Every finding on record at Cuba Memorial Hospital Inc SNF

Based on interviews, and record review conducted during survey, the facility failed to protect resident's rights from verbal, mental and physical abuse by another resident for one (Resident #17) of four residents reviewed for abuse. Specifically, on 10/05/2025, Resident #17 was yelled at, grabbed by their arms and thrown back into their wheelchair by Resident #3. Following the abusive interaction, Resident #17 displayed emotional distress and was observed crying. Using the reasonable person concept, as referenced on the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity guide, this resulted in psychosocial harm to Resident #17, that is not Immediate Jeopardy.The findings include: The facility policy titled Abuse, Neglect, Mistreatment dated 02/2026, documented the facility recognized that each elder had the right to be free from all types of abuse including verbal, physical, mental abuse, corporal punishment, and involuntary seclusion. The American Medical Association defines elder abuse and neglect as the intentional or unintentional physical, psychological or financial mistreatment of an elderly person. Resident #17 had diagnoses including Arnold Chiari Syndrome (congenital structural defect where brain tissue expands into the spinal canal and blocks the flow of cerebrospinal fluid (clear liquid that cushions and protects your brain and spinal cord) with hydrocephalus (abnormal buildup of cerebrospinal fluid), Alzheimer's disease, and dementia without behavioral disturbances. The Minimum Data Set (a resident assessment tool) dated 05/08/2025 documented Resident #17 was severely cognitively impaired, was usually understood by others, usually understands others, and did not exhibit behaviors. Resident #17 Comprehensive Care Plan dated 07/03/2025 documented interventions related to their psychosocial well-being that included for staff to provide comfort, reassurance, and a safe, quiet, low-stimuli environment. Resident #3 had diagnoses including vascular dementia with behavioral disturbance (condition driven by cardiovascular disease rather than direct brain tissue degeneration), bipolar disorder (mental health condition that causes extreme, cyclical shifts in mood, energy, activity level, and concentration), and depression. The Minimum Data Set, dated [DATE] documented Resident #3 was moderately cognitively impaired, was understood by others, usually understands, and did not exhibit behaviors.Resident #3 current Comprehensive Care Plan, initiated on 10/17/2024, documented they were non-compliant, had poor safety awareness, self-transferred/ambulated daily, needed frequent education and reminders to call for help. Interventions included psychiatry consultations as needed, reapproach and offer different choices when they were non-compliant. The facility Incident Report Summary completed by the former Administrator dated 10/05/2025 documented at 4:15 PM, staff were assisting residents into the dining room for meal service; residents and a family member were present in the dining room. Resident #17 was located at one end of the dining room and Resident #3 was located on the other. Resident #17 had a history of making a throat clearing/grunting noise and was making the noise at the time. Resident #3 yelled across the room to Resident #17 to shut up. Resident #3 stood up and quickly walked over to Resident #17 who stood up as Resident #3 approached them. Resident #3 grabbed Resident #17 on both of their arms and threw Resident #17 back into their wheelchair. The family member who was present called for help and staff members responded immediately. Resident #3 was removed from the dining room and Resident #17 was taken to their room and assessed by Registered Nurse #1. Resident #3 was interviewed in their room and stated, son of a b doesn't let up, if they have to throw me out so be it. The Medical Director, and the responsible parties for Resident #3 and Resident #17 were notified. Resident #17 was assessed by nursing and was visibly upset about the incident, had red marks on their arms where Resident #3 had grabbed them, and a scratch on their back from where they were thrown into the chair. Resident #3 was sent to the emergency room for a psychiatric evaluation, but the hospital refused to do an evaluation due to their dementia diagnosis. When Resident #3 returned to the facility, they were placed on 15-minute checks, they were not allowed to be in group settings or communal dining until the team confidently could say Resident #3 aggression was under control, and a psychiatric consultation was ordered for 10/09/2025. Resident #17 family came in to visit and provided comfort following the incident, and Resident #17 was seen by the Licensed Clinical Social Worker #1 daily for three days following the incident. A clinic note written by the Medical Director dated 10/07/2025, documented Resident #17 was being seen because another resident (Resident #3) had physically assaulted them in the facility. The Medical Director documented Resident #17 had no obvious injuries but cried a lot. They had no physical injuries but Resident #17 looked emotional. The Medical Director documented the incident was an emotional trauma to Resident #17. A clinic note written by the Medical Director dated 10/07/2025, documented Resident # 3, was seen on that date due to being the aggressor in an incident involving Resident #17. They documented, initially Resident #3 was sent out for a psychiatric evaluation, but the hospital denied one and sent the resident back to the facility. When asked about the incident, Resident #3 stated Resident #17 was making too much noise and they got annoyed. The Medical Director documented Resident #3 had a large psychiatric history, so they consulted a psychiatrist who recommended medication changes. The changes were made and Resident #3 behavior was to be monitored. During a telephone interview on 06/10/2026 at 4:08 PM, the former Administrator stated they were made aware of the incident involving Resident #3 and Resident #17 on 10/05/2025 and started their investigation. The former Administrator stated immediately following the incident that Resident #17 was upset but did not show any signs of fear. They stated the residents were kept separated. Resident #3 had a psychiatric evaluation, and their medications were adjusted and were on 15-minute checks until they felt their behavior was under control. During a telephone interview on 06/11/2026 at 8:53 AM, Resident #17's Health Care Proxy stated they were made aware of the incident on 10/05/2025 and their son went to visit immediately following the incident. Resident #17's Health Care Proxy stated when their son arrived at the facility, Resident #17 was visibly upset but the resident could not communicate why. The Health Care Proxy stated that Resident #17 typically did not show emotion due to their type of dementia, so when they were crying during the visit, their son became concerned. They stated Resident #17 would not have been accepting of something like this happening to them prior to their cognitive decline. During an interview on 06/11/2026 at 9:38 AM, Licensed Clinical Social Worker #1 stated following the incident on 10/05/2025 between Resident #3 and Resident #17 they followed up with each resident individually. Neither resident displayed any signs of fear. Social Worker #1 stated Resident #3 had a psychiatric consultation and medication adjustments. Resident #17 did not recall the incident and remained their normal self. They stated they were unaware Resident #17 was upset and had cried following the incident. During a telephone interview on 06/11/2026 at 9:57 AM, Registered Nurse #1 (former Unit Manager) stated on 10/05/2025, they were near the nurse's station when they heard a family member calling for help. They responded immediately and saw Resident #3 walking out of the dining room, mumbling under their breath. They stated the family member of another resident told them Resident #3 yelled at Resident #17 for making noise, got up, walked over to Resident #17 and Resident #3 threw Resident #17 back into their wheelchair. They stated they immediately went over and removed Resident #17 from the dining room and assessed them. Registered Nurse #1 stated when Resident #17 was brought to their room, they were sobbing uncontrollably, which was not normal behavior for them. They stated Resident #17 normally spoke very little and did not often display emotion. It was so sad. Registered Nurse #1 stated it was a traumatic event for Resident #17. They reported the incident to their superiors so that the proper channels could be followed. The residents were separated and assessed. Resident #3 was sent to the hospital by the provider for a psychiatric evaluation. During an interview on 06/11/2026 at 10:23 AM, the Medical Director stated they examined Resident #17 on 10/07/2025 following a 10/05/2025 altercation with Resident #3. Resident #17 had been crying for a day or two but could not say why. The Medical Director stated they did not see any long-term effects from the altercation but in the short term it was a traumatizing event for Resident #17. The Medical Director further stated If someone grabbed someone else unwantedly you could call that abuse. 10 New York Codes, Rules, and Regulations 415.4 (d)(1)(vii)

Based on interview and record review conducted during a survey, the facility failed to ensure that all alleged violations of abuse and neglect were thoroughly investigated for two (Residents #2 and #6) of six residents reviewed. Specifically, the facility did not maintain documentation that an alleged violation was thoroughly investigated. The findings include:The policy and procedure titled Abuse- Identification, Investigation, and Reporting reviewed 01/2026 documented when any suspicious or actual forms of abuse were witnessed by any staff member, they were immediately reported to the nurse in charge. The nurse in charge would then generate an Event Form and immediately inform the Nurse Manager, Nursing Supervisor or Director of Nursing or immediate investigation and prevention of any further potential abuse. An investigation would include staff, patient, family, elder interviews, observation, and follow up investigation.Resident #2 had diagnoses including Type 2 Diabetes Mellitus, schizophrenia, and obstructive sleep apnea. The Minimum Data Set (a resident assessment tool) dated 03/28/2026 documented Resident #2 was always understood, always understands others and was cognitively intact.Resident #6 had diagnoses including Type 2 Diabetes Mellitus, schizophrenia, and bipolar disorder. The Minimum Data Set, dated [DATE] documented Resident #6 was sometimes understood, usually understands others and was cognitively intact.Review of the Internet Quality Improvement and Evaluation System Complaint/Incident Investigation Report dated 08/27/2025 documented the Former Administrator reported an allegation of neglect to the New York State Department of Health. It further documented that Resident #6 reported that Licensed Practical Nurse #4 did not perform their blood sugar check. The Former Administrator documented that Resident #2 stated they did not think Licensed Practical Nurse #4 checked their blood sugar either.Review of the facility Incident Report Summary dated 08/26/2025 documented Resident #6 stated to the Former Director of Nursing that Licensed Practical Nurse #4 did not take their blood sugar reading. The Former Director of Nursing brought it to the attention of the Former Administrator, and a full investigation was initiated. There were no attached staff interviews or statements included in the summary.On 06/08/2026 at 10:47 AM the Facility Reported Incident was requested for Resident #2 and Resident #6.During an interview on 06/10/2026 at 8:06 AM Licensed Practical Nurse #1 stated that the glucometers (portable medical device to calculate blood sugar levels) at the facility were very finicky and from time to time would not work correctly. Either the glucometers would not accept the test strip, would shut off in the middle of a test or would not record and save the reading. They stated they remembered writing a statement about the glucometers, but they could not recall when they did that or what was included in their statement.During a telephone interview on 06/10/2026 at 9:08 AM, Licensed Practical Nurse #4 stated the glucometers at the facility were horrible and did not work half the time. They stated that they remembered one day that they were pulled into the Former Administrator's office regarding a low blood sugar reading. Licensed Practical Nurse #4 stated the Former Director of Nursing and Former Administrator would not provide any details about what they were investigating and never asked for a written statement.During an interview on 06/10/2026 at 12:22 PM, the Administrator stated they were unable to locate the facility reported investigations. Usually there would be a full investigation with statements and interviews available at the facility.During a telephone interview on 06/10/2026 at 3:38 PM, Licensed Practical Nurse #5 stated that they remembered hearing about the investigation regarding a nurse not completing blood sugar checks. They stated the Former Director of Nursing and Former Administrator did not ask them any questions or to write any statements regarding the glucometers or nurses not completing blood sugar checks.During a telephone interview on 06/10/2026 at 3:53 PM, the Former Administrator stated they remembered the incident with the glucometers and reported it as an allegation of neglect to the New York State Department of Health. They stated they remembered Licensed Practical Nurses and Registered Nurses writing statements. The Former Administrator stated they scanned the statements into the computer at the facility. After scanning the documents, they would have shredded the hard copies.During a telephone interview on 06/11/2026 at 9:45 AM, Registered Nurse #1 stated they were the unit manager when there was an alleged incident that Licensed Practical Nurse #4 was not completing blood sugar checks. They stated that Resident #6 had a fall on the floor and stated to Registered Nurse #1 that Licensed Practical Nurse #4 did not check their blood sugar that morning. Registered Nurse #1 stated they reported that to the Former Director of Nursing, even though Resident #6 was not a reliable historian. They stated that an investigation needed to be done in the event that Resident #6 was not fabricating a story. They stated that they could not recall writing a statement and they did not remember asking any Licensed Practical Nurses or other Registered Nurses to write any statements regarding the allegation. Registered Nurse #1 stated that a full investigation would have included a report and witness statements from anyone who could have been involved.During an interview on 06/11/2026 at 11:41 AM, the Administrator stated they talked to the Former Administrator and was working on finding the Facility Reported Incidents in the computer system.During an interview on 06/11/2026 at 12:31 PM, the Administrator stated they were not able to find the Facility Reported Incident regarding an allegation of neglect for Resident #2 and Resident #6 in the computer system.During an interview on 06/11/2026 at 12:33 PM, the Administrator reviewed the facility Incident Report Summary dated 08/26/2025 and stated they felt it was not a thorough investigation. They stated that it was all very general and there were no written statements from staff attached. They stated that all staff who came in contact with Resident #2 and Resident #6 and all Licensed Practical Nurses and Registered Nurses who used the glucometers should have been interviewed and provided witness statements. They stated that the manufacturer of the glucometers should have been reached out to. There was a general statement regarding an audit, but it was unknown what the audit was about; it should have been in a file that was readily available. A thorough investigation would have captured all variables to make sure it exhausted all potential situations to keep the incident from happening again. They stated it was important to have a thorough investigation because then they could find out what caused the incident to occur and decide on how to correct it. 10 New York Codes, Rules, Regulations 415.4(b)(3)

Based on observations, interviews, and record review conducted during the survey, the facility failed to ensure the nursing staff information was posted on a daily basis and contained the required information. Specifically, the facility did not post daily the current resident census and the total number, and the actual hours worked by licensed and unlicensed nursing staff, in a prominent place readily accessible to residents and visitors for two out of five days; the facility did not complete and update the form, each shift, to include accurate resident census, and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care for five out of five days. Additionally, the facility failed to retain records for 18 months per regulation. The findings include:The facility policy titled Benefits Improvement and Protection Act (BIPA) Posting, approved 06/2026, documented the purpose of Benefits Improvement and Protection Act posting was to have staffing numbers and resident census accessible for all staff, residents, and visitors. The facility would post daily at the beginning of each shift the facility specific shift scheduled for the 24-hour period, the number and categories of nursing staff employed or contracted by the facility, as well as the total number of hours worked by licensed and unlicensed nursing staff who are directly responsible for resident care. Other posted data included facility name, current date and resident census. Data must be displayed in a clear and readable format and be posted in a prominent place readily accessible to residents and visitors. Records must be kept for 18 months or as required by State law, whichever greater.During intermittent observations made on 06/07/2026 at 10:30 AM and 06/08/2026 at 8:33 AM, the Daily Schedule was not visible and was unable to be located in the facility. Continued observations on 06/09/2026 at 1:04 PM, 06/10/2026 at 8:36 AM, and 06/11/2026 at 10:11 AM, the Daily Schedule was posted on a bulletin board across from the elevators leading to the facility units. The documents included the current census number of residents and the total number of hours worked and ratios for direct care staff. The document did not include the updated licensed and unlicensed staff hours for each shift.Review of the Daily Schedule sheets dated 06/07/2026 to 06/11/2026 revealed the hours of licensed and unlicensed staff did not reflect staff schedule changes.There was no documented evidence that the Benefits Improvement and Protection Act form was completed, updated, or posted and readily available for the public for the requested dates of 05/07/2026 to 06/06/2026.During an interview on 06/08/2026 at 3:01 PM, the Scheduler stated they just started three weeks prior and had posted their first Benefits Improvement and Protection Act on the bulletin board that morning, 06/08/2026. They stated a policy was created by the Administrator recently, and they were made aware of the Daily Schedule regulations then. The Scheduler stated prior to 06/08/2026 they were not filling out or posting the Benefits Improvement and Protection Act form in a place available for the public to see, no one was posting it. They stated they were unaware that changes needed to be made to the Benefits Improvement and Protection Act posting when schedule changes occurred each shift, they were not completing that. They stated the nursing staffing schedules (Daily Schedule) had a census, ratios, and number of direct care staff on them, but they were not readily available to the public. During an interview on 06/11/2026 at 12:44 PM, the Administrator stated the Benefits Improvement and Protection Act should be readily available, posted in a public area; it should reflect the ratio of direct care staff based upon census, with total ratios, and updated each shift with staffing changes. The Administrator stated they were unaware the Benefits Improvement and Protection Act was not being posted in a public area on 06/07/2026 and 06/08/2026, or that the Benefits Improvement and Protection Act was not updated with staffing changes each shift on 06/07/2026 through 06/11/2026. The Administrator stated they created a Benefits Improvement and Protection Act posting policy for the facility that was approved on 06/03/2026, prior to that date there was no policy for Benefits Improvement and Protection Act posting regulations. Additionally, the Administrator stated it was important for the Benefits Improvement and Protection Act to be posted in a readily accessible area, and updated with staffing changes as needed each shift, so that visitors, staff and residents could view it and ensure the facility was meeting their staffing ratios. 10 New York Codes, Rules, and Regulations 415.13

