Every finding on record at Daughters of Sarah Nursing Center

Based on record review and interviews conducted during a survey, the facility failed to immediately notify the resident's legal representative of a significant change in the resident's physical, mental, or psychosocial status, for one (1) out of three (3) residents reviewed for notification of changes. Specifically, when Resident #1 experienced a vasovagal episode (a sudden, temporary drop in heart rate and blood pressure that reduces blood flow to the brain, leading to brief fainting) and episodes of vomiting on 05/14/2026, Family Member #2 was not notified. Findings include: Resident #1 was admitted to the facility with diagnoses of pneumonitis due to inhalation of food and vomit (an inflammation of the tiny air sacs in the lungs, usually triggered by inhaling foreign substances,) dysphagia (difficulty swallowing food, liquids, or saliva) and stage three (3) chronic kidney disease (moderate kidney damage). The Minimum Data Set (an assessment tool) dated 05/06/2026, documented the resident could sometimes be understood, could sometimes understand others, and had moderate cognitive impairment. Facility Policy titled Notification Policy, dated 02/2021, documented Attending Physician or designee and resident or resident's legal representative (or interested family member) is to be notified by the nurse of a significant change in resident condition. A significant change is defined as: significant change in the resident's physical, mental or psychosocial status. This may include change in mentation, change in behavior, change in vital signs, including fever, respiratory distress, bleeding, vomiting, sudden onset of pain accident involving injury, new pressure ulcer. Progress Note dated 05/13/2026 at 10:32 AM by Licensed Practical Nurse #1 documented Asked to see resident for complaint of right sided abdominal pain at 7:30 AM, bowel sounds present but diminished on right lower quadrant. Physician #1 updated on arrival and examined resident. Abdominal x-ray ordered for Kidneys, Ureters, and Bladder ordered to rule out ileus (temporary lack of normal muscle contractions in the intestines). Progress Note dated 05/13/2026 at 3:09 PM by Registered Nurse#1 documented Resident was assessed for abdominal pain. Rebound tenderness (a clinical sign where a person experiences sharp, intense pain when manual pressure to the abdomen is quickly released) noted, no palpation performed, no bowel sounds in right lower quadrant. They were unable to detect bowel sounds in all four quadrants as resident jumped several times as stethoscope bothered them. Resident stated they had a bowel movement yesterday (05/12/2026) and threw up clear liquid today (05/13/2026). It further documented an x-ray was ordered, waiting results, and Medical Doctor was made aware. Progress Note dated 05/14/2026 at 8:04 AM by Licensed Practical Nurse #3 documented that Certified Nurse Aide #1 reported resident not responding appropriately. Licensed Practical Nurse was notified of current situation, upon entering resident responded very little. Physician Assistant #1 was notified, vitals were taken . Progress Note dated 05/14/2026 at 9:20 AM by Registered Nurse #1 documented the resident had vomited and a call was placed to Physician Assistant #1. There was no documented evidence that the resident's legal representative was immediately notified of the change of condition that Registered Nurse #1 recorded. Progress note dated 05/14/2026 at 1:00PM by Physician Assistant #1 documented they saw the resident for what appeared to be a syncopal episode (a temporary, sudden loss of consciousness caused by reduced blood flow to the brain) while showering. and chest x-ray ordered. There was no documented evidence that the resident's legal representative was immediately notified of the change of condition that Physician Assistant #1 recorded. During an interview on 05/26/2026 at 12:27 PM Licensed Practical Nurse #3 stated on the morning of 05/14/2026, Resident #1 was in the shower and had a vasovagal episode but did not completely pass out. They notified Physician Assistant #1. Physician Assistant #1 came to see Resident #1. Physician Assistant #1 stated they thought the resident had a vasovagal incident and said to monitor the resident and notify them with any changes. They stated they offered Resident #1 their morning medication, which they accepted. A bit later Resident #1 had some brown colored vomit. They notified Physician Assistant #1 and Physician Assistant #1 ordered Ondansetron (a prescription medication used to treat nausea and vomiting). They stated the resident passed away before they were able to administer the Ondansetron. During an interview on 05/26/2026 at 2:35 PM Physicians Assistant #1 stated that on the morning of 05/14/2026, they were asked to see Resident #1 after they had a vasovagal incident in the shower. They stated Resident #1 had been returned to bed and was seen and assessed at that time. They also stated mid to late morning, around 10 AM, they were notified the resident had vomited and was asked to see them again. They stated they ordered Ondansetron (a prescription medication used to treat nausea and vomiting) and monitoring of vital signs. They were again contacted around 11:15 AM and notified the resident had passed away. During an interview on 05/27/2026 at 1:44 PM, Family Member #2 stated that on the morning of 05/13/2026, they attended a care conference via telephone for Resident #1. They stated they did discuss that Resident #1 was having fatigue and nausea on 05/13/2026. Family member #2 stated that on the morning of 05/14/2026, they did not receive notification that Resident #1 had had a vasovagal episode or that they vomited. The first notification they received from the facility was on 05/14/2026 at 12:07 PM when they were informed that Resident #1 had passed away. During an interview on 05/27/2026 at 1:38 PM, Director of Nursing #1 stated a family member or representative would be notified for any change in a resident's baseline. They stated family would be notified of incidents and accidents, any increase in pain from baseline, any new signs or symptoms the resident is displaying that show a change in medical condition. During an interview on 05/27/2026 at 2:20PM, Licensed Practical Nurse #1 stated that family would be notified if there was a severe change in a resident condition, death, any medication changes, when they went to see an outside provider, or for any change in the plan of care. They would consider a severe change in a resident condition to be an altered mental status, altered respiratory status, or vital signs outside of the normal range. They stated Family Member #2 was not notified of the vasovagal incident that occurred on 5/14/2026 when Resident #1 was in the shower. During an interview on 05/29/2026 at 9:53 AM, Physician #1 stated they would expect the family of a patient to be notified if there was an unexpected change in a resident's condition, especially if a resident was one who could not make their own decisions about treatment. 10 New York Codes, Rules, and Regulations 415.3 (f)(2)(ii)

Based on observation, interviews, and record review conducted during a recertification survey, the facility did not ensure their policy regarding foods brought to residents by family and other visitors to ensure safe and sanitary handling and consumption. Specifically, the facility did not provide accommodations for heating of food brought to residents from outside the facility. This was evident for all residents in the facility. This is evidenced by: Facility's policy titled, Resident Personal Food and dated 11/2021, documented resident personal food (food not provided by facility) should be ready to eat, requiring little or no preparation. Food requiring refrigeration may be stored in the unit kitchenette refrigerator or personal refrigerator provided by resident/resident representative. Resident personal food could not require re-heating. At all times, residents who were unable to access their personal food or eat independently would be assisted by facility staff, as needed. It further documented the facility was a 'Kosher' facility. All food served by the facility was prepared in accordance with traditional Jewish rules of Kashrut, and only facility-provided, kosher food was permitted in the facility's public areas. Resident personal food must be consumed in resident's room. Microwaves were not allowed in resident care areas. The policy did not document how residents would be assisted in reheating personal food brought from outside. The New York State Department of Health Nursing Home Resident Rights Booklet 2022, documented under Self-Determination, page 4: Resident had the right to: - Be offered choices and allowed to make decisions important to them. - Receive services with reasonable accommodations for individual needs and preferences. Facility admission Agreement for Resident #5 dated 9/20/2006 documented, under section 2.1.8 Serviced Provided by the Home: Assistance and/or supervision, when required, with activities of daily living, including but not limited to toileting, bathing, feeding and ambulation assistance. Section 2.1.11 documented: Activities program, including but not limited to a planned schedule of recreational motivational, social, and other activities; together with necessary materials and supplies to make the resident's life more meaningful. The facility has 210 beds. The census at the time of the survey was 202 residents. The Facility Assessment, last reviewed 8/22/2024, included a detailed breakdown of religious and ethnic group by resident. The attachment documented that 21.9% of the resident population were Jewish. It additionally documented that the facility's nutritional services staff provided kosher meals and included 'cater-to-you meal service' for Short Term Care residents. Record review of the aforementioned Facility Assessment revealed the majority of residents served by the facility did not require a Kosher diet based on their religious beliefs and/or personal convictions. During an interview on 8/30/2024 at 12:45 PM, Resident #5 inquired of their right to have food brought in from outside heated up. Resident #5 stated they often had food in a resident refrigerator that they wanted to be heated up. During an interview on 8/30/2024 at 2:45 PM, Administrator #1 stated it was the facility's policy not to heat food brought in from outside for the safety of residents, and staff would not heat up food for residents because it could 'potentially result in burns to the resident.' During an interview on 9/09/2024 at 9:39 AM, a microwave oven was observed on the Red Unit, Unit Managers office. Licensed Practical Nurse #2 stated the microwave was for staff use only and had always been there. During an interview on 9/05/2024 at 11:18 AM, Registered Nurse #1 stated they used to have microwave in their office up to about one year ago; everyone used the microwave to the point where it was 'out of control,' therefore, they had it removed. Registered Nurse #1 stated previously staff would go to a staff lounge in back of building and heat items for residents, but that staff no longer heated up food for residents brought in from the outside per policy. During an interview on 9/05/2024 at 11:18 AM, Social Worker #1 stated there was a resident who had since passed away about 6 months ago, who wanted pizza warmed up, but staff did not have 'the right' to test temperature and warm food properly. Social Worker #1 stated it was the facility's policy that staff were unable to heat food brought in from outside. During an interview on 9/03/2024 at 9:00 AM, Resident #5 stated they often ordered take-out food, and saved the leftover food in refrigerator. They also stated their family member used to bring in food that they would like heated up in the evening. Resident stated they had been in the facility for over 15 years and previously had a microwave in their room. After they were readmitted from a hospitalization, they were told they could no longer have a microwave, and were permitted to use the microwave in unit managers office. They further stated that approximately 6 months ago they were told by several staff that they were no longer allowed to heat up food for resident because they could not test the temperature. Resident #5 stated 'that is just not right.' They stated food choices were limited at the facility and they would like to have other meals. During an interview on 9/06/2024 at 11:04 AM, Director of Maintenance #1 stated there had been no work orders to remove microwave ovens. They further stated there were some microwave ovens still in the facility, and there was a microwave in the memory care unit pantry. During an interview on 9/04/2024 at 2:45 PM, Administrator #1 stated they were not aware there was a concern about heating up food. They stated it had always been the facility's policy not to reheat food brought in from the outside. Administrator #1 concluded that Resident #5 had the concern and stated they would discuss concerns with resident. During an interview on 9/06/2024 at 11:30 AM, Resident #5 stated they met with Administrator #1 who stated a designated Certified Nurse Aide would heat food brought in from outside, specifically for them. Resident #5 further stated that if the designated Certified Nurse Aide was not at the facility on any given day, then their outside meals could not be heated. 10 New York Codes, Rules, and Regulations 415.12

