she had no knowledge of the blanks in the MARs. Since learning of the blanks in the MARs the facility had started to educate their own nurses and agency nurses in regards to the process of ordering medications. The Medical Director and Nurse Practitioner are educating staff on the use of the MD communication books for notifying the physicians of resident needs. During an interview on 7/23/15 at 11:35 am the Quality Assurance Registered Nurse (QARN) stated she was recently hired to be the full time Quality Assurance Nurse. Following the discovery of the blanks in the Medication Administration Record [REDACTED]. The Electronic Medication Administration Record [REDACTED]. The QARN felt that their own nurses as well as the agency nurses have been using that tab to reorder medications, which were not being ordered at all. A full house inservice on the sticker system for the reorder of medications had started. QARN is in the process of developing an audit to look at the MARS, and to run a report daily of the medications administered. The daily checks were to start today. 10NYCRR415.27 (a-c)

Based on observation, medical record review and interviews during a recertification survey it was determined that the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. It was determined the facility failed to have an effective system in place to ensure critical medications were administered to all residents as ordered by the physician. The lack of an effective system resulted in fourteen (14) out of twenty-six (26) residents not receiving significant necessary medications. This resulted in Immediate Jeopardy to the health and safety of the residents. This is evidenced by: Interviews conducted with the nursing supervisors, the Director of Nursing (DON), the contract pharmacy pharmacist, the Medical Director and the Nursing Home Administrator reveal that they were unaware of the medication omissions until it was brought to their attention by the Department of Health's survey team. The Medical Director stated he would have expected to be notified of any medication omissions. Refer to F 333-Scope and Severity-L. During an interview on 7/22/15 at 1:30 pm the DON stated they were looking into the problem with medication omissions and noted the medication computer system has a keystroke for reorder of medications and the keystroke was not operational. All nurses will be re-educated to order medications using the sticker system, and will be made aware that the reorder keystroke in the computer is not functional. During an interview on 7/22/15 at 3:00 pm the Medical Director stated he expects to be notified by phone or in writing (in the communication log) when a medication is not given as ordered. He ststed that he encourages staff to call and let the medical staff make decisions so nursing staff will not be accountable for problems. During an interview on 7/23/15 at 11:35 the Administrator stated that she had no knowledge of the blanks in the MARs. Since learning of the blanks in the MARs the facility had started to educate their own nurses and agency nurses in regards to the process of ordering medications. The Medical Director and Nurse Practitioner are educating staff on the use of the MD communication books for notifying the physicians of resident needs. 10NYCRR415.26

Based on record review and interview during a recertification survey and a complaint survey (NY 131), it was determined that the facility failed to have an effective system in place to ensure critical medications were administered to all resident's as ordered by the physician. The facility's lack of an effective system resulted in twelve (Resident #'s 27, 39, 60, 61, 105, 118, 121, 135, 142, 147, 170 and #174) out of twenty-six residents not receiving significant necessary medications. Specifically, a record review for the months of May, June, and July 2015 revealed that thirteen of twenty-six residents did not receive significant medications on multiple occasions. Significant medication omissions included several medications critical to resident care including [MEDICATION NAME], [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. There was no documented evidence in the resident records indicating the reason the above medications were not given or that the physician was notified. This resulted in no actual harm, but there was a potential for serious harm for all residents in the facility and this resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This was evidenced by: The Policy & Procedure (P&P) dated 3/27/13 titled Proper Administration and Storage of all Medications documented: chart any failure to give medications by checking the not given button on the eMAR (electronic medication administration record); Click the given button to proceed to chart reason for any failures and to complete medication pass; Document in progress note and on report sheet any failure to administer medication with the reason and time. The P&P dated 4/2014 titled Medication Errors-Reporting and Documenting included documentation that a medication error includes deviations from facility policy and procedure regarding the safe delivery of medications. An example of a medication error included the omission of a medication. The P&P also documented that a procedural error included medication doses not being charted. The P&P noted that upon discovery of any medication error, the nurse discovering or committing the error would immediately notify the Nurse Manager (NM) and initiate a Medication Error Incident Report. A review of the eMAR revealed that for each medication the nurse must document whether the medication was given or not given. If a medication was not given, there is a drop down box for facility licensed staff to choose the reason for not giving the medication. The choices in the drop down box include: medication not in from pharmacy; medication on hold; medication refused; resident out of facility; and monitoring protocol. The following medications that were not administered in the examples below, varied in the choice selected from the drop down box. Additionally, there was no evidence of supporting documentation in the nursing progress notes regarding the reason medications were not administered. Resident #39 The facility failed on multiple occasions to ensure that the resident received significant medications to treat [MEDICAL CONDITION] and an enlarged Prostrate . The Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13, which indicates intact cognition. A review of physician's orders [REDACTED]. [MEDICATION NAME] (treats [MEDICAL CONDITION]) 50-200-200 milligram (mg) 1 1/2 tab twice per day (bid), start date 3/16/15; [MEDICATION NAME] (treats [MEDICAL CONDITION]) 1 mg once per day (qd), start date 3/16/15; [MEDICATION NAME] (antibiotic) 250 mg bid, start date 4/1/15; [MEDICATION NAME] CR (treats [MEDICAL CONDITION]) 50-200 mg at bedtime (hs), start date 3/16/15; and [MEDICATION NAME] (treats an enlarged prostate) 5 mg every morning (qam), start date 4/1/15. A review of this resident's eMARs dated May, June and July 2015 revealed that the physician ordered medications were not administered as indicated by a circled X on the following dates: 5/01/15: [MEDICATION NAME] 50-200-200 mg 1 1/2 tab bid missed 5:00 am dose and 11:00 am dose. 5/05/15: [MEDICATION NAME] 1 mg bid, missed 7:00 am dose. 7/03/15: [MEDICATION NAME] 1 mg bid, missed 7:00 am dose. 7/04/15: [MEDICATION NAME] 1 mg bid, missed 7:00 am dose. 7/19/15: [MEDICATION NAME] 1 mg bid, missed 7:00 am dose. 5/20/15: [MEDICATION NAME] 250 mg bid, missed 5:00 pm dose. 6/21/15: [MEDICATION NAME] 250 mg bid, missed 5:00 pm dose 6/13/15: [MEDICATION NAME] 250 mg bid, missed 9:00 am dose. 5/27/15: [MEDICATION NAME] CR 50-200 mg at hs, missed 7:00 pm dose. 6/02/15: [MEDICATION NAME] CR 50-200 mg at hs, missed 7:00 pm dose. 6/04/15: [MEDICATION NAME] CR 50-200 mg at hs, missed 7:00 pm dose. 6/05/15: [MEDICATION NAME] CR 50-200 mg at hs, missed 7:00 pm dose. 6/22/15: [MEDICATION NAME] CR 50-200 mg at hs, missed 7:00 pm dose. 7/01/15: [MEDICATION NAME] CR 50-200 mg at hs, missed 7:00 pm dose. 7/19/15: [MEDICATION NAME] 5 mg qam, missed 7:00 am. A review of the nursing progress notes from May, June and July 2015 did not include documentation regarding the reason the above medications were not given or that the physician was notified. During interview on 7/21/15 at 11:40 am, the Registered Nurse Unit Manager (RNUM) #3 stated, if medications were not available, or a resident refuses their medications there should be a nursing progress note. The RNUM stated that if a medication is not available the nurse needs to notify the physician. The RNUM was not aware that the medications were not given. The RNUM stated that the [MEDICAL CONDITION] drugs are especially important not to miss. During interview on 7/21/15 at 12:15 pm, the Director of Nursing (DON) stated there was no system in place at this time to ensure medications were given as ordered by the physician. The DON stated that all medications should be given. She stated that the facility pharmacy will deliver emergency medications when needed and that there was a local pharmacy available to dispense medications when needed. Resident #142 The facility failed, on two occasions, to ensure that the resident received the significant medication [MEDICATION NAME] (injectable blood thinner) for the prevention of [MEDICAL CONDITION] (blood clot in the deep veins). The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as having intact cognitive skills for daily decision making. A Physicians Order Form with a start date of 6/30/15 documented: [MEDICATION NAME] Sodium injectable solution 5,000 units/millimeters (ml), 0.5 ml every 8 hours for [MEDICAL CONDITION]. A review of the resident's eMARs dated May, June and July 2015 revealed that the medication [MEDICATION NAME] was not administered as indicated by a circled X on the following dates: 7/12/15 [MEDICATION NAME] at 10:00 pm 7/13/15 [MEDICATION NAME] 6:00 am The Nursing Progress Note dated 7/12/15 at 10:41 pm documented: [MEDICATION NAME] not given; RNS (Registered Nurse Supervisor) notified; medication unavailable; and pharmacy states too early for med refill. There was no documented evidence of a nursing note regarding the unavailable injectable medication [MEDICATION NAME] on 7/13/15. During interview on 7/23/15 at 2:50 pm, Registered Nurse Manager (RNUM) #1 reported she was made aware of the missed dose on 7/13/15. RNUM #1 called the pharmacy and they agreed to send [MEDICATION NAME] even though it was too early for a refill. RNUM #1 reported that the physician should have been contacted both times the [MEDICATION NAME] was not administered. RNUM #1 was unable to provide documented evidence of physician notification of the missed doses of [MEDICATION NAME]. During interview on 7/23/15 at 3:15 pm, the Director of Nursing (DON) stated that she was not aware that a [MEDICATION NAME] dose was not administered as it was unavailable and that she was unaware that another [MEDICATION NAME] dosage did not include documented evidence that it had been administered. The DON reported that there was no investigation or Medication Error Incident Report. Resident #135 The facility failed, on multiple occasions, to ensure that the resident received significant medications for the treatment of [REDACTED]. The resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have moderate impairment in cognitive skills for daily decision making and as usually understood and able to understand others. The physician's orders [REDACTED]. [MEDICATION NAME]-[MEDICATION NAME] (Carb/Levo) Oral Tablet Extended Release (ER) 50-200 mg ([MEDICATION NAME] CR) one tablet by mouth bedtime; Carb/Levo 25-100 mg tab two tablet(s) by mouth five times daily at 6:00 am, 09:00 am, 12:00 pm, 3:00 pm, and 6:00 pm; [MEDICATION NAME] Sodium oral tablet 88 mcg ([MEDICATION NAME]) (6 pm) 1 tablet by mouth every evening; [MEDICATION NAME] oral tablet 0.5 mg ([MEDICATION NAME]) one tablet by mouth three times daily at 5:00 am, 11:00 am, 6:00 pm. The physician's orders [REDACTED]. [MEDICATION NAME] oral tablet 15 mg ([MEDICATION NAME]) tab 15 mg) 0.5 tablet by mouth bedtime. A review of the electronic Medication Administration Record [REDACTED] 05/01/15 Carb/Levo 50-200 mg ER tab one tablet by mouth bedtime, 9 pm dose 05/03/15 Carb/Levo 50-200 mg ER tab one tablet by mouth bedtime, 9 pm dose 05/02/15 Carb/Levo 25-100 mg, 3 pm dose 05/24/15 Carb/Levo 25-100 mg, 6 am dose 05/03/15 [MEDICATION NAME] oral tablet 0.5 mg, 6 pm dose 05/24/15 [MEDICATION NAME] oral tablet 0.5 mg, 5:00 am dose 05/03/15 [MEDICATION NAME] sodium oral tablet 88 mcg ([MEDICATION NAME]) 6 pm dose 05/03/15 [MEDICATION NAME] oral tablet 15 mg 0.5 tablet, 9 pm dose 05/16/15 [MEDICATION NAME] oral tablet 15 mg 0.5 tablet, 9 pm dose A review of the eMAR dated May 2015 revealed that three of the following physician ordered medications were not documented as administered as indicated by a red x with no documented evidence of an explanation of a reason the medications were not given on the following dates: 05/13/15 [MEDICATION NAME] oral tablet 15 mg 0.5 tablet, 9 pm dose 05/15/15 [MEDICATION NAME] oral tablet 15 mg 0.5 tablet, 9 pm dose 05/24/15 