Based on interview and record review conducted during a Complaint (NY00325631) investigation conducted during a Standard Survey completed on 5/17/24, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for two (Resident #28 and #39) of fifteen residents reviewed for quality of care. Specifically, there was no Registered Nurse assessment for a resident with a reddened area on their coccyx, and there was no order obtained from the physician for treatment of a Stage 2 (a shallow wound that affects the skin and the tissue below it) pressure ulcer (#28). Additionally, there was no evidence of a Registered Nurse assessment for a resident who experienced a change in their behavior, received an antipsychotic medication and after the resident had an adverse reaction to the medication (Resident #39). The findings are: The policy titled Skin - Pressure Ulcer/Injury Treatment dated 10/05, documented that an assessment by a Registered Nurse included: the date assessed, measurements including length, width, and depth, stage of ulcer if appropriate, the location and type of wound. The policy titled Standard Physician Orders dated 6/23/11, documented that telephone or verbal orders for Long Term Care residents may be accepted by a licensed nurse and must be countersigned by a physician within 48 hours. The undated facility job description for a Licensed Practical Nurse, documented that the Licensed Practical Nurse was to provide nursing care under the guidance of a Registered Nurse, must be able to document in the patient's records, and identify appropriate nursing interventions. The undated facility job description for a Registered Nurse, it documented that the Registered Nurse assures the delivery of safe, comprehensive, effective, appropriate nursing care including resident assessments, documentation, and medication administration. 1. Resident #28 was admitted to the facility with Alzheimer's disease, stroke, and type 2 diabetes mellitus. Review of the Minimum Data Set (a resident assessment tool) dated 9/3/23 documented the resident was severely cognitively impaired. Further review of the Minimum Data Set documented the resident was at risk for developing pressure areas. The resident's Care Plan dated 9/12/22, documented the resident was at risk for altered skin integrity related to a history of pressure areas, incontinent bowel and bladder, and dementia. Review of the chronological nursing progress notes dated 8/1/23 to 12/27/23 documented the following: 8/24/23 - The Director of Nursing wrote that a Stage 2 open area was noted on the resident's left buttock measuring 0.5 centimeters by 0.3 centimeters, area was cleansed with wound wash with skin prep (protective barrier) and covered with a foam border dressing. 8/30/23 - Registered Nurse Unit Manager #1 wrote that assessed resident's left buttock and area resolved; also assessed the coccyx and found no open area; skin is peeling; apply [NAME] (calmoseptine- a moisture barrier cream to prevent skin irritation from urine and feces) three times a day and as needed. 9/7/23 - Licensed Practical Nurse #2 wrote that patient has redness in coccyx area, cleaned area, and foam border dressing applied. 12/19/23 - Licensed Practical Nurse #1 wrote that resident continues with open area on coccyx; Calmoseptine applied, unit manager aware and will continue to monitor. There was no documented evidence that there was a registered nurse assessment regarding the reddened area to the resident's coccyx 9/7/23, and there was evidence of a registered nurse assessment on 12/19/23 of the open area on the resident's coccyx. Review of the chronological Physician Order Report - Treatments flow sheet dated 9/12/22 to 2/28/24 documented the following: 9/12/22 - skin checks weekly on shower days. 7/28/23 - remove lidocaine patch from back. 8/11/23 - Calmoseptine to buttocks as needed per shift. 12/20/23 - oxygen to at 2 liters via nasal canula as needed. 2/28/24 - apply Calmoseptine to right and left buttock, cover with foam border dressing once a day. There was no evidence a physician's order was obtained on 8/24/23 for the Stage 2 pressure ulcer on the resident's left buttocks to include the use of skin prep and dry foam dressing; the discontinuation and the initiation of applying Calmoseptine three times daily and as needed on 8/30/23; and there was no evidence there was a physician's order on 9/7/23 to add the foam dressing. During an interview on 5/16/24 at 10:09 AM, the Medical Director, they stated they expected the nurses to contact them to obtain an order for a foam border dressing and any treatment for any open area on a resident. They stated they expected the registered nurses to assess any open area on a resident. During an interview on 5/16/24 at 10:45 AM, Licensed Practical Nurse #1 stated an order from the physician's was needed for any dressing and treatment. During an interview on 5/16/24 at 11:08 AM, Registered Nurse Unit Manager #1 stated they expected the Licensed Practical Nurses to get a registered nurse to assess all skin issues. They stated that if it was after the day shift ended and there were no Registered Nurses in the skilled nursing facility, the Licensed Practical Nurses were to go to the Medical Care Unit or call the Medical Care Unit to find a Registered Nurse to assess any skin concerns. hey stated they would expect the Licensed Practical Nurses to write a progress note and document they contacted a Registered Nurse to complete the assessment. They stated that a foam border dressing and any skin treatment needed an order from a physician. During an interview on 5/16/24 at 12:02 PM, the Director of Nursing stated the physician should be notified about any open areas on a resident. The Director of Nursing stated that any foam border dressing for an open area required an order from the physician. They stated they thought they obtained an order for the Stage 2 on 8/24/23, then verified that the order was not on the Physician Order Report - Treatment flow sheet. During an interview on 5/17/24 at 9:05 AM, Licensed Practical Nurse #2, they stated that they should have contacted a Registered Nurse to assess the reddened area on the resident. They stated if the area wasn't followed up on by the morning shift nurse, they should have contacted the Registered Nurse on their next shift. During an interview on 5/17/24 at 9:19 AM, Registered Nurse Unit Manager #2, they expected any of the Licensed Practical Nurses to call the Medical Care Unit to get a Registered Nurse to assess any skin concerns. They stated they expect their nurses to document in progress notes that they contacted the Registered Nurse or Supervisor to assess a skin area. 2. Resident #39 had diagnoses including unspecified dementia, macular degeneration (loss of the central field of vision), and lung cancer. The Minimum Data Set, dated dated dated [DATE], documented Resident #39 was severely cognitively impaired, and displayed no behaviors. Resident #39's Care Plan dated 3/6/24, documented resident was at risk for pain due to diagnosis of cancer and admitted on palliative care (comfort care). Further review of the Care Plan documented monitor for changes in behavior that may be contributed to pain and monitor for verbal and non-verbal signs of pain. Review of Resident #39's progress note dated 2/28/24 at 3:00 PM revealed the Director of Nursing documented they were made aware that Resident #39 was becoming very agitated, restless, and physically aggressive with staff during routine care and rounds. They contacted Nurse Practitioner #1, and a new order was received for Haldol 5 milligrams intramuscular X 1. There was no evidence a Registered Nurse or the Director of Nursing completed a comprehensive resident assessment of the resident's condition/status when the resident experienced a change in their behavior. The Prescription Order dated 2/28/24 at 3:13 PM, documented an order for haloperidol lactate (Haldol) 5 milligrams intramuscularly injection, one time and as needed every 4 hours. The order was written for vascular dementia with other behavioral disturbance by the Director of Nursing. Review of the Medication Administration History dated 2/1/24- 2/29/24, revealed Licensed Practical Nurse #4 administered the haloperidol lactate 5 milligrams intramuscularly injection on 2/28/24 at 9:07 PM. Review of Resident #39's progress note dated 2/29/24 at 2:00 PM (late entry on 3/1/24 at 7:27 AM) revealed the Unit Manager Registered Nurse #1 documented they communicated with Nurse Practitioner #1 about the resident's reaction to the Haldol. There was no evidence a comprehensive resident assessment was completed by a Registered Nurse when the resident experienced an adverse reaction to the Haldol. During an interview on 5/16/24 at 9:40 AM, the Medical Director stated if a resident was having a change in condition or a reaction to a medication, they would expect the Registered Nurse to document a complete assessment. The provider might not be able to come into the facility so they would trust the nurse's assessment, make recommendations, or give orders. During an interview on 5/16/24 at 11:40 AM, the Director of Nursing stated when a resident has a change in condition or a reaction to a medication, a thorough physical assessment should be documented in the resident's progress note by the Registered Nurse. They stated that the progress note dated 2/28/24 at 3:00 PM did not contain a thorough physical assessment of Resident #39. The Director of Nursing also stated that the progress note dated 2/29/24 at 2:00 PM did not contain a thorough physical assessment of Resident #39. During an interview on 5/17/24 at 10:05 AM, the Administrator stated that as a standard of practice a thorough registered nurse assessment should be completed and documented for any change in a resident's condition. 10 NYCRR 415.12

Based on interview and record review conducted during a Standard survey completed on 5/17/24 the facility did not immediately inform resident's representatives of a change in their physical and/or mental status for two (Resident #39 and Resident #28) of three residents reviewed for notification of change. Specifically, Resident #39 was given an intramuscularly injection (IM) of Haldol (antipsychotic medication) 5 milligrams and the family was not notified until after the resident had an adverse reaction to the medication. Additionally, the facility did not notify Resident #28's representative of a reddened area on their coccyx until 6 days later, and there was no documented evidence Resident #28's representative was notified of a stage II pressure area. The findings are: The policy titled Change in Condition dated 2/2021 documented that it was the responsibility of the Registered Nurse or Registered Nurse Supervisor to notify the resident, the physician, and the resident's responsible party, of changes in the resident's medical or mental condition, and document the notification in the medical record. The form titled Your Rights as a Nursing Home Resident in New York State dated 2022, documented that residents had the right to refuse medications, treatments, and chemical restraints. It also documented that the resident's representative had those rights in the instance that the resident was unable to make their own decisions. 1. Resident #39 had diagnoses including unspecified dementia, macular degeneration (loss of the central field of vision), and lung cancer. The Minimum Data Set (a resident assessment tool) dated 2/22/24, documented Resident #39 was severely cognitively impaired and displayed no behaviors. Resident #39's care plan dated 3/6/24, documented the resident was at risk for pain and receiving palliative care (comfort care). Interventions included to monitor for changes in behavior that may be contributed to pain and to monitor. The care plan also documented interventions to maintain family contacts. Resident #39's progress note dated 2/28/24 at 3:00 PM revealed the Director of Nursing documented they were made aware that Resident #39 had become very agitated, restless, and physically aggressive with staff during routine care and rounds. They contacted Nurse Practitioner #1, and a new order was received for Haldol 5 milligrams intramuscularly X 1 dose and every 4 hours as needed. There was no documented evidence the family was notified of the resident's behaviors, or that they were notified of the new order for Haldol prior to its administration. The Prescription Order dated 2/28/24 at 3:13 PM, documented an order for haloperidol lactate (Haldol) 5 milligrams intramuscularly injection, one time and as needed every 4 hours. The order was written for vascular dementia with other behavioral disturbance by the Director of Nursing. Review of the Medication Administration History dated 2/1/24- 2/29/24, revealed Licensed Practical Nurse #4 administered the haloperidol lactate 5 milligrams intramuscularly injection on 2/28/24 at 9:07 PM. Review of Resident #39's progress note dated 2/29/24 at 2:00 PM (documented as late entry on 3/1/24 at 7:27 AM) revealed the Unit Manager Registered Nurse #1 documented they communicated with Nurse Practitioner #1 about the resident's reaction to the Haldol and that the family was aware. During an interview on 5/13/24 at 12:43 PM, Resident #39's representative stated they had not been notified of the resident's behaviors or that Haldol was administered until they came to visit (2/29/24). The representative stated they noticed Resident #39 was not behaving as they normally did; their arms and legs were flailing around, and they were unable to respond or communicate. At that time, the unit manager told them the resident's change was a reaction to the Haldol they had received the night before. During an interview on 5/15/24 at 10:39 AM, Registered Nurse Unit Manager #1 stated when the resident had a change in condition and a new order was received from the provider the receiving nurse (Director of Nursing) should have notified the resident's representative and documented the notifications in the progress notes. During an interview on 5/15/24 at 11:46 AM, the Director of Nursing stated that nursing staff should notify the family before a new medication was given. The Director of Nursing stated that it was important because the family could be aware that the resident had an adverse reaction to the medication in the past, and they have the right to refuse the medication. During an interview on 5/15/24 at 1:21 PM, Nurse Practitioner #1 stated they expected the nursing staff to notify the resident's family or representative prior to giving any new medication. Especially with a medication like Haldol because it was considered a form of chemical restraint. 2. Resident #28 had diagnoses including Alzheimer's disease, stroke, and type II diabetes mellitus. The Minimum Data Set, dated dated dated [DATE], documented the resident was severely cognitively impaired, and was at risk for developing pressure areas. Resident #28's care plan dated 9/12/22, documented the resident was at risk for altered skin integrity related to a history of pressure areas, incontinence of bowel and bladder, and dementia. Review of Resident #28's progress note dated 8/24/23 revealed the Director of Nursing documented that a Stage 2 open ulcer (shallow ulcer cause by pressure) was noted on the resident's left buttock that measured 0.5 centimeters by 0.3 centimeters. The ulcer was cleansed with wound wash skin prep applied (a liquid film forming a protective barrier on a patient's skin to help reduce friction from removing adhesive dressings), and covered with a foam border dressing. There was no documented evidence the resident representative was notified of the development of the stage 2 pressure ulcer. Review of Resident #28's progress note dated 8/30/23 revealed Registered Nurse Unit Manager #1 documented they assessed resident's left buttock, and the area was resolved. They also assessed the coccyx and found no open area; skin was peeling; apply [NAME] (Calmoseptine- a moisture barrier cream to prevent skin irritation from urine and feces) three times a day and as needed. Review of Resident #28's progress notes dated 9/7/23 revealed Licensed Practical Nurse #2 documented that patient had redness in coccyx area, cleaned area, and foam border dressing applied. There was no documented evidence the resident representative was made aware of the redness and the need to start a treatment. Review of Resident #28's progress notes dated 12/19/23 revealed Licensed Practical Nurse #1 documented that resident continues with open area on coccyx; Calmoseptine applied, unit manager aware and will continue to monitor. There was no documented evidence the resident representative was made aware of the skin concerns. Review of the Physician Order Report - Treatments flow sheet dated 9/12/22 to 2/28/24 documented the following: 9/12/22 - skin checks weekly on shower days. 7/28/23 - remove lidocaine patch from back. 8/11/23 - Calmoseptine to buttocks as needed per shift. 12/20/23 - oxygen to at 2 liters via nasal canula as needed. 2/28/24 - apply Calmoseptine to right and left buttock, cover with foam border dressing once a day. Review of the View Care Conference - Care Conference Information dated 9/13/23 revealed no evidence the family was notified of the reddened area. During an interview on 5/16/24 at 10:09 AM, the Medical Director stated they would expect the nurses to contact them to notify them of any open area. During an interview on 5/16/24 at 10:45 AM, Licensed Practical Nurse #1 stated they do not recall being told about the reddened area on the resident's coccyx by Licensed Practical Nurse #2 who worked the night shift before them. They stated they would document they contacted the family or the physician about the reddened area. During an interview on 5/16/24 at 11:08 AM, Registered Nurse Unit Manager #1 stated they expect the Licensed Practical Nurses to tell them about any skin conditions. They stated they would have documented in progress notes about contacting the family and the Medical Director for any skin issues. During an interview on 5/16/24 at 12:02 PM, the Director of Nursing stated the physician should be notified about any open area on the resident, because Resident #28's coccyx was a chronic pressure area, they would not have notified the family. They stated family should be notified about any change in condition within 24 hours. They also stated that it should be documented in progress notes that family was notified. The Director of Nursing reviewed the medical record and stated the family attended the care conference meeting on 9/13/23, and may have been notified at that time of skin concerns. During an interview on 5/17/24 at 9:05 AM, Licensed Practical Nurse #2 stated they should have contacted a Registered Nurse to assess the reddened area. They stated if the area wasn't followed up on by the morning shift nurse, they should have contacted the Registered Nurse on their next shift. During an interview on 5/17/24 at 9:19 AM, Registered Nurse Unit Manager #2 stated if there was not a registered nurse available in long term care, they expected the Licensed Practical Nurses to call the Medical Care Unit to get a Registered Nurse to assess any skin areas. They stated they expect their nurses to document in progress notes they contacted the Registered Nurse or Supervisor to assess a skin area. During an interview on 5/17/24 at 10:05 AM, the Administrator stated they expected nursing staff to notify family, and the physician of any change in condition, or any new treatment or medication. 415.3 (e)(2)(ii)(c)

Based on interview and record review conducted during a Standard survey completed on 5/17/24, the facility did not ensure that a resident has the right to refuse treatment for one (Resident #10) of five residents reviewed for immunizations. Specifically, Resident #10 was administered the pneumococcal vaccine (used to prevent pneumonia) by facility staff without consent. The finding is: The policy and procedure titled Resident Rights dated 10/22 documented the facility will protect and promote the rights of the resident. The policy and procedure documented the resident had the right to accept or refuse care and treatment. Residents have a right to be provided a statement that should they be unable to make their own decisions and be adjudicated incompetent and not be restored to legal capacity, or if a conservator should be appointed for you, these rights and responsibilities shall be exercised by the appointed committee or conservator in a representative capacity. The policy and procedure titled Vaccinations - Patient/Elder revised 9/22 documented residents [AGE] years or older are assessed for pneumococcal status at time of admission and immunization consent/declination received at that time. The policy and procedure documented prior to vaccination, double check the chart for physician's order, normal baseline temperature, serious reaction to applicable vaccine, and signed consent form. Resident #10 was admitted with diagnoses that included dementia, diabetes mellitus (high blood sugar), and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 4/17/24 documented Resident #10 was always understood, always understands, and had moderate cognitive impairment. The Minimum Data Set documented Resident #10 received the pneumococcal vaccine. The Health Care Proxy form dated 9/26/23 documented Resident #10's responsible party was their Health Care Proxy. The Health Care Proxy documented the responsible party would make decisions for Resident #10 when Resident #10 was unable to make their own health care decisions. The Employee/Resident/Inpatient Vaccine Administration Consent/Waiver Form dated 1/26/24 documented verbal declination was obtained via phone with the Health Care Proxy for Influenza (flu), Pneumococcal, Respiratory Syncytial Virus (RSV- a common respiratory virus), Hepatitis B and Covid-19 Vaccines. The form further documented Resident #10 received the Pneumococcal Vaccine on 2/28/24. The History and Physical dated 11/10/23 documented Resident #10 had baseline Alzheimer dementia and was definitely confused. The Physician General Clinic Note dated 2/8/24 documented Resident #10 was pleasantly confused. Review of the Medication Administration History Report dated 2/1/24-2/29/24 documented Resident #10 received the Prevnar 20 (pneumococcal) vaccination on 2/28/24. Review of the Care Plan edited on 4/24/24 documented Resident #10 had advance directives. The Care Plan documented Resident #10's wishes would be honored and the Health Care Proxy was in the chart. During an interview on 5/15/24 at 2:56 PM, Registered Nurse #3 stated they had helped to obtain vaccination consents and declinations from the residents or the residents' responsible party. Registered Nurse #3 stated based on Resident #10's Brief Interview for Mental Status score, they would not be able to make the decision to consent to or decline a vaccination. Registered Nurse #3 stated a verbal declination was obtained from Resident #10's Health Care Proxy by Registered Nurse #2 and cosigned by Registered Nurse #3. Registered Nurse #3 stated Resident #10 received the pneumococcal vaccination after the declination was obtained. Registered Nurse #3 stated Resident #10 should not have received the pneumococcal vaccination because they had the right to refuse the vaccination. During an interview on 5/15/24 at 3:13 PM, the Social Worker stated Resident #10's Health Care Proxy was very involved in their care and made health care decisions for Resident #10. During an interview on 5/15/24 at 3:22 PM, Registered Nurse #2 stated Resident #10 was unable to make their own decisions and that was why they contacted Resident #10's Health Care Proxy. Registered Nurse #2 stated, based on the electronic medication administration record, the Director of Nursing gave the pneumococcal vaccination on 2/28/24. During an interview on 5/15/24 at 3:30 PM, the Director of Nursing stated the consent and declination form was filled out incorrectly. The Director of Nursing stated Resident #10 should not have received the vaccination because the family did not want them to have it. The Director of Nursing stated they signed in two places that Resident #10 received the vaccination. removed. During an interview on 5/16/24 at 9:52 AM, the Medical Director stated it was expected for nurses to follow Resident #10's wishes. During an interview on 5/17/24 at 10:00 AM, the Administrator stated it was expected for nursing to administer or not administer a vaccination based on the consent and declination form. The Administrator stated it was the Director of Nursing's responsibility to make sure consent forms and administering immunizations were done accurately. 10 NYCRR 415.3f(1)(ii)