Based on observation, interviews, and record reviews conducted during a recertification survey, the facility did not ensure treatment with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality for 3 (Resident #'s 33, 86 and 197) of 35 residents reviewed for dignity. Specifically, (a.) Resident #33 stated Certified Nurse Aide #3's tone of voice was rude, they felt rushed during care and requested Certified Nurse Aide #3 not to be assigned to them as caregiver; (b.) Resident #86 stated they waited a long time for care and then the care was rushed; (c.) Resident #197 stated Certified Nurse Aide #3 was argumentative and used inappropriate language. This is evidenced by: New York State Department of Health Division of Nursing Homes and ICF/IID Surveillance, Resident Rights Handbook, documented: As a resident in this facility, they have rights guaranteed to them by state and federal laws. This facility was required to protect and promote their rights. Resident rights strongly emphasized individual dignity and self-determination, promoting their independence, and enhancing their quality of life. Facility memorandum dated 5/01/2024, documented facility's Community for Seniors was 'privileged' to be in a position to serve their needs. It documented the facility took 'very seriously' their commitment to provide exceptional, dignified personal care to all residents, and intended to do so each and every time with compassion and acts of loving kindness. Resident #33 was admitted to the facility with diagnoses diabetes mellitus (a disease where the hormone insulin is impaired resulting in elevated levels of glucose/sugar), limited range of motion and Lower extremity edema (swelling). The Minimum Data Set (an assessment tool) dated 5/2024, documented the resident was cognitively intact, could be understood and understand others. During an interview on 8/30/2024 at 11:31 AM, Resident #33 stated some Certified Nurse Aides were rude. There was one Certified Nurse Aide that they complained to facility leadership about and requested Certified Nurse Aide #3 not care for them anymore. Resident #33 denied feeling fearful but stated Certified Nurse Aide #3 had a bad attitude and came in rushing them after they had waited so long to be taken off the bedpan. They stated they were now more independent and could do their own transfers from chair to toilet. Although before they graduated to independent level, they used to wait a very long time for assistance. During an interview on 9/06/2024 at 2:10 PM, Registered Nurse #1 stated they had no knowledge of reported incident that an aide was rude and no restriction on who cared for Resident #33. Registered Nurse #1 stated if resident reported that a Certified Nurse Aide was rude, they would conduct a full investigation, notify Medical Doctor, report to facility leadership, and remove the Certified Nurse Aide until investigation was completed. They further stated that training on abuse and neglect was upon hire and annually. During an interview on 9/06/2024 at 2:15 PM, Licensed Practical Nurse #7 stated when Resident #33 was on the rehabilitation unit, Resident #33 did not like Certified Nurse Aide #3's approach and requested Certified Nurse Aide #3 not to care for them because they were rude. Certified Nurse Aide #3 was no longer assigned to Resident #33. Licensed Practical Nurse #7 stated there had been other complaints about Certified Nurse Aide #3 from other residents, however, those residents had been discharged . Licensed Practical Nurse #7 stated they reported complaints about Certified Nurse Aide #3 to the Unit Manager. During an interview on 9/06/2024 at 2:20 PM, Licensed Practical Nurse #5 stated so many personality things had happened but did not remember anything about Resident #33 and Certified Nurse Aide #3. They stated Certified Nurse Aide #3 could be noisy. Resident #33 was apprehensive in the beginning, and Certified Nurse Aide #3 may not have been patient with them. Licensed Practical Nurse #5 stated if they had been made aware they would have conducted an investigation. Resident #86 was admitted to the facility with diagnoses osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), lower extremity fracture (bone break) and limited range of motion. The Minimum Data Set, dated dated dated ,d+[DATE], documented resident was cognitively intact, could be understood and understand others. During an interview on 9/09/2024 at 10:25 AM, Resident #86 stated they were generally the last resident to receive care and when staff finally got to them, staff rushed through them. Everything happens [NAME] and you were done. Resident #86 stated staff were always in a rush, and was reluctant to specify further. Resident #197 was admitted to the facility with diagnoses including lower extremity fracture, weakness and decreased mobility. Resident #197 was alert and oriented to person, time, place, and event. Resident could understand and was understood by others. During an interview an 9/09/2024 at 10:10 AM, Resident #197 stated Certified Nurse Aide #3 appeared hot and cold. Some days they were okay, but there were days where Certified Nurse Aide #3 was very rude and abrasive. Resident #197 stated the previous week they put on light to get remote that had fallen on floor behind table. Certified Nurse Aide #3 answered after a long wait and stated 'what do you want' in a 'very harsh tone.' When Resident #197 replied to the staffer, Certified Nurse Aide #3 stated over their talking, 'make up your mind.' Resident #197 then stated they asked Certified Nurse Aide #3 why they had to be so nasty, and Certified Nurse Aide #3 replied, 'why do you have to be so nasty?' In another example, Resident #197 stated that on the evening of 9/05/2024, Certified Nurse Aide #3 stated 'get your ass out of the bed' while providing care to them. Resident #197 stated they did not report Certified Nurse Aide #3 because word would get out to the other aides that they had complained, and they would then not receive care from any of the Certified Nurse Aides. During an interview on 9/06/2024 at 2:37 PM, Director of Nursing #1 stated they had no knowledge of Resident #33's complaint about Certified Nurse Aide #3. They stated Certified Nurse Aide #3 was a good aide but had a rough tone to their voice. Director of Nursing #1 stated if they had been made aware, they would have conducted an investigation and provided training to staff. During an interview on 9/06/2024 at 3:45 PM, Administrator #1 stated Registered Nurse #1 and Social Worker #1 met with Resident #33 on 9/06/2024 at 3:00 PM and that Resident #33 stated they were not fearful, but had been left on a bed pan for a very long time. When Certified Nurse Aide #3 came to take them off, they were rushing and pushing things around in room to get to them and assist with bedpan. Administrator #1 stated Resident #33 did not like Certified Nurse Aide #3's attitude. Resident asked that Certified Nurse Aide #3 not to care for them anymore, and Administrator #1 and Registered Nurse #2, (Unit Manager) were not made aware of the incident or request. Administrator #1 stated Certified Nurse Aide #3 had been with the facility for a long time and received shining star comments from other residents. They stated Certified Nurse Aide #3 resigned as of 9/06/2024. Administrator #1 stated if they were notified at the time, an investigation would have been initiated. Administrator #1 stated staff received annual abuse and neglect training and with each anniversary date. During an interview on 9/09/2024 at 9:40 AM, Registered Nurse #2 stated they were not made aware of incident with Resident #33 and Certified Nurse Aide #3. In addition, they had no knowledge of other resident complaints regarding Certified Nurse Aide #3. A call was placed to Certified Nurse Aide #3 for an interview; message was left requesting a call back with no response. 10 New York Codes Rules and Regulations 415.5(a)

Based on observation, interviews, and record review conducted during a recertification survey, the facility did not promoted and facilitated the residents right to self-determination through support of resident choice. Specifically, the facility did not provide accommodations for heating of food brought to residents from outside the facility. This was evident for Resident #5. This is evidenced by: Facility's policy titled, Resident Personal Food and dated 11/2021, documented resident personal food (food not provided by facility) should be ready to eat, requiring little or no preparation. Food requiring refrigeration may be stored in the unit kitchenette refrigerator or personal refrigerator provided by resident/resident representative. Resident personal food could not require re-heating. At all times, residents who were unable to access their personal food or eat independently would be assisted by facility staff, as needed. It further documented the facility was a 'Kosher' facility. All food served by the facility was prepared in accordance with traditional Jewish rules of Kashrut, and only facility-provided, kosher food was permitted in the facility's public areas. Resident personal food must be consumed in resident's room. Microwaves were not allowed in resident care areas. The policy did not document how residents would be assisted in reheating personal food brought from outside. The New York State Department of Health Nursing Home Resident Rights Booklet 2022, documented under Self-Determination, page 4: Resident had the right to: - Be offered choices and allowed to make decisions important to them. - Receive services with reasonable accommodations for individual needs and preferences. Facility Admission Agreement for Resident #5 dated 9/20/2006 documented, under section 2.1.8 Serviced Provided by the Home: Assistance and/or supervision, when required, with activities of daily living, including but not limited to toileting, bathing, feeding and ambulation assistance. Section 2.1.11 documented: Activities program, including but not limited to a planned schedule of recreational motivational, social, and other activities; together with necessary materials and supplies to make the resident's life more meaningful. During an interview on 8/30/2024 at 12:45 PM, Resident #5 inquired of their right to have food brought in from outside heated up. Resident #5 stated they often had food in a resident refrigerator that they wanted to be heated up. During an interview on 8/30/2024 at 2:45 PM, Administrator #1 stated it was the facility's policy not to heat food brought in from outside for the safety of residents, and staff would not heat up food for residents because it could 'potentially result in burns to the resident.' During an interview on 9/09/2024 at 9:39 AM, a microwave oven was observed on the Red Unit, Unit Managers office. Licensed Practical Nurse #2 stated the microwave was for staff use only and had always been there. During an interview on 9/05/2024 at 11:18 AM, Registered Nurse #1 stated they used to have microwave in their office up to about one year ago; everyone used the microwave to the point where it was 'out of control,' therefore, they had it removed. Registered Nurse #1 stated previously staff would go to a staff lounge in back of building and heat items for residents, but that staff no longer heated up food for residents brought in from the outside per policy. During an interview on 9/05/2024 at 11:18 AM, Social Worker #1 stated there was a resident who had since passed away about 6 months ago, who wanted pizza warmed up, but staff did not have 'the right' to test temperature and warm food properly. Social Worker #1 stated it was the facility's policy that staff were unable to heat food brought in from outside. During an interview on 9/03/2024 at 9:00 AM, Resident #5 stated they often ordered take-out food, and saved the leftover food in refrigerator. They also stated their family member used to bring in food that they would like heated up in the evening. Resident stated they had been in the facility for over [AGE] years and previously had a microwave in their room. After they were readmitted from a hospitalization , they were told they could no longer have a microwave, and were permitted to use the microwave in unit managers office. They further stated that approximately 6 months ago they were told by several staff that they were no longer allowed to heat up food for resident because they could not test the temperature. Resident #5 stated 'that is just not right.' They stated food choices were limited at the facility and they would like to have other meals. During an interview on 9/06/2024 at 11:04 AM, Director of Maintenance #1 stated there had been no work orders to remove microwave ovens. They further stated there were some microwave ovens still in the facility, and there was a microwave in the memory care unit pantry. During an interview on 9/04/2024 at 2:45 PM, Administrator #1 stated they were not aware there was a concern about heating up food. They stated it had always been the facility's policy not to reheat food brought in from the outside. Administrator #1 concluded that Resident #5 had the concern and stated they would discuss concerns with resident. During an interview on 9/06/2024 at 11:30 AM, Resident #5 stated they met with Administrator #1 who stated a designated Certified Nurse Aide would heat food brought in from outside, specifically for them. Resident #5 further stated that if the designated Certified Nurse Aide was not at the facility on any given day, then their outside meals could not be heated. 