Carb/Levo 25-100 mg tablet, 3 pm dose There was no documented evidence that the physician was notified that any of the above medications were not available or not given. During interview on 07/25/15 at 2:45 pm, Registered Nurse Manager (RNUM) #2 stated that he is not sure why there are so many blanks and red x's on the eMAR regarding medications. The RNUM #2 stated that when there is a red x on the eMAR there should always be a corresponding note documenting why the medication was not administered and there should be no blanks. RNUM #2 stated that in the past, he had put a note in the eMAR regarding a medication only to go back and see what he had previously put in the eMAR was not there. RNUM #2 said he thought it could be computer glitch. During interview on 7/22/15 at 11:20 am, the Pharmacist stated that there are delivery times with cut off times for new medication orders to be delivered. The cut off times are 9:00 am for the delivery to leave the pharmacy at 11:00 am; cut off time for 4:00 pm for the delivery to leave the pharmacy at 6:00 pm; and cut off time for 9:00 pm for the delivery to leave the pharmacy at 11:00 pm. There is also a local back-up pharmacy that the facility pharmacy will contact if a medication need is emergent. The Pharmacist stated the medication omissions for Resident #39 were reviewed and it was found that on some occasions, the facility ran out of the medication because they ordered the medications just before or after they ran out. During interview on 7/22/15 at 1:30 pm, the Director of Nursing (DON) stated they were looking into the problem with medication omissions and noted the medication computer system had a keystroke for reorder of medications and that the keystroke was not operational. The DON stated all nurses will be re-educated to order medications using the sticker system, and will be made aware that the reorder keystroke in the computer is not functional. During interview on 7/22/15 at 3:00 pm, the Medical Director stated he expects to be notified by phone or in writing in the (facility) communication log when a medication is not given as ordered. He stated he encourages staff to call and let the medical staff make decisions so nursing staff will not be accountable for problems. During interview on 7/23/15 at 11:35 am, the Administrator stated that she had no knowledge of the blanks in the eMARs. Since learning of the blanks in the eMARs, the Administrator stated that the facility had started to educate their own nurses and agency nurses in regards to the process of ordering medications. She stated the Medical Director and Nurse Practitioner are educating staff on the use of the physician communication books for notifying the physicians of resident needs. 10 NYCRR 415.12(m)(2)

Based on observation, interview and record review during a partially extended recertification survey and abbreviated survey (Case #s NY 359 and NY 068) it was determined that the facility did not ensure the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents for two (2) (Resident #'s 110 and 170) of three (3) residents reviewed. Specifically, for Resident #170 who had a known history of falls, the facility did not assess for and implement fall prevention interventions. Subsequently, the resident fell and sustained a subdural hematoma (a potentially life threatening accumulation of blood on the brain). Additionally, for Resident #110 the facility did not implement fall prevention interventions when she fell three (3) times in one day, and did not implement care planned interventions prior to a fourth fall. Subsequently, the resident fell and sustained a fractured nose. This was evidenced by: A Policy & Procedure (P&P) for Falls dated 7/2004, documented that the medical staff and the interdisciplinary care team (IDT) were to assess residents on admission, annually, after a significant overall change and after acute falls. The Physical Therapy (PT) department was to assess for fall risk injury on admission. The nursing and medical staff were to review the bedrail/fall risk form and obtain MD orders as indicated. The P&P for Change in Resident's Condition dated 11/2008, documented that the medical staff were to be promptly notified of changes in a resident's physical, mental or psychosocial condition. The charge nurse was to notify medical staff and/or a Supervisory Registered Nurse (RN) of a change in the resident's condition. Resident #170 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Nursing Home Transfer form from the previous facility dated 6/17/15, documented that the resident was alert, oriented, and confused at times. It also documented that transfer and ambulation required two assist with walker, and assistance with personal hygiene A Nurses Note dated 6/17/15 at 4:14 pm, entered by the Licensed Practical Nurse Unit Manager (LPNUM) documented that the resident was alert with some confusion, and was redirected with fair effect and that the Nurse Practitioner (NP) had reviewed the orders. The Admission Skin assessment dated [DATE] at 5:28 pm, was completed by Registered Nurse Unit Manager (RNUM) #1. There was no documented evidence of other assessments. The Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Kardex (used by staff to know what care the resident required) dated 6/17/15, documented that the resident ambulated and transferred with a wheeled walker and the assistance of two staff. A Nurses Note dated 6/18/15 at 3:12 am entered by an LPN documented that at 1:00 am, the nurse was called to resident's room where it was observed resident lying on the floor on his left hip. The RNS (Registered Nurse Supervisor) assessed the resident and neurological checks (which help detect the presence of neurological injury and monitor its progression) were initiated. The resident was transferred into a wheelchair and placed at the nurses station for observation. There was no documented evidence in the progress note that the physician was notified that the resident was found on the floor. A Nurses Note dated 6/18/15 at 9:00 am entered by the RNS documented that the resident had been found lying on his side on the floor in a fetal position. The resident had stated that he was going to the bathroom when he fell . The RNS documented that the Certified Nurse Aide (CNA) reported that she had just toileted him. The resident had no complaint of pain and his range of motion (ROM) was reasonable. Because he was restless, he was put in his wheelchair and seemed happy to roam about the hallway, and was kept in a high visibility area. As he tired, he was assisted to bed, and chair and bed alarms were placed. An untimed Incident & Accident Report (I&A) dated 6/18/15, documented that the resident had been found lying on his left side in fetal position. He was alert, confused and denied pain. The resident had stated that he had been trying to get to the bathroom when he fell . There was no apparent injury, and it was documented that the medical staff had been notified of the fall by phone. The areas on the form to document who and when the medical staff were notified were blank. A Fall Risk assessment dated [DATE], completed by a Registered Nurse, documented that the resident had intermittent confusion, a history of one to two falls in past three months, was ambulatory and incontinent, required the use of assistive devices, and had three or more predisposing diseases. He was assessed to be a high risk for falls. A Nurses Note dated 6/18/15 at 3:34 pm entered by LPN #1, documented that the resident was a new admission and had had a fall. He appeared to be more tired that shift. During lunch a CNA reported that the resident appeared to be more lethargic than in the morning. A neurological check was within normal limits, his speech was not clear at the time, moans and groans were noted, but the resident was able to nod his head back and forth for yes and no answers. The Nurse Manager was made aware and the NP (nurse practitioner) was called to assess the resident. The Neurological Check Sheet was completed at 1:00 am, 1:15 am, 1:30 am, 1:45 am, 2:45 am, 3:45 am, 4:45 am, 5:45 am, 7:45 am, 9:45 am, and 11:45 am. The areas to document drowsiness, restlessness, resistance, aggressive combativeness, and speech were blank for each neuro check. A Nurses Note dated 6/18/15, entered by the LPNUM, documented that she had received a report that morning that the resident had been found on floor next to his bed. She went to the resident's room at 8:00 am and the resident was in bed, awake and alert. After breakfast the resident was sleeping in his wheelchair. When the resident was called by name, he responded with a moan, and denied pain by shaking his head. The resident's daughter was notified that he had fallen, and was very sleepy today. It was documented that the daughter stated that the resident did that when there was a change in environment and schedule. The NP saw the resident at 1:30 pm, and he was in his wheelchair with head bent, lethargic, not responding to verbal or physical stimuli, pulse was 88, respirations 18, and he was drooling out the right side of his mouth. There was no evidence of injury on the resident's head. The NP ordered the resident to be sent to the hospital and 911 was called. An NP Note dated 6/18/15, documented that the resident was admitted to the facility on [DATE]. He fell while reaching for the phone, broke his hip, underwent surgery, had a closed reduction of his right hip and was doing well. The resident had decided not to initiate long term anticoagulation because of his age and history of falls. The resident had a fall in the night, and it was believed he did not hit his head. Neuro checks were being completed and the resident had a decreased level of consciousness. On assessment, the resident was not responsive to verbal stimuli, and was responsive only to painful stimuli or sternal rub. His pupils were reactive, but he had a pronounced right-sided facial droop. He was drooling, which was new for him, and he was not speaking. The nurse manager was immediately instructed to call 911, and he was sent to the hospital for an evaluation for either stroke or head injury, which was unclear at the time. The Hospital physician progress notes [REDACTED]. The SDH was far too big to reabsorb, and the resident would most likely die from this injury. According to his previously expressed wishes and discussion with his Health Care Proxy (HCP), the hospital would endeavor to keep his suffering and pain to a minimum. During an interview on 7/21/15 at 2:45 pm, LPN #1 stated she was present on the day of admission (6/17/15) for this resident and he had intermittent confusion. On 6/18/15 CNA#1 asked her to see the resident, who was sitting at the table with his head down and sleeping, and had swatted at the LPN when she approached him. At approximately 12:45 pm, a CNA came to the LPN because the resident was not eating. LPN #1 reported to the LPNUM about the change in the resident in the morning. LPN#1 stated that the NP came to see the resident at about 1:30 pm, and the ambulance came 10 minutes later. During an interview on 7/21/15 at 3:45 pm, the LPNUM stated that the resident arrived at the facility at approximately 12:15 pm for admission on 6/17/15. She stated that the RN Infection Control Nurse (RNICN) covered the LPNUM's unit for assessments of residents, but she did not assess this resident on the day of admission. At 2:30 pm, RNUM #1 completed a body assessment. The LPNUM stated that she did not discuss the resident's fall risk with an RN on 6/17/15. The fall assessment was not completed until 6/18/15 by the RNICN. On 6/18/15, the LPNUM and the RNICN discussed the resident's fall risk and decided to continue the bed and chair alarm, which were both initiated immediately following the fall by the night Registered Nurse Supervisor (RNS). If the fall risk was done on 6/17/15 when admitted , a bed and chair alarm would have been put into place. During an interview on 7/22/15 at 8:00 am, the Registered Nurse Supervisor (RNS) who worked the 10:00 pm to 6:00 am shift, stated that she had initiated a bed and chair alarm following the fall at 1:00 am and that prior to the fall there had been no safety devices in place. At the time of the post fall assessment the resident's cognition was good. The resident was very restless following the fall and he was kept up in the wheelchair. During an interview on 7/22/15 at 8:30 pm, the LPNUM reviewed the resident's record and stated that she was not sure when the physician was notified of the fall, and that the time had not been documented. She stated that the resident's fall was not documented in the 6/2015 physician notification book. She stated the CNA ADL Kardex was written when the resident was admitted but the bed and chair alarm were not checked on the form until the following day after the fall. She stated that when completing the CNA ADL Kardex, she used the information from the previous facility to determine the level of assistance a resident required because it usually took Physical Therapy (PT) up to 24 hours to see new residents. Admission paperwork was also done within 24 hours. On 6/18/15, she was notified that the resident had a decline in transfer status from