Based on record and interview review conducted during a Standard survey completed on 5/17/24, the facility did not maintain complete and accurately documented medical records for six (Resident #3, #10, #25, #36, #39, and #41) of 16 residents. Specifically, medical orders were not accurately entered under the prescribing providers name in the medical record. The findings are but not limited to: The policy and procedure titled Medication - Verbal and Written Physician Orders reviewed 2/21 documented verbal orders will be written by the person receiving the order as soon as it is received, noting the date and time received, the name of the physician/PA (physician assistant)/NP (nurse practitioner) and the receiver's name and title. The prescriber shall co-sign the order within 48 hours. The policy and procedure titled Standard Physician Orders reviewed 2/21 documented telephone or verbal orders for Long Term Care elders may be accepted by a licensed nurse only and must be countersigned by the physician within 48 hours of receiving the orders. 1. Resident #39 had diagnoses including dementia, macular degeneration (loss of the central field of vision), and lung cancer. The Minimum Data Set (MDS-a resident assessment tool) dated 2/22/24, documented Resident #39 was severely cognitively impaired. Resident #39's progress note dated 2/28/24 at 3:00 PM documented the Director of Nursing contacted Nurse Practitioner #1 and obtained a new order for Haloperidol (Haldol-an antipsychotic medication) five milligrams (mg- a unit of measurement) intramuscularly (an injection into a muscle) for one dose and an order for Haloperidol five milligrams intramuscularly every four hours as needed. Review of the prescription order report for Resident #39, revealed an order, for Haloperidol lactate five milligrams for one dose and as needed every four hours, was created on 2/28/24 at 3:13 PM by the Director of Nursing. It was entered as a written order by the Medical Director. The order was signed electronically by the Medical Director on 3/19/24. Resident #39's progress note dated 2/29/24 at 2:00 PM revealed the Registered Nurse Unit Manager #1 documented they communicated with Nurse Practitioner #1 about Resident 39's reaction to the Haldol and obtained an order to discontinue the Haloperidol and to increase the Ativan (an antianxiety medication). Review of the prescription order report for Resident #39, revealed an order, to increase Ativan to one milligram every four hours as needed, was created on 2/29/24 at 1:50 PM by Registered Nurse Unit Manager #1. It was entered as a written order by the Medical Director. The order was signed electronically by the Medical Director on 3/19/24. Review of the prescription order report for Resident #39, revealed an order, to discontinue Haloperidol, was created on 3/1/24 at 1:02 PM by Unit Manager Registered Nurse #1. It was entered as a written order by the Medical Director. The order was signed electronically by the Medical Director on 3/19/24. During an interview on 5/15/24 at 1:21 PM, Nurse Practitioner #1 stated the orders for Resident #39 should have been entered under their name, if they gave the orders. During an interview on 5/17/24 at 9:36 AM, Licensed Practical Nurse #3 stated that if the order was written, there would have been a handwritten order in the paper chart. Licensed Practical Nurse #3 stated that they would then choose which provider gave them the order and complete the entry. After completing the order entry process, the nurse should have documented in a progress note. 2. Resident #3 had diagnoses including osteoarthritis (a type of arthritis), neuropathy (a disorder effecting the nervous system), and cellulitis (inflammation of tissue under the skin) of the toe. The Minimum Data Set, dated dated dated [DATE] documented Resident #3 had moderate cognitive impairment. The progress note dated 3/8/24, documented Resident #3's left great toe was red, swollen, and warm with scant yellow/white drainage. The progress note documented the On-Call Physician was notified and a new order was written for Keflex (an antibiotic) 500 milligrams by mouth three times a day for 10 days, for an infection. The prescription order report dated 3/8/24 documented an order for Keflex 500 milligrams three times a day by mouth. The order was created by Registered Nurse Unit Manager #2 as a written order and signed by the Medical Director on 3/19/24. During an interview on 5/16/24 at 2:42 PM, Registered Nurse Unit Manager #2 stated the On-Call Physician was not an available option in the computer system when creating new orders. Nurse Practitioner #1 and the Medical Director were the only options. 3. Resident #41 was admitted to the facility with diagnoses of aphasia (a communication and comprehension disorder resulting from a traumatic brain injury), stroke, and hemiparesis (paralyzed on one side). Review of the Minimum Data Set, dated dated dated [DATE] documented that the resident was severely cognitively impaired, sometimes understands others, and sometimes was understood by others. The progress note dated 3/6/24 documented Resident #41 was seen for a 60-day assessment by the On-Call Physician and documented there were new orders for the resident including to obtain labs (blood work), Lasix 20 milligrams (a medication that reduces extra fluid in the body), and potassium (supplement) 10 milliequivalent. Review of Resident #41's Physician orders - medications flow sheet dated 3/6/24 documented the resident was ordered Lasix 20 milligrams by mouth once a day and potassium 10 milliequivalent tablet once a day every other day. Further review of the medication orders documented the orders were signed by the Medical Director on 3/19/24. Review of Resident #41's Physician Orders - labs flow sheet dated 3/7/24 documented the resident was ordered a complete metabolic panel and complete blood count with differential. Further review of the laboratory orders documented the orders were signed by the Medical Director on 3/19/24. During an interview on 5/16/24 at 9:40 AM, the Medical Director stated Nurse Practitioner #1, and the On-Call Physician were covering the facility from 2/22/24 through 3/18/24. The Medical Director stated the orders should have been entered under the name of the provider that gave the order. The Medical Director stated there have been times staff put the Medical Director's name on the orders when they were not the prescriber. The Medical Director stated they have told staff to pick the correct prescriber, but they end up signing the orders anyway. During a telephone interview on 5/16/24 at 9:58 AM, the On-Call Physician stated they expected the staff to choose the correct prescriber- either physician or nurse practitioner, when creating new orders. During an interview on 5/17/24 at 9:48 AM, Registered Nurse Unit Manager #1, stated that they should have had the orders signed by the attending physician. During an interview on 5/16/24 at 11:40 AM, the Director of Nursing stated orders should have been entered under the provider that gave the order. They stated that if it was a written order there should have been a paper order in the resident's chart. During a telephone interview 5/16/24 at 3:19 PM, the Computer Tech for the electronic medical record stated there have been no requests for updating a providers list submitted. They stated the nursing staff had to call the help desk number or put in an electronic ticket (request) on the hospital internet system to add a provider. During an interview on 5/17/24 at 10:00 AM, the Administrator somebody should have brought it to their attention the On- Call Physician's name was not on the list of providers in the electronic medical record system. 10 NYCRR 415.22(a)(1)(2)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00328841) completed on 12/8/23, the facility did not ensure that residents were treated with respect and dignity, free from physical restraints for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (Resident #1) of four residents reviewed. Specifically, Certified Nursing Assistant #1 was observed by a staff member to have sat Resident #1 into a standard chair in the dining room where the back of the chair was against the wall with a window, pushed the dining table up to the resident's chair, then proceed to sit on top of the dining table preventing the resident from moving freely from the table. Additionally, Certified Nursing Assistant #1 was observed to have their back to Resident #1 and was using their cellular phone as they sat on top of the dining table. The finding is: The policy & procedure titled Restraints dated 4/27/23 documented that a physical restraint was defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body, which the individual cannot remove easily and restricts freedom of movement or normal access to one's body. The policy & procedure documented that to consider using a restraint only when a medical symptom or condition warrants the use of a restraint. The policy & procedure documented that restraint use would be considered to treat a medical symptom/condition that endangers the physical safety of the patient or other patients and under the conditions of a physician order and with the consent of the patient or legal representative. 1.Resident #1 had diagnoses which included Alzheimer's disease, dementia, and post-traumatic stress disorder. The Minimum Data Set (a resident assessment tool) dated 10/1/23 documented Resident #1 was severely cognitively impaired, rarely/never understood and sometimes understands. The Minimum Data Set documented the resident wandered on a daily basis and it significantly intruded on the privacy or activities of others. The Minimum Data Set documented Resident #1 was independent with transfers and ambulation. In addition, the Minimum Data Set revealed no evidence that a physical restraint was used. The comprehensive care plan edited on 10/11/23, documented Resident #1 was at risk for alteration in their mood and behavior related to dementia and post-traumatic stress disorder and often wandered into other elder's rooms without being invited. Interventions included a door alert alarm and 1:1 (one on one) redirection at all times while awake. The comprehensive care plan did not document the use of restraints. Review of the undated physician's active orders for Resident #1 revealed there was no physician's order for the use of any type of physical restraint. The facility investigation titled Investigation into incident 11/25/23 signed by the Director of Nursing, documented that on 11/27/23 they were notified that on 11/25/23 a photograph was taken of a Certified Nursing Assistant sitting on a dining room table while they were on a cellular phone in the third-floor dining room. It was documented that per the dietary staff member (who had taken the photograph) statement, the Certified Nursing Assistant #1 had placed Resident #1 in a chair, moved the table in front of Resident #1 and sat on the table. A copy of the photograph that was included in the investigation packet revealed an individual sitting on top of a table holding a cellular phone with their back to another individual seated in a chair. The left arm of the person sitting in the chair could be seen with the back of the chair to the wall/window and the table in front of the chair. The copy of the photograph was labeled with the name of the person sitting on top of the table as Certified Nursing Assistant #1 and the arm of the person sitting in the chair as Resident #1. Review of the written statement provided in the facility investigation folder signed by Cook #1 and dated 11/27/23 documented that on 11/25/23 they observed Resident #1 in a chair up against the wall, with their arms pinned down in the chair by a table while a staff member was sitting on top of the table. The statement documented that the staff member proceeded to sit on the table to keep Resident #1 from getting up. The statement documented that the staff member sat on top of the table for about 8-10 minutes while texting on their cellular phone. Review of the Disciplinary Action Form signed by the Director of Nursing dated 11/28/23 documented that Certified Nursing Assistant #1 was seen restraining Resident #1. The form documented Certified Nursing Assistant #1 placed Resident #1 in a chair with Resident #1's back to a window. The form documented that the table was pushed in front of Resident #1 and that Certified Nursing Assistant #1 was sitting on the table which did not allow Resident #1 to get up. The form documented that Certified Nursing Assistant #1 was on the phone and a photograph was taken of the incident. During intermittent observation on 12/7/23 to 12/8/23 from 7:55 AM to 4:38 PM, Resident #1 was observed to have a 1:1 (one on one) care giver and no restraints in place. During an interview on 12/7/23 at 1:08 PM, Cook #1 stated that on 11/25/23 at 4:07 PM they were preparing hallway trays on the third-floor dining room when they took a picture of a staff member that was sitting on top of a table using their cellular telephone. Cook #1 stated that they were familiar with Resident #1 and Resident #1 was sitting in a chair that was up against the wall/window. Cook #1 stated that they witnessed a staff member (unknown name) push the table up to Resident #1 while Resident #1's hands were at their side. They stated Resident #1 attempted to push the table away from themself and the staff member then sat on top of the table. Cook #1 stated that there was no room for Resident #1 to stand up or get around the chair or table and the resident appeared to be agitated. Cook #1 stated they reported and sent the picture to Hospital Operation Manager #1 when they completed serving the dinner meal. Cook #1 stated they notified Hospital Operation Manager #1 because what the staff member did was not right and would consider it abuse. During a telephone interview on 12/7/23 at 3:36 PM, Certified Nursing Assistant #1 stated on 11/25/23 at mealtime they were responsible for 1:1 (one on one) care for Resident #1. Certified Nursing Assistant #1 stated prior to the start of the dinner meal, they walked Resident #1 to their chair in the dining room and pushed the dining room table toward them. Certified Nursing Assistant #1 stated they sat on top Resident #1's table with their back to Resident #1 and was texting on their phone. Certified Nursing Assistant #1 stated they did not know why they sat on top of the table, but they thought it was okay because they have seen other staff members do the same thing. Certified Nursing Assistant #1 stated that at the time they did not realize they were restraining Resident #1 but after speaking with the Director of Nursing and Administrator they understand how sitting on top of a table would be a form of a restraint. They stated sitting on top of Resident #1 dining table was a restraint because it prevented Resident #1 from getting up and moving freely from the table. Certified Nursing Assistant #1 stated that by having their back to a resident and using their personal cellular phone in the presence of Resident #1, they did not treat Resident #1 with respect or dignity. During an interview on 12/8/23 at 8:15 AM, Social Worker #1 stated that on 11/27/23 it was brought to their attention that Resident #1 was restrained on 11/25/23 in the dining room. Social Worker #1 stated they were shown a picture of a staff member sitting on top of a table with their back to an individual while looking at their cellular phone. Social Worker #1 stated that the Director of Nursing identified the individual as Resident #1. Social Worker #1 stated after review of the photograph it appeared as Resident #1 was restrained due to the staff member sitting on a table causing Resident #1 to be unable to get up from the table and possibly unable to move their arms. Social Worker #1 added that it was disrespectful of the staff member to sit on top of a table with their back to Resident #1. During an interview on 12/8/23 at 9:32 AM, the Hospital Operation Manager #1 stated on 11/25/23 they received a text message from Cook #1 that they needed to speak with them and a picture was sent that was taken with Cook #1's cellular phone. The Hospital Operation Manager #1 stated the picture was of a staff member sitting to top of the table with the left arm of someone behind the staff member. The Hospital Operation Manager #1 stated when they spoke with Cook #1, Cook #1 stated that a staff member pushed Resident #1 arms down and pushed the table up to them and then sat on top of the table. The Hospital Operation Manager #1 stated Cook #1 said that Resident #1 did not appear harmed. The Hospital Operation Manager #1 then stated to Cook #1 that they would take care of it first thing Monday morning. The Hospital Operation Manager #1 stated from the interview with Cook #1 and review of the photograph the situation was potential abuse because Resident #1 could not move. During an interview on 12/8/23 at 10:47 AM, the Director of Nursing stated that on 11/27/23 the Hospital Operation Manager #1 informed them that Cook #1 was distraught and witnessed Resident #1 being restrained in the dining room on 11/25/23. The Director of Nursing stated they were shown a photograph of a staff member (that they identified as Certified Nursing Assistant #1) sitting on top of a table with their back to a resident (that they identified as Resident #1). The Director of Nursing stated the picture also showed that Certified Nursing Assistant #1 had their cellular phone in their hand. The Director of Nursing stated that per the statement made by Cook #1, Resident #1 was in a chair against the window and the table was pushed pinning Resident #1 in. The Director of Nursing stated that a restraint is a physical device that stops an elder from moving freely. They stated Resident #1 was restrained on 11/25/23 because Certified Nursing Assistant #1 prevented Resident #1 from freely moving from the table by sitting on the table. The Director of Nursing added that by Certified Nursing Assistant #1 having their back to a resident and being on their cellular phone while they were caring for Resident #1 was disrespectful and undignified. During an interview on 12/8/23 at 10:09 AM, the Administrator stated that they were notified on 11/27/23 Resident #1 was witnessed by Cook #1 to be restrained in the dining room by Certified Nursing Assistant #1 on 11/25/23. The stated that they were shown a picture, gather statements and it was determined that Certified Nursing Assistant #1 was sitting on top of a table which resulted in preventing Resident #1 from moving freely from the table. The Administrator stated that they concluded that Resident #1 was restrained by Certified Nursing Assistant #1 without harm. The following corrective actions were implemented by the facility to correct the non-compliance as of 12/7/23 at 10:15 AM. -Certified Nursing Assistant #1 was removed from resident contact on 11/29/23. -Resident #1 was assessed and no ill effects noted. -During the abbreviated survey completed 12/7/23-12/8/23 no restraints were observed to be in use. -Starting on 11/29/23 facility nursing staff were re-educated on resident rights, abuse, and restraints. -During the abbreviated survey completed 12/7/23-12/8/23, it was verified through staff interviews and record review that the facility had re-educated 86% of their nursing staff on resident rights, abuse and neglect which included restraint use. 10 NYCRR 415.4 (a)(2)(iv)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY00328841) completed on 12/8/23, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse, to the facility's Administrator and the State Survey Agency for one (Resident #1) of four residents reviewed for abuse. Specifically, facility staff did not report an allegation of abuse/mistreatment of a resident to the Director of Nursing or the Administrator which resulted in the alleged abuse not getting reported to the appropriate officials including the New York State Department of Health as required. Additionally, the allegation occurred on 11/25/23 and it was inaccurately reported to the New York State Department of Health that it occurred on 11/26/23. The finding is: The policy and procedure titled Abuse-Identification, Investigation and Reporting dated 1/22, documented that physical abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The policy and procedure documented that examples of mistreatment are restraints. Any forms of abuse needed to be reported the nurse manager, supervisor or Director of Nursing needed to be immediately informed to prevent further abuse and upon conclusion of the investigation the findings would be reported to the Administrator. The policy and procedure documented that per New York State Department of Health Guidance for Nursing Home (2016) incidents resulting in serious bodily injury must be reported within two hours after forming the suspicion and to refer to the New York State Department of Health Nursing Home Incident Reporting Manual for the elements that must be present for an incident to be reportable. The policy and procedure did not include that all allegations of abuse must be reported immediately but no more than two hours to the administrator and the New York State Department of Health. 1. Resident #1 had diagnoses which included Alzheimer's disease, dementia, and post-traumatic stress disorder. The Minimum Data Set (a resident assessment tool) dated 10/1/23 documented Resident #1 was severely cognitively impaired, rarely/never understood and sometimes understands. The Minimum Data Set documented the resident wandered on a daily basis and it significantly intruded on the privacy or activities of others. The Minimum Data Set documented Resident #1 was independent with transfers and ambulation and no physical restraint was used. The comprehensive care plan edited on 10/11/23, documented Resident #1 is a risk for alteration in mood and behavior related dementia and post-traumatic stress disorder and often wandered into other elder's rooms without being invited. Interventions included a door alert alarm and 1:1 (one on one) redirection at all times while awake. The comprehensive care plan did not document the use of restraints. The facility investigation titled Investigation into incident 11/25/23 signed by the Director of Nursing, documented that on 11/27/23 they were notified that on 11/25/23 a photograph was taken of a Certified Nursing Assistant sitting on a dining room table while they were on a cellular phone in the third-floor dining room. It was documented that per the dietary staff member (who had taken the photograph) statement that Certified Nursing Assistant #1 had placed Resident #1 in a chair, moved the table in front of Resident #1 and sat on the table. The investigation also documented that a further issue was noted that the picture of the incident was sent to a manager on 11/25/23 and that manager did not report the incident to administration until 11/27/23 at 9:25 AM. Review of the Department of Health Nursing Home Facility Incident Report documented that the Administrator submitted the following information on 11/27/23 at 10:22 AM: On 11/26/23 at 5:46 PM, a dietary aide witnessed a Certified Nursing Assistant restrain Resident #1 in the dining room. The report documented that a picture was taken, and a statement was written from the dietary aide (Cook #1). During an interview on 12/7/23 at 1:08 PM, Cook #1 stated that on 11/25/23 at around 6:00 PM, they reported and sent the picture to Hospital Operation Manager #1 when they completed serving the dinner meal. Cook #1 stated they notified the Hospital Operation Manager #1 because what the staff member did was not right and would consider it abuse. During an interview on 12/8/23 at 9:32 AM, the Hospital Operation Manager #1 stated on 11/25/23 they received a text message from Cook #1 that they needed to speak with them, and a picture was sent that was taken with Cook #1's cellular phone. The Hospital Operation Manager #1 stated they reported the incident to the Director of Nursing and Administrator on 11/27/23 after morning report. The Hospital Operation Manager #1 stated they were not aware of the New York State Department of Health regulations for reporting, nor had they been educated on the regulations for reporting before or after the incident. During an interview on 12/8/23 at 10:47 AM, the Director of Nursing stated that on 11/27/23 after morning report, the Hospital Operation Manager #1 informed them that Cook #1 witnessed Resident #1 being restrained in the dining room on 11/25/23. The Director of Nursing stated that any allegation of abuse should be reported to the New York State Department of Health within two hours. They stated they were not made aware of the incident until 11/27/23 and should have been made aware right when the incident occurred because restraining a resident was a form of abuse. During an interview on 12/8/23 at 10:09 AM, the Administrator stated that they were notified on the morning of 11/27/23 that Resident #1 was witnessed by Cook #1 to be restrained in the dining room by Certified Nursing Assistant #1 on 11/25/23. The Administrator stated they reported the incident occurred on 11/26/23 and made an error of on the Department of Health Nursing Home Facility Incident Report and should have been reported the incident occurred on 11/25/23. The Administrator stated that they follow the Nursing Home Incident Reporting Manual and that they need to notify the New York State Department of Health within two hours after they are made aware of a potential abuse allegation. 10 NYCRR 415.4(b)(2)