10 New York Codes, Rules, and Regulations 415.5(b)(1-3)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates; (b.) pre-poured medication cup was noted in medication cart (c.); medication refrigerator temperature was outside of therapeutic range; and (d.) non-medication items were stored in medication cart for 2 (Green and Purple unit medication carts) of 3 medication carts reviewed and 3 (Green, Red, and Purple) of 3 medication storage rooms reviewed. This is evidenced by: The facility's Medication Administration Guidelines, last reviewed 2/2024, Section III. 6, documented each nurse was responsible to date and time all multi-dose vials, and maintain pharmacy standards regarding storage and time between opening and discarding. All scheduled medications would be signed for as administered or not administered. Reason for non-administration was required and would be noted by using the reason code on the electronic medication administration record. The facility's policy titled, Medication Refrigerators Issued 02/08, documented medications requiring refrigeration would be stored in a refrigerator which stored medications only. The temperature would be maintained between 36-46 degrees Fahrenheit. The temperature would be monitored daily by the night shift. The facility's Dispensing and Labeling Drugs and Biologicals from Pharmacy Policy revised 8/19, documented medications must be kept or stored in their originally dispensed containers and transferring between container was forbidden. During an observation on 9/03/2024 at 8:56 AM, the [NAME] Unit medication room refrigerator contained 2 open bottles of purified protein derivative with no open and or expiration dates. In an interview at this time, Licensed Practical Nurse #3 stated when administering purified protein derivative, they would label the open date and verify the expiration date. During an observation on 9/03/2024 at 9:05 AM, [NAME] Unit, Cart #2 was noted to have two pre-poured medication cups: One cup had 1 pill; the other cup had 3 pills. Both cups had no cover but written on the cup was the number 30 space and an illegible notation. In an interview at this time, Licensed Practical Nurse #3 stated when they went to give medication to the resident, they had gone to therapy. They stated they stored the medications cup in cart and would give the medication when resident returned from therapy. During an observation on 9/03/2024 at 9:05 AM, [NAME] Unit, Cart #2 was noted to have two open bottles of Lidocaine solution with no open and or expiration dates: 1 open Glargine insulin pen had no open date; 2 open vials of Lispro insulin, one with illegible open and expiration dates, the second had no open and or expiration date. During an observation on 9/03/2024 at 9:58 AM, the Red Unit Medication Room refrigerator temperature was noted to be 60 degrees Fahrenheit. During an observation on 9/03/2024 at 10:54 AM, Purple Unit, Cart #2, bottom overflow drawer contained multiple non-medication items including non-skid socks, an open tube of toothpaste with no name or label, an open jar of Eucerin cream with no name or label or open date, and yellow personal protective equipment gowns. During an observation on 9/03/2024 at 10:59 AM, Purple Unit Medication Room refrigerator contained one open bottle of purified protein derivative with no open and or expiration date; one open vial of Lispro insulin with no open or expiration date. During an interview on 9/04/2024 12:28 PM, Director of Nursing #1 stated nursing staff attend mandatory orientation in person that included medication administration, and agency nursing staff were given a binder to review prior to hire. They further stated that there was a medication assessment test that was given prior to nurse passing medication for all nursing staff. Director of Nursing #1 stated it was the responsibility of each nurse to ensure their cart was clean and medications were labeled appropriately. During an interview on 9/05/2024 10:41 AM, Nurse Educator #1 stated all nursing staff attended general orientation including medication administration. They further stated agency staff were provided a binder with all nursing competencies and were complete an exam upon completion. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observations and staff interviews during the recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, the staff did not put on and take off personal protective equipment correctly when entering and exiting the room of a COVID-19 positive resident. This was evident for 1 of 5 resident units observed. This is evidenced by: The Centers for Disease Control document titled Sequence for Putting on Personal Protective equipment (PPE) stated the correct sequence for putting on personal protective equipment was gown, mask or respirator, goggles, or face shield, then gloves. The document stated the correct sequence for removing personal protective equipment was gloves, goggles or face shield, gown, and then mask or respirator. (https://www.cdc.gov/infection-control/media/pdfs/Toolkits-PPE-Sequence-P.pdf) During an observation on 8/30/2024 at 11:08 AM in from room [ROOM NUMBER], Licensed Practical Nurse #4 put on personal protective equipment for droplet precautions in the following order: N95 mask, gown, face shield and then gloves. Licensed Practical Nurse #4 was observed removing their personal protective equipment in the following order: face shield, gown, gloves and N95 mask. Licensed Practical Nurse #4 was observed bringing in a piece of medical equipment into the room, removing it from the room, and placing it in the hall; the equipment was not cleaned. During an interview on 9/05/2024 at 9:36 AM, Certified Nurse Aide #1 stated the facility always provided enough personal protective equipment for the staff. They stated the following order for putting on personal protective equipment: sanitize hands, gloves, gown, mask, then face shield. They stated the following order for taking off personal protective equipment: gown, first set of gloves, face shield, mask, second set of gloves, then wash hands. During an interview on 9/05/2024 at 9:43 AM, Certified Nurse Aide #2 stated they would put on personal protective equipment in the following order: N95 mask, face shield, gown, then gloves. They would take off personal protective equipment in the following order: gown, face shield, N95 mask, gloves then wash hands. During an interview on 9/05/2024 at 9:49 AM, Licensed Practical Nurse #2 stated they would put on personal protective equipment in the following order: gown, N95 mask, face shield, then gloves. They would take off personal protective equipment in the following order: gown, gloves, shield, mask, and then wash hands. They stated that a COVID-19 positive resident with droplet precautions would have their own blood pressure cuff and thermometer if possible. The sphygmomanometer (medical device that measures blood pressure) would be non-dedicated medical equipment and would need to be wiped down with wipes between uses. They stated they received training on infection control upon hire and yearly, more often if policies or guidance changed. During an interview on 9/05/2024 at 9:58 AM, Infection Preventionist #1 stated staff training on infection control was given on hire and if there was an outbreak. There was also annual training done. They stated there were signs posted for putting on and taking off personal protective equipment posted in the bathrooms. They stated COVID-19 residents should have their own blood pressure cuff and thermometer. During an interview on 9/05/2024 at 10:41 AM, Nurse Educator #1 stated employees were given training on hire and annually upon anniversary date. The training was offered through an on-line program or on a paper version of the on-line program. They stated staff were trained on putting on and taking off personal protective equipment as part of the infection control training. They stated agency staff received the same training including the infection control trainings. They stated that any medical equipment would have to be sanitized between residents. During an interview on 9/05/2024 at 10:56 AM, Licensed Practical Nurse #5 stated that there were 3 sphygmomanometers, on the unit, each hallway had its own tower. The tower observed on 8/30/2024 was used for all residents. New York Code of Rules and Regulation 415.19(a)(1-3)

Based on record review and interviews during an abbreviated survey (Case #NY00260768), the facility did not ensure that each resident was treated with respect and dignity for 1 (Resident #4) of 4 residents reviewed. Specifically, the facility did not ensure Resident #4 was treated with respect and dignity on 7/17/2020, when the resident had wandered onto the Blue unit and was escorted inappropriately by the Licensed Practical Nurse (LPN) #3 back to the Gold unit. LPN #3 forcefully grabbed the resident from behind and dragged them towards the Gold unit. This is evidenced by: Refer to F684 Resident #4: Resident #4 was admitted to the facility with diagnoses of dementia with behavioral disturbance, recurrent major depressive disorder, and unsteadiness on feet. The MDS dated [DATE], documented the resident had severe cognitive impairment. The Policy and Procedure (P&P) titled Resident Care Policy #250: Resident Dignity issued 2/2020, documented each resident would be cared for in a manner that promoted and enhanced their well-being, level of satisfaction with life, feeling of self-worth and self-esteem. It documented residents were to be treated with respect and dignity at all times. Demeaning practices and standards of care that compromise dignity was prohibited. It documented staff were expected to treat cognitively impaired residents with dignity and sensitivity. The Comprehensive Care Plan (CCP) for resident was an Elopement Risk/Wanderer as evidenced by the ability to mobilize independently, confusion, diagnosis of dementia with behavioral disturbances, anxiety, and impaired safety awareness, last revised 8/28/2023, documented the resident roamed between the Blue and the Gold units and was in constant motion. The CCP interventions documented to redirect the resident when wandering or upset and to encourage the resident to stay out of other resident rooms and bathrooms. The facility Investigation dated 7/17/2020, documented it was reported that at approximately 3:15 PM on 7/17/2020, Licensed Practical Nurse (LPN) #3 was inappropriately handling Resident #4. Per the eyewitness, LPN #3 forcefully grabbed the resident from behind and dragged them towards the Gold unit. Upon arriving at the Gold unit, a different eyewitness claimed LPN #3 was forceful with Resident #4 when they sat the resident into a chair. LPN #3 denied being forceful or aggressive and stated they were trying to avoid being hit by the baby doll the resident was swinging. It documented some of the event was viewable by camera. The Statement Regarding Incident dated 7/17/2020, and written by LPN #3, documented they escorted Resident #4 back to the Gold unit after observing the resident with someone's property. The resident attempted to go down another hallway and LPN #3 redirected the resident to their unit. LPN #3 documented they were not forceful or aggressive and what they were doing was evading the baby doll's head that the resident was swinging. The Statement Regarding Incident dated 7/17/2020, and written by the Caseworker (CW) #1, documented they observed the LPN yell and grab Resident #4 after the resident had walked behind the secretarial desk and grabbed an employee's drink. The LPN then grabbed Resident #4 from behind, around their waist and took the drink out of their hand. Resident #4 then continued to walk down First hall and the LPN again