the previous day after 10:00 am following the PT evaluation. Also on 6/18/15, it was lunchtime before she was notified that the resident was spitting out food and medications at breakfast. When she saw the resident in the morning he was lying in bed, and when she spoke to him he just looked at her. When she returned from morning report (which started at 9:00 am), the resident was sitting at a table by the window, she said hi to the resident and he groaned. She felt something was wrong and he needed to be evaluated, so at 10:00 am, she called the NP to ask him to see this resident due to a change in condition. The NP came to the unit at 1:30 pm. She stated that she did not speak to an RN or the NP after her 10:00 am call. During an interview on 7/22/15 at 10:00 am, the NP stated he did not remember the exact time he was called in regards to this resident on 6/18/15. At some point he was told to see this resident when he got a chance. He was not informed of the resident's decline in condition, but was told to see the resident before he left for the day. He stated that if he had known about the change in condition with the transfer status and behavior, he would have sent the resident to the emergency room for evaluation. He stated that he saw the resident mid-day and he was not responsive. He performed a sternal rub, noted the resident had a pronounced facial droop and told the LPNUM to send him to the emergency room . The NP stated that the staff did not speak to him about safety devices for the resident before his fall. During an interview on 7/22/15 at 10:15 am, CNA #1 stated she was with the resident on the day of admission (6/17/15) and obtained his weight and vital signs. The resident was a stand and pivot with two staff assisting for toileting and the resident was a simple transfer, and he was talking and pleasant. On 6/18/15, she saw the resident at 7:30 am and he was antsy and trying to get out of bed. She assisted the resident and his ability to transfer was not as good as the day prior. When she brought him to the dining room for breakfast, he ate but was less talkative, sleepy and drowsy. She reported to LPN #1 that the resident was different than the day before as he was sleepier and drooling at that time, and had a facial droop. The resident was brought back to his room and PT was called to help transfer the resident for a weight. PT decided to make his transfer status a mechanical lift. At lunchtime, the resident was less responsive, still had a facial droop, did not eat lunch and was put back to bed using a mechanical lift. During an interview on 7/22/15 at 11:40 am, the LPNUM stated that she and the RN who performed the body assessment of the resident when he was admitted , should have made sure all of the admission assessments, documentation, and safety devices were completed and put in place when the resident arrived on 6/17/15. She stated that when this resident was found on the floor at 1:00 am, and the fall was unwitnessed, 911 should have been called. During an interview on 7/22/15 at 1:30 pm, the Director of Nursing (DON) stated that the facility had recently developed a template to guide nurses in the admission process. The RNICN covers the unit for the LPNUM for RN duties that need to be done, such as assessments. She also stated that she would have expected the LPNUM to call the DON or another RN to assess a resident for a change in condition. During an interview on 7/22/15 at 3:00 pm, the Medical Director stated that all the assessments for a new resident admission should have been completed as soon as possible. He stated that he thought the system was followed appropriately, the CNA reported to the LPN who reported to the LPNUM, who reported it to the NP. During an interview on 7/23/15 at 8:15 am, the Physical Therapy Rehab Director (PTRD) stated that on 6/18/15, after morning report, a CNA asked him to help transfer the resident to take his weight. The resident was in his chair, eyes were open, and the resident was sleepy and had to tap him to talk with him. CNA #1 told him that the she was able to transfer the resident with two staff assisting earlier that morning. At that point the resident was unable to stand and he changed the resident's transfer status to mechanical lift. He also stated that this resident's fall was reported in morning report, but there was no mention of injury. Resident #110 This resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented that the resident had severe cognitive impairment. Finding #1 During an observation on 4/16/15 at 3:45 pm, Resident #2 was sitting in her recliner chair in her room. Her right eye and surrounding area was moderate purple in color, the left eye extending down the left cheek to mid face had dark purple bruising. An Incident & Accident Report (I&A) dated 4/12/15 at 6:45 am, documented that the resident had slid out of her chair and was sitting on the floor in front of her recliner. She had bumped the left side of forehead, ice was applied and neuro checks started. No other injuries were noted. Possible factors for the fall were documented as Dementia, lack of safety awareness, history of falls and independent in her room. The medical staff were notified by telephone on the 3:00 pm to 11:00 pm shift (evening shift). Documented under heading RN Assessment/Input was that the resident had been leaning for the past few days and was not her usual self. A head check was performed once, then the resident refused to have additional checks done. The root cause of her fall was documented as Dementia, asleep in chair, and leaning a lot. Measures to prevent recurrence were documented as 1:1 supervision for safety. An I&A dated 4/12/15 at 9:30 am, documented that the resident was found sitting on the floor in front of her recliner. A CNA reported that the resident had been leaning forward in her chair and refused to sit back. It was documented that possible factors included: the resident leaned forward and fell out of her chair, and her oxygen was off and was reapplied. There was no documentation under the headings Root Cause, Medical Staff Notified, RN Assessment/Input or Measures to Prevent Recurrence. There was no documentation of 1:1 supervision or for 15 minute checks prior to the second fall. A Nurses Note dated 4/12/15 at 11:53 am, documented that the resident was found sitting on the floor in front of her recliner at 9:30 am. A CNA had been in prior, checked on her and noted her to be leaning forward in her chair. The resident refused to sit back and she was transferred to a wheelchair and taken into the unit kitchen so staff could observe her and keep her safe. A Nurses Note dated 4/12/15 at 2:49 pm, documented that the resident was on the floor in in front of her chair in the unit kitchen, and there was blood on the floor. There was a small cut to the left side of her forehead and a small cut to the underside of her left thumb and one on top of her index finger. A Nurses Note dated 4/12/15 at 7:58 pm, documented that the resident's son expressed concern to the supervisor that the resident was not herself the past few days, that she was bending over more in her chair causing her to slide out of chair. She had several slides in her chair that day, was on neuro checks which remained stable. An I&A dated 4/12/15 at 12:30 pm, documented that a visitor found and reported that this resident was sitting on the floor with a small cut to left side of forehead, a cut on top of the left index finger, and a cut under the left thumb. Possible factors for the fall were documented as: the resident continued to lean forward in her chair. Medical staff were notified by phone and by a matrix message. There was no documentation under the headings: time of notification; RN assessment/Input and; measures to prevent recurrence. There was no documented evidence that this resident was receiving 1:1 supervision or that the resident was on 15 minute checks prior to the third fall. The 15 Minute Check Forms documented that 15 minute checks were performed from 4/14/15 through 4/17/15. There was no evidence of 15 minute check sheets being completed prior to 4/14/15. A Nurses Note dated 4/12/15 at 11:43 pm, and entered by an RN, documented that at 6:45 am this resident was sitting on the floor at base of her recliner chair. She has been leaning a lot, and her positioning had been poor while in her chair. She did not use her bed and only stayed in her chair. The resident was independent in her room and took herself to bathroom. She had bumped her head and had a small bump on top of her forehead on the left side and a cold pack applied. There was no documentation of safety measures to prevent subsequent falls, or notification to PT in regard to resident falling due to her recent leaning in chair. A Nurses Note dated 4/13/15 at 1:15 am, and entered by an RN, documented that on 4/12/15 at 9:15 am, the resident was found sitting on the floor in front of her chair. There were no injuries and the resident was transferred to a wheelchair with a seat alarm, and taken to the dining room for lunch. This nurse was called back to the unit to assess the resident as she fell forward from her wheelchair hitting the left side of her forehead and sustained a cut on her index finger. The NP was notified of this fall and the two previous ones. Informed the NP that the resident was not being cooperative with her neuro checks or allowing staff to see her injuries, and that there may have been an injury to her nose. There was no documentation regarding safety measures to prevent subsequent falls or notification to PT in regard to resident falling due to her recent leaning in chair. A Nurses Note dated 4/14/15 at 6:02 am, documented the resident had an increase in bruising around her eyes and forehead. The RN was made aware. The Comprehensive Care Plan (CCP) for ADL Functional/Rehabilitation Potential dated 5/31/14, documented that on 4/13/15, the resident had a change in ambulation status from independent with front wheeled walker to one person assistance with ambulation. The CCP for Falls documented that on 4/13/15, a chair alarm was applied to all seating surfaces to alert staff that the resident was up, and that she tended to lean over in her chair. She was to be on 15 minute checks if there was no 1:1 attendee, and staff were to sign the 15 minute check sheet. A Nurses Note dated 4/16/15 at 4:39 pm, and entered by the DON, documented that the resident was not leaning over in her chair the way she was 4/12/15 when she fell out of her chair three times. She was seen by PT and OT, and were awaiting report for any changes to her lounge chair to assist in keeping her in her chair. The resident had refused an alarmed belt. Staff were to continue 1:1 assistance when available but the resident was on 15 minute checks at all other times. During an interview on 4/16/15 at 1:45 pm, the DON stated that this resident was now on 15 minute checks and that the resident refused to have an alarmed belt as a safety reminder. During an interview on 4/17/15 at 3:30 pm, the DON stated that following the three (3) falls on 4/12/15, PT and OT talked about seeing the resident and wanted her walked in her room with one assist. The resident was evaluated by PT on 4/16/15, and she did not know why the PT referral was not sent after the falls. Finding #2 An untimed I&A dated 5/9/15, documented that a chair alarm sounded and this resident had started to walk down the hall. Staff found her on her left side with puddles of blood under her head and a skin tear to her hand. The possible factors for the fall were documented as: the resident refused to wear her oxygen, became dizzy and lost balance. The Physician Assistant was notified by phone at 5:30 pm. The resident had been found lying on her left side in the living room area, with blood around her face. She was on the floor bleeding from her nose, nose swollen, bruised. Measures to prevent recurrence were documented as a PT evaluation after resident returned from the emergency room , 15 minute checks, and bed and chair alarms were to continue. There was no documented evidence that 15 minute checks were done or that the resident had 1:1 supervision prior to the fall. There was no documentation of the time of this fall. The 15 Minute Check forms documented that 15 minute safety checks were performed from 4/14/15 through 4/17/15; 4/20/15 through 4/23/15; 4/25/15 through 4/27/15; and one for 5/11/15 which was the day she was readmitted from the hospital following a fall. There was no evidence of 15 minute check sheets being completed prior to the fall or on the day of the fall on 5/9/15. A Nurses Note dated 5/9/15 at 5:38 pm, and entered by an LPN documented that the resident continued to have increased confusion, continued to get up and walk into the hallway, refused to return to her room, and walked to the living room and sat in a wheelchair. The resident kept removing her oxygen. Staff heard the chair alarm and found resident laying on her left side with blood under head, she was bleeding from her nose. The resident wanted to go to the emergency room . Medical staff were made aware and said to send to the emergency room . There was no documented time of the fall. A Nurses Note dated 5/9/15 at 7:17 pm, and entered by an RN, documented that the resident fell and was lying on her left side. Excessive blood was noted on the floor, and the resident was face down in the blood. The resident was bleeding from nose, and the bridge of the nose was noted to be swollen and bruised and she complained of pain to left shoulder and leg. The Physician Assistant was notified and ordered the resident to be sent to the hospital. A Hospital History and Physical dated 5/9/15 at 8:08 pm, documented that the resident came to the hospital after a fall at the nursing home. She stated she was walking in the hall and her knee gave out and she fell on her face. She complained of pain in her nose and left shoulder, and had a nasal septal fracture. During an interview on 5/26/15 at 1:45 pm, the Acting DON stated that the I&As of this resident should have included when the resident was last seen, the root cause of the falls, steps to prevent further falls and the 15 minute checks. 10NYCRR415.12(h)(1)