Based on interview and record review conducted during the Standard survey started on 9/18/22 and completed on 9/22/22, the facility did not have a designated Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis. Specifically, the Acting RN Director of Nursing was not designated as the DON from 5/25/2022 through 9/22/22 on a full-time basis. The finding is: The undated facility job description for the DON provided by the Human Resource (HR) Manager documented the DON provides administrative and clinical leadership and direction for nursing practice with 24-hour accountability on her/his nursing units. Assures the delivery of comprehensive, safe and effective nursing care in accordance with the established policies and procedures of the long-term care (LTC) nursing department. The DON is directly responsible for the adequate staffing and scheduling of the nursing personal, oversees the staffing schedule and delegates assignments. Review of the untitled form identified as the Acting DON's time sheet provided by the HR Manager dated 6/25/22 through 9/22/22 revealed there was no documented evidence the Acting DON work full time for the Skilled Nursing Facility (SNF). During an interview on 9/21/22 at 2:07 PM, the Acting DON stated they have been in the Acting DON position since 5/25/22. They also oversee the Medium Care Unit (MCU) in the hospital (a nursing care unit that was lower than the Intensive Care Unit (ICU) but above the standard floor care). The Acting DON stated they work in the MCU approximately seventy percent (70%) of the time and in the SNF approximately 30% of the time. Their job duties for the SNF included attending morning report, reviewing referrals, skin rounds and admissions. During an interview on 9/22/22 at 10:23 AM, the HR Manager stated the Acting DON has been in the position since May and was unsure of the DON's duties in the SNF. The facility had been recruiting but they had no prospects and no one in house was qualified. During an interview on 9/22/22 at 11:41 AM, the Administrator stated the Acting DON was available full time for the SNF, but they have other job duties in the hospital. The Administrator was unsure of how the Acting DON job responsibilities were divided between the SNF and the MCU. The Administrator stated they did not apply for an RN waiver, and they have tried to hire a DON, but the candidates have not worked out. 415.13(b)(1)

Based on observation, interview, and record review conducted during the Standard survey started 9/18/22 and completed 9/22/22, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. Specifically, one (Unit 3) of two units were observed to have black houseflies in residents' rooms and in the dining room. This involved Residents #8, 14, 24, 28, and 31. The findings are: The facility policy and procedure titled Facility Pest Control with a revised date of 1/11 documented the purpose was to provide safe effective pest control for the facility. The pest control service is contracted to come once each month, or more often if necessary. During an observation on 9/18/22 at 12:00 PM three flies were flying between Resident #14's bed, pillow, and their person while they were eating. The resident was observed swatting at the flies, and stated the flies were bothersome. During an observation of the 3rd floor dining room on 9/18/22 at 12:15 PM residents were eating their lunch meal and there were multiple common house flies flying around and landing on the residents and their food. During an observation in Resident #24's room on 9/18/22 at 1:41 PM, there were several flies flying around the resident, their face and landing on them. Resident #24 kept swatting the flies away. At that time Resident #24 stated, there were always flies in here and they were always bothering me. My father always said there is one thing on earth we don't need and that is flies. During an observation in Resident #14's room on 9/18/22 at 3:00 PM the resident was lying in their bed sleeping and there were 2-3 flies flying and landing on the resident and their covers. During an observation in Resident #14's room on 9/19/22 at 8:57 AM there were several flies flying around and landing on the resident and their food. At the time of the observation Resident #14 stated there were always flies in their room and that the flies bothered them. The flies usually show up in the afternoon and it started a couple weeks ago. During an observation on 9/19/22 at 8:07 AM in the third-floor dining room there were several flies flying around during the breakfast meal. During the Resident Council meeting on 9/19/22 at 9:48 AM Resident #31 stated there were flies in their room and that were bothersome. Additionally, they stated the third-floor dining room was swarming with flies once the sun comes up. During an observation in Resident #28's room on 9/20/22 at 10:43 AM there were four flies that were flying around and landing on the bed. The room was occupied, but the Resident #28 was not present in the room at the time. At 12:33 PM Resident #28 was in their room lying in bed and there were 4-5 flies flying around and landing on the resident. During an observation on 9/20/22 at 12:36 PM in the third-floor dining room area there were several flies flying around and landing on tables and plates. On 9/20/22 at 1:42 PM while sitting at the 3rd floor nursing station there were multiple flies observed flying around. During an observation of Resident #8's room on 9/20/22 at 1:02 PM approximately 4-5 flies were flying around the room and landing on the resident and their bed. Resident #8 stated, these flies are horrible. They are disgusting. During an observation in Resident #8's room on 9/21/22 at 10:47 AM approximately 3-4 flies were flying around and landing on the over the bed tray table and bed. Review of the Resident Council Minutes dated 9/13/22 documented under housekeeping: Can something be done about the flies in the dining room? Review of the Pest Control Service Report dated 8/27/22 documented large fly program serviced. Glue boards were 50% full. Glue boards replaced. Illuminated light trap bulbs replaced. Replace one bulb in fly light by elevator. During an interview on 9/20/22 at 12:38 PM, the Housekeeper stated there had been flies flying around on the third-floor unit for about 2- 3 weeks. I have seen flies especially in Resident #8's room and in the third-floor dining room. I have told my supervisor (Director of Housekeeping) and I was told to just keep on top of getting rid of the garbage. During an interview on 9/20/22 at 12:47 PM Certified Nurse Aide (CNA) #4 stated, I have noticed the flies have been flying around since last week. They are in the dining room and resident rooms. I did not report it to anyone, but we all have been talking about it. The resident in room #314 has asked for a fly swatter because of the flies. During an interview on 9/20/22 at 12:51 PM Licensed Practical Nurse (LPN) #2 stated, I have seen flies flying everywhere. Mostly in the patient rooms and the dining room. I started noticing them probably two weeks ago. I reported the flies to the Maintenance Technician last week who came and then had the Maintenance Supervisor come up and look around, and told me they didn't see anything. I then took them in a room and pulled on the pant leg of a resident's pants and multiple flies flew up and off of them. I asked them what they were going to do about these flies and the response I got was that they did not know. During an interview on 9/20/22 at 1:04 PM, the Director of Housekeeping went to Resident #8's room and made an observation of the flies in the resident's room. There were approximately 4- 5 flies flying around and landing on the resident and their bed. The Director of Housekeeping stated Oh my, I did not know the flies were in the residents room. I only knew they were in the dining room. I was made aware of the flies by the Activities Director via e-mail yesterday as the residents were complaining about flies in the dining room at the resident council meeting on 9/13/22. During an interview on 9/21/22 at 10:25 AM the Acting Director of Nursing (DON) stated, I have not seen flies on the third floor. No one has come to me regarding flies. I would expect staff to report to maintenance and housekeeping immediately if there is an issue with flies. Flies are an infection control risk, and they are just not healthy. During an interview on 9/21/22 at 10:37 AM the Maintenance Supervisor stated, I have not noticed any flies up on the third floor. No one has reported it to me that there have been any issues with flies. I would hope they would tell me, but flies to me is more of a housekeeping issue not maintenance. During an interview on 9/21/22 at 10:43 AM, the Maintenance Technician stated that LPN #2 spoke to them about fly problems about 2 weeks ago, but when they went up to the third floor, they did not see any problems. During an interview on 9/21/22 at 11:54 AM, the Activities Director stated at the resident council meeting held on 9/13/22 in the third-floor dining room it was reported that there was an issue with flies in the that dining room. During the meeting we were all actually swatting at the flies. The Activities Director stated I had reported the issue verbally at a morning meeting either on 9/15/22 or 9/16/22. I sent out an e-mail on 9/20/22 to the Director of Housekeeping and Maintenance because that was the day, I was able to actually sit down and type up the minutes from the meeting. During an interview on 9/21/22 at 11:50 AM, Registered Nurse (RN) #2 Infection Preventionist (IP) stated concerns with having flies would be the bacteria they are carrying is being spread around the facility. Flies can carry all kinds of things. During an interview on 9/21/22 at 1:40 PM, the Administrator stated that yesterday was the first time they had heard about a fly issue. I expect the staff to report it to their supervisor when there are problems like this. That is why I have morning meetings every day. 415.29(j)(5)

Based on observation, interview, and record review conducted during the Standard survey started on 9/18/22 and completed 9/22/22, the facility did not ensure appropriate use, entrapment risk assessment, and maintenance of bed rails for one (Resident #25) of one resident reviewed for bed rail use. Specifically, the facility did not follow manufacturer's instructions on proper use of a bed rail, did not perform an entrapment risk assessment prior to installing a bariatric portable bed rail to the adjustable hospital bed frame, and did not implement a routine monitoring system to protect residents from entrapment risk when using bed rails. The finding is: The facility policy and procedure (P&P) titled Side Rail Safety - Environmental Safety Side Rail Assessment and Maintenance Side Rail Safety assessment dated ,d+[DATE], documented a Registered Nurse (RN) will complete documentation on the Environmental Safety Side Rail Assessment which will include mental status, mood state, medical diagnoses, elimination, falls history, visual impairment, mobility, medications (sedative/hypnotic, antidepressant, [CONDITION(S)], diuretic, antihypertensive), and total score. Additionally, the maintenance staff/designee will complete documentation on the Maintenance Side Rail Safety Assessment which includes measurements of seven (7) potentially hazardous zones to the resident. The product description of the bariatric portable bed rail, provided by the Maintenance Technician, documented the bed rail was not intended for use on adjustable beds. The bariatric bed manufacturers User Manual documented the bed had an adjustable frame, adjustable height, adjustable head, and adjustable foot of bed. Additionally, the use of bed accessories by other manufacturers have not been tested by the manufacturer. Use of non-manufacturer bed accessories may result in injury or death. Use only manufacturer rails, mattresses, bed extenders and other accessories with bed products. 1. Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - resident assessment tool) dated 7/5/22 documented the resident was cognitively intact, required extensive assistance of two people for bed mobility, total assistance of two people for transfers, and bed rails were used daily. Additionally, the MDS documented the resident received antipsychotic, antidepressant, diuretic, and opioid medications daily. During observations on 9/18/22 at 1:54 PM and 9/19/22 at 10:45AM, a single portable bed rail was attached to the right side of Resident #25's adjustable bed. The bed rail was attached loosely to the bed frame and was able to be moved 3 to 4 inches away from the mattress. The facility Event Form dated 6/26/22 documented Resident #25 fell out of bed at 3:00AM and the intervention to prevent reoccurrence was to place a grab bar to the right side of the bed. The comprehensive care plan documented Resident #25 utilized a grab bar on right side of their bed to assist with repositioning (start date 7/1/22). The goal was to maintain their ability to participate with bed mobility and approaches included the risks and benefits were explained and acknowledged. The facility Side Rail Consent form signed and dated 7/5/22 by Resident #25, documented Resident #25 was informed of alternatives to the right side grab bar and the potential benefits and risks of use. During a telephone interview on 9/22/22 at 9:42 AM, the bed manufacturer Customer Service Representative stated the manufacturer did not recommend using other manufacturers products with theirs secondary to other manufacturers products were not tested for compatibility. During an interview on 9/22/22 at 10:27 AM, the Acting Director of Nursing (DON) stated they expected the maintenance department to ensure the installed bed rail was compatible with the bed frame. The DON stated the bed rails should be checked periodically but was unsure of the timeframe. During an interview on 9/22/22 at 10:32 AM, the Director of Maintenance stated they received a request to install the bed rail on Residents #25's bed and the rail was installed. Additionally, the Director of Maintenance stated they did not ensure the bed rail was compatible with the bed frame and maintenance did not perform any safety checks/inspections on the bed rail. During an interview on 9/22/22 at 10:46 AM, the Administrator stated they did not consider the bed rail a siderail, but an assist bar for mobility and any device installed on a resident's bed should be assessed. During an interview on 9/22/22 at 11:21 AM, Licensed Practical Nurse (LPN) #1/ MDS Coordinator stated the bed rail was installed by maintenance to the right side of Resident #25's bed. LPN #1 stated an Environmental Safety Side Rail Assessment was not performed prior to bed rail placement. 415.12(h)(1)

Based on interview and record review conducted during the Standard survey started on 9/18/22 and completed 9/22/22, the facility did not maintain an infection prevention and control program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility had no documented evidence that one (Certified Nursing Assistant (CNA) #2) of three staff reviewed for COVID-19 testing, whom were not up to date with their COVID-19 vaccinations, were tested for COVID-19 as required. The finding is: The Centers for Medicare and Medicaid Services (CMS) QSO 20-38-NH revised 3/10/22 documented that staff who are not up to date with their COVID-19 vaccinations needed to be tested at a minimum once a week when the COVID-19 community transmission level was at moderate (yellow) and at minimum twice a week when the COVID-19 community transmission level is at high (red). The QSO documented up to date meant a person had received all recommended COVID-19 vaccines, including any booster doses when eligible. The facility policy and procedure (P&P) titled COVID-19 Outbreak & Testing Requirements for Staff, Residents, and Patients dated 8/22 documented the facility will follow the most current guidelines and recommendations of the Centers for Disease Control and Prevention (CDC), CMS, and/or New York State Department of Health (NYS DOH) for the testing of patients, residents, and staff. Routine testing will be performed on all COVID-19 Medical Exempt staff, staff who have not completed their primary COVID-19 vaccination series, and staff who are not up to date with COVID-19 vaccination booster. The County Level Timeseries Data for New York report documented Allegany County had a substantial level of community COVID-19 transmission from 8/14/22-8/20/22 and had a high level of community transmission of COVID-19 from 8/28/22 through 9/21/22. The facility Request for Medical Immunization Exemption Form - COVID-19 Vaccination signed and dated by a medical provider on 2/15/22, documented CNA #2 was granted a medical exemption for the COVID-19 vaccination. The untitled, undated employee timecard documented CNA #2 worked: 4 days (8/14/22, 8/16/22, 8/18/22, 8/19/22) during the week of 8/14/22-8/20/22 3 days (8/28/22, 9/1/22, 9/2/22) during the week of 8/28/22-9/3/22 3 days (9/13/22, 9/15/22, 9/16/22) during the week of 9/11/22-9/17/22 2 days (9/19/22, 9/20/22) during the week of 9/18/22-9/21/22 The facility was unable to provide documented evidence CNA #2 had been tested for COVID-19 for the weeks of 8/14/22-8/20/22, 8/28/22-9/3/22, 9/11/22-9/17/22, and 9/18/22-9/21/22. During an interview on 9/22/22 at 7:59 AM, Registered Nurse (RN) #2 Infection Preventionist (IP) stated they check the county level transmission daily on the CDC website. The IP stated the county was at a moderate level and the facility policy was to test all staff not up to date on COVID-19 vaccinations twice weekly. Additionally, the IP stated they were aware CNA #2 was noncompliant with COVID-19 testing and has discussed the problem several times with administration. During a telephone interview on 9/22/22 at 8:26 AM, CNA #2 stated they were aware of the facility COVID-19 testing regulation and that they had not been compliant with the regulation. The CNA stated they were unsure how to be tested for COVID-19 outside of the facility COVID-19 testing schedule. During an interview on 9/22/22 at 8:26 AM, the Administrator stated they were unaware CNA #2 was non- complaint with COVID-19 testing and apparently there was a fault in the system. 415.19