forcefully grabbed the resident from behind and dragged them towards the Gold unit. Resident #4 appeared frightened as shown by facial expressions. It documented demeanor was overall very forceful. The Statement Regarding Incident dated 7/17/2020, and written by LPN #4, documented they observed the nurse from Blue unit forcefully pushing Resident #4 towards the Gold unit and into the TV room, and then forced the resident to sit down. The nurse from the Blue unit stated the resident was stealing people's food. It documented the resident was very upset, swearing, and throwing things. The Statement Regarding Incident dated 7/17/2020, and written by LPN #5, documented they witnessed a staff member forcefully shove Resident #4 into the TV lounge and into a chair. The staff member stated the resident was eating someone's food. LPN #5 documented they calmed the resident down with cookies and a hug. The incident was reported to the nurse manager and Social Worker. Review of video footage labeled BLUE NURSE STATION_July172020_1516 showed the following on 7/17/2020 at 3:16:07 PM: -LPN #3 was behind Resident #4 and had their hands on either side of the resident close to their underarms and was walking the resident forward in a quick manner through the corridor, towards the Gold unit. The resident's facial expressions were not visualized. Resident #4 was holding a doll but was not seen swinging it. Review of video footage labeled GOLD NURSE STATION_July17202_1516 showed the following on 7/17/2020: -At 3:16:28 PM, LPN #3 was behind Resident #4 and had their hands on either side of the resident close to their underarms and was walking the resident forward in a quick manner onto the Gold unit. -At 3:16:35 PM, Resident #4 had the doll in their left hand and swung their left arm back toward LPN #3. -At 3:16:37 PM, LPN #3 was still behind Resident #4 as they both entered an area off the corridor. There was no additional video footage. During an interview on 8/24/2023 at 9:32 AM, the Administrator (ADMIN) stated LPN #3 had inappropriately redirected the resident. The ADMIN stated the resident fell and LPN #3 picked them up and continued to walk them towards their unit. The ADMIN stated there was no injury to the resident. The ADMIN stated LPN #3 was terminated and was reported to the NYS Office of the Professions. During an interview on 9/29/2023 at 11:53 AM, the Caseworker (CW) #1 stated they recalled the incident with Resident #4 and the LPN. When asked, CW #1 confirmed it was LPN #3. CW #1 stated they saw Resident #4 with a drink in their hand and then LPN #3 took it away from the resident. CW #1 stated LPN #3's demeanor was forceful as they walked Resident #4 in the hallway between the Blue and Gold units. CW #1 stated Resident #4 was able to ambulate independently without an assistance device. CW #1 stated Resident #4 could become combative at times but was generally lovely and very confused. During an interview on 9/29/2023 at 1:21 PM, LPN #4 stated Resident #4 resided on the Gold unit, would wander to the Blue unit and would go about picking up things. LPN #4 stated it was completely unnecessary for LPN #3 to act the way they saw them act. LPN #4 stated LPN #3 should have been walking beside the resident and guiding them to where they needed to be. LPN #4 stated Resident #4 wandered daily and was not aware of the things that did not belong to them. Resident #4 was for the most part, a pleasant resident. During an interview on 9/29/2023 at 1:41 PM, Registered Nurse Manager (RNM) #2 stated that after reviewing the video, LPN #3 was a little more forceful than they needed to be when they escorted the resident back to their unit. RNM #2 stated Blue and Gold was one big circle and the resident was bound to go from one side to the other. RNM #2 stated the resident was independent with ambulation but needed supervision. RNM #2 stated that Resident #4 would cry often, and they could be consoled one minute and the next, the resident would punch you. During an interview on 9/29/2023 at 2:00 PM, LPN #5 stated LPN #3 was pushing Resident #4 forward and Resident #4 was trying not to move forward. LPN #5 stated the resident was upset and they reported it right away. LPN #3 was contacted but was not available for interview. 10 NYCRR 415.5(a)

Based on record review and interviews during an abbreviated survey (Case #s NY00310437 and NY00260768), the facility did not ensure each resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan (CCP) for 2 (Resident #s 2 and 4) of 4 residents reviewed. Specifically, Resident #2 was assessed upon admission with having 3 surgical wounds and a total of 8 staples, following repair of a left hip fracture (a break that occurs in the upper part of the thigh bone). The CCP did not document the location, number of surgical wounds, and the number of staples in the wounds. The facility did not ensure all staples were removed on 12/23/2022, as ordered by the Orthopedic provider. On 1/9/2023, the resident was discharged to another facility. The receiving facility assessed the resident with having 4 staples in their left hip. For Resident #4, the resident fell on the floor while being escorted by the Licensed Practical Nurse (LPN) #3 on 7/17/2020 at 3:16 PM. The facility did not ensure an immediate assessment of the resident prior to moving the resident off the floor. This is evidenced by: Refer to F550 Resident #2: Resident #2 was admitted to the facility with diagnoses of displaced subtrochanteric fracture of left femur (left hip fracture) subsequent encounter for closed fracture with routine healing, dementia, and history of falling. The Minimum Data Set (MDS - an assessment tool) dated 12/15/2022, documented the resident's cognitive skills for daily decision making were severely impaired. The Policy and Procedure (P&P) titled Resident Care: Comprehensive Care Plan: Person-Centered Comprehensive Care Planning Process revised 2/21, documented the facility must develop a comprehensive person-centered care plan for each resident. The care plan was based on the nursing/clinical assessments, including the MDS, triggered Care Assessment Areas (CAAs), and the facility's rationale for deciding whether to proceed with care planning. It documented the care plan must reflect the resident's needs, strengths, goals, and preferences identified in the comprehensive assessments. Review of Hospital records dated 12/5/2022, documented the resident was admitted following an unwitnessed fall and sustained a left hip fracture. The fracture was surgically repaired on 12/5/2022, and there were 3 wounds incisions. One wound incision was on the left hip and two wound incisions were on the upper left leg. The Hospitalist Discharge Summary dated 12/9/2022, documented the resident had surgical intervention for left hip fracture on 12/5/2022, and was to follow up with Orthopedics in 2-3 weeks for staple removal. The number of staples was not documented. The Nurse's Progress Note dated 12/9/2022 at 4:15 PM and written by Registered Nurse Manager (RNM) #1, documented the resident was admitted following left hip fracture repair. It documented there were two smaller incisions that measured 1.5 cm each with 2 staples each and a slightly larger incision that measured 4 cm and had 4 staples. The CCP for Potential for Wound Infection at Surgical Site, last revised 1/12/2023, documented a CCP intervention for treatment as ordered by the MD (physician). did not document the location and number of surgical wounds and the number of staples in the wounds. The Wound Tracking Tool dated 12/9/2022, documented three surgical incisions located on the left hip that originated 12/5/2022. It did not document staples were present. The Orthopedic Provider Orders dated 12/22/2022, documented nursing may remove staples. It was handwritten on the document by RNM #1 that the staples were removed on 12/23/2022. The Medication Administration Record (MAR) dated 12/23/2022, documented an order to remove staples from left hip surgical site. It was signed as being done by the Licensed Practical Nurse (LPN) #2. The Nurse's Progress Note dated 12/23/2022 at 9:39 AM, and written by RNM #1, documented a call was placed to Orthopedics regarding staple removal. A verbal order was given for nursing to remove the staples and there was no need for the resident to follow up unless needed. It documented the staples were removed this AM without issue and steri-strips were in place. There were no signs and symptoms of infection or dehiscence (opening of a wound). The number of staples removed was not documented. The Discharge Summary Note dated 1/6/2023 for discharge date [DATE], written by NP #5, documented the following skin examination: left hip bruising improved, left hip incision healing well. The Nurse's Progress Note dated 1/9/2023 at 10:00 AM, documented the resident was transferred to transportation's wheelchair and their belongings and paperwork were given to the driver. The Nursing Progress Note dated 1/9/2023 at 2:12 PM, documented the resident was admitted from named facility today. It documented the resident was noted to have 4 staples still present in the left hip. The Medical Progress Note dated 1/10/2023 at 8:41 AM by the Nurse Practitioner (NP) #4, documented the resident had the majority of their staples removed from the left hip. There were 4 remaining. Orthopedics was contacted to ask if they may be removed. The Medical Progress Note dated 1/10/2023 at 9:00 AM, and written by NP #4, documented that after calling Orthopedics to discuss the four remaining staples, they received a voicemail from the nurse stating the named sending facility was given an order to remove the staples. Permission was received to remove the remaining staples. The Medical Progress Note dated 1/12/2023 at 11:09 AM, and written by the physician (MD) #3, documented staples were removed and there was one staple remaining that was difficult to remove. It documented they would try again in the AM. The Medical Progress Note dated 1/13/2023 at 9:33 AM, and written by MD #3, documented a staple x1 was finally removed yesterday and there was no evidence of any infection. During an interview on 8/23/2023 at 11:31 AM, RNM #1 stated the resident had three incisions. It was noted at the time of admission that there were four staples in the larger one and two staples each in the smaller ones. RNM #1 stated they wrote a pretty thorough note when they removed the staples and there was no sign of infection. RNM #1 stated they believed they removed all staples and stated their only other thought was the staples that were missed were somehow buried and could not be visualized. During an interview on 8/23/2023 at 3:56 PM, the Assistant Director of Nursing (ADON) stated they were currently responsible for wound care/tracking but not when the resident was in the facility. The ADON stated the Wound Tracking form dated 12/9/2022, just showed the incisions, not the staples. ADON stated the Orthopedic provider dictated when the staples were to be removed and stated the Registered Nurse (RN) called and got the order. The ADON stated an RN was responsible for removing the staples and could not explain why it was signed off by LPN #2. During a subsequent interview on 9/29/2023 at 9:00 AM, RNM #1 stated the nurse managers were responsible for developing and revising the CCP. RNM #1 stated when they have a resident come in with staples in an incision, they generally would have an order to remove them. RNM #1 stated they did not know they were going to have remove Resident #2's staples because the Health Care Proxy (HCP) was supposed to take the resident to the Orthopedic appointment. RNM #1 stated the facility ended up calling the Orthopedic provider because the HCP did not bring the resident and was given an order to remove the staples. RNM #1 stated a CCP should be completed for whatever diagnoses the resident had. RNM #1 was asked about the facility's system for ensuring all staples would be removed, RNM #1 stated they would not have documented the number of staples the resident was admitted with on the CCP because they were supposed to be going out to the Orthopedic provider to have them removed. RNM #1 stated they did not review the resident's admission note prior to removing the staples and stated they thought they removed all the staples. During an interview on 9/29/2023 at 10:32 AM, the Director of Nursing (DON) was asked about the facility's process for ensuring all staples would be removed, the DON stated the number of staples was documented in the admission note by the RN who removed the staples. The DON stated there was an order to remove the staples and that was what RNM #1 did. The DON stated that as far as they were concerned, all staples were removed. The DON stated that although the location and number of incisions, along with the number of staples was not documented on the CCP, it was documented in other places in the medical record. The