Based on record review and staff interview during an abbreviated survey (Complaint #'s NY 457, NY 119 and NY 542, and a Post Survey Revisit for Case #NY 353) the facility did not consult with residents' physicians when there were significant changes in the residents' physical status for three (3) (Resident #'s 14, 9 and #5) of fourteen (14) residents reviewed. Specifically, baseline temperatures were not established for Resident #'s 14, 9 and #5. For Resident #14, the facility did not consult with the resident's physician when the resident had a significant change in condition exhibited by fevers over 101 degrees Fahrenheit (F) on 12/7/14, 12/8/14, and 12/10/14, and lethargy 12/8/14 through 12/10/14, with subsequent hospital admission for [MEDICAL CONDITION] (spreading bacterial infection just below the skin surface). Additionally, the facility did not consult with physicians when Resident #9 developed fevers over 101 degrees F on 10/30/14, 10/31/14 and 11/3/14 with subsequent hospital admission on 11/3/14 for fever; Resident #5 had complaints of cold symptoms on 12/3/14 through 12/6/14 with subsequent hospital admission for urosepsis (serious condition occurring after the microorganisms that cause a urinary tract infection spread to the bloodstream). This resulted in actual harm for Resident #14, which is not Immediate Jeopardy. This was evidenced by: A Policy and Procedure (P&P) for Change in Resident's Condition dated 11/2008, documented that staff were to promptly notify the medical staff of changes in a resident's physical, mental or psychosocial condition. Resident #14 This resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. It was also documented that, on the resident's readmission from the hospital on [DATE], the resident had been diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented that the resident was cognitively intact, was able to make herself understood and was able to understand others. Review of the resident record revealed that the last note documented by the physician was dated 10/31/14. An open-ended physician's orders [REDACTED]. A Nurses Note dated 12/7/14 at 3:49 am, documented that the resident had a temperature of 102 degrees Fahrenheit (F), and the resident was given 650 mg of [MEDICATION NAME]. The note was signed by a Licensed Practical Nurse (LPN), and there was no documented evidence that the physician was notified. A Nurses Note dated 12/8/14 at 6:53 am, documented that at 3:48 am, the resident had a temperature of 102.2F. The resident voiced no complaints but was noted to be, "very lethargic". She was given 650 mg of [MEDICATION NAME]. Staff would continue to monitor the resident. The note was signed by an LPN, and there was no documented evidence that the physician was notified. A Nurses Note dated 12/9/14 at 10:14 pm, documented that the resident continued with increased periods of lethargy off and on throughout the evening. The note was signed by an LPN, and there was no documented evidence that the physician was notified. A Nurses Note dated 12/10/14 at 3:37 am, documented that at 12:00 am, the resident's face was flush and she was sweating. Her temperature was 104F, she was alert and responsive and offered no complaints other than feeling warm. The resident's quilt was removed, and she was covered with a sheet and a cool compress was applied. On re-check of the temperature she was 100.4F. The resident stated she still felt warm and not herself. Staff would continue to monitor the resident closely. The note was signed by a Registered Nurse Supervisor (RNS), and there was no documented evidence that the physician was notified. A Nurses Note dated 12/10/14 at 4:03 pm, documented that this was a late entry. At 8:00 am, the resident's temperature was 98.9F, and she continued to be lethargic off and on throughout the day. At 3:10 pm, the resident was noted to have shaking chills and a temperature of 102.2, and [MEDICATION NAME] was given at 3:35 pm. The resident began vomiting a large amount of undigested food, and continued shaking chills, and requested to go to the hospital for evaluation. The note was signed by an LPN, and there was no documented evidence that the physician was notified of the resident's lethargy throughout the day, and no documented evidence that the physician was notified of the resident's vomiting, shaking, chills or temperature of 102.2F. A Nurses Note dated 12/10/14 at 3:57 pm, documented that the resident had a temperature of 102.2F, and [MEDICATION NAME] was given. The resident had a large emesis which contained undisolved [MEDICATION NAME]. Her blood pressure was 110/62, pulse 104, respirations 32 breaths per minute, and her oxygen saturation was 94% on 4 liters per minute of oxygen. The resident stated that she wanted to go to the hospital for evaluation. The family was notified and emergency services were called to transport the resident to the hospital. The note was signed by a Registered Nurse (RN), and there was no documented evidence that the physician was notified. A Nurses Note dated 12/10/14 at 9:28 pm, documented that the resident was admitted to the hospital with [REDACTED]. The Hospital Discharge Summary dated 12/15/14, documented that the resident had been hospitalized for [REDACTED]. Blood cultures revealed that the resident had a [DIAGNOSES REDACTED] (Group B) infection in her blood, and was treated with antibiotics given through the vein. The resident's status improved day-by-day, and was discharged to the nursing home on 12/15/14. During an interview on 12/16/14 at 1:05 pm, LPN #1 stated that this resident had been running fevers, but he had an order to give [MEDICATION NAME] for fever. The LPN stated that she did not know what the acceptable range for a fever was, other than a temperature over 98.6F. She stated that she probably would not give [MEDICATION NAME] for a fever unless the resident asked for it, or if it get as high as 100F. She also stated that she was not aware of any specific temperature a resident had to have before an RN had to be notified, and that the LPN's were not the staff that notified physicians except by writing a note in the physician communication book. There was no documented evidence of MD notification in the physician communication book. During an interview on 12/16/14 at 12:10 pm, Nurse Practitioner (NP) #1 stated that she was notified on 12/6/14, that this resident had a temperature of 102F and that she was shaking and spitting up mucus. This resident was known to get fevers, and she was given [MEDICATION NAME]. She was not made aware that the resident had continued to have fevers, was lethargic, or having chills and shaking until after the resident had been sent to the hospital on [DATE]. She stated that staff should have informed her, NP #2 or the physician when the resident continued to have changes in her condition. During an interview on 12/16/14 at 1:46 pm, Registered Nurse Manager (RNM) #1 stated that this resident started having fevers on 12/6/14. The Nurse Practitioner was notified, and there were no new orders at that time. The resident continued to have fevers, chills, and lethargy, but the LPN's did not notify an RN or the physician until 12/10/14. On 12/10/14 at 12:00 am, the resident did not feel well and had a temperature of 104F. The Nurse Practitioners nor the physician were notified of the resident's continued fevers, lethargy or chills until she requested to go to the hospital on [DATE]. The RNM stated that there was no policy that defined what constituted a fever as ordered by the physician in the resident's order for [MEDICATION NAME]. She also stated that the LPN's should have notified a Registered Nurse, a supervisor, a Nurse Practitioner or the physician when the resident had a fever over 101F, or when she was lethargic or having chills as these were a change in the resident's condition. During an interview on 12/17/14 at 1:54 pm, the Physician who was the Medical Director (MD), stated that in an acute situation, the NP's relied on nurses to report to the RN's to assess residents and report to them. He stated that there seemed to be a contentious relationship between the nursing staff and the NP's, and that he had been, and was concerned about how that relationship could affect the residents. He also stated that changes in a resident's condition should have been reported to the NP's or to the physician. Resident #9 This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented that the resident was cognitively intact, was able to make himself understood and was able to understand others. A physician's orders [REDACTED]. A Nurses Note dated 10/30/14 at 2:50 am, documented that the resident's temperature was 101.8F. The resident was given [MEDICATION NAME] and a cool compress. The note was signed by a LPN, and there was no documented evidence that the physician was notified. The Medication Administration Record [REDACTED]. The Medication Assistance Record (MAR) was signed by an LPN. There was no documented evidence that the physician was notified. There was no documentation in the Nurses Notes regarding this temperature. A Nurses Note dated 10/31/14, at 6:05 am, documented that the resident's temperature was 102.2F at 11:20 pm on 10/30/14, and the resident was given [MEDICATION NAME]. The LPN documented that the care plan would continue to be followed. There was no documented evidence that the physician was notified. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Nurses Note dated 10/31/14, documented that at 8:00 am, the resident's temperature was 101.4F, and the resident was given [MEDICATION NAME]. The note was signed by an LPN, and there was no documented evidence that the physician was notified. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Nurses Note dated 11/3/14, documented that the resident's temperature was 103.2F, and the resident was given [MEDICATION NAME]. The resident's temperature was taken again one hour later and was 102.8, and the resident was given a cool compress. The LPN documented that the plan of care would continue to be followed. There was no documented evidence that the physician was notified. A Nurses Note dated 11/3/14 at 8:13, and signed by RNM #1, documented that the resident's "increased temps" had continued through the weekend, and that "last night" his temperature was over 103F, and did not decrease below 102F. Emergency Medical Services were called and the resident was transported to the hospital. A Nurses Note dated 11/3/14 at 1:04 pm, documented that the resident had been admitted to the hospital with [REDACTED]. During an interview on 12/11/4 at 1:30 pm, RNM #1 stated that this resident regularly ran a high temperature, so staff may not have given it a second thought. She stated that the facility did not have a policy that defined what temperature constituted a fever, or when the physician was to be notified, but that the physician should have been immediately notified when the resident's temperature was 103F. The RNM also stated that the physician should have set parameters for a fever, when the resident was to receive [MEDICATION NAME], and when the physician was to be notified. During an interview on 12/11/4 at 2:20 pm, the Director of Nursing (DON) stated that the facility did not have a policy that defined what temperature constituted a fever, or when the physician was to be notified. She stated that she felt that a Registered Nurse and the physician should have been notified for temperatures over 100F. The DON also stated that the physician should have set parameters for a fever, and when the physician was to be notified. Resident #5 This resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented that the resident was cognitively intact, was able to make herself understood and was able to understand others. A Nurses Note dated 12/3/14 at 6:40 am, documented that this resident's voice was hoarse, and she complained of excessive throat drainage which was hard to clear. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/3/14 at 10:22 pm, documented that this resident complained of cold symptoms and headache. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/4/14 at 6:44 am, documented that this resident continued to have cold symptoms, cough and sore throat. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/5/14 at 12:03 am, documented that this resident continued to have cold symptoms, and had no fever. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/5/14 at 3:04 pm, documented that this resident continued to have cold symptoms, and had no fever. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/6/14 at 1:10 am, documented that this resident continued to have cold symptoms. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/6/14 at 2:38 am, documented that this resident was noted to be unresponsive to verbal stimulus or to touch. The resident's coloring was dusky, and the skin was warm and dry to the touch. Her blood pressure was 90/50, pulse 80 beats per minute, she was breathing 20 times per minute, and her oxygen percentage was 90%. Emergency services and the physician were notified, and the resident was transported to the hospital. The note was signed by an RN. A Nurses Note dated 12/6/14 at 5:33 am, documented that this resident was admitted to the hospital with [REDACTED]. During an interview on 12/10/14 at 12:07 pm, LPN#1 stated that on 12/5/14, he noticed that the resident had a cold, which seemed to have been going around the unit at that time. He stated that her symptoms did not seem serious, she, "just had a cold," so he did not give it a second thought, and did not notify an RN or physician. During an interview on 12/10/14 at 11:55 am, RNM #2 stated that, on 12/5/14 this resident had complained the she felt like she had a cold, so she wanted to cancel an appointment. The RNM stated that, at the time the resident stated this, she did not know how long the resident had been feeling this way. Later on 12/6/14, after the resident had been transferred to the hospital, another staff member told her that the resident had been feeling ill for a few days prior, and that she had been sleeping more than usual. The RNM stated that prior to that conversation, nobody had notified her that the resident had not been feeling well. She also stated that the LPN's should have notified her, the Nurse Practitioners, or the physician that the resident was not feeling well, and that she should have notified the physician when the resident reported to her on 12/5/14, that she was not feeling well. 10NYCRR 415.3(e)(2)(ii)(b)

Based on record review and staff interview during an abbreviated survey (Complaint #'s NY 457, NY 119 and NY 542, and a Post Survey Revisit for Case #NY 353) the facility did not consult with residents' physicians when there were significant changes in the residents' physical status for three (3) (Resident #'s 14, 9 and #5) of fourteen (14) residents reviewed. Specifically, baseline temperatures were not established for Resident #'s 14, 9 and #5. For Resident #14, the facility did not consult with the resident's physician when the resident had a significant change in condition exhibited by fevers over 101 degrees Fahrenheit (F) on 12/7/14, 12/8/14, and 12/10/14, and lethargy 12/8/14 through 12/10/14, with subsequent hospital admission for [MEDICAL CONDITION] (spreading bacterial infection just below the skin surface). Additionally, the facility did not consult with physicians when Resident #9 developed fevers over 101 degrees F on 10/30/14, 10/31/14 and 11/3/14 with subsequent hospital admission on 11/3/14 for fever; Resident #5 had complaints of cold symptoms on 12/3/14 through 12/6/14 with subsequent hospital admission for urosepsis (serious condition occurring after the microorganisms that cause a urinary tract infection spread to the bloodstream). This resulted in actual harm for Resident #14, which is not Immediate Jeopardy. This was evidenced by: A Policy and Procedure (P&P) for Change in Resident's Condition dated 11/2008, documented that staff were to promptly notify the medical staff of changes in a resident's physical, mental or psychosocial condition. Resident #14 This resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. It was also documented that, on the resident's readmission from the hospital on [DATE], the resident had been diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented that the resident was cognitively intact, was able to make herself understood and was able to understand others. Review of the resident record revealed that the last note documented by the physician was dated 10/31/14. An open-ended physician's orders [REDACTED]. A Nurses Note dated 12/7/14 at 3:49 am, documented that the resident had a temperature of 102 degrees Fahrenheit (F), and the resident was given 650 mg of [MEDICATION NAME]. The note was signed by a Licensed Practical Nurse (LPN), and there was no documented evidence that the physician was notified. A Nurses Note dated 12/8/14 at 6:53 am, documented that at 3:48 am, the resident had a temperature of 102.2F. The resident voiced no complaints but was noted to be, "very lethargic". She was given 650 mg of [MEDICATION NAME]. Staff would continue to monitor the resident. The note was signed by an LPN, and there was no documented evidence that the physician was notified. A Nurses Note dated 12/9/14 at 10:14 pm, documented that the resident continued with increased periods of lethargy off and on throughout the evening. The note was signed by an LPN, and there was no documented evidence that the physician was notified. A Nurses Note dated 12/10/14 at 3:37 am, documented that at 12:00 am, the resident's face was flush and she was sweating. Her temperature was 104F, she was alert and responsive and offered no complaints other than feeling warm. The resident's quilt was removed, and she was covered with a sheet and a cool compress was applied. On re-check of the temperature she was 100.4F. The resident stated she still felt warm and not herself. Staff would continue to monitor the resident closely. The note was signed by a Registered Nurse Supervisor (RNS), and there was no documented evidence that the physician was notified. A Nurses Note dated 12/10/14 at 4:03 pm, documented that this was a late entry. At 8:00 am, the resident's temperature was 98.9F, and she continued to be lethargic off and on throughout the day. At 3:10 pm, the resident was noted to have shaking chills and a temperature of 102.2, and [MEDICATION NAME] was given at 3:35 pm. The resident began vomiting a large amount of undigested food, and continued shaking chills, and requested to go to the hospital for evaluation. The note was signed by an LPN, and there was no documented evidence that the physician was notified of the resident's lethargy throughout the day, and no documented evidence that the physician was notified of the resident's vomiting, shaking, chills or temperature of 102.2F. A Nurses Note dated 12/10/14 at 3:57 pm, documented that the resident had a temperature of 102.2F, and [MEDICATION NAME] was given. The resident had a large emesis which contained undisolved [MEDICATION NAME]. Her blood pressure was 110/62, pulse 104, respirations 32 breaths per minute, and her oxygen saturation was 94% on 4 liters per minute of oxygen. The resident stated that she wanted to go to the hospital for evaluation. The family was notified and emergency services were called to transport the resident to the hospital. The note was signed by a Registered Nurse (RN), and there was no documented evidence that the physician was notified. A Nurses Note dated 12/10/14 at 9:28 pm, documented that the resident was admitted to the hospital with [REDACTED]. The Hospital Discharge Summary dated 12/15/14, documented that the resident had been hospitalized for [REDACTED]. Blood cultures revealed that the resident had a [DIAGNOSES REDACTED] (Group B) infection in her blood, and was treated with antibiotics given through the vein. The resident's status improved day-by-day, and was discharged to the nursing home on 12/15/14. During an interview on 12/16/14 at 1:05 pm, LPN #1 stated that this resident had been running fevers, but he had an order to give [MEDICATION NAME] for fever. The LPN stated that she did not know what the acceptable range for a fever was, other than a temperature over 98.6F. She stated that she probably would not give [MEDICATION NAME] for a fever unless the resident asked for it, or if it get as high as 100F. She also stated that she was not aware of any specific temperature a resident had to have before an RN had to be notified, and that the LPN's were not the staff that notified physicians except by writing a note in the physician communication book. There was no documented evidence of MD notification in the physician communication book. During an interview on 12/16/14 at 12:10 pm, Nurse Practitioner (NP) #1 stated that she was notified on 12/6/14, that this resident had a temperature of 102F and that she was shaking and spitting up mucus. This resident was known to get fevers, and she was given [MEDICATION NAME]. She was not made aware that the resident had continued to have fevers, was lethargic, or having chills and shaking until after the resident had been sent to the hospital on [DATE]. She stated that staff should have informed her, NP #2 or the physician when the resident continued to have changes in her condition. During an interview on 12/16/14 at 1:46 pm, Registered Nurse Manager (RNM) #1 stated that this resident started having fevers on 12/6/14. The Nurse Practitioner was notified, and there were no new orders at that time. The resident continued to have fevers, chills, and lethargy, but the LPN's did not notify an RN or the physician until 12/10/14. On 12/10/14 at 12:00 am, the resident did not feel well and had a temperature of 104F. The Nurse Practitioners nor the physician were notified of the resident's continued fevers, lethargy or chills until she requested to go to the hospital on [DATE]. The RNM stated that there was no policy that defined what constituted a fever as ordered by the physician in the resident's order for [MEDICATION NAME]. She also stated that the LPN's should have notified a Registered Nurse, a supervisor, a Nurse Practitioner or the physician when the resident had a fever over 101F, or when she was lethargic or having chills as these were a change in the resident's condition. During an interview on 12/17/14 at 1:54 pm, the Physician who was the Medical Director (MD), stated that in an acute situation, the NP's relied on nurses to report to the RN's to assess residents and report to them. He stated that there seemed to be a contentious relationship between the nursing staff and the NP's, and that he had been, and was concerned about how that relationship could affect the residents. He also stated that changes in a resident's condition should have been reported to the NP's or to the physician. Resident #9 This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented that the resident was cognitively intact, was able to make himself understood and was able to understand others. A physician's orders [REDACTED]. A Nurses Note dated 10/30/14 at 2:50 am, documented that the resident's temperature was 101.8F. The resident was given [MEDICATION NAME] and a cool compress. The note was signed by a LPN, and there was no documented evidence that the physician was notified. The Medication Administration Record [REDACTED]. The Medication Assistance Record (MAR) was signed by an LPN. There was no documented evidence that the physician was notified. There was no documentation in the Nurses Notes regarding this temperature. A Nurses Note dated 10/31/14, at 6:05 am, documented that the resident's temperature was 102.2F at 11:20 pm on 10/30/14, and the resident was given [MEDICATION NAME]. The LPN documented that the care plan would continue to be followed. There was no documented evidence that the physician was notified. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Nurses Note dated 10/31/14, documented that at 8:00 am, the resident's temperature was 101.4F, and the resident was given [MEDICATION NAME]. The note was signed by an LPN, and there was no documented evidence that the physician was notified. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Nurses Note dated 11/3/14, documented that the resident's temperature was 103.2F, and the resident was given [MEDICATION NAME]. The resident's temperature was taken again one hour later and was 102.8, and the resident was given a cool compress. The LPN documented that the plan of care would continue to be followed. There was no documented evidence that the physician was notified. A Nurses Note dated 11/3/14 at 8:13, and signed by RNM #1, documented that the resident's "increased temps" had continued through the weekend, and that "last night" his temperature was over 103F, and did not decrease below 102F. Emergency Medical Services were called and the resident was transported to the hospital. A Nurses Note dated 11/3/14 at 1:04 pm, documented that the resident had been admitted to the hospital with [REDACTED]. During an interview on 12/11/4 at 1:30 pm, RNM #1 stated that this resident regularly ran a high temperature, so staff may not have given it a second thought. She stated that the facility did not have a policy that defined what temperature constituted a fever, or when the physician was to be notified, but that the physician should have been immediately notified when the resident's temperature was 103F. The RNM also stated that the physician should have set parameters for a fever, when the resident was to receive [MEDICATION NAME], and when the physician was to be notified. During an interview on 12/11/4 at 2:20 pm, the Director of Nursing (DON) stated that the facility did not have a policy that defined what temperature constituted a fever, or when the physician was to be notified. She stated that she felt that a Registered Nurse and the physician should have been notified for temperatures over 100F. The DON also stated that the physician should have set parameters for a fever, and when the physician was to be notified. Resident #5 This resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented that the resident was cognitively intact, was able to make herself understood and was able to understand others. A Nurses Note dated 12/3/14 at 6:40 am, documented that this resident's voice was hoarse, and she complained of excessive throat drainage which was hard to clear. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/3/14 at 10:22 pm, documented that this resident complained of cold symptoms and headache. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/4/14 at 6:44 am, documented that this resident continued to have cold symptoms, cough and sore throat. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/5/14 at 12:03 am, documented that this resident continued to have cold symptoms, and had no fever. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/5/14 at 3:04 pm, documented that this resident continued to have cold symptoms, and had no fever. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/6/14 at 1:10 am, documented that this resident continued to have cold symptoms. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/6/14 at 2:38 am, documented that this resident was noted to be unresponsive to verbal stimulus or to touch. The resident's coloring was dusky, and the skin was warm and dry to the touch. Her blood pressure was 90/50, pulse 80 beats per minute, she was breathing 20 times per minute, and her oxygen percentage was 90%. Emergency services and the physician were notified, and the resident was transported to the hospital. The note was signed by an RN. A Nurses Note dated 12/6/14 at 5:33 am, documented that this resident was admitted to the hospital with [REDACTED]. During an interview on 12/10/14 at 12:07 pm, LPN#1 stated that on 12/5/14, he noticed that the resident had a cold, which seemed to have been going around the unit at that time. He stated that her symptoms did not seem serious, she, "just had a cold," so he did not give it a second thought, and did not notify an RN or physician. During an interview on 12/10/14 at 11:55 am, RNM #2 stated that, on 12/5/14 this resident had complained the she felt like she had a cold, so she wanted to cancel an appointment. The RNM stated that, at the time the resident stated this, she did not know how long the resident had been feeling this way. Later on 12/6/14, after the resident had been transferred to the hospital, another staff member told her that the resident had been feeling ill for a few days prior, and that she had been sleeping more than usual. The RNM stated that prior to that conversation, nobody had notified her that the resident had not been feeling well. She also stated that the LPN's should have notified her, the Nurse Practitioners, or the physician that the resident was not feeling well, and that she should have notified the physician when the resident reported to her on 12/5/14, that she was not feeling well. 10NYCRR 415.3(e)(2)(ii)(b)

2 Based on record review and staff interview during an abbreviated survey (Complaint #'s NY 457, NY 119 and NY 542, and a Post Survey Revisit for Case #NY 353) the facility did not consult with residents' physicians when there were significant changes in the residents' physical status for three (3) (Resident #'s 14, 9 and #5) of fourteen (14) residents reviewed. Specifically, baseline temperatures were not established for Resident #'s 14, 9 and #5. For Resident #14, the facility did not consult with the resident's physician when the resident had a significant change in condition exhibited by fevers over 101 degrees Fahrenheit (F) on 12/7/14, 12/8/14, and 12/10/14, and lethargy 12/8/14 through 12/10/14, with subsequent hospital admission for [MEDICAL CONDITION] (spreading bacterial infection just below the skin surface). Additionally, the facility did not consult with physicians when Resident #9 developed fevers over 101 degrees F on 10/30/14, 10/31/14 and 11/3/14 with subsequent hospital admission on 11/3/14 for fever; Resident #5 had complaints of cold symptoms on 12/3/14 through 12/6/14 with subsequent hospital admission for urosepsis (serious condition occurring after the microorganisms that cause a urinary tract infection spread to the bloodstream). This resulted in actual harm for Resident #14, which is not Immediate Jeopardy. This was evidenced by: A Policy and Procedure (P&P) for Change in Resident's Condition dated 11/2008, documented that staff were to promptly notify the medical staff of changes in a resident's physical, mental or psychosocial condition. Resident #14 This resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. It was also documented that, on the resident's readmission from the hospital on [DATE], the resident had been diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented that the resident was cognitively intact, was able to make herself understood and was able to understand others. Review of the resident record revealed that the last note documented by the physician was dated 10/31/14. An open-ended physician's orders [REDACTED]. A Nurses Note dated 12/7/14 at 3:49 am, documented that the resident had a temperature of 102 degrees Fahrenheit (F), and the resident was given 650 mg of [MEDICATION NAME]. The note was signed by a Licensed Practical Nurse (LPN), and there was no documented evidence that the physician was notified. A Nurses Note dated 12/8/14 at 6:53 am, documented that at 3:48 am, the resident had a temperature of 102.2F. The resident voiced no complaints but was noted to be, very lethargic. She was given 650 mg of [MEDICATION NAME]. Staff would continue to monitor the resident. The note was signed by an LPN, and there was no documented evidence that the physician was notified. A Nurses Note dated 12/9/14 at 10:14 pm, documented that the resident continued with increased periods of lethargy off and on throughout the evening. The note was signed by an LPN, and there was no documented evidence that the physician was notified. A Nurses Note dated 12/10/14 at 3:37 am, documented that at 12:00 am, the resident's face was flush and she was sweating. Her temperature was 104F, she was alert and responsive and offered no complaints other than feeling warm. The resident's quilt was removed, and she was covered with a sheet and a cool compress was applied. On re-check of the temperature she was 100.4F. The resident stated she still felt warm and not herself. Staff would continue to monitor the resident closely. The note was signed by a Registered Nurse Supervisor (RNS), and there was no documented evidence that the physician was notified. A Nurses Note dated 12/10/14 at 4:03 pm, documented that this was a late entry. At 8:00 am, the resident's temperature was 98.9F, and she continued to be lethargic off and on throughout the day. At 3:10 pm, the resident was noted to have shaking chills and a temperature of 102.2, and [MEDICATION NAME] was given at 3:35 pm. The resident began vomiting a large amount of undigested food, and continued shaking chills, and requested to go to the hospital for evaluation. The note was signed by an LPN, and there was no documented evidence that the physician was notified of the resident's lethargy throughout the day, and no documented evidence that the physician was notified of the resident's vomiting, shaking, chills or temperature of 102.2F. A Nurses Note dated 12/10/14 at 3:57 pm, documented that the resident had a temperature of 102.2F, and [MEDICATION NAME] was given. The resident had a large emesis which contained undisolved [MEDICATION NAME]. Her blood pressure was 110/62, pulse 104, respirations 32 breaths per minute, and her oxygen saturation was 94% on 4 liters per minute of oxygen. The resident stated that she wanted to go to the hospital for evaluation. The family was notified and emergency services were called to transport the resident to the hospital. The note was signed by a Registered Nurse (RN), and there was no documented evidence that the physician was notified. A Nurses Note dated 12/10/14 at 9:28 pm, documented that the resident was admitted to the hospital with [REDACTED]. The Hospital Discharge Summary dated 12/15/14, documented that the resident had been hospitalized for [REDACTED]. Blood cultures revealed that the resident had a [DIAGNOSES REDACTED] (Group B) infection in her blood, and was treated with antibiotics given through the vein. The resident's status improved day-by-day, and was discharged to the nursing home on 12/15/14. During an interview on 12/16/14 at 1:05 pm, LPN #1 stated that this resident had been running fevers, but he had an order to give [MEDICATION NAME] for fever. The LPN stated that she did not know what the acceptable range for a fever was, other than a temperature over 98.6F. She stated that she probably would not give [MEDICATION NAME] for a fever unless the resident asked for it, or if it get as high as 100F. She also stated that she was not aware of any specific temperature a resident had to have before an RN had to be notified, and that the LPN's were not the staff that notified physicians except by writing a note in the physician communication book. There was no documented evidence of MD notification in the physician communication book. During an interview on 12/16/14 at 12:10 pm, Nurse Practitioner (NP) #1 stated that she was notified on 12/6/14, that this resident had a temperature of 102F and that she was shaking and spitting up mucus. This resident was known to get fevers, and she was given [MEDICATION NAME]. She was not made aware that the resident had continued to have fevers, was lethargic, or having chills and shaking until after the resident had been sent to the hospital on [DATE]. She stated that staff should have informed her, NP #2 or the physician when the resident continued to have changes in her condition. During an interview on 12/16/14 at 1:46 pm, Registered Nurse Manager (RNM) #1 stated that this resident started having fevers on 12/6/14. The Nurse Practitioner was notified, and there were no new orders at that time. The resident continued to have fevers, chills, and lethargy, but the LPN's did not notify an RN or the physician until 12/10/14. On 12/10/14 at 12:00 am, the resident did not feel well and had a temperature of 104F. The Nurse Practitioners nor the physician were notified of the resident's continued fevers, lethargy or chills until she requested to go to the hospital on [DATE]. The RNM stated that there was no policy that defined what constituted a fever as ordered by the physician in the resident's order for [MEDICATION NAME]. She also stated that the LPN's should have notified a Registered Nurse, a supervisor, a Nurse Practitioner or the physician when the resident had a fever over 101F, or when she was lethargic or having chills as these were a change in the resident's condition. During an interview on 12/17/14 at 1:54 pm, the Physician who was the Medical Director (MD), stated that in an acute situation, the NP's relied on nurses to report to the RN's to assess residents and report to them. He stated that there seemed to be a contentious relationship between the nursing staff and the NP's, and that he had been, and was concerned about how that relationship could affect the residents. He also stated that changes in a resident's condition should have been reported to the NP's or to the physician. Resident #9 This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented that the resident was cognitively intact, was able to make himself understood and was able to understand others. A physician's orders [REDACTED]. A Nurses Note dated 10/30/14 at 2:50 am, documented that the resident's temperature was 101.8F. The resident was given [MEDICATION NAME] and a cool compress. The note was signed by a LPN, and there was no documented evidence that the physician was notified. The Medication Administration Record [REDACTED]. The Medication Assistance Record (MAR) was signed by an LPN. There was no documented evidence that the physician was notified. There was no documentation in the Nurses Notes regarding this temperature. A Nurses Note dated 10/31/14, at 6:05 am, documented that the resident's temperature was 102.2F at 11:20 pm on 10/30/14, and the resident was given [MEDICATION NAME]. The LPN documented that the care plan would continue to be followed. There was no documented evidence that the physician was notified. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Nurses Note dated 10/31/14, documented that at 8:00 am, the resident's temperature was 101.4F, and the resident was given [MEDICATION NAME]. The note was signed by an LPN, and there was no documented evidence that the physician was notified. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Nurses Note dated 11/3/14, documented that the resident's temperature was 103.2F, and the resident was given [MEDICATION NAME]. The resident's temperature was taken again one hour later and was 102.8, and the resident was given a cool compress. The LPN documented that the plan of care would continue to be followed. There was no documented evidence that the physician was notified. A Nurses Note dated 11/3/14 at 8:13, and signed by RNM #1, documented that the resident's increased temps had continued through the weekend, and that last night his temperature was over 103F, and did not decrease below 102F. Emergency Medical Services were called and the resident was transported to the hospital. A Nurses Note dated 11/3/14 at 1:04 pm, documented that the resident had been admitted to the hospital with [REDACTED]. During an interview on 12/11/4 at 1:30 pm, RNM #1 stated that this resident regularly ran a high temperature, so staff may not have given it a second thought. She stated that the facility did not have a policy that defined what temperature constituted a fever, or when the physician was to be notified, but that the physician should have been immediately notified when the resident's temperature was 103F. The RNM also stated that the physician should have set parameters for a fever, when the resident was to receive [MEDICATION NAME], and when the physician was to be notified. During an interview on 12/11/4 at 2:20 pm, the Director of Nursing (DON) stated that the facility did not have a policy that defined what temperature constituted a fever, or when the physician was to be notified. She stated that she felt that a Registered Nurse and the physician should have been notified for temperatures over 100F. The DON also stated that the physician should have set parameters for a fever, and when the physician was to be notified. Resident #5 This resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented that the resident was cognitively intact, was able to make herself understood and was able to understand others. A Nurses Note dated 12/3/14 at 6:40 am, documented that this resident's voice was hoarse, and she complained of excessive throat drainage which was hard to clear. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/3/14 at 10:22 pm, documented that this resident complained of cold symptoms and headache. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/4/14 at 6:44 am, documented that this resident continued to have cold symptoms, cough and sore throat. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/5/14 at 12:03 am, documented that this resident continued to have cold symptoms, and had no fever. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/5/14 at 3:04 pm, documented that this resident continued to have cold symptoms, and had no fever. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/6/14 at 1:10 am, documented that this resident continued to have cold symptoms. The note was signed by an LPN, and there was no documented evidence that that the physician was notified. A Nurses Note dated 12/6/14 at 2:38 am, documented that this resident was noted to be unresponsive to verbal stimulus or to touch. The resident's coloring was dusky, and the skin was warm and dry to the touch. Her blood pressure was 90/50, pulse 80 beats per minute, she was breathing 20 times per minute, and her oxygen percentage was 90%. Emergency services and the physician were notified, and the resident was transported to the hospital. The note was signed by an RN. A Nurses Note dated 12/6/14 at 5:33 am, documented that this resident was admitted to the hospital with [REDACTED]. During an interview on 12/10/14 at 12:07 pm, LPN#1 stated that on 12/5/14, he noticed that the resident had a cold, which seemed to have been going around the unit at that time. He stated that her symptoms did not seem serious, she, just had a cold, so he did not give it a second thought, and did not notify an RN or physician. During an interview on 12/10/14 at 11:55 am, RNM #2 stated that, on 12/5/14 this resident had complained the she felt like she had a cold, so she wanted to cancel an appointment. The RNM stated that, at the time the resident stated this, she did not know how long the resident had been feeling this way. Later on 12/6/14, after the resident had been transferred to the hospital, another staff member told her that the resident had been feeling ill for a few days prior, and that she had been sleeping more than usual. The RNM stated that prior to that conversation, nobody had notified her that the resident had not been feeling well. She also stated that the LPN's should have notified her, the Nurse Practitioners, or the physician that the resident was not feeling well, and that she should have notified the physician when the resident reported to her on 12/5/14, that she was not feeling well. 10NYCRR 415.3(e)(2)(ii)(b)

Based on observation, record review and staff interviews the facility failed to ensure that all alleged violations involving mistreatment, neglect or abuse are reported immediately to the administrator of the facility, and that all alleged violations are thoroughly investigated for 2 (#s-1and 2 )of 10 residents reviewed during a partial extended abbreviated survey (case # NY 0590). Specifically, for Resident # 2 the facility did not thoroughly investigate a resident to resident incident. This was no actual harm and had the potential for more than minimal harm for Resident #2. For Resident # 1 the facility failed to identify abuse, failed to implement timely interventions to protect the residents from immediate and further abuse. Additionally, the facility failed to, investigate, and report the suspected abuse to the Department of Health (DOH). This had the potential to effect all of the residents in the facility. This had the potential for more than serious harm and was Immediate Jeopardy to the health and safety of residents and Substandard Quality of Care. This is evidenced by the following: Resident # 1 The resident was admitted to the nursing home on 12/7/12 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], documented that the resident had moderate cognitive impairment for daily decision making and short and long-term memory deficits. It documented that the resident is sometimes understood and sometimes understands. An e-mail, dated 8/2/13, from the Supervising Administrator (SA) to the Acting Administrator (AA) documented that he was to be notified immediately in the event of any situation that put residents, staff and/or public at risk for their health or safety. A progress note, dated 9/14/13 at 1:41 pm written by the Licensed Practical Nurse (LPN) #1, documented that at approximately 9:30 am the resident was discovered kneeling at the beside of his bed with his arms on the bed. The note documented that the Supervising Clinical Service Coordinator (SCSC) came to see the resident and that he was assisted to his feet with 2 assistance and a gait belt. It was documented that no injury was noted. A late entry progress note, dated 9/15/13 at 4:43 pm written by the SCSC, documented that the resident's behavior of being found on the floor on his knees facing the bed was discussed with the Acting Director of Nursing (ADON). It documented that the ADON was asked if they could try leaving the resident on the floor for 5 minutes while frequently checking on him. The ADON was agreeable to this attempt to modify the resident's behavior. It documented that the resident did not place himself on the floor for the rest of the day. A progress note, dated 9/16/13 at 1:50 pm written by the ADON, documented that she was educated by the Nurse Practitioner (NP) about the resident's behaviors and the fact that his behaviors were unable to be modified. It documented that the resident had no concept of what he was doing when he did things, therefore attempting to modify his behaviors was unnecessary as he doesn't know what it is that he is doing wrong. A staffing sheet dated 9/15/13 documented the SCSC worked 7:00am - 7:00pm as the nursing supervisor. During an interview on 9/25/13 at 5:10 pm the Universal Unit Worker stated that on 9/14/13 at approximately 10:00 am she was in the kitchen area of the unit. This area is located across the hall from the resident's room. The resident was in his room behind the Dutch Doors (DD) because it was meal time. The staff member heard LPN #1 say that the resident was on the floor again. The staff member stated that she thought LPN #1 contacted the SCSC because the SCSC came up to the unit. The unit worker stated that she went out in the hall and saw LPN #1 and SCSC in the resident's room. The resident was on his knees in the room facing the bed with his arms on the bed. The unit worker stated that the LPN # 1 and SCSC did not check the resident to see if he was injured. She heard the SCSC say to leave him on the floor for 10 minutes, then heard LPN #1 say "don't you think that is a bit much, how about 5 minutes". The SCSC agreed. The staff member then heard LPN #1 ask about an incident report and the SCSC told the LPN that she was not going to fill one out because it happens too much and she was not going to do an incident report every time the resident put himself on the floor. The unit worker stated that after the SCSC left other staff members got the resident up. The unit worker stated that she thought the resident was on his knees for a total of 3 1/2 - 4 minutes. During an interview on 9/26/13 at 11:30 am, the Acting Administrator (AA) stated that she was told about the incident on 9/16/13 by the ADON, but did not know why she did not look further into it. The AA stated that she thought it was an improper direction to the staff but that it was not abuse because the staff got the resident up after the SCSC left the unit. The AA stated that the SCSC was counseled on 9/24/13 and would no longer be supervising staff. During an interview on 9/26/13 at 4:20 pm the unit Registered Nurse Clinical Service Coordinator (RNCSC) stated that she was not working on 9/14/13. She stated the ADON made her aware of the incident and when she came in at 12:00 pm on 9/16/13. She stated that the ADON told her about a note that the SCSC wrote in the chart documenting that the ADON gave permission to leave the resident on the floor. The RNCSC stated that due to the resident's cognitive decline he lays on his stomach and brings his legs over the side of the bed but then can' t get up. RNCSC further stated that the SCSC made an inappropriate comment telling staff to leave the resident on the floor and that she did not think it was abuse because the staff got the resident up after the SCSC left the unit. During an interview on 9/26/13 at 4:45 pm, the ADON stated that the SCSC contacted her by phone on 9/14/13 and told her that the resident was on the floor and that maybe they should leave him there. The ADON stated that she told the SCSC that she needed to get the resident off the floor, because she assumed that he was on the floor at that time. The ADON stated that on 9/16/13 the NP talked to her about behavior modification on the resident and that behavior modification of any kind was not effective on this resident. During an interview on 9/27/13 at 8:08 am the LPN #1 stated that while doing her medications on 9/14/13 in the kitchen area at around 9:30 am the resident was in his room at the DD asking to come out. The LPN stated that because he had had a recent history of putting himself on the floor she looked in to check on him when he got quiet. The LPN stated that the resident was on the floor on his knees facing the bed with his arms on the bed. She stated she told a CNA who she did not remember, to watch the resident while she contacted the SCSC. She stated that the SCSC was on the unit in 1-2 minutes and asked the resident if he was in pain and the resident responded no. She stated that the SCSC did not assess the resident's knees because he was on them. She stated that the SCSC then stated that "maybe we should not get him up right away, maybe in 10 minutes then thought 10 minutes was too much and changed it to 5 minutes. LPN # 1 stated she thought the SCSC said something like "maybe it would help to deter the behavior of putting himself on the floor". The LPN further stated that she asked the SCSC if an Incident/Accident ( I&A) should be made out. The SCSC told her that they did not need one. The LPN stated that she felt the SCSC ' s comment was inappropriate and was a negative reinforcement. She stated she left the resident for a short time while the supervisor was near the resident's room to inform the Charge LPN (CLPN) of the incident and what the SCSC said. She stated that the SCSC left shortly after she came back to the room and it could not have been any longer that 5 minutes from the time the resident came to the room and the resident was taken off his knees. The LPN stated that she reported it to her CLPN on 9/14/13 and to the unit Clinical Services Coordinator (CSC) on 9/16/13. LPN#1 stated it would be considered abusive and that it could be reportable to the state but that she