Based on observation, interview, and record review conducted during a complaint investigation (NY 464) completed during a Standard survey started 9/18/22 and completed 9/22/22, the facility did not ensure the resident's rights to be free from abuse for three (Resident #19, 24 and 31) of four residents reviewed for abuse. Specifically, it was determined CNA #3 was verbally abusive to three residents during care. The findings are: The policy titled Resident Abuse Investigation dated issue 9/21/2022 documented it is the policy of the facility to investigate incidents that may involve resident abuse. The Nursing Home Administrator is responsible for ensuring the safety and wellbeing of the residents. All staff are trained on the definition, identification, and responsibility to report suspected abuse. Staff are encouraged to contact the nursing home administrator to in the event there is an incident. The nursing home administrator will gather information including accident/incident reports and witness statements if available. Based on the type of abuse reported the administrator may request a resident being assessed by nurse, social worker, or appropriate clinical professional to determine if the resident suffered emotional or physical injury. Based on the initial findings a timely incident form will be completed and submitted via the (name of state incident reporting system) by the administrator. If the suspected abuser is an employee, the he or she may be suspended or terminated from employment depending on the state of the investigation. The policy titled Abuse- Identification and Reporting date revised 2/19 documented the facility recognizes each elder has the right to be free for all types of abuse including, verbal, sexual, physical, mental abuse, corporal punishment, and involuntary seclusion. 1. Resident #31 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 5/18/2022 documented Resident #31 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 4/21/22 documented Resident #31 was at risk for alteration in elimination related to bowel incontinence at times. Approaches included to toilet the resident every 2-4 hours and per request, and wears briefs or pull ups AAT (at all times). During an observation on 9/19/22 at 8:20 AM Resident #31 was sitting in the hallway outside their room in a wheelchair with the door to their room shut behind them. Resident appeared comfortable and calm. During an interview on 9/19/22 at 8:22 AM, Resident #31 stated I had an issue with one of the CNAs. It was CNA #3. I had a medical problem at the time, and I accidentally had a bowel movement in my pants. CNA #3 stated to me, I can't believe you (explicit word) yourself. I told CNA #3 I did not appreciate that attitude and under no terms will I be sworn at. I told another CNA about it, and they reported it to the Social Worker, who came and spoke to me about the incident. I was then told that CNA #3 will no longer be working on my unit, and I haven't seen them since. At the time I was so embarrassed and ashamed. I now feel comfortable and safe because they no longer work on the unit. Review of the interdisciplinary Progress notes between 5/24/22 through 5/28/22 revealed there was no documentation regarding the incident or any assessment of the resident or contact with the physician regarding the incident. 2. Resident #24 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #24 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 7/13/22 documented Resident #24 has impaired ADL (activities of daily living)/ self-care ability and physical function related to muscle weakness. Approach for dressing is limited with one assist. During an interview on 9/18/22 at 1:35 PM, Resident #24 stated several months ago CNA #3 made me go to bed and get up on their time not my time and was very nasty about it. CNA #3 was also nasty and did the same thing to my roommate Resident #19. I reported it to the Social Worker, and they spoke to me regarding the incident. I was told that CNA #3 no longer works here. I feel safe with the staff who work with me now. When situations like this arise, I know who to go to if things need to be addressed. Review of interdisciplinary Progress Notes dated between 5/20/22 to 5/30/22 revealed there was no documentation regarding the incident, any assessment of the resident and there was no contact with the physician regarding the incident. 3. Resident #19 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #19 was sometimes understood, sometimes understands and severely cognitively impaired. Review of the Comprehensive Care Plan last reviewed/ revised date 7/6/22 documented no problem, goal or approaches for ensuring a safe environment for a resident who was severely cognitively impaired with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 9/18/2022 at 2:07 PM Resident #19 was in the dining room sitting up in a Geri chair (specialized chair) visiting with their sister. Resident #19 was unable to verbally communicate with their sister but was responding to their questions by looking at them and smiling. Resident #19 appeared to be comfortable. Throughout the survey during multiple intermittent observations revealed Resident #19 appeared to be comfortable with no signs of agitation. Review of interdisciplinary Progress Notes from 5/23/22 to 5/26/22 revealed there was no documentation regarding the incident or any assessment of the resident, contact with the physician and contacting the family regarding the allegation. Review of the Automated Complaint Tracking System (ACTS) completed by the Administrator with the date/time of occurrence of 5/24/2022 at 11:17 AM and submitted by facility 5/24/2022 at 2:34 PM documented yes there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. Overview: I received an email from Licensed Practical Nurse (LPN) #1 Unit Manager that LPN #2 reported multiple residents on the third floor with complaints against Certified Nurse Aide (CNA) #3. LPN #2 called me due to Resident #31 and Resident #24 had verbalized the complaints against CNA #3. Resident #31 stated CNA #3 got mad that I was incontinent of stool, and I didn't want to report them because they will be meaner to me. Resident #24 stated CNA #3 tried to tell me at 3:30 AM I had to get up and get dressed for the day. Then CNA #3 dragged Resident #19 up and dressed them at 3:30 AM. CNA #3 said to me they didn't care if I liked it or not and then they yelled at Resident #19. It is likely that CNA #3 violated residents' rights and was verbally abusive to multiple residents. The Social Worker is interviewing all residents on the floor to determine the scope of the situation. CNA #3 was called immediately upon receipt of the complaint. They were suspended indefinitely and will be terminated upon completion of the investigation at 1:15 PM. Their next shift would have been at 10:00 PM this evening. Social Work is interviewing and counseling the affected residents. The investigation is ongoing until all residents on that floor are interviewed. Review of the untitled Director of Social Work interviews ( part of facility investigation) dated 5/24/2022 documented this social worker interviewed Resident #24 in the privacy of their room to discuss a complaint they had with CNA #3. They reported that for some time now CNA #3 was coming into the room anywhere between 3:30 AM and 4:00 AM to get them up and dressed for the day. CNA #3 would have them dress and then lay back in bed and turn their lights off. They reported CNA #3 did this to their roommate Resident #19 as well. (Resident #19 is unable to be interviewed due to cognitive impairment). Resident #24 reported they finally had enough and told CNA #3 they did not want to do this any longer. Resident #24 reported CNA #3 stood at the end of their bed with gloves on their hands and would slap their hands telling them Come on let's go. Resident #31 was interviewed in the privacy of their room to discuss their complaint they had with CNA #3. They reported CNA #3 was in their room Monday night as they had been incontinent of bowel. Resident #31 reported CNA #3 said, I can't believe you are grown man and (explicit word stated) yourself. Resident #31 reported they were embarrassed, felt disrespected and was afraid to say anything. Two other residents were interviewed and reported no issues with CNA #3. During an interview on 9/21/22 at 9:43 AM, the Director of Social Work stated I remember the incident vaguely. I do remember interviewing Resident # 31 and Resident #24. Resident #24 was talking about CNA #3 coming in their room very early in the morning to get them dressed and then was put back to bed. Resident #24 made a comment that this was also happening to their roommate Resident #19. I was unable to interview Resident #19 because of their cognitive status. When I interviewed Resident #31, they told me what had happened and what CNA #3 said to them, and it was a harsh statement, and it is not what we feel to be appropriate to say to a resident as it is demeaning and possibly borderline verbal abuse. In a further interview on 9/22/22 at 8:41 AM the Director of Social Work stated I am really just responsible for interviewing residents in these situations. I do not do any conclusions on the investigations. I felt with Resident #31 the language was inappropriate and should be looked into by the Administrator who would be the one to decide if it was truly abuse. The Administrator would be the one to write up the final conclusions on investigations. During an interview on 9/21/22 at 10:49 AM, LPN #2 stated Resident #24 told them that CNA #3 yelled at them and Resident #19 and that they did not like the way they were spoken too and that they were too stern with the residents. In addition, CNA #3 stood at the ends of their beds clapping their hands together and telling them to hurry up. Resident #31 reported that they were incontinent, and CNA #5 was not nice about it and made demeaning comments to them. During an interview on 9/21/22 at 1:26 PM the Administrator stated, the Director of Social Work basically did the complaint. I submitted the report to the state and fired the employee (CNA #3). My conclusion was that CNA #3 was inappropriate with the residents involved. In my opinion once I reviewed the investigation, I believe abuse did occur. During an interview on 9/22/22 at 8:17 AM, the Acting Director of Nursing (DON) stated they were not involved in this investigation, but they would consider this incident a form of abuse. 415.4(b)(1)(i)

Based on interview and record review during a complaint investigation (NY 464) completed on a Standard survey started 9/18/22 and completed 9/22/22, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made to the appropriate officials (including the State Survey Agency). Four (Resident #3, 19, 24, and 31) of four residents reviewed for abuse were involved in incidents either not reported or not reported timely to the New York State (NYS) Department of Health (DOH) as required. Specifically, resident to resident altercation (#3 and 31) and allegations of verbal abuse (#19, 24 and 31). The findings are: The policy titled Resident Abuse Investigation dated issue 9/21/2022 documented it is the policy of the facility to investigate incidents that may involve resident abuse. All staff are trained on the definition, identification, and responsibility to report suspected abuse. Staff are encouraged to contact the nursing home administrator to in the event there is an incident. Based on the type of abuse reported the administrator may request a resident being assessed by nurse, social worker, or appropriate clinical professional to determine if the resident suffered emotional or physical injury. Based on the initial findings a timely incident form will be completed and submitted via the (name of states incident reporting system) by the administrator. 1. Resident #31 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 5/18/2022 documented Resident #31 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 4/21/22 documented Resident #31 was at risk for alteration in elimination related to bowel incontinence at times. Approaches included to toilet the resident every 2-4 hours and per request, and wears briefs or pull ups AAT (at all times). 2. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #24 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 7/13/22 documented resident has impaired ADL (activities of daily living)/ self-care ability and physical function related to muscle weakness. Approach for dressing is limited with one assist. 3. Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #19 was sometimes understood, sometimes understands and severely cognitively impaired. Review of the Comprehensive Care Plan last reviewed/ revised date 7/6/22 documented no problem, goal or approaches for ensuring a safe environment for a resident who was severely cognitively impaired with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Resident #3 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #3 was understood, understands and severely cognitively impaired. Review of Comprehensive Care Plan last reviewed/revised 8/12/22 documented Resident #3 was at risk for alteration in mood and behavior related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Often wanders into other elders' rooms without being invited. Resident #3 is at risk for elopement due to Dementia with wandering behaviors. a.) Review of the Customer Service Opportunity for Improvement report signed by the Director of Social Work dated 7/5/22 documented occurrence date as 7/5/22, no time documented. Resident #31 reported to Licensed Practical Nurse (LPN) #2 the back of their neck hurts because Resident #3 keeps patting them on the back of their neck. This social worker interviewed Resident #31 and they reported the same thing. The social worker asked when does this happen and Resident #31 reported every morning when they are in the hall outside of their room waiting to go back to the room after breakfast and during any activity program. Resident #31 also reported they do not like the other elder and stated, I was very close to grabbing Resident #3 by the neck and punching them. This social worker explained physical altercations should be avoided and they should allow staff to intervene. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Facility Summary between 6/4/22 and 9/12/22 revealed that no report had been filed regarding the alleged resident to resident altercation on 7/5/22. b.) Review of the untitled Director of Social Work interviews (part of facility investigation) dated 5/24/2022 documented this social worker interviewed Resident #24 in the privacy of their room to discuss a complaint they had with CNA #3. They reported that for some time now CNA #3 was coming into the room anywhere between 3:30 AM and 4:00 AM to get them up and dressed for the day. CNA #3 would have them dress and then lay back in bed and turn their lights off. They reported CNA #3 did this to their roommate Resident #19 as well. (Resident #19 is unable to be interviewed due to cognitive impairment). Resident #24 reported they finally had enough and told CNA #3 they did not want to do this any longer. Resident #24 reported CNA #3 stood at the end of their bed with gloves on their hands and would slap their hands telling them Come on let's go. Resident #31 was interviewed in the privacy of their room to discuss their complaint they had with CNA #3. They reported CNA #3 was in their room Monday night as they had been incontinent of bowel. Resident #31 reported CNA #3 said, I can't believe you are grown man and (explicit word stated) yourself. Resident #31 reported they were embarrassed, felt disrespected and was afraid to say anything. Two other residents were interviewed and reported no issues with CNA #3. Review of the Automated Complaint Tracking System (ACTS) completed by the Administrator with the date/time of occurrence of 5/24/2022 at 11:17 AM and submitted by facility 5/24/2022 at 2:34 PM for allegations of resident verbal or mental abuse for Residents #19, 24 and 31. During an interview on 9/22/22 at 8:17 AM, the Acting Director of Nursing stated, I do not know what the reporting regulations are for the state and CMS (Centers for Medicare & Medicaid Services). The Administrator takes care of the reporting. During an interview on 9/22/22 at 11:02 AM, the Administrator stated the incident involving Resident #3 and Resident #31 was not reported to the state. Additionally, the incident with Resident #19, 24 and 31 was not reported within the two hours because I fired the CNA #3 and felt there was no immediate threat anymore to the three residents. I am familiar with the reporting rules on abuse and am familiar with the 2-hour rule. 415.4(b)(4)

Based on interview and record review conducted during a complaint investigation (NY 464) completed on a Standard survey started 9/18/22 and completed 9/22/22, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for four (Residents #3, 19, 24, and 31) of four residents reviewed. Specifically, there was a lack of a thorough investigation to include nursing assessments, interviews with staff and other potential victims into alleged verbal abuse by a certified nursing assistant (CNA) (Residents #19, 24, and 31) and into a resident-to-resident confrontation (Residents #3 and 31). The findings are: The policy titled Resident Abuse Investigation dated issue 9/21/2022 documented it is the policy of the facility to investigate incidents that may involve resident abuse. The Nursing Home Administrator is responsible for ensuring the safety and wellbeing of the residents. All staff are trained on the definition, identification, and responsibility to report suspected abuse. Staff are encouraged to contact the nursing home administrator to in the event there is an incident. The nursing home administrator will gather information including accident/incident reports and witness statements if available. Based on the type of abuse reported the administrator may request a resident being assessed by nurse, social worker, or appropriate clinical professional to determine if the resident suffered emotional or physical injury. Based on the initial findings a timely incident form will be completed and submitted via the Health Commerce System by the administrator. If the suspected abuser is an employee, the he or she may be suspended or terminated from employment depending on the state of the investigation. The policy titled Abuse-Identification and Reporting date revised 2/19 documented the facility recognizes each elder has the right to be free for all types of abuse including, verbal, sexual, physical, mental abuse, corporal punishment, and involuntary seclusion. 1. Resident #31 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 5/18/2022 documented Resident #31 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 4/21/22 documented Resident #31 was at risk for alteration in elimination related to bowel incontinence at times. Approaches included to toilet the resident every 2-4 hours and per request, and wears briefs or pull ups AAT (at all times). Review of the interdisciplinary Progress notes between 5/24/22 through 5/28/22 revealed there was no documentation regarding the incident, any assessment of the resident or contact with the physician regarding the incident. Review of the Progress Notes from 7/4/22 to 7/10/22 had no documentation of the physician being contacted regarding the incident with Resident #3. 2. Resident #24 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #24 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 7/13/22 documented Resident #24 has impaired ADL (activities of daily living)/ self-care ability and physical function related to muscle weakness. Approach for dressing is limited with one assist. Review of interdisciplinary Progress Notes dated between 5/20/22 to 5/30/22 revealed there was no documentation regarding the incident or any assessment of the resident and contact with the physician regarding the incident. 3. Resident #19 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #19 was sometimes understood, sometimes understands and severely cognitively impaired. Review of the Comprehensive Care Plan last reviewed/revised date 7/6/22 documented no problem, goal or approaches for ensuring a safe environment for a resident who was severely cognitively impaired with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the interdisciplinary Progress Notes from 5/23/22 to 5/26/22 revealed there was no documentation regarding the incident, or an RN assessment of the Resident 19, contact with the physician and contacting the family regarding the allegation. In addition, there was no documentation of monitoring the resident's status for possible psychologic affects. 4. Resident #3 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #3 was understood, understands and severely cognitively impaired. Review of the Comprehensive Care Plan last reviewed/revised 8/12/22 documented Resident #3 was at risk for alteration in mood and behavior related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Often wanders into other elders' rooms without being invited. Resident #3 was at risk for elopement due to dementia with wandering behaviors. Review of the interdisciplinary Progress Notes from 7/4/22 to 7/10/22 had no documentation regarding the incident on 7/5/22 or contact with the physician regarding the incident. a. Review of the Automated Complaint Tracking System (ACTS) completed by the Administrator with the date/time of occurrence of 5/24/2022 at 11:17 AM and submitted by facility 5/24/2022 at 2:34 PM documented yes there is reasonable cause to believe that abuse, neglect, or mistreatment occurred. Overview: I received an email from Licensed Practical Nurse (LPN) #1 Unit Manager that LPN #2 reported multiple residents on the third floor with complaints against Certified Nurse Aide (CNA) #3. LPN #2 called me due to Resident #31 and Resident #24 had verbalized the complaints against CNA #3. Resident #31 stated CNA #3 got mad that I was incontinent of stool, and I didn't want to report them because they will be meaner to me. Resident #24 stated CNA #3 tried to tell me at 3:30 AM I had to get up and get dressed for the day. Then CNA #3 dragged Resident #19 up and dressed them at 3:30 AM. CNA #3 said to me they didn't care if I liked it or not and then they yelled at Resident #19. It is likely that CNA #3 violated residents' rights and was verbally abusive to multiple residents. The Social Worker is interviewing all residents on the floor to determine the scope of the situation. CNA #3 was called immediately upon receipt of the complaint. They were suspended indefinitely and will be terminated upon completion of the investigation at 1:15 PM. Their next shift would have been at 10:00 PM this evening. Social Work is interviewing and counseling the affected residents. The investigation is ongoing until all residents on that floor are interviewed. Review of the untitled Director of Social Work interviews (within facility investigation) dated 5/24/2022 documented this social worker interviewed Resident #24 in the privacy of their room to discuss a complaint they had with CNA #3. They reported that for some time now CNA #3 was coming into the room anywhere between 3:30 AM and 4:00 AM to get them up and dressed for the day. CNA #3 would have them dress and then lay back in bed and turn their lights off. They reported CNA #3 did this to their roommate Resident #19 as well. (Resident #19 is unable to be interviewed due to cognitive impairment). Resident #24 reported they finally had enough and told CNA #3 they did not want to do this any longer. Resident #24 reported CNA #3 stood at the end of their bed with gloves on their hands and would slap their hands telling them Come on let's go. Resident #31 was interviewed in the privacy of their room to discuss their complaint they had with CNA #3. They reported CNA #3 was in their room Monday night as they had been incontinent of bowel. Resident #31 reported CNA #3 said, I can't believe you are grown man and (explicit word stated) yourself. Resident #31 reported they were embarrassed, felt disrespected and was afraid to say anything. Two other residents were interviewed and reported no issues with CNA #3. During an interview on 9/21/22 at 9:43 AM the Director of Social Work stated, I remember the incident vaguely. I do remember interviewing Resident # 31 and Resident #24. Resident #24 was talking about CNA #3 coming in their room very early in the morning to get them dressed and then was put back to bed. Resident #24 made a comment that this was also happening to their roommate Resident #19. I was unable to interview Resident #19 because of their cognitive status but probably should have contacted the family to see if they had noticed any changes in mental status and informing them of the allegation but felt the sister would have contacted them if there was an issue. When I interviewed Resident #31, they told me what had happened and what CNA #3 said to them, and it was a harsh statement, and it is not what we feel to be appropriate to say to a resident as it is demeaning and possibly borderline verbal abuse. The Social Worker stated they only interviewed two other residents but thinks that these residents were not even on CNA #3's assignment and staff interviews would have been done by the Administrator. During an interview on 9/21/22 at 1:26 PM, the Administrator stated the Director of Social Work basically did the complaint investigation and they submitted the report to the state. The Administrator stated, I felt we did not need to do further investigation or interviewing of other staff members because we fired the employee involved. During a telephone interview on 9/21/22 at 4:11 PM, RN #3 stated typically, we go to the social worker with this type of incident, and they do a full interview with the residents and then would do a report on it. Someone who was cognitively impaired I would take a look at. Yes, I would contact the resident's representative if they were cognitively impaired. Any form of abuse I would contact the doctor and do a full assessment on. During an interview on 9/22/22 at 8:17 AM, the Acting Director of Nursing (DON) stated they were not involved in this investigation, but they would expect their staff to interview other staff members who worked with this employee to see if they have heard anything and knew anything about this incident. Would also expect interviews to be completed with other residents to see if they were potential victims. Because Resident #19 isn't cognitively able to express what happen they would expect the staff to contact the family regarding any changes they may have seen with the resident and to inform the family of the allegation. Also, staff should be contacting the physician for all three residents about the allegation and the findings. b. Review of the Customer Service Opportunity for Improvement report signed by the Director of Social Work dated 7/5/22 documented occurrence date as 7/5/22, no time noted. Resident #31 reported to Licensed Practical Nurse (LPN) #2 the back of their neck hurts because Resident #3 keeps patting them on the back of their neck. This social worker interviewed Resident #31 and they reported the same thing. The social worker asked when does this happen and Resident #31 reported every morning when they are in the hall outside of their room waiting to go back to the room after breakfast and during any activity program. Resident #31 also reported they do not like the other elder and stated, I was very close to grabbing Resident #3 by the neck and punching them. This social worker explained physical altercations should be avoided and they should allow staff to intervene. Review of the Progress Note completed by RN #3 dated 7/5/22 documented Resident #31 reported neck pain after they stated another resident touched their back. Social worker spoke with Resident #31 at their bedside. RN #3 asked the resident to point exactly where it hurt, and the resident pointed to the base of their neck. RN assessment revealed no abnormalities of the neck. No redness/ swelling/ bruising was noted. Resident #31 was able to move their neck in all directions/ had full range of motion without any signs of difficulty/ discomfort. No tenderness to palpation. The resident wishes to continue to receive Tylenol (a medication to help relieve pain). During a telephone interview on 9/21/22 at 4:11 PM, RN #3 stated typically we go to the social worker with this, and they would do the interviews with the residents. An RN assessment was completed on Resident #31 and no red marks were found on their neck. The doctor was not contacted, and I did not interview other staff. During an interview on 9/22/22 at 8:45 AM, the Director of Social Work stated they did speak to Resident #31 about Resident #3 patting them on the neck and that it started to hurt. They stated they offered Resident #31 a room change to the second floor but that they declined. Other residents were not interviewed regarding this incident. During an interview on 9/22/22 at 8:03 AM, the Administrator stated the incident between Resident #3 and Resident #31 was not really a resident to resident because there was no harm. We did not interview other residents that Residents #3 has patted on the back to see if they were bothered by it or even possible hurt them, and we did not interview staff regarding Resident #3 and their wandering and behaviors because I didn't think it could have been abuse and both residents have rights. Further interview at 11:03 AM the Administrator stated, I guess I could have done a better investigation. During an interview on 9/22/22 at 8:17 AM, the Acting DON stated they would expect their staff to interview other staff members and residents to see if they were having similar issues with Resident #3. They would have expected the physician to be called. 415.4(b)(3)