DON stated the Nurse Practitioner (NP) #5 also assessed the wound before the resident was discharged and did not see the staples. During an interview on 9/29/2023 at 2:15 PM, LPN #2 stated they signed off on the staple removal by mistake, got called away, and forgot to write a note. LPN #2 stated they did not remove the staples and stated RNM #1 removed them. During an interview on 10/2/2023 at 3:42 PM, NP #5 stated they would have written the Discharge Summary based on their observations of the resident. NP #5 stated if there were staples in place, the incision could be healing still. NP #5 stated there tended to be 3 incisions for the type of surgery the resident had and would have been located on the upper thigh close to the hip. NP #5 stated the resident fell and fractured their hip and had significant bruising on their hip. NP #5 stated a lot of the nurses would refer to the admission note for questions concerning wounds because that is where the notes about the condition of the skin were documented. NP #5 stated the nurses could also refer to the hospital records which would have the operative notes. NP #5 stated that if it was not scanned in the electronic medical record (EMR) it might be in the hard chart. NP #5 stated it would be very unlikely that the incisions would heal and cause the staples to no longer be visible. Resident #4: Resident #4 was admitted to the facility with diagnoses of dementia with behavioral disturbance, recurrent major depressive disorder, and unsteadiness on feet. The MDS dated [DATE], documented the resident had severe cognitive impairment. The P&P titled Resident Care Policy #24; Incident and Accident Reporting and Follow-Up revised 3/19, documented a fall was defined as an unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). It documented a nursing assessment would be completed for all incidents, by the RN (Registered Nurse) Supervisor/RN Charge Nurse/RN On-Call. A RN assessment was required for all observed and unobserved falls prior to the resident being moved. The CCP for resident was an Elopement Risk/Wanderer as evidenced by the ability to mobilize independently, confusion, diagnosis of dementia with behavioral disturbances, anxiety, and impaired safety awareness, last revised 8/28/2023, documented the resident roamed between the Blue and the Gold units and was in constant motion. The CCP interventions documented to redirect the resident when wandering or upset and to encourage the resident to stay out of other residents' rooms and bathrooms. The CCP for At High Risk for Falls related to confusion, incontinence, poor balance, poor communication/comprehension, and psychoactive drug use, last revised 8/28/2023, documented the resident was at risk for falls and fracture. The Incident/Accident Form dated 7/17/2020 at 3:20 PM, documented an incident in the Blue unit hallway. Resident #4 was being brought by staff from the Blue to the Gold unit. Resident #4 lost their footing and fell without injury. The facility Investigation dated 7/17/2020, documented it was reported that at approximately 3:15 PM on 7/17/2020, LPN #3 was inappropriately handling Resident #4. It documented that per the eyewitness, while walking with LPN #3, the resident fell , and LPN #3 got the resident back up and continued to assist the resident to the Gold unit. It documented some of the event was viewable by camera and review of the video tape revealed the resident did fall and LPN #3 picked the resident up and continued to guide them to the Gold unit. The Statement Regarding Incident dated 7/17/2020, and written by LPN #3, documented they escorted Resident #4 back to the Gold unit after observing the resident with someone's property. LPN #3 documented the resident did not fall and that the resident sat down on LPN #3's feet and LPN #3 held them from falling and raised them to walk back to their unit. The Statement Regarding Incident dated 7/17/2020, and written by the Caseworker (CW) #1, documented they observed Resident #4 fall while the LPN was pushing the resident towards the unit. Review of video footage labeled BLUE NURSE STATION_July172020_1516 showed the following on 7/17/2020 at 3:16 PM: -LPN #3 was behind Resident #4 and had their hands on either side of the resident close to their underarms and was walking the resident forward in a quick manner through the corridor. Resident #4's feet were then seen sliding to the right of them as they fell to the floor in front of LPN #3. LPN #3 then stood the resident up and continued to walk behind the resident through the corridor. The fall was observed by other staff and residents. -There was no assessment of the resident prior to moving the resident off the floor. The RN Fall Note dated 7/17/2020 at 4:34 PM and written by the former Registered Nurse Manager (RNM) #2, documented the resident was being escorted from the third hall on the Blue unit, back to the Gold unit and fell on to their buttock and was leaning to the left. The resident was lifted off the floor by the nurse who was escorting the resident back to the Gold unit. During an interview on 8/24/2023 at 9:32 AM, the Administrator (ADMIN) stated LPN #3 had inappropriately redirected the resident. The ADMIN stated the resident fell and LPN #3 picked them up and continued to walk them towards their unit. The ADMIN stated there was no injury to the resident. The ADMIN stated LPN #3 was terminated and was reported to the NYS Office of the Professions. During an interview on 9/29/2023 at 11:53 AM, the Caseworker (CW) #1 stated they recalled the incident with Resident #4 and the LPN. When asked, CW #1 confirmed it was LPN #3. CW #1 stated they saw Resident #4 fall to the floor as they were being walked by LPN #3 in the hallway towards the Gold unit. CW #1 stated they saw LPN #3 stand the resident up and continue to walk towards the Gold unit. CW #1 stated they went over to the Gold unit to make sure the resident was okay and was received by staff from the Gold unit. During an interview on 9/29/2023 at 1:21 PM, LPN #4 stated if a resident were to fall, they were to be left in the position they were in, and staff were to get help. LPN #4 stated they were not to move the resident in case there was an injury they did not know about. During an interview on 9/29/2023 at 1:41 PM, RNM #2 stated they did not recall the LPN or a Certified Nurse Aide (CNA) telling them about Resident #4 falling. RNM #2 stated another staff member told them about the fall and stated they watched the video because no report was given by the LPN. RNM #2 stated if a resident falls, they needed to be left where they were so that the RN could do an assessment for possible injury. RNM #2 stated Resident #4 needed to be assessed before they were moved. RNM #2 did not recall any injuries. During an interview on 9/29/2023 at 2:00 PM, LPN #5 stated if a resident falls, they were to leave the resident where they were and were to call the supervisor immediately, before moving the resident off the floor. LPN #5 stated the RN needed to assess the resident's range of motion (ROM) before they were moved. 10 NYCRR 415.12

Based on record review and staff interview during the recertification survey, the facility did not ensure the policy regarding foods brought to residents is in accordance with adopted regulations. Specifically, the policy does not include a procedure to ensure all residents have the necessary assistance in accessing and consuming food brought to them by visitors. This is evidenced is as follows. Record review of the facility policy for food brought in by visitors was reviewed on 10/12/2021. This policy did not include a procedure to assist residents that are unable on their own to access and consume food brought to them by visitors. The Director of Nursing stated in an interview on 10/13/2021 at 1:05 PM, that the policy for food brought to residents does not include guidelines on how staff dependent residents will access and consume food brought to them. The Administrator stated in an interview on 10/13/2021 at 3:05 PM, that the facility will update the policy for food brought to residents to include a provision for residents that are dependant on staff to access the food brought in by visitors

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was not clean and the area around the compactor was not maintained. This is evidenced as follows. The trash compactor was inspected on 10/12/2021 at 9:30 AM, revealing that the trash compactor, the area under the trash compactor, the walls in the trash compactor access room, and the trash compactor access portal were heavily soiled with a black build-up. The Director of Building Services stated in an interview on 10/01/2020 at 2:45 PM, that the facility will develop a regular cleaning schedule for the trash compactor with the Director of Dining Services. The Administrator stated in an interview on 10/13/2021 at 2:55 PM, that the facility will clean the trash compacter, the area under the trash compactor, the access portal, and walls in the access room. 10 NYCRR 415.14(h)

Based on observation, record review and interview during a recertification survey on 10/12/2021, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (Resident #'s 45 and 55) of 33 residents reviewed. Specifically: For Resident #45, the facility did not ensure that an assessment was made following the loss of the resident's lower denture, regarding whether the resident was able to eat and maintain adequate nutrition, whether the resident needed a dietary alteration in the consistency of their diet to accommodate the loss of the denture and did not identify or address the decrease in the percentages of meals eaten and the progressive weight loss (31.2 pounds) from the time period the resident's lower denture was missing on 8/6/2021 through 9/15/2021; Also, the facility did not ensure the residents weights were taken and monitored after 9/14/2021 and after additional supplements were ordered on 9/28/2021 and 10/4/2021; for Resident #55, the facility did not ensure that the reason for the residents weight gain was accurately and comprehensively assessed and addressed to determine whether the residents weight gain was related to appetite and/or [CONDITION(S)] and did not ensure treatment measures were implemented to reduce the [CONDITION(S)] in the resident's lower extremities and the resident's risk of fluid volume overload. This was evidenced by: Resident #45: Refer to F Tag 790 Dental Services Resident #45 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 8/5/2021, documented the resident's cognition was intact, was able to make self understood and able to understand others. The resident had pressure ulcers on their bottom and heels. The facility Policy & Procedure (P&P) titled Dental Services dated 1/2021, documented that it is the policy of the Nursing Center to ensure that residents receive proper dental care in accordance with Department of Health regulations. The Center will refer residents with lost or damaged dentures for dental services. If the referral does not occur within three days, the facility will maintain adequate nutrition and hydration and provide documentation for the reason why this did not occur. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Regular diet, Regular texture, thin consistency. The Comprehensive Care Plan (CCP) titled Resident has a potential for oral/dental health problems related to decline in functional mobility dated 7/30/2021, did not include further updates to include or address the loss of the lower dentures. The Comprehensive Care Plan (CCP) dated 8/2/2021 titled Resident is at nutritional risk related to altered skin integrity, pain. The CCP was updated with Supplements to the resident's diet dated: 8/11/2021 Mighty Shake, 8/12/2021 Pro Source, 8/26/2021 Super Cereal, 9/28/2021 Juven, 10/4/2021 Hi Cal. A review of Resident #45's weights from 7/31/2021 through 9/14/2021 documented the following: 07/31/2021=200 lbs; 08/01/2021=201 lbs; 08/02/2021=198.6 lbs; 08/06/2021=193.4 lbs; 08/20/2021=179.2 lbs; 09/14/2021=168.8 lbs. There were no other weights documented. The weekly Nutrition Wound Notes documented the average percentage of all the meal intakes from 7/31/2021 through 9/14/2021 documented the following: 08/05/21-75% average; 08/13/21-51% average; 08/26/21-39% average; 09/03/21-47% average; 09/13/21-35% average; Additionally, the resident's percentage of meal intakes documented a further decline from 9/17/2021 through 9/28/2021 as follows: 9/17/21-35% average; 9/28/21-24% average; 10/7/21-38% average. The Social Work (SW) Progress Note dated 8/9/2021, documented the following; Resident #45 was missing their lower dentures. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident continues to have pressure ulcers to bottom and heels. Weight 193 lbs. Continue with [MEDICATION(S)], weight has improved. A Nursing Progress Note dated 9/29/2021, written by LPN #4, documented; Resident continues with very poor intake despite much encouragement and many alternatives offered. Resident needing much encouragement to drink Juven (dietary supplement) and HiCal (dietary supplement) to assist with wound healing with fair effect. The resident record did not include documentation regarding whether or not the resident drank each supplement. A Nursing Progress Note dated 10/1/2021, written by Licensed Practical Nurse (LPN) #4, documented; Resident continues with poor solid intake despite much encouragement and alternatives offered. A review of Nursing Progress Notes dated from 7/30/2021 thru 10/15/2021, did not include documentation that the facility had assessed whether the resident was able to eat without their lower denture, whether the resident needed a dietary alteration in the consistency of their diet to accommodate the loss of denture and did not identify or address the decrease in the percentages of meals eaten and the resident's weight loss. During an interview on 10/15/2021 10:18 AM, Resident #45 stated that the resident had lost a good deal of weight. The resident stated that losing their lower denture made it difficult to eat, they could no longer eat hotdogs and hamburgers and many other things. The resident stated the weight loss was because of not having the lower dentures and stated they told the staff that the resident was not able to eat because the lower denture was missing. During an interview on 10/15/2021 at 1:06 PM, Registered Nurse Manager (RNM) #1 stated they knew Resident #45 had lost their dentures. RNM #1 stated Resident #45 had no problem eating. RNM #1 also stated that the resident was eating, they all knew of the weight loss and they had discussed it. During an interview on 10/15/2021 at 01:58 PM, Registered Dietician (RD) #1 stated when Resident #45 was admitted they had a significant weight loss due to [CONDITION(S)]. The resident was given [MEDICATION(S)] on 8/13/2021, 14 days prior to the large weight loss. Usually the provider would document expected weight loss and when weights are improving. When Resident #45 lost the dentures, they were not evaluated for safe eating. During an interview on 10/18/2021 at 09:57 AM, RD #1 stated they spent a lot of time talking with Resident #45 because her meal intake was less. The daughter would bring food in, Resident #45 never expressed problems with chewing. RD #1 never knew Resident #45 was missing dentures. RD #1 stated if they had known of the missing dentures they would have asked for a speech evaluation. During the Wound and Weight loss meetings every Thursday the residents with wounds and nutrition issues would be discussed, and there was no mention of dentures. Resident #45 was already on supplements for the wounds, the HiCal was for the weight and the power potatoes and super cereal was to improve intakes. The Prosource and Juven was for the wounds. During an interview on 10/18/2021 at 10:08 AM, with the Director of Social Work (DSW) and Social Worker (SW) both present, the DSW stated the dentures were last seen on 8/6/21 and it was reported on the 9th. The Missing Item Report was initiated, and was sent out to nursing, RD, Administrator, Director of Nursing, and Housekeeping. During an interview on 10/18/2021 at 10:08 AM, SW #1 stated they did not know Resident #45 was losing weight. SW #1 had been aware of meal intake decrease, and did not know anything about her needing to be evaluated for eating without the denture. During an interview on 10/18/2021 at 10:30 AM, RNM #1 stated when Resident #45 lost their dentures, the OT and RNM #1 would assess the resident and did not think Speech therapy was needed because they did not think it was an issue. RNM #1 was aware of the decreased meal intake and the resident did not have a problem eating. During an interview on 10/18/21 at 10:56 AM, the Assistant Director of Nursing (ADON) stated they remembered talking about Resident #45 a few times and discussed the weight loss and being diuresed, they thought that was what the weight loss was related to. When the dentures were lost the resident should have had a Speech Therapy evaluation. Resident #55: Resident #55 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 8/13/21, documented the resident was without cognitive impairment. The Minimum Data Set (MDS-an assessment tool) documented the resident had a weight gain of five percent or more in the last month or a gain of ten percent or more in the last six months and the resident was not on a physician-prescribed weight-gain regimen program. The Policy and Procedure (P&P) Nutrition and Weight Management revised 8/2021, documented the dietician will complete a quarterly nutrition review, the dietician would determine nutritional and weight goals for the resident. The P&P, Hydration and Nutrition Policy revised 8/2021, documented the purpose of the policy was to initiate appropriate interventions to recent dehydration and fluid overload, to provide learning opportunities to staff, residents and resident representatives. A resident at risk for central or peripheral [CONDITION(S)] (fluid overload, heart failure, [CONDITION(S)]) would have interventions based on the severity of presenting symptoms and may include; increased weight monitoring, symptom monitoring, lower extremity compression devices, and elevation of lower extremities. During an observations on 10/12/2021 at 11:00 AM, 10/13/2021 at 1:16 PM, 10/14/2021 at 9:33 AM, 10/15/2021 at 9:41 AM and 10/15/2021 at 1:55 PM, the resident was out of bed in their wheelchair with their feet on the floor. The resident had orthopedic shoes strapped on with Velcro straps in place. A CCP for Alteration in Cardiac status updated 10/20/2020, documented an intervention to evaluate for fluid overload by assessing the presence of dependent [CONDITION(S)], weight gain or decreased urinary output, to provide diet recommended by the dietician and ordered by MD (Medical Doctor) and reinforce dietary restrictions. A CCP for Circulatory Insufficiency related to CHF dated 8/2/2021, documented to check for proper fit of shoes, evaluate for possible need of further lower leg protection: TEDS, Stockinet, Ace wraps or geri-legs. Additionally, it documented an intervention to report increased [CONDITION(S)] to the MD (Medical Doctor). A facility document titled Weights and Vitals Summary dated 10/15/2021, documented the following weights; - 07/29/21 - 237 pounds (lbs.) - 07/30/21 - 242 lbs. - 07/31/21 - 248 lbs. - 08/01/21 - 247 lbs. - 08/06/21 - 238 lbs. - 090/6/21 - 243.6 lbs. - 10/06/21 - 247 lbs. A nursing progress note dated 7/27/2021 documented a physician visit was completed and a new order to increase [MEDICATION(S)] (a medication used to reduce extra fluid in the body ([CONDITION(S)])) to 1 mg by mouth twice daily and complete daily weights. A Physician's (MD) Progress Note dated 7/27/2021, documented the resident was seen for reported increased shortness of breath and increased bilateral lower extremity [CONDITION(S)] reported by the resident and nursing staff. The resident had +1 [CONDITION(S)] (a system used to determine the severity of [CONDITION(S)] on a scale of +1 to +4). A Nursing Progress Note dated 7/30/2021, documented a weight increase and a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility document titled Quarterly Nutrition Review dated 8/17/2021 documented the resident had a weight increase of 6.3% from the previous 90 days and a weight increase of 16.7% and the resident had [CONDITION(S)]. It documented the resident's increase in weight since admission was due to the resident's excellent appetite and due to [CONDITION(S)]. A goal was for the resident to lose one to two pounds per month. Additionally, it documented an intervention to monitor weight weekly for four weeks and then monthly if stable and to evaluate labs for abnormalities and communication with the doctor and nursing. Nursing Progress Notes dated 9/1/2021 through 10/15/201 did not include documentation regarding the resident's weight gain, evaluation of bilateral lower extremity [CONDITION(S)], elevating the resident bilateral lower extremities to decrease [CONDITION(S)], or the resident's refusal of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility document titled Nutrition Wound Progress Note completed by a dietician documented the resident's weight trend over last 30/90/180 days: - On 8/12/2021, 8/20/2021, 8/27/2021 and 9/3/201 as the resident's current body weight (CBW) of 238 pounds. - On 9/17/2021, 10/1/2021 and 10/8/2021 as the resident's CBW of 243.6 pounds. - On 10/15/21 as the resident's CBW of 247 pounds. A Physician's Progress Note dated 9/16/2021, documented the resident had [CONDITION(S)] to their bilateral lower extremity [CONDITION(S)] and the plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A dietician's progress note dated 9/17/2021 documented the resident did not require interventions for weight loss or weight gain and had an increase in weight related to the resident's excellent appetite. During an interview on 10/12/2021 at 11:00 AM, Resident #55 stated they did not have a way to elevate their legs when out of bed. The resident stated compression stockings or a device to decrease [CONDITION(S)] was not offered to them for [CONDITION(S)]. The resident stated shoes did not fit their feet secondary to the swelling and therefore the Velcro shoes were needed to allow them to ambulate. During an interview on 10/15/2021 at 1:57 PM, Certified Nurse Assistant #3 stated Resident #55 consistently had swelling in their legs. CNA #3 stated Resident #55 did not use compression stockings on the resident, and they did not encourage the resident to elevate their legs if the resident's care plan did not specify to complete those tasks. CNA #3 stated, Resident #55's care plan did not include compression stockings or to encourage them to elevate their legs. During an interview on 10/15/2021 at 2:10 PM, Licensed Practical Nurse (LPN) #3 stated they look at Resident #55's legs when they were assigned to them. LPN #3 stated they would contact the MD if they noticed the resident had increased [CONDITION(S)] to their legs. LPN #3 stated the resident consistently had +1 or +2 [CONDITION(S)] and they would occasionally check the resident's weight. LPN #3 stated they would communicate a change in the resident's condition via verbal report but would not consistently document when the resident presented with [CONDITION(S)]. LPN #3 stated they were unaware of a tool used at the facility to consistently monitor a resident's level of [CONDITION(S)]. During an interview on 10/18/21 at 10:08 AM, Dietician #2 stated the resident had a weight gain over the previous 2 months secondary to a good appetite and lower leg [CONDITION(S)]. Dietician #2 stated if a resident was recommended to have weekly weights by the dietician, then they would be responsible for monitoring for a weight gain, but the routine orders for monthly weight monitoring would be addressed by nursing when a weight gain was noted. The dietician stated they felt the resident's increase in weight between August to October was secondary to [CONDITION(S)] not dietary intake. Dietician #3 stated the resident should have been recommended for a low sodium diet and a diabetic diet and neither have been ordered or offered to the resident as options. Dietician #3 stated when they complete a Nutrition Progress Note, they do not complete a weight trend evaluation from the previous 30/90/180 days as written, and they did not know why they documented the resident's usual body weight instead, and a weight gain of 9 pounds was not identified over the previous two months. During an interview on 10/18/2021 at 11:09 AM, Registered Nurse (RN) #2 stated the facility did not have a system to track and monitor [CONDITION(S)]. RN #2 stated Resident #55 consistently had [CONDITION(S)] +1 or +2 and this would not be documented in the resident's medical record as the regular staff would be able to identify when the resident's [CONDITION(S)] increased. RN #2 stated she was unaware of the resident's current level of [CONDITION(S)] or a recent weight gain. During an interview on 10/18/21 at 11:09 AM Registered Nurse Unit Manager (RNUM) #3 stated they would expect staff to be made aware of the resident's weight gain in two consecutive months, to ensure the interdisciplinary team would discuss possible causes of the resident's weight gain and inform the MD if indicated. Additionally, RNUM #3 stated they would expect staff to consistently monitor and document the resident's [CONDITION(S)] in the medical record. During an interview on 10/18/2021 at 11:23 AM, the Director of Nursing (DON) stated Resident #55 consistently had [CONDITION(S)] in their bilateral lower extremities. The DON stated staff should be monitoring weight gain and [CONDITION(S)] consistently and this should be documented to identify a baseline and changes from baseline. 10NYCRR 415.12