did not think of it. During an interview on 9/27/13 at 11:07 am CNA # 1 stated that she was walking down the hall by Resident # 1's room at approximately 9:30 am and someone called for her to help get the resident off the floor. The resident was on the floor on his knees facing the bed when she came in the room and the LPN # 1 and CNA #2 were already in there. CNA #1 stated the resident was assisted without difficulty by the 3 staff persons and that she had heard that the resident was on the floor for a few minutes. During an interview on 9/27/13 at 11:33 am CNA #5 stated that the SCSC told him 10 plus days ago that if the resident was on the floor that he would be left on the floor for maybe 10 minutes for the behavior and that maybe he would learn from it and not put himself on the floor again. During an interview on 9/27/13 at 12:10pm CNA #2 stated that on Saturday 9/14/13 at approximately 9:30 am she was asked by the LPN # 1 to watch the resident while the LPN contacted the supervisor. The LPN and herself were outside the resident's DD. CNA #2 stated that the SCSC came to the unit, looked in the door but did not enter, and said they had to do something different from what they were doing which was giving the resident candy if he was not on the floor all day. CNA #2 then stated that SCSC suggested that they try leaving the resident on his knees for 10 minutes and then asked the LPN if she thought 10 minutes was too long. CNA #2 stated that the LPN said yes and that the SCSC and the LPN decided on 5 minutes. CNA #2 stated that this entire conversation took place in the hall outside the resident's room while the resident was on his knees and not more that 2-3 minutes later the SCSC left the unit and they got the resident off the floor. CNA #2 stated that she thought it was abuse but that she was doing what her supervisor told her to do. During an interview on 9/27/13 at 12:50 am the Supervising Administrator (SA) stated that he was not notified of the incident and he was in the building and on that unit for another issue the day of the incident. He further stated that he was not notified or made aware of the incident until 9/18/13 when the AA notified him. The SA further stated that the facility needed to do a better job on investigations. He stated the incident was reportable to the state. During a telephone interview on 9/28/13 at 8:25 am, the Nurse Practitioner (NP) stated that the staff told her about the incident when she came in on Monday morning. She stated she had been told by another staff member that it had been approved by administration. The NP stated she was looking at the resident for another issue and saw the entry in the chart on 9/15/13 written by the SCSC that documented leaving the resident on his knees was approved by the A-DON. The NP stated the facility staff had discussed behavioral modification with psychology and it was determined due to the extent of the residents frontal lobe damage behavioral modification would not work. The NP stated that she reported the incident to administration and thought that they would take care of the situation quickly. She stated that she also had a conversation with the unit CSC and told her to have a meeting with staff to discuss this incident as staff were very upset, explain to them that leaving him on his knees was inappropriate. The NP further stated that she did not call the state because she told the ADON and another staff member said they were going to do it and she did not deter them. During an interview on 9/28/13 at 10:56 am the SCSC stated that she was called to the unit because the resident was found on his knees. The SCSC stated that she went to the unit and saw the resident in the room, but that she did not enter the room or assess the resident. She stated that she discussed with LPN # 1 in the presence of CNA #2 that they should try leaving the resident on the floor for 10 minutes. LPN # 1 stated she thought that was too long, so they agreed on leaving the resident on his knees for 5 minutes. The SCSC stated that she remained outside the room for a while but did not remember how long. Before she left the area she told CNA #2 to check the resident frequently to ensure he was safe. The SCSC then stated that LPN # 1 offered to start an incident/accident report but told her no. The SCSC stated that she had a face to face conversation with the ADON on 9/12/13 regarding trying behavior modification and was agreeable to delaying getting him off the floor but that they had not discussed the amount of time he would be left on the floor. The SCSC stated that she now sees the incident as negative behavior modification and does feel it is abuse. During an interview on 9/28/13 at 11:50 am the Medical Director (MD) who is also the resident's attending physician, stated that he was not aware of the incident until he called the facility today. The MD stated that the action by the SCSC was a serious transgression and a heinous breech of responsibility. The MD stated that the facility did not do negative behavior modification and that this resident is not appropriate for any type of modification due to the extent of dementia. The MD further stated that he would have expected to be contacted about the incident which could be considered abuse and was DOH reportable. During an interview with the AA on 9/30/13 at 8:06 am the AA stated that on the morning of 9/16/13 the incident was brought to her attention. The AA stated that she believes that she did not follow up on the incident at that time. On Wednesday 9/18/2013 a telephone call was received from the Attorney General's office and was informed that a hot line call was received regarding abuse. It was than that an investigation was started. Resident # 2 The resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented that the resident had moderate cognitive impairment for daily decision making and short and long-term memory deficits. It documented that the resident is sometimes understood and sometimes understands. During an observation on 9/28/13 at 2:28pm resident was ambulating down left hallway. During an observation on 9/28/13 at 2:30pm the resident was in the room with the DD locked and was banging on the door. A policy for Resident to Resident abuse dated 8/01 under procedure A. documented; If a resident to resident incident occurs to separate the residents and take them to areas away from each other until the situation calms down. Under F. it documented to complete a resident Accident/Incident form as appropriate. Under G. it documented to complete a physical altercations between residents form(victim/aggressor form) and place it in the victim/aggressor forms book. There was no documented evidence of a victim or aggressor sheet on either resident and no documented evidence of the resident being on 15 minute checks. During an interview on 9/28/13 at 2:30pm CNA #3 stated that she put the resident behind the locked DD for 15 minutes because she slapped an off sample resident in the face. During an interview on 9/30/13 at 9:00am the ADON stated that they do not neccessarily do an incident report for a resident to resident altercation but that the did a victim/aggressor sheet. The ADON was unable to produce a victim or aggressor sheet for either resident for this incident. During an interview on 9/30/13 at 11:20am the Charge Licensed Practical Nurse (CLPN) stated that when a resident to resident altercation takes place a victim/aggressor sheet would be filled out and the aggressor would be placed on every 15 minute checks for 72hours. She stated that these forms are kept in a victim/aggressor book on the unit. She further stated that a universal worker (UW) told her that the resident slapped an off sample resident in the face 3 times and that she redirected the resident. The CLPN stated that the UW told her that CNA #3 then approached and put the resident in her room because she was "out of control". The CLPN further stated that the UW asked the resident if her face hurt and the resident told her it hurt a little. A while later when the CLPN asked, the resident told her it did not hurt. The CLPN stated she did not know if the resident was assessed by an RN. 10NYCRR415.4(b)(1)(ii)

Based on medical record review and interview during a partial extended survey (Case# NY 059) it was determined that the Administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychological well being of each resident. Specifically, on 9/14/13 a resident was found on his knees, on the floor in his room. The Supervising Clinical Services Coordinator (SCSC) was called to the room by the Licensed Practical Nurse to assess the resident. The SCSC was over heard telling the cognitively impaired resident that the staff were to leave him on his knees and not assist him off the floor. The LPN waited until the SCSC left the room and assisted the resident back to bed. The incident was not identified as potential abuse and was not reported to facility administration. The alleged accused worked the entire 12 hour shift the next day. This has the potential to affect all of the residents in the facility. This caused no actual harm but has the potential for more than serious harm that is Immediate Jeopardy to the health and safety of the residents. This is evidenced by the following: Refer to F 225- Abuse- scope and severity- L During an interview on 9/26/13 at 11:30 am, the Acting Administrator (AA) stated that she was told about the incident on 9/16/13 by the Assistant Director of Nurses (ADON) but does not know why she did not look further into it. The AA stated that she thought it was an improper direction to the staff but that it was not abuse because the staff got the resident up after the Supervising Clinical Service Coordinator (SCSC) left the unit. The AA stated that the SCSC was counseled and would no longer be supervising staff. During an interview on 9/26/13 at 4:45pm, the ADON stated that the SCSC contacted her by phone on 9/14/13 and told her that the resident was on the floor and that maybe they should leave him there. The ADON stated that she told the SCSC that she needed to get the resident off the floor, because she assumed that he was on the floor at that time. The ADON stated that on 9/16/13 the NP talked to her about behavior modification on the resident and that behavior modification of any kind was not effective on this resident. The ADON further stated that on 9/16/13 the resident was assessed by the unit Clinical Services Coordinator (CSC) and that she did notify the AA. During an interview with the AA on 9/30/13 at 8:06 am the AA stated that on the morning of 9/16/13 the incident was brought to her attention. The AA stated that she believes that she did not follow up on the incident at that time. On Wednesday 9/18/2013 a telephone call was received from the Attorney General's office and was informed that a hot line call was received regarding abuse. It was than that an investigation was started. During an interview on 9/27/13 at 12:50am the Supervising Administrator (SA) stated that he was not notified of the incident and he was in the building and on that unit for another issue the day of the incident. He further stated that he was not notified of the incident until 9/18/13 by the AA after she was contacted by the Attorney General ' s Office that they were coming in to investigate the complaint. The SA further stated that the facility needed to do a better job on investigations. During a telephone interview on 9/28/13 at 8:25am the Nurse Practitioner (NP) stated that she was told of the incident by staff when she came in on Monday morning and had been told by another staff member that it had been approved by administration. The NP stated she was looking at the resident for another issue and saw the entry in the chart on 9/15/13 by the SCSC that said leaving the resident on his knees was approved by the ADON. The NP stated the facility staff had discussed behavioral modification with psychology and it was determined due to the extent of the residents frontal lobe damage behavioral modification would not work. The NP stated that she reported the incident to administration and thought that they would take care of the situation quickly. She stated that she also had a conversation with the unit CSC and told her to have a meeting with staff to discuss this incident as staff were very upset, explain to them that leaving him on his knees was inappropriate. The NP further stated that she did not call the state because she told the ADON and another staff member said they were going to do it and she did not deter them. During an interview on 9/28/13 at 11:50am the Medical Director (MD) who is also the resident ' s attending physician stated that he was not aware of the incident until he called the facility today. The MD stated that the action by the SCSC was a serious transgression and a heinous breech of responsibility. The MD stated that the facility did not do negative behavior modification and that this resident is not appropriate for any type of modification due to the extent of dementia. The MD further stated that he would have expected to be contacted about the incident which could be considered abuse and was state reportable. 10NYCRR 415.26