Based on observation, interview, and record review conducted during the Standard survey started on 9/18/22 and completed on 9/22/22, the facility did not post, on a daily basis, the following information: the facility name, current date, the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The finding is: Review of the policy and procedure (P&P) titled Staff Census Posting dated 9/21/22 documented based on days scheduled provided by the schedular, the unit secretary will post the Daily Census Sheet in a public place breaking down the number of Registered Nurses (RN's) Licensed Practical Nurses (LPN's) and Certified Nursing Assistants (CNA's) working that day and on that unit. 1. Intermittent observations from 9/18/22 to 9/19/22 between 9:30 AM and 3:00 PM the Daily Census Sheet were displayed on a bulletin board across from the nurses' station on the 2nd and 3rd floor skilled nursing units. The Daily Census Sheet that was posted was dated 9/16/22. Review of the Daily Census Sheet provided by the facility for the dates 9/18/22 through 9/22/22 revealed the total number and actual hours worked by RNs, LPNs and CNAs was not documented on the daily census sheet. During an interview on 9/21/22 at 12:35 PM, the 2nd floor Unit Secretary stated they fill in the number of staff, the date, and the census on the Daily Census Sheets, then posts the sheets on the bulletin boards. The Unit Secretary also stated they do not post the sheets on Saturday and Sunday because they are not working those days. They fill out the Daily Census Sheets on Mondays for the weekend, then files them. During an interview on 9/21/22 at 11:09 AM, CNA #1/Scheduler stated they were not responsible for posting the Daily Census Sheet and the 2nd floor Unit Secretary fill's the form out and posts the sheets on the units. During an interview on 9/21/22 at 12:44 PM, the Acting Director of Nursing (DON) stated the Daily Census Sheets should be posted daily. The staffing scheduler fills out the census forms and posts them for each floor on the bulletin board, if the scheduler is not here the sheets are made up in advance, we only post the number of staff for each shift.

Based on interview and record review conducted during the COVID-19 Infection Control Focus Survey completed on 11/3/20, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility did not ensure staff were checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks every 12 hours while on duty. The finding is: Executive Order 202.11, dated March 27, 2020, as codified at 9 NYCRR 8.202.11, documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The NYS DOH (New York State Department of Health) Commissioner of Health letter to Nursing Home (NH) Administrators, dated April 29, 2020, documented As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Requiring all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. The NYS DOH DAL (Dear Administrator Letter) NH-20-07, Required COVID-19 Testing for all Nursing Home and Adult Care Facility Personnel, dated May 11, 2020, documented: This Directive supplements the prior (DOH) Advisory concerning hospital discharges to nursing homes (NHs), as well as the DAL sent on April 29, 2020. The directive documented: With respect to COVID-19, state and federal rules and regulations require that NHs adhere to appropriate safety measures including, but not limited to: Requiring all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. The facility policy and procedure (P&P) titled COVID-19 Symptom Screening of CMH (Cuba Memorial Hospital) Employees and Non-Employee Individuals Entering the Health Care Facility dated May 20, 2020 documented Cuba Memorial Hospital will implement COVID-19 screening guidelines for individuals entering the facility as part of CDC (Center for Disease Control) and NYSDOH (New York State Department of Health) guidance and the facility's effort to minimize potential spread of the COVID-19 virus while protecting the health and safety of patients, residents, and staff. All CMH employees will be screened for COVID-19 symptoms upon arrival to work and every 12 hours while at work as per NYSDOH guidance. During an interview on 11/3/20 at 9:40 AM, Registered Nurse (RN) #1 Infection Preventionist (IP) stated the facility census was 50 residents. This included 15 residents on contact and droplet precautions (14 residents due to exposure to a COVID-19 positive employee and 1 resident due to new admission status) all located on Floors 2 and 3. During an interview on 11/3/20 at 10:14 AM, Certified Nurse Aide (CNA) #2 stated she has worked overtime and double shifts. She stated employees get screened when they enter the facility at the start of their shift and do not get rescreened or have temperature re-taken when working a double shift (which are two 8-hour shifts, totaling 16 hours). CNA #2 was not aware they needed to be re-screened every 12 hours while on duty. During an interview on 11/3/20 at 10:30 AM, Licensed Practical Nurse (LPN) #1 stated she has worked double shifts. The facility does not rescreen her after working 12 hours. LPN #1 was not aware they needed to be re-screened every 12 hours while on duty. During an interview on 11/3/20 at 1:08 PM, RN #2 Unit Manager (UM) Third Floor, stated he is screened when he enters the facility. The facility does not rescreen him after working 12 hours and he was not aware they needed to be re-screened every 12 hours while on duty. During an interview on 11/3/20 at 1:40 PM, the RN Director of Nursing (DON) stated employees are not rescreened when working double shifts because they haven't left the building. During an interview on 11/3/20 at 1:45 PM, the facility Administrator stated he was aware employees are screened at the beginning of their shift. The Administrator stated he was unsure of the P&P for rescreening employees when working double shifts. During an interview on 11/3/20 at 2:34 PM, RN #1 IP stated employees should be rescreened after working an 8-hour shift but was unsure if rescreening employees was being done. Additionally, she stated CNA #1 was the regular staff member assigned to screen employees and that CNA #1 was provided education to screen employees. During an interview on 11/3/20 at 2:47 PM, CNA #1 stated for staff screening they were told to do whatever the state recommended, and the screening form would be updated when the state makes changes. CNA #1 also stated employees are screened upon entering the facility, if employees do not exit the building they are not rescreened. Review of an untitled and undated facility document, identified by staff as the employee screening tool, revealed no instructions that employees are to be re-screened every 12 hours while on duty. During an interview on 11/3/20 at 2:59 PM, RN #1 IP stated she was unable to locate any specific education provided to the screeners and that no one is ensuring employees are being screened every 12 hours. 415.19(a)(1) 400.2

Based on observation, interview and record review conducted during a COVID-19 Infection Control Focus Survey completed on 11/3/2020, the facility did not conduct testing and specimen collection in a manner that is consistent with current infection control measures during resident testing for COVID-19. Specifically, for one (Resident #1) of one residents observed, the Director of Nursing (DON) did not wear an N95 mask during specimen collection. The finding is: A CMS (Centers for Medicare and Medicaid Services) memorandum dated August 26, 2020, (Reference QSO-20-38-NH) documented that during COVID-19 specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 10/14/20 documented the resident had severe cognitive impairment. During an interview on 11/3/20 at 9:40 AM, Registered Nurse (RN) #1 Infection Preventionist (IP) stated the facility census was 50 residents. This included 15 residents on contact and droplet precautions (14 residents due to exposure to a COVID-19 positive employee and 1 resident due to new admission status) all located on Floors 2 and 3. Review of the undated document provided by the RN #1 IP titled COVID & Influenza Results revealed Resident #1 was on transmission based precautions. During an interview on 11/3/2020 at 1:45 PM, the DON and RN #1 IP stated all the nursing staff and some ancillary staff have been fit tested for N95 masks but do not currently wear N95 masks because there are no COVID-19 positive residents in the building. During an observation on 11/3/20 at 1:52 PM, the DON completed a nasal swab for COVID-19 on Resident #1 while wearing a gown, goggles, gloves and a surgical face mask. The DON did not wear an N95 mask. During an interview on 11/3/2020 at 2:03 PM, the RN #1 IP stated she didn't know if the facility had a policy and procedure for swabbing. The RN #1 IP stated the proper protective equipment to be worn by the staff member during nasal specimen collection should be full PPE; which includes gloves, gowns, face shield or goggles and an N95 mask. During further interview on 11/3/2020 at 2:04 PM, the DON stated she had performed all the swabbing for residents in the building on October 19th and October 22nd and she had not worn an N95 mask during the COVID-19 swabbing procedure. She stated no one told her to wear an N95, she follows the guidelines for the technique and doesn't believe the guidelines address what to wear for swabbing. During an interview on 11/3/2020 at 2:34 PM, the RN #1 IP stated she was unable to locate a facility policy for COVID-19 swabbing. She stated when collecting nasal specimens, she uses an N95, goggles/face shield, gown and gloves. During further interview on 11/3/2020 at 2:49 PM, the DON stated she had been trained elsewhere to wear a gown, surgical mask, face shield and gloves to swab. She didn't need to wear an N95 unless the resident was suspected as positive. She also stated we do not suspect our residents to have COVID because they are not showing symptoms, therefore she didn't wear an N95 mask. During an interview on 11/3/2020 at 3:10 PM, the RN #1 IP stated the DON should have worn an N95 mask while swabbing because swabbing is invasive and can cause a cough response causing contamination. The IP stated she is unable to find a policy or education that addresses PPE use for swabbing. 415.19(a)(1)

Based on observation, interview, and record review conducted during the COVID-19 Infection Control Focus Survey (Complaint #NY 533) completed on 5/27/20, it was determined the facility did not maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility did not appropriately social distance (at least 6 feet apart) residents while communal dining on one of two units (Unit 3) as required. This involved Residents # 1, 2, 3, 4, 5 and 6. The finding is: Review of a CMS (Centers for Medicare and Medicaid) memorandum (QSO-20-28-NH) dated 4/24/20 documented residents may still eat in dining rooms, however, nursing homes should adhere to social distancing, such as being seated at separate tables at least 6 feet apart. We note social distancing should be practiced at all times (not just while dining). We further note that eating in dining areas with appropriate social distancing only applies to residents without signs or symptoms of a respiratory infection, and without confirmed [DIAGNOSES REDACTED]. The facility policy and procedure (P&P) titled 2019 Novel Coronavirus (COVID-19) Plan dated 3/27/20 documented staff should maintain social distancing of at least 6 feet except for when brief, necessary interactions related to care are required. During an interview on 5/27/20 at 9:50 AM, the Administrator stated we have tested a total of ten residents for COVID-19. We have had no positive cases of COVID-19 for residents or staff, on the skilled side, to this point from the beginning. The facility census was 47. During an observation on 5/27/20 at 11:40 AM, there were 11 residents seated in the Unit 3 dining room. Two 4 foot x 4 foot tables were observed with three residents sitting at each table. Residents #1, 2, 3, 4, 5 and 6 were not wearing face masks and were not socially distanced. During an observation on 5/27/20 a 12:00 PM, CNA #1, CNA #2, Licensed Practical Nurse (LPN) #1 and the Director of Nurses (DON) passed meal trays and began feeding the residents without attempting social distancing. During an interview on 5/27/20 at 3:36 PM the DON stated initially, we tried keeping all the residents in their rooms, we were worried about weight loss, behaviors from residents. We couldn't seem to get to them all in a timely manner. They are supposed to be 6 feet apart and they were not. During an interview on 5/27/20 at 3:50 PM, the Administrator stated that was my fault, I told them they could have a few residents in the dining room, but they are not 6 feet apart at the tables. We will have to figure something out. 10 NYCRR 415.19(a)(1-3)

Based on observation, interview and record review conducted during the Standard survey completed on 6/22/15, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two (Resident's #18, 36) of twenty one residents reviewed for quality of care. The issues included the lack of blood pressure monitoring per physician's orders [REDACTED].#36). The resident developed uncontrolled epistaxis (bursting of blood vessels within the nose), was transported to the emergency room for treatment which included chemical cauterization (burning the affected area with acid to control the bleeding) of the nostril, and required an injection of Vitamin K (helps the blood clot) for an increased INR of 5.20 (normal 0.8 - 1.2). This resulted in actual harm for Resident #36 and potential harm for Resident #18 that is not immediate jeopardy. The findings are: 1. Resident #36 was admitted to the facility 6/9/14 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/29/14 revealed the resident has moderate cognitive impairment, is understood, and understands. The resident requires extensive assistance with most activities of daily living (ADLs') and had received anticoagulant, antidepressant, and diuretic (promotes the production of urine) medication during the last seven days. Review of the physician's orders [REDACTED]. - 6/11 Start [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg (milligrams) 1 tab po (by mouth) starting 6/13/14, repeat PT/ INR. - 6/19 Increase [MEDICATION NAME] 3 mg po QD (daily), PT/ INR in one week. - 6/24 Continue [MEDICATION NAME] 3 mg 1 tab po QD, repeat PT/ INR in two weeks. - 7/8 D/C (discontinue) [MEDICATION NAME] 3 mg po QD. Start [MEDICATION NAME] 2.5 mg po QD. Repeat PT/ INR 7/15. - 7/15 [MEDICATION NAME] 2 mg po QD, D/C [MEDICATION NAME] 2.5 mg po QD. Repeat PT/ INR 7/18. - 7/21 Continue [MEDICATION NAME] 2 mg po QD and repeat PT/ INR in one month. - D/C [MEDICATION NAME] 2 mg po QD. Start [MEDICATION NAME] 2.5 mg po QD at HS (bedtime), repeat PT/ INR on 7/28. - 7/28 D/C [MEDICATION NAME] 2.5 mg po QHS, start [MEDICATION NAME] 3.0 mg po QHS, repeat PT/ INR on 7/31. - 7/31 Continue [MEDICATION NAME] 3.0 mg po QHS, repeat PT/ INR in two weeks 8/14. - 8/14 No [MEDICATION NAME] today. [MEDICATION NAME] 2 mg po qd starting 8/15. PT/ INR 8/19. - 8/19 Continue [MEDICATION NAME] 2 mg po QHS, repeat PT/ INR in 2 weeks. - 9/2 Continue [MEDICATION NAME] 2 mg po QD, repeat PT/ INR in 2 weeks. - 9/18 D/C [MEDICATION NAME] 2 mg po QD. [MEDICATION NAME] 3 mg po QD. Recheck PT/ INR in one week 9/26. There were no further physician's orders [REDACTED]. Review of the Medication History Report revealed the resident was administered [MEDICATION NAME] 3 mg orally once a day from 9/19/14 through 11/10/14. Review of the PT/ INR lab results revealed Resident #36's PT/ INR was obtained on the following dates: - 6/11/14, 6/17/14, 6/25/14, 7/8/14, 7/15/14, 7/18/14, 7/21/14, 7/28/14, 7/31/14, 8/14/14, 8/19/14, 9/2/14, and 9/19/14. There were no further PT/ INR lab results from 9/20/14 through 11/11/14. Review of Patient Care Plan Report initiated 6/10/14 revealed the problem area Anticoagulant Therapy with the goal Elder Will Be Free of Bruising, Bleeding, or Injury approaches included Monitor Lab Reports - Daily; Observe For Signs of Bleeding. Review of Nursing Progress Note Inquiry included the following entry dated 11/11/14: - 2:00 PM - called to evaluate elder re: nose bleed. Large amount of bleeding noted from left nare (nostril). Ice and pressure applied. Unable to stop bleeding. Elder currently on 3 mg of [MEDICATION NAME] daily. Dr. (Doctor) notified of the situation and new order to ship elder to ER (emergency room ) for eval (evaluation). Review of the Hospital emergency room Report dated 11/11/14 with an arrival time 3:18 PM revealed [DIAGNOSES REDACTED]. The record revealed the epistaxis was treated using silver [MEDICATION NAME] (a cauterizing agent) cauterization. INR was obtained with the result of 5.20. Resident was transported back to the facility at approximately 5:45 PM. Review of Nursing Progress Note Inquiry included the following entry dated 11/11/14: - 10:46 PM - Elder called out for help at 9:25 PM. CNA (certified nursing assistant) and nurse to bedside. Elder was bleeding profusely from nose and had saturated several layers. MD (medical doctor)notified and ordered to be sent back to ER for further evaluation and treatment. Review of Hospital emergency room Report dated 11/11/14 with arrival time 10:53 PM revealed the following assessment: - Appears uncomfortable, behavior is calm, cooperative. Denies pain. Nares with bleeding noted on left. Pt (patient) returns with epistaxis of the left nares this evening. Seen earlier for the same and cauterized at that time. This evening Pt had a rhino rocket (nasal packing) placed by MD to control bleeding. Bleeding has stopped once pressure was placed. Given 10 mg IM (intramuscular) injection of Vitamin K for bleeding control. Pt is on [MEDICATION NAME]. Supposed to be holding anticoagulation therapy until Friday. Pt ready for discharge. Review of facility Event Report Form dated 11/11/14 revealed the following description of the event: - Elder was noted to have nose bleed, upon investigation of Medical Record it was noted that an order was written for PT/ INR on 9/18/14 and to be drawn on 9/26/14 and it was never transcribed into the computer. Further review of the physician's orders [REDACTED]. Two undated signatures were located directly beneath the NP order. Beneath the signatures was the entry; 24 hour, a check mark, initials, and 9-20-14. Interview with the Registered Nurse (RN) acting Director of Nursing (DON) on 6/19/15 at approximately 2:20 PM revealed the two signatures indicate that the order was double noted. The two staff, which can be either a unit secretary or nurse, verify that the order was transcribed correctly and facility procedure was followed. The DON stated the 24 hour entry is a 24 hour chart check that is completed by the 10:00 PM to 6:00 AM nurse; the night nurse verifies that the physician's orders [REDACTED]. The DON further stated, With having the check system nothing should get missed, they (the staff that signed and initialed) did not do what they were supposed to do. During an interview with the acting DON on 6/22/15 at approximately 9:26 AM, the acting DON stated The INR was never transcribed into the computer so it was never obtained. The error was not identified until the investigation of the nose bleed. There was elder harm here for an error that was made. Interview with the Medical Director on 6/22/15 at approximately 11:48 AM revealed normally a resident will have a PT/ INR check every one to two weeks once their [MEDICATION NAME] dose has been stabilized, PT/ INR may be checked more frequently if the dose has not been stabilized. The Medical Director stated the PT/ INR definitely needed to be monitored every one to two weeks and that there needs to be some type of a checks and balance system so that this type of omission does not occur again. Review of facility Policy and Procedure entitled Anticoagulation Therapy/ PTT, PT/ INR, CBC (complete blood count) Monitoring, reviewed 1/2014 and 1/2015, revealed All elders receiving anticoagulation therapy will have lab work monitored per physician's orders [REDACTED]. 2. Resident #18 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident understands, is understood and has moderate impaired cognition. Review of physician's orders [REDACTED]. Review of treatment assessment reviews (TARs) for 2015 revealed the following: March - two of five BP & P were not recorded. April - four of four, BP & P were not recorded. May - three of four BP & P were not recorded. June - one of two BP & P were not recorded. Review of [MEDICAL TREATMENT] report sheets from 3/3/15 through 6/20/15 revealed the report of the BP's were only on four days (6/18/15, 5/14/15, 4/4/15, 3/24/15). Review of vitals in the computer revealed the only dates with recorded BP & P's are on 6/1/15, 5/3/15 and 4/1/15. Review of Patient Care Plan Report dated 6/22/15 revealed under hypertension plan- check BP per order (check BP & P in right arm). Interview with Licensed Practical Nurse (LPN)/ Medication Nurse on 6/22/15 at 11:10 AM, the LPN stated, We do the resident's BP and P 1 x per week on the right arm. The left arm has the site for [MEDICAL TREATMENT]. If the BP and P is not recorded on the TAR sheets than the nurse either forgot to record it or they did not do it. Interview with LPN/ Resident Care Coordinator (RCC) on 6/22/15 at 12:10 PM, the LPN RCC stated, The nurses on evenings are to do BP weekly on Monday. I see they are not recorded on the TAR's, so in my opinion they did not do them. We send a [MEDICAL TREATMENT] communication book with the resident to [MEDICAL TREATMENT] and they would write some information in the book, but they usually do not write the resident's BP in the book. Occasionally they will do it here and there. The vitals are also recorded in the computer, but those are only recorded monthly, so the weekly BP & P would not be in there. 415.12