Based on observation, record review and interview the facility did not promptly, within 3 days, refer residents with lost or damaged dentures for dental services. Specifically, for one (Resident #45) of one resident reviewed for dental services, the facility did not ensure a referral to a dentist was made within 3 days when facilty staff noted Resident #45's lower denture was missing. This is evidenced by: Resident #45: Resident #45 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 8/5/2021, documented the resident's cognition was intact, was able to make self understood and able to understand others. The facility policy & procedure (P&P) titled Dental Services dated 1/2021, documented that it is the policy of the facility (partially named) to ensure that residents receive proper dental care in accordance with Department of Health regulations. The facility (partially named) will refer residents with lost or damaged dentures for dental services. The Social Work (SW) Progress Note dated 8/9/2021, documented the following; Resident #45 was missing their lower dentures. Missing item report completed with statements provided by both therapist and recreation as they both helped search the room. Therapy reported they last saw the dentures on 8/6/2021. Email sent out notifying of missing dentures, Daughter aware. Review of the resident's medical record did not include subsequent SW documentation regarding the missing lower dentures. Review of the Nursing Progress Notes dated from 7/30/2021 thru 10/15/2021, did not include documentation that Resident #45 did not have lower dentures or that the resident was offered a dental visit for denture replacement. During an interview on 10/15/2021 10:18 AM, Resident #45, stated that it was difficult to eat without the dentures and that they told staff that the resident was not able to eat because their lower dentures were missing. During an interview on 10/15/2021 at 1:06 PM, Registered Nurse Manager (RNM) #1 stated RNM #1 knew Resident #45 had lost their dentures. RNM #1 stated Resident #45 had no problem eating, that they all knew of the resident's weight loss and they all had discussed it. During an interview on 10/18/21 at 10:08 AM, the Director of Social Work (DSW) stated the dentures were last seen on 8/6/21 and it was reported on the 9th. The Missing Item Report was initiated, complete room search was done by several people; SW, Activities, Nursing. The DSW went to the laundry and searched, they did not turn up. Within 3 days we would contact family. The next step would be for family to go outside to dental because the Resident refused to see dental on admission. Resident #45 was not offered dental again after losing the denture. The Missing Items Report was sent out to nursing, RD, Administrator, Director of Nursing, and Housekeeping. The DSW did not speak to Resident #45 about seeing the dentist to have new dentures made. The daughter was notified. If the resident wanted new dentures after losing them the facility would have helped her to obtain them. 10NYCRR415.17 (a-d)

Based on record review and interviews during an abbreviated survey (Case #NY 193), the facility did not ensure residents were provided with dental services from an outside resource for 1 (Resident #1) of 3 residents reviewed. Specifically, for Resident #1, the facility did not ensure a consult for outside dental services was scheduled. On 2/19/2019, the resident was seen by the facility dentist and recommendations for tooth extractions and dentures were documented. On 8/6/2019, the facility dentist spoke with the health care proxy (HCP) and explained that a referral for outside dental services would be written, needed to be addressed by the business office, and then an appointment would be made. The resident was not seen by the outside dental office until 2/26/2021. This is evidenced by: The Policy and Procedure (P&P) titled Medical Orders: In-House Consultation Processing last revised 2/21, documented the facility was responsible to provide all medically necessary oral and dental services ordered by the in-house dental service than could not be provided in-house and that was not covered by the resident's insurance. Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 4/2/2021, documented the resident had moderately impaired cognition. The Comprehensive Care Plan (CCP) for Potential for Oral/Dental Health Problems (dental root caries) last revised on 3/4/2021, documented dental problems were related to a decline in functional mobility. CCP interventions included dental consult, dental exam within 60 days of admission and annually thereafter, and resident may choose to visit own dentist. The Dental Orders and Progress Notes form dated 2/19/2019 by the facility dentist (DDS #1), documented Resident #1 told DDS #1 that she/he was told all teeth should be removed. DDS #1 explained the resident needed to see an oral surgeon (OS) to evaluate the removal of all upper teeth for new upper denture, and possible removal of lower retained root for new partial lower. DDS #1 recommended not to remove all lower teeth. It was documented to have personnel talk to Resident #1 about his/her wants. DDS #1 documented she/he did not recommend the removal of lower anterior teeth. DDS #1 documented the resident may need to seek care with an OS and/or private dentist and requested medical clearance. The Dental Orders and Progress Notes form dated 4/23/19, documented the resident came into the clinic for prophylaxis ([MEDICATION(S)] - routine preventive care). The medical clearance was reviewed, and [MEDICATION(S)] and scaling were done. The resident inquired about extraction of maxillary (upper) teeth. The Dental Orders and Progress Notes form dated 6/4/2019 by DDS #1, documented she/he spoke with Resident #1's grandson (HCP) about the policy of the facility dentist services and past information from Resident #1. DDS #1 documented the resident's grandson was looking into an outside dental office (named) for necessary treatment. The Dental Orders and Progress Notes form dated 8/6/2019 by DDS #1, documented she/he spoke with the (HCP) and explained to him/her that she/he would write the referral for the resident. The HCP was made aware that everything must go through the business office and then the unit secretary would make the appointment. The Dental Orders and Progress Notes form dated 12/31/2019 by DDS #1, documented the resident was not seen for annual examination because the unit was closed. The Dental Orders and Progress Notes form dated 3/10/2020 by DDS #1, documented the resident was not examined because she/he was in bed per staff. There were no further Dental Orders and Progress Notes. The Nurse's Progress Note dated 2/26/2021 at 9:36 AM, documented the resident was out of the facility with her/his grandson for a dental appointment. The Consultation Request and Report dated 2/26/2021 by the oral surgeon (DDS #2), documented the resident needed maxillary (upper) teeth extractions and complete dentures. The resident also needed 3 mandibular (bottom) teeth extractions, removal of partial denture, and fillings. The Physician Visit/Order Note dated 2/26/2021 at 3:04 PM by the Nurse Practitioner (NP), documented a consultation from an outside dental office. The resident needed teeth extractions, removal of partial denture, and fillings. Appointments were made for 3/12/2021, 3/16/2021 and 3/25/2021. The resident and grandson were aware. The Order Listing Report dated 1/1/2021 through 4/30/2021, documented the resident was to have an outside dental appointment on 3/12/2021 and 3/16/2021 for teeth extraction, and an outside dental appointment on 3/25/2021. The Nurse's Progress Note dated 3/12/2021 at 8:36 AM, documented the resident was out of the facility with her/his grandson for a dental appointment. The Consultation Request and Report dated 3/12/2021 by DDS #2, documented the patient had 8 teeth (#4, 5, 6, 7, 8, 9, 10 and 11) extracted. The Physician Order/Visit Note dated 3/12/2021 at 3:19 PM by the NP, documented 8 teeth (#4, 5, 6, 7, 8, 9, 10 and 11) were extracted. The Nurse's Progress Note dated 3/16/2021 at 1:30 PM, documented the resident was out of the facility with her/his grandson for a dental appointment. The Consultation Request and Report dated 3/16/2021 by DDS #2, documented the resident was seen for extractions. The Consultation Report Note (out of house appointment) dated 3/16/2021 at 4:30 PM, documented the resident had an appointment with DDS #2. The Nurse's Progress Note dated 3/25/2021 at 9:01 AM, documented the resident was out of the facility for a follow-up appointment at the dental office. The Consultation Request and Report dated 3/25/2021 by the DDS #2, documented 3 teeth (#21, 28, and 29) were extracted and bone was removed in the process. The Physician Visit/Order Note dated 3/25/2021 by the NP, documented the resident had a consultation with DDS #2. The resident had 3 teeth (#21, 28, and 29) extracted. The resident and family were aware. The Grievance Report dated 3/10/2021 for a compliant received on 3/4/2021, documented the resident's grandson (HCP) made the facility aware of a complaint regarding the dental care of the resident. His/her concerns arose from a dental consult in August 2019. The consult report stated the resident needed an external referral for a dental procedure outside the scope of the in-house dental service abilities. He stated there had been no follow through by the facility since the consult in August 2019. The Dental Issues Investigation dated March 2021, documented the resident was admitted on [DATE] with dental caries. It was documented: On 2/19/2019, the resident was seen by the dentist. The resident told the dentist that he/she was told all of his/her teeth should be removed. It was explained to the resident that he/she needed to see an oral surgeon for evaluation. The dentist documented the resident may need to seek care with an oral surgeon. On 4/23/2019, the resident saw the dentist and had a regular cleaning and scaling. The resident inquired about his/her upper teeth. On 6/14/19, a note from the dentist documented she/he spoke with the resident's grandson about the policy of the in-house dental service and past information from the resident. On 8/6/2019, a note from the dentist documented she/he spoke with the grandson and explained that she/he would write a referral for the resident. He was made aware that it must first go through the business office and then the unit secretary would make the appointment. Per the Unit Secretary (USEC #1), efforts were made to identify a dental service who would take Medicaid payment. None were identified at the time. All dental services and out of house appointments were suspended starting March 2020 due to the COVID-19 pandemic. The resident did not have dental complaints, dental abscesses, or significant weight loss during the period August 2019 through February 2021. On 2/26/2021, the resident was seen by an outside dentist. The consult note stated the resident needed extractions with complete denture on the top, and some extractions with a partial denture on the bottom. The Grievance Investigation Appeal dated 3/19/2021, documented the investigation disclosed that in August 2019, the facility dentist had suggested the resident receive a further dental consult and that the prospect of having the resident's teeth extracted be considered. The dentist noted she/he could not perform the extractions in-house, and the referral was suggested as each dentist had their own philosophy of treatment in such circumstances as the one presented. It was not disputed that the consult was not scheduled, and that the consult did not occur until recently. An appointment was made at an outside dental office on 2/26/2021. During an interview on 4/15/2021 at 9:33 AM, the Administrator (ADMIN) stated the facility dentist was talking about extracting the Resident #1's teeth in February 2019, after the resident told the dentist he/she needed to have teeth pulled. The unit secretary started calling around for a dentist but could not find one that accepted Medicaid. She said former staff were responsible for ensuring dental services were provided to the resident. ADMIN said it was the perfect storm. She said staff did not follow up as was expected in 2019 and then COVID-19 hit in 2020. She said the facility had a contract with a dentist and additional services would be provided from an outside source if medically necessary. During an interview on 4/15/2021 at 10:19 AM, the Registered Nurse Manager (RNM #1) stated all residents could see the in-house dentist and always had the opportunity to go out to see a dentist. She recently addressed Resident #1's complaints about her/his teeth. She said when the resident first complained, it was about broken teeth. RNM #1 said she put him/her on the list to see the facility dentist. The next time the resident complained it was about pain and that was when RNM #1 started the process of looking for an oral surgeon. She said she instructed the unit secretary (USEC #1) to work on the consult. RNM #1 stated the resident's grandson called and said he made an appointment with an outside dental office (named). There were no dental services in March 2020 due to COVID-19. She said if the resident complained of pain back then, they would have addressed it. She said the resident had a consultation with the oral surgeon on 2/26/2021 and had appointments for extractions in March. She said all the dental work had been completed, except for the dentures. During an interview on 4/15/2021 at 10:25 AM, USEC #1 stated the resident asked to see an outside dentist during the Fall months of 2019. The resident saw the in-house dentist and the grandson asked about getting the resident's teeth pulled because they were hurting his/her mouth. The in-house dentist was not able to do the work. She said she started making calls in 2019, but there no dental offices that would accept Medicaid. She said she reported the dental issue to the former nurse manager. She said the resident never reported tooth pain until recently and said the resident would complain to her/his grandson but not to the facility. She said in March 2020, everything was shut down due to COVID-19. She said there were no complaints from the resident or the grandson in 2020. She said the first she learned about the resident being in pain was in February 2021 and that is when she started looking for an oral surgeon. 10 NYCRR 415.17(a-d)