Based on interview and record review conducted during the Standard survey completed on 6/22/15 it was determined that for one (Resident #36) of ten residents reviewed for unnecessary drugs, the facility failed to ensure that the resident was free from unnecessary drugs. The issue involved the lack of adequate monitoring of [MEDICATION NAME] ([MEDICATION NAME] - an anticoagulant medication used to prevent blood from clotting) medication for approximately eight weeks at which time Resident #36 developed uncontrolled epistaxis (bursting of blood vessel within the nose). Resident #36 was transported to the emergency room for treatment which included chemical cauterization (burning the affected area with acid to control the bleeding) of the nostril. Laboratory tests in the emergency room determined Resident #36's INR (International Normalizing Ratio- standardized normalized blood coagulating values) at 5.20 (normal 0.8 - 1.2) requiring an injection of vitamin K (helps the blood clot) to decrease INR. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #36 was admitted to the facility 6/9/14 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/29/14 revealed the resident has moderate cognitive impairment, is understood, and understands. The resident requires extensive assistance with most activities of daily living (ADLs') and had received anticoagulant, antidepressant, and diuretic (promotes the production of urine) medication during the last seven days. Review of the physician's orders [REDACTED]. - 6/11 Start [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg (milligrams) 1 tab po (by mouth) starting 6/13/14, repeat PT/ INR. - 6/19 Increase [MEDICATION NAME] 3 mg po QD (daily), PT/ INR in one week. - 6/24 Continue [MEDICATION NAME] 3 mg 1 tab po QD, repeat PT/ INR in two weeks. - 7/8 D/C (discontinue) [MEDICATION NAME] 3 mg po QD. Start [MEDICATION NAME] 2.5 mg po QD. Repeat PT/ INR 7/15. - 7/15 [MEDICATION NAME] 2 mg po QD, D/C [MEDICATION NAME] 2.5 mg po QD. Repeat PT/ INR 7/18. - 7/21 Continue [MEDICATION NAME] 2 mg po QD and repeat PT/ INR in one month. - D/C [MEDICATION NAME] 2 mg po QD. Start [MEDICATION NAME] 2.5 mg po QD at HS (bedtime), repeat PT/ INR on 7/28. - 7/28 D/C [MEDICATION NAME] 2.5 mg po QHS, start [MEDICATION NAME] 3.0 mg po QHS, repeat PT/ INR on 7/31. - 7/31 Continue [MEDICATION NAME] 3.0 mg po QHS, repeat PT/ INR in two weeks 8/14. - 8/14 No [MEDICATION NAME] today. [MEDICATION NAME] 2 mg po qd starting 8/15. PT/ INR 8/19. - 8/19 Continue [MEDICATION NAME] 2 mg po QHS, repeat PT/ INR in 2 weeks. - 9/2 Continue [MEDICATION NAME] 2 mg po QD, repeat PT/ INR in 2 weeks. - 9/18 D/C [MEDICATION NAME] 2 mg po QD. [MEDICATION NAME] 3 mg po QD. Recheck PT/ INR in one week 9/26. There were no further physician's orders [REDACTED]. Review of the Medication History Report revealed the resident was administered [MEDICATION NAME] 3 mg orally once a day from 9/19/14 through 11/10/14. Review of the PT/ INR lab results revealed Resident #36's PT/ INR was obtained on the following dates: - 6/11/14, 6/17/14, 6/25/14, 7/8/14, 7/15/14, 7/18/14, 7/21/14, 7/28/14, 7/31/14, 8/14/14, 8/19/14, 9/2/14, and 9/19/14. There were no further PT/ INR lab results from 9/20/14 through 11/11/14. Review of Patient Care Plan Report initiated 6/10/14 revealed the problem area Anticoagulant Therapy with the goal Elder Will Be Free of Bruising, Bleeding, or Injury approaches included Monitor Lab Reports - Daily; Observe For Signs of Bleeding. Review of Nursing Progress Note Inquiry included the following entry dated 11/11/14: - 2:00 PM - called to evaluate elder re: nose bleed. Large amount of bleeding noted from left nare (nostril). Ice and pressure applied. Unable to stop bleeding. Elder currently on 3 mg of [MEDICATION NAME] daily. Dr. (Doctor) notified of the situation and new order to ship elder to ER (emergency room ) for eval (evaluation). Review of the Hospital emergency room Report dated 11/11/14 with an arrival time 3:18 PM revealed [DIAGNOSES REDACTED]. The record revealed the epistaxis was treated using silver [MEDICATION NAME] (a cauterizing agent) cauterization. INR was obtained with the result of 5.20. Resident was transported back to the facility at approximately 5:45 PM. Review of Nursing Progress Note Inquiry included the following entry dated 11/11/14: - 10:46 PM - Elder called out for help at 9:25 PM. CNAs (certified nursing assistant) and nurse to bedside. Elder was bleeding profusely from nose and had saturated several layers. MD (medical doctor)notified and ordered to be sent back to ER for further evaluation and treatment. Review of Hospital emergency room Report dated 11/11/14 with arrival time 10:53 PM revealed the following assessment: - Appears uncomfortable, behavior is calm, cooperative. Denies pain. Nares with bleeding noted on left. Pt (patient) returns with epistaxis of the left nares this evening. Seen earlier for the same and cauterized at that time. This evening Pt had a rhino rocket (nasal packing) placed by MD to control bleeding. Bleeding has stopped once pressure was placed. Given 10 mg IM (intramuscular) injection of Vitamin K for bleeding control. Pt is on [MEDICATION NAME]. Supposed to be holding anticoagulation therapy until Friday. Pt ready for discharge. Review of facility Event Report Form dated 11/11/14 revealed the following description of the event: - Elder was noted to have nose bleed, upon investigation of Medical Record it was noted that an order was written for PT/ INR on 9/18/14 and to be drawn on 9/26/14 and it was never transcribed into the computer. During an interview with the acting Director of Nursing (DON) on 6/22/15 at approximately 9:26 AM, the DON stated, The INR was never transcribed into the computer so it was never obtained. The error was not identified until the investigation of the nose bleed. There was elder harm here for an error that was made. Interview with the Medical Director on 6/22/15 at approximately 11:48 AM revealed normally a resident will have a PT/ INR check every one to two weeks once their [MEDICATION NAME] dose has been stabilized, PT/ INR may be checked more frequently if the dose has not been stabilized. The Medical Director stated the PT/ INR definitely needed to be monitored every one to two weeks and that there needs to be some type of a checks and balance system so that this type of omission does not occur again. Review of facility Policy and Procedure entitled Anticoagulation Therapy/ PTT, PT/ INR, CBC (complete blood count) Monitoring, reviewed 1/2014 and 1/2015, revealed All elders receiving anticoagulation therapy will have lab work monitored per physician's orders [REDACTED]. 415.12(I)(1)

Based on observation, record review, resident, family and staff interviews conducted during an Abbreviated Partial Extended survey (complaint #NY 243) completed 10/7/10, it was determined the facility did not maintain comfortable and safe temperature levels inside the Skilled Nursing Facility. This affected 56 of 56 residents. Issues include the lack of an effective plan to monitor and maintain heat in the facility during a disruption of services, planned loss of heat due to taking the main heating system off line, inability of the electric wall unit heaters to maintain comfortable and safe room temperatures. In addition, there was a delay in implementing additional heating measures that would protect residents against hypothermia. This was widespread with no actual harm and potential for serious harm that resulted in IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The findings are: 1. An interview with the Administrator on 10/6/10 at approximately 10:15 AM revealed the facility's two main boilers are the primary source of heat for the entire facility. The boilers were voluntarily taken out of service on 9/29/10 for a replacement project. The Administrator further stated this replacement project was planned in advance and would take approximately two to three weeks until the new boilers are installed. An interview with the Director of Maintenance on 10/6/10 at approximately 10:25 AM revealed that the resident rooms are equipped with electric wall unit heaters that are being used as the only heat source in the building. These electric wall heater units supply heat only to the resident sleeping rooms on Unit Two and Unit Three of the nursing home. Further interview at this same time revealed portable electric space heaters are in use in two or three resident rooms. During the same interview, the Director of Maintenance stated the facility tested room air temperatures one time on either 10/5/10 or 10/6/10. A review of the facility's Maintenance logs for room Air Temperatures on 10/6/10 at approximately 10:40 AM revealed resident room air temperatures were taken on Tuesday, 10/5/10 at approximately 3:30 PM. Temperatures were recorded below comfortable and safe temperatures in four of nine resident rooms as follows (room #/Temperature Degrees Fahrenheit (F)): #232/66F, #240/66F, #304/65F and #313/64F. Air temperatures were again taken on 10/6/10 at approximately 8:30 AM and were recorded below comfortable and safe temperatures in six of nineteen resident rooms as follows (room #/Temperature degrees F): #313/66F, #314/65F, #309/66F, #308/66F, #302/66F, and #241/64.2F. An interview on 10/6/10 at approximately 10:20 AM with both the Administrator and Maintenance Director revealed the Dining Room on Unit Two and Unit Three were not being used due to the low air temperatures. 2. Air temperatures were taken on 10/6/10 from approximately 10:45 AM until 11:45 AM on three of three resident use floors (Ground, Unit Two, Unit Three) using two Taylor Thermometers model #9840N. Temperatures were also recorded at resident room thermostats. Temperatures were taken in resident rooms and common areas including corridors, lounges, shower rooms and dining rooms. Temperatures were recorded with both Taylor thermometers in the common corridor of the Physical Therapy Wing located at the Ground Floor on 10/6/10 at approximately 11:40 AM. These temperatures ranged from 63.5 to 64.9 degrees F. The Kitchen Pantry room within the Physical Therapy Corridor was recorded at the same time at 64.6 to 64.8 degrees F. There were four portable electric space heaters being used in Physical Therapy. Resident #1 stated on 10/6/10 at approximately 10:53 AM "It is cold in here". Temperatures were recorded in Resident #1's room with both Taylor thermometers with readings of 65.9 and 66.9 degrees F. Resident #2 and Resident #3, both of whom share a room, stated on 10/6/10 at approximately 10:55 AM they thought it was cold in the building. The room thermostat read 68 degrees F and was set for 83 degrees F. Temperatures were recorded with both Taylor thermometers with readings of 67.1 and 67.0 degrees F. The surveyor informed Resident #3 the thermostat read 68 degrees F at which time he stated it doesn't feel like 68 degrees, it feels much colder. Resident #4 stated on 10/6/10 at approximately 11:00 AM "It's ok as long as I have my blankets on". Temperatures were recorded in Resident #4's room with both Taylor thermometers with readings of 66.9 and 67.5 degrees F. The room thermostat read 64 degrees F and was set for 84 degrees F. Unit Three corridor temperatures ranged from 62.5 degrees F to 69.4 degrees F in different locations on the unit. The resident Shower/Tub room was recorded with both Taylor Thermometers with reading of 63.6 and 64.6 degrees F. The Unit Three Dining room was temped at 61.1 and 61.5 degrees F. Resident #5 stated on 10/6/10 at approximately 11:17 AM "It's fine but I wouldn't want it any colder". Temperatures were recorded in Resident #5's room with both Taylor thermometers with readings of 67.9 and 68.2 degrees F. The room thermostat was set for 80 degrees F. Observations on 10/6/10 at approximately 11:25 AM revealed several residents sitting at the Unit Two Corridor Television Lounge located directly in front of the Unit Two nurses' station. These residents, approximately nine, were all dressed in multiple layers (sweaters etc.) and were covered with blankets. Staff were also observed wearing jackets and/or sweaters. The corridor temperatures on Unit Two ranged from 66.4 to 70.5 degrees F at different locations on the Unit. The Unit Two dining room temperatures were recorded with both Taylor thermometers with readings of 60.3 and 59.3 degrees F. Resident #6 has [DIAGNOSES REDACTED]. During an interview with Resident #6 on 10/6/10 at approximately 11:30 AM, the resident stated "It was cold, but it is comfortable now with the blankets and my heater". An interview with a family member of the resident at this same time revealed the facility was extra cold over the weekend and the facility Administration was doing nothing extra to maintain the heat. This family member further stated she brought in a personal space heater to help heat up the room. Observation of the resident on 10/7/10 at approximately 1:40 PM revealed she was fully dressed in a long sleeve sweatshirt and long pants. The resident's portable electric space heater was on and she was covered with a fleece lap blanket. The resident stated "it is comfortable now with the blanket and my heater". During a second interview with Resident #6 on 10/7/10 at approximately 11:30 AM she stated "it was so cold, my daughter took me home with her for awhile to warm up and brought me the heater for my room on Friday (10/1/10)". On Thursday (9/30/10) it was so cold I had to bundle up with my winter jacket and blankets just to keep warm". Resident #7 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident is independent in cognitive skills, has intact short and long term memory, full memory recall and is understood and understands. During an interview on 10/6/10 at approximately 1:15 PM, the resident revealed he is cold in his room and it has been cold since the weekend. The room thermostat read 62 degrees Fahrenheit (F) and the thermostat was set for 72 degrees F with a maximum temperature of 90 degrees F. Temperatures were recorded by the surveyor with both Taylor thermometers with readings of 64.0 and 65.0 degrees F. During a second interview conducted on 10/7/10 at approximately 1:50 PM, the resident stated "I stayed in bed all weekend it was too cold to get out of the bed". He further stated it was "too cold to get my shower". The resident was observed to be wearing a fleece zip up over his shirt with pants and had 2 blankets over him in bed. An interview with the Director of Nursing (DON) on 10/6/10 at approximately 2:35 PM revealed additional resident body temperatures were not being taken as a result of the cold air temperatures and at this point the only extra heating measures taking place are that the DON has directed nursing staff to ask residents if they need extra blankets and ask if the residents are warm enough. The DON at this same time identified the resident Census on the Unit Three as 28 residents and Unit Two as 28 residents (56 resident Census total). An interview with the CEO (Chief Executive Officer) on 10/6/10 at approximately 2:30 PM revealed a decision was made this morning for a portable furnace to be brought in and installed in the Third Floor Dining Room to bring supplemental heat to the Unit Three Dining Room and attached nearby corridor. A letter from the company contracted to install the facility's new boilers was submitted on 10/6/10 at approximately 2:55 PM. This letter was dated 10/6/10 and stated the company's intent to "Install a temporary furnace in the third floor dining room to provide increased comfort to the residents. This work will be started on Thursday, 10/7/10. The furnace should be operational on Thursday, 10/7/10 or Friday, 10/8/10. We will look to locate a second unit to be installed on the second floor for additional comfort for the residents. This will start upon locating a second floor rental unit". A New York State Dear Administrator Letter (DAL), Cold Weather Advisory, dated 11/9/06 states "Hypothermia can occur with air temperatures of 60 to 65 degrees Fahrenheit. The present regulations contained in Part 711 and Sub-parts 713-1 and 713-2 require nursing homes to be equipped with a heating system capable of maintaining all resident areas at a minimum temperature of 75 degrees Fahrenheit. This does not require that all occupied areas must be kept at 75 degrees Fahrenheit. Nursing homes should be cognizant of the needs and wishes of each resident and ensure that a safe and appropriate temperature is provided". On 10/6/10 at approximately 7:50 PM the Administrator presented a letter explaining its 14 point plan to be immediately implemented at this facility. The steps include: 1. All SNF (Skilled Nursing Facility) residents will have their body temperatures taken every four hours. The temperatures will be compared to the resident base line temp to monitor for hypothermia. 2. All clinical staff in house today will be in-serviced on facilities hypothermia prevention policy before beginning their shift thereafter. 3. Dear Administrator letter Cold Weather Precautions will be reviewed with all clinical staff. 4. All resident room doors will be kept closed to maintain heat in the room. Residents at risk for falls requiring extra supervision will be excluded for safety reasons. 5. All SNF residents will be offered hot beverages (coffee, tea, hot chocolate) every four hours. Hot beverages will be available 24/7 to all SNF residents upon request. 6. Resident rooms will have a functioning wall heater. 7. All family members will be notified that we are experiencing fluctuations in temperature that may be below State and Federally required temperatures. 8. The facility will accept no new admissions until it is approved to do so by NYS Department of Health and CMS (Centers for Medicare and Medicaid Services). 9. The facility will activate its emergency evacuation plan which will, in turn, put potential evacuation sites on notice of possible evacuation. 10. The facility Medical Director will be notified of the low temperature situation and will be asked to make the determination of whether or not the facility needs to evacuate. 11. Any negative outcomes such as hypothermia will be reported to the NYS Department of Health. 12. Gerster-Trane will be installing two propane fueled furnaces, one on each floor to make up heat. Before systems are started, they will be inspected by a local code enforcement officer for safety. 13. Resident Room and Corridor temps will be taken and recorded every two hours. 14. Portable electric heaters in place will be checked for proper placement and safety every 15 minutes. On 10/7/10 at approximately 10:30 AM, the Dietitian was interviewed. She stated it had been "cold in here since last week" and that staff were notified that there would be a loss of heat. Everyone knew it was cold in the facility but nothing was done to address the cold temperatures even though residents, family and staff were complaining. On 10/7/10 at approximately 12:00 PM during an interview with certified nurse aide (CNA) #1 the CNA stated she had worked over the weekend (10/2/10 and 10/3/10) and that it was "really" cold. "Residents who were scheduled for showers refused them", they "didn't even want to get out of their beds" and "staff did not give the cognitively impaired residents' showers because it was just too cold". An interview with the Director of Maintenance on 10/7/10 at approximately 11:50 AM revealed not all resident rooms were being checked for temperatures every two hours overnight, as per bullet point #13 from the facility's safety plan. Further interview with the Director of Maintenance at this same time revealed six rooms on each resident unit were checked for temperature overnight and he believed all rooms were checked at least one time overnight. A review of facility logs of Room temperatures on 10/7/10 revealed no less than five rooms and no more than seven rooms on each unit were being tested during the two hour testing schedule. All resident rooms were tested at least one time from 10:00 PM until 8:00 AM. Between 10:00 PM and 8:00 AM resident rooms #234, 237, 239, 308, 313, 314 and 316 were tested for room temperature only one time during the night. The Administrator implemented a written memorandum that "Effective 2:00 PM on 10/7/10 all resident rooms will be checked every two hours". On 10/7/10 at approximately 1:30 PM during an interview with Licensed Practical Nurse (LPN) #1 who worked the weekend of 10/2/10 and 10/3/10 stated it was "so cold". I notified the Supervisor that it was "freezing" and that she was not going to have the residents taken down to the main dining room for meals because it was "even colder in there". The LPN stated she had no knowledge of how to work the wall units and stated that over the weekend the ones that were on were blowing cold air so staff gathered residents in the main lounge area and bundled them in blankets. She further stated that until 10/6/10 no interventions were in place for the residents until the NYS Department of Health came onsite that day. Resident #9 has a [DIAGNOSES REDACTED]. During an interview on 10/7/10 at approximately 1:50 PM the resident stated "it was mighty cold since last weekend and worse over the weekend", "I had to dress in winter clothes" including "coat, hat and gloves". The resident stated it was "ridiculous" that he had to dress for winter inside a building with so many people living here. "They finally got me a heater for my room after days of complaining". An interview with the Administrator on 10/7/10 at approximately 3:00 PM revealed the boilers were taken out of service on 9/29/10. There were no issues on Thursday (9/29/10) or Friday (9/30/10) with temperatures being too low or resident/family complaints. The Administrator was first aware of temperature complaints that occurred over the weekend on Monday 10/4/10 and received more complaints on Tuesday 10/5/10. An interview with the Administrator on 10/7/10 at 3:10 PM revealed a portable boiler heating system had left Pittsburgh at 10:00 AM and was en route to the facility set to arrive at approximately 4:00 PM with anticipated operation time to begin at 9:00 PM. A phone call from the Administrator to the Health Department on 10/7/10 at approximately 11:30 PM the heating contractors were running into problems and the temporary boilers were still not operational. The temporary heating system was operational on 10/8/10. 415.29(h)

Based on observation, record review, resident, family and staff interview conducted during an Abbreviated Partial Extended survey (complaint #NY 243) completed 10/7/10, the facility failed to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This affected 56 of the 56 residents in the facility. Issues involved the lack of a plan to assess and monitor the residents for signs and symptoms of hypothermia due to unsafe temperature levels in resident rooms. In addition, there was no documented evidence that staff were trained to recognize signs and symptoms of hypothermia or that interventions were put in place to prevent hypothermia. This was widespread with no actual harm and potential for serious harm that resulted in IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The findings are: 1. On interview with the facility Administrator on 10/6/10 at approximately 10:15 AM, revealed the facility's two main boilers are the primary source of heat for the entire facility. The boilers were taken out of service on 9/29/10 for a replacement project and it would be approximately two to three weeks until the new boilers are installed. Further interview with the Administrator on 10/7/10 at approximately 2:00 PM, the Administrator explained that electric wall unit heaters were to be used to supply heat to the residents' rooms. However, there was no testing of the units to ensure they were properly functioning and would provide adequate heating to maintain comfortable room temperatures and safe body temperatures for the residents prior to the boiler heating system being removed. 2. Resident #7 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed he is independent in cognitive skills, no short or long term memory problems, and full memory recall, is understood and understands. During an interview on 10/6/10 at approximately 1:15 PM, the resident revealed he is cold in his room and it has been cold since the weekend. The room thermostat read 62 degrees Fahrenheit (F) and the thermostat was set for 72 degrees F with a maximum temperature of 90 degrees F. Temperatures were recorded by the surveyor with both Taylor thermometers with readings of 64.0 and 65.0 degrees F. During a second interview conducted on 10/7/10 at approximately 1:50 PM, the resident stated "I stayed in bed all weekend it was too cold to get out of the bed". He further stated it was "too cold to get my shower". The resident was observed to be wearing a fleece zip up over his shirt with pants and had 2 blankets over him in bed. 3. Resident #6 has a [DIAGNOSES REDACTED]. During an interview with Resident #6 on 10/6/10 at approximately 11:30 AM, she stated "it was so cold my daughter took me home with her for awhile to warm up and brought me the heater for my room on Friday" (10/1/10). "On Thursday" (9/30/10) and until my daughter took me to her house to warm up" (10/1/10) "it was so cold I had to bundle up with my winter jacket and blankets just to keep warm". During interview with the resident's daughter on 10/6/10 at approximately 11:30 AM, it was revealed the facility was extra cold over the weekend and facility Administration was doing nothing extra to maintain the heat. This family member further stated she brought in the space heater to help heat up the room. Observation of the resident on 10/7/10 at approximately 1:40 PM revealed she was fully dressed in a long sleeve sweat shirt and long pants. The resident's portable electric heater was on and she was covered with a fleece lap blanket. The resident stated "it is comfortable now with the blanket and my heater". 4. Resident #9 has a [DIAGNOSES REDACTED]. During an interview on 10/7/10 at approximately 1:50 PM, he stated "it was mighty cold since last weekend and worse over the weekend". The resident explained "I had to dress in winter clothes" including "coat, hat and gloves". He stated it was "ridiculous" that he had to dress for winter inside a building with so many people living here. "They finally got me a heater for my room after days of complaining". The resident's room was observed to have a portable space heater on and set at "high". The resident stated he keeps the door closed to make the heat stay in his room. 5. An interview with the Director of Nursing (DON) on 10/6/10 at approximately 2:35 PM revealed the resident Census on the Unit Three as 28 residents and Unit Two as 28 residents (56 resident Census total). The DON stated temperatures in the resident rooms ranged between 64 to 68 degrees Fahrenheit and 62.5 to 69 degrees Fahrenheit in the common areas. During the interview it was learned that until 10/6/10 the only extra heating measures that had been implemented was direction to the nursing staff to ask residents if they needed extra blankets or were warm enough. The DON stated there were no interventions in place to assess the resident's body temperatures. 6. On 10/7/10 at approximately 1:30 PM during an interview with Licensed Practical Nurse (LPN) #1 who worked the weekend of 10/2/10 and 10/3/10, she stated it was "so cold I notified the Supervisor that it was freezing and I was not going to have the residents taken down to the main dining room for meals because it was even colder in there". The LPN explained she did not know how to work the electric wall unit heaters and stated that over the weekend the wall units that were on were blowing cold air, so staff gathered residents in the main lounge area and bundled them in blankets. She further stated that until 10/6/10 no interventions were in place for the assessment of the residents' body temperatures until the Department of Health (DOH) came onsite that day. 7. On 10/6/10 at approximately 12:00 PM, certified nurse aide (CNA) #1 was interviewed. The CNA stated she had worked over the weekend (10/2/10 and 10/3/10) and that it was "really" cold. "Residents who were scheduled for showers refused them and didn't even want to get out of their beds, staff did not give the cognitively impaired residents showers because it was just too cold and no residents' body temperatures were being taken every 4 hours." 8. On 10/7/10 at approximately 11:45 AM, the Director of Nursing (DON) stated, during an interview, that she was not aware of the lack of heat until Monday, 10/4/10. At approximately 3:00 PM, the DON submitted a policy and procedure for hypothermia, for staff to reference, that had been developed that day, after the policy was requested by the DOH. The DON stated neither she nor the Administrator were aware that there was no policy and procedure for hypothermia. The DON further stated that all the measures currently in place; resident body temperatures every 4 hours, warm beverages being passed and the inservicing of staff to know signs and symptoms of hypothermia were implemented after the NYS Department of Health came onsite 10/6/10. 415.12

Based on record review and staff interviews conducted during an Abbreviated Partial Extended survey (complaint #NY 243) completed on 10/7/10, it was determined that the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This affected 56 of 56 residents. The Administrator did not notify the NYSDOH (New York State Department of Health) regarding a disruption to residents' services during a loss of the facility's primary heat source. The Administrator did not have adequate Policies and Procedures in place prior to a scheduled disruption in heating services. There was a lack of an effective plan to monitor and maintain heat in the facility. The Administrator did not immediately implement emergency measures upon identifying inadequate heat to maintain comfortable and safe temperatures. There was no actual harm with potential for serious harm that resulted in IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The findings are: 1. An interview with the Administrator on 10/6/10 at approximately 10:15 AM revealed the facility's two main boilers are the primary source of heat for the entire facility. The boilers were voluntarily taken out of service on 9/29/10 for a replacement project. It would be approximately two to three weeks until new boilers are installed. This replacement project was planned in advance. Further interview with the Administrator on 10/7/10 at approximately 3:00 PM revealed there were no issues on Thursday (9/29/10) or Friday (9/30/10) with temperatures being too low or resident/family complaints. The Administrator was first aware of temperature complaints that occurred over the weekend (10/2/10 and 10/3/10) on Monday 10/4/10 and received more complaints on Tuesday 10/5/10. Further interview with the Administrator on 10/7/10 at approximately 3:05 PM revealed: "It was suggested on Monday, 10/4/10 to upper management (Chief Executive Officer and Chief Financial Officer) that the Department of Health be notified. However, it was determined a loss of services did not occur "because electric wall heaters were being used". As of the beginning of the Abbreviated survey (complaint #NY 243) on 10/6/10, the Administrator had not notified the New York State Department of Health of the facility's inability to maintain safe and comfortable temperatures. 2. A review of the facility's Policies and Procedures for Heat Loss on 10/6/10 at approximately 2:50 PM revealed the following plan for Heat Loss: "The hospital's heat plant has two 200-hp boilers fired by natural gas. In the event of interruption of the natural gas supply, one back-up system may be employed: which would be fuel oil #2. There is one 2000-gallon fuel oil tank hooked to the boilers. In the event of electrical interruptions, the hospitals 350 KVA 12-cylinder generator will be employed automatically (within 9 seconds)". This policy does not cover an emergency in which both boilers are out of service simultaneously and the primary heat source is out of service. An interview with the Administrator on 10/7/10 at approximately 3:00 PM revealed both boilers were voluntarily taken out of service on 9/29/10 for a replacement project that is expected to last at least three weeks. By taking both boilers out of service the facility was unable to follow its own Policies and Procedures of implementing the use of one boiler with an alternative fuel supply. An interview with the Director of Maintenance on 10/6/10 at approximately 10:25 AM revealed the resident rooms are equipped with electric wall unit heaters that are being used as the only heat source in the building. These electric wall heaters supply heat only to the resident sleeping rooms on Nursing Home Units Two and Three. Further interview at this same time revealed portable electric space heaters are in use in two or three resident rooms. The existing Heat loss policy did not address the use of electric wall unit heaters or the use or monitoring of portable electric space heaters in the event of the Loss of Heat. The use of portable electric space heaters, in resident sleeping rooms, is prohibited per the 2000 edition of NFPA 101 Life Safety Code. An interview with the Chief Executive Officer on 10/6/10 at approximately 2:50 PM revealed the facility's disaster policy was changed today (10/6/10) to reflect an addendum to safely monitor the use of the portable electric space heaters. Further interview conducted at this same time revealed there had been no policy in place to monitor the use of the portable electric space heaters prior to the addendum being implemented. A review of this Addendum to the policy was conducted at this time. It is entitled "Heat Loss Addendum". The heat loss addendum states to "Supplement existing system with portable heaters a) All portable heaters will be safety checked by maintenance department before implementation" and a Fire Watch policy will be implemented. "This will include evaluation of portable heaters for proper operation and assure that they are clear of debris, bedding and other hazards". Prior to this change in Policy there has not been a revision since 4/05 (April 2005). An interview with the Administrator on 10/7/10 at approximately 3:00 PM revealed the Administrator was "not sure" if the Electric Wall heaters were tested to see if they could supply enough heat to maintain comfortable and safe levels prior to the boilers being taken out of service. An interview with the Director of Maintenance on 10/7/10 at approximately 3:30 PM revealed the electric wall unit heaters were not tested to see if they could supply enough heat to maintain comfortable and safe temperature levels prior to the boilers being taken out of service, and then added "just the operation of the unit (was tested )". 3. Temperatures were taken in resident sleeping room, shower rooms, dining rooms and corridors on 10/6/10 between 10:45 AM to 11:44 AM. Temperatures were measured to be between 62.5F and 69.4F in resident corridors and 64 to 68F in some resident sleeping rooms. An interview with the Administrator on 10/7/10 at approximately 3:00 PM revealed he was first made aware of temperature complaints that occurred over the weekend on Monday, 10/4/10 and received more complaints regarding temperatures on Tuesday, 10/5/10. A review of the facility's Maintenance logs for room Air Temperatures on 10/6/10 at approximately 10:40 AM revealed resident room air temperatures were taken on Tuesday, 10/5/10. Temperatures were first recorded below comfortable and safe temperatures in four of nine resident rooms as follows (room #/Temperature Degrees Fahrenheit (F)): #232/66F, #240/66F, #304/65F and #313/64F. Air temperatures were again taken on 10/6/10 and were recorded below comfortable and safe temperatures in six of nineteen resident rooms as follows (room #/Temperature degrees Fahrenheit): #313/66F, #314/65F, #309/66F, #308/66F, #302/66F, and #241/64.2F. Further interview with the Director of Maintenance at this same time revealed there was no other documentation available that demonstrated the facility tested room air temperatures on either 10/5/10 or 10/6/10 more than once on either date. During the course of the survey on 10/6/10 and 10/7/10 it was determined there were no immediate measures implemented to maintain the safety and comfort of residents. During an interview with the Director of Nursing (DON) on 10/6/10 at approximately 2:35 PM, the DON stated residents' body temperatures were not being taken as a result of the cold air temperatures. The DON explained that the nursing staff were directed to ask the residents if they were warm enough or needed extra blankets. Further interview with the DON on 10/7/10 at approximately 11:45 AM revealed she was not aware of the lack of heat until Monday, 10/4/10 and stated that all the measures currently in place were implemented after the DOH (Department of Health) came onsite 10/6/10. At approximately 3:00 PM the DON submitted a policy and procedure for hypothermia, for staff to reference, that had been developed that day after being requested by NYSDOH. The DON stated neither she nor the Administrator were aware that there was no policy and procedure. The following measures were implemented by the Administrator on the evening of 10/6/10: 1. All SNF residents will have their body temperatures taken every four hours. The temperatures will be compared to the resident base line temp to monitor for hypothermia. 2. All clinical staff in house today will be in-serviced on facilities hypothermia prevention policy before beginning their shift thereafter. 3. Dear Administrator letter Cold Weather Precautions will be reviewed with all clinical staff. 4. All resident room doors will be kept closed to maintain heat in the room. Residents at risk for falls requiring extra supervision will be excluded for safety reasons. 5. All SNF residents will be offered hot beverages (coffee, tea, hot chocolate) every four hours. Hot beverages will be available 24/7 to all SNF residents upon request. 6. Resident rooms will have a functioning wall heater. 7. All family members will be notified that we are experiencing fluctuations in temperature that may be below State and Federally required temperatures. 8. The facility will accept no new admissions until it is approved to do so by NYS Department of Health and CMS (Centers for Medicare and Medicaid Services). 9. The facility will activate its emergency evacuation plan which will, in turn, put potential evacuation sites on notice of possible evacuation. 10. The facility Medical Director will be notified of the low temperature situation and will be asked to make the determination of whether or not the facility needs to evacuate. 11. Any negative outcomes such as hypothermia will be reported to the NYS Department of Health. 12. Gerster-Trane will be installing two propane fueled furnaces, one on each floor to make up heat. Before systems are started, they will be inspected by a local code enforcement officer for safety. 13. Resident Room and Corridor temps will be taken and recorded every two hours. 14. Portable electric heaters in place will be checked for proper placement and safety every 15 minutes. 415.26