Based on observation, record review and interviews during an abbreviated survey (Case #NY 351) the facility did not ensure a resident's right to be free from abuse for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, the facility did not ensure Resident #1, who had severe cognitive impairment, was free from abuse by Resident #2 who had mildly impaired cognition. This is evidenced by: The Policy and Procedure (P&P) on Abuse Prohibition and Abuse last reviewed in 6/2020 documented each resident would be free and protected from abuse. Abuse could include verbal, mental, sexual or physical abuse, and that non-consensual sexual contact of any type with a resident, the P&P documented sexual abuse was non-consensual sexual intrusion, touching intimate body parts or the clothing covering intimate body parts. The Investigation Form dated 6/6/20 at 8:00 PM documented Resident #2 had a sexual altercation with Resident #1 in Resident #1's room. Resident #2 was in a wheelchair and seated behind Resident #1 fondling her breasts underneath her night gown. Resident #1 was heard screaming and Certified Nursing Assistant (CNA) #1 separated the two residents. During an interview by the facility, a staff member recalled that on a day shift, Resident #1 was trying to go into Resident #2's room and was redirected. Resident #2 then tried to enter Resident #1's room and needed to be redirected. Resident #1: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had severely impaired cognition, usually made herself understood to others and usually had the ability to understand others. The Comprehensive Care Plan (CCP) dated 2/20/15 documented the resident was at risk for exploitation for sexual aggression due to psychotic medications, decreased mobility, intermittent confusion, progressive dementia, being hard of hearing and language barrier. A Nursing Progress Note dated 6/6/20 at 10:07 PM, written by the Clinical Coordinator-Licensed Practical Nurse (LPN) documented Resident #2 was observed fondling Resident #1's breasts. Resident #1 appeared upset at the time and did not respond when asked what had happened, instead gave a blank look. The police stated that due to both residents having dementia, there was really nothing they would do. A Social Service Altercation Progress Note dated 6/7/20 at 12:23 PM, by the Director of Resident Life (DRL) documented follow up was attempted to discuss the resident to resident incident that occurred the evening before. Resident #1 could not understand because she was hard of hearing and did not speak English. Resident #1's representative (RESREP) was called. Resident #2: Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact. A Nursing Progress Note dated 6/6/20 at 9:12 PM documented Resident #2 was observed in Resident #1's room fondling her breasts. A Social Service Altercation Progress Note dated 6/7/20 at 12:08 PM by the (DRL) documented Resident #2 admitted touching Resident #1's breasts. The Psychologist Progress Note dated 6/11/20 at 6:10 PM, documented the resident was seen for discussion of an incident on 6/6/20. Resident #2 stated he felt embarrassed about what he had done with Resident #1. Resident #2 was assessed as having Major [MEDICAL CONDITION], recurrent episode, mild degree. The treatment goal was for the resident to work to maintain appropriate boundaries between himself and his peers, and refrain from engaging in sexual behaviors with other residents. Interviews: During an interview on 7/10/20 at 2:00 PM the RNUM stated Resident #2 had an extensive psychiatric history and dementia, and had a cognitive decline in the past 2-3 months. During an interview on 7/10/20 at 12:15 PM the Administrator stated Resident #2 went into Resident #1's room. He came up behind her and grabbed her breasts while she was changing her clothes. Resident #1 yelled out and CNA #1 arrived and broke it up. During an interview on 7/14/20 at 2:05 PM, Resident #1's RESREP stated Resident #1 was distraught and shocked when she discussed the incident with her and that if Resident #1 was still able to think clearly Resident #1 would have wanted to press charges against Resident #2. During an interview on 8/20/20 at 2:45 PM the Director of Nursing and the DRL stated Resident #1 and Resident #2 both had the capacity to consent and capacity to make daily decisions. Resident #1 was able to verbalize what she wanted and what she did not want, and screamed when the abuse happened, indicating that was something she did not want. 10 NYCRR 415.4 (b)(1)(i)

Based on observation, record review and interviews during an abbreviated survey (Case #NY 776), the facility did not ensure each resident was free from abuse for 1 (Resident #5) of 5 residents reviewed. Specifically, the facility did not ensure Resident #5, who had severe cognitive impairment, was free from sexual abuse when he was assaulted by Resident #4 who had moderate cognitive impairment. Due to the Resident #5's severe cognitive impairment and his inability to express his feelings, it was determined that actual harm occurred as a result of the assault, using the reasonable person concept referenced in Appendix Q of the State Operations Manual. This is evidenced by: Resident #5: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment tool) documented the resident had severe cognitive impairment, was rarely understood, and could rarely understand others. Resident #4: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had moderate cognitive impairment, could be understood and could understand others. The Policy and Procedure for Abuse revised 1/2017, documented that each resident will be free from abuse. Abuse could include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. Additionally, residents were to be protected from abuse, neglect, and harm while residing at the facility. The Cognitive Comprehensive Care Plan (CCP) dated 12/27/17, documented Resident #5 had impaired thought process and short-term memory impairment. A facility investigation documented that on 5/9/19 at 1:45 PM, a nurse reported that, upon entering the living room the nurse observed Resident #4 touching Resident #5 on the chest area under Resident #5's shirt. Resident #5 was sleeping during incident. Staff immediately intervened and removed Resident #4 from the common area. Upon interview by the Social Worker (SW), Resident #4 recalled the incident and stated he was rubbing Resident #5 for physical effect. Resident #5 did not recall the incident and did not display any signs or symptoms of emotional or physical distress. An Accident and Incident Report dated 7/31/19 at 2:30 PM, documented Resident #4 was self-propelling around the unit. Resident #4 was offered an activity and declined to attend activity. An Activity Aide (AA) went to sign out another resident to go to an activity, and upon turning around saw Resident #4's hand in Resident #5's groin area. Staff immediately intervened and separated the residents. A Nurse's Note dated 7/31/19 at 3:04 PM, written by SW #1, documented Resident #5 was unable to engage in conversation or recall the incident involving Resident #4 due to Resident #5's cognitive impairment. During an interview on 9/18/19, at 3:50 PM, AA #1 stated that on 7/31/19, she observed Resident #4 self-propel next to Resident #5 in a common area, then grabbed Resident #5 in his private area over his pants. AA #1 separated the residents as soon as she noticed. During an interview on 9/19/19 at11:00 am, the DON stated there had been a previous incident between Resident #4 and Resident #5, and as a result, Resident #4 was to be encouraged to spend time in the TV lounge at a specific location. The DON stated Resident #5 had a short attention span and was independently mobile in the wheelchair, and she did not know why Resident #5 was in the common area when the 7/31/19 incident occurred. During an interview on 9/19/19 at 3:50 pm, the Medical Director stated that he was not aware of the 7/31/19 incident between Resident #4 and Resident #5, but that a reasonable person would be upset if another individual was touching their private parts (groin) without permission. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews during an abbreviated survey (Case# NY 637), the facility did not ensure that, based on the comprehensive assessment of a resident, that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 (Resident #1) of 5 residents reviewed. Specifically, the facility did ensure Resident #1 was assessed by a Registered Nurse (RN) prior to being moved after a fall. This is evidenced by: Resident #1: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 7/26/19 documented the resident was severely cognitively impaired, was usually understood and could usually understand others. The Policy and Procedure for Incident and Accident Reporting and Follow-up with a revision date of 2/2019, documented a Registered Nurse (RN) assessment was required for all observed and unobserved falls prior to the resident being moved. An Accident and Incident Report dated 9/7/19 at 10:25 AM, documented Resident #1 was found lying on the floor with two abrasions to her forehead. Licensed Practical Nurse (LPN) # 1 documented the resident was assisted off the floor to a mobile reclining chair (Geri Chair) then transported to her room. A Nurse's Note dated 9/7/19 at 10:25 AM written by LPN #1, documented Resident #1 was observed laying on her left side on the floor with two abrasions to her forehead measuring 1.0 centimeters (cm) x 1.0 cm and 1.0 cm x 0.7 cm. Resident #1 was lifted off the floor by 4 staff members with a sheet and transferred to a Geri Chair, then sheet lifted into the bed. A written statement dated 9/7/19, by LPN #1 documented that Resident #1 was observed laying on the floor, moving around and moaning. The resident was sheet-lifted off the floor by 4 staff members and placed into a Geri Chair. A written statement dated 9/7/19, by LPN #2 documented staff used a sheet to lift Resident #1 off the floor and into a Geri Chair. During an interview on 9/10/19, at 11:57 am, the Director of Nursing (DON) stated the supervisor on duty at the time of the fall was an LPN. An RN assessment of Resident #1 was not completed before being lifted and transferred to a Geri Chair and then transferred to her bed. During an interview on 9/18/19 at 9:20 AM, the DON stated that LPN#1 should have called her before moving the resident. During an interview on 9/18/19 at 1:15PM, LPN #1 stated that Resident #1 had two abrasions to the forehead and was moaning when LPN #1 rolled her to the right. LPN #1 instructed the staff to obtain a sheet to lift Resident #1 off the floor. LPN #1 stated an RN needs to be contacted before a resident is moved after a fall. LPN #1 stated that neither the RN medication nurse in the facility or the RN on call were notified before Resident #1 was moved off the floor. During an interview on 9/18/19 at 2:30 PM, LPN #5 stated it is the responsibility of the LPN supervisor to notify the RN if an assessment of a resident is needed. During an observation and interview on 9/18/19, at 2:53 PM, with the DON present, a security video dated 7/9/19, at 10:25 AM revealed that LPN #1 observed Resident #1 on the floor with other staff present. A bedsheet was obtained and placed under the resident. The resident was lifted by the sheet and 4 staff members to a Geri Chair. The DON stated a resident was not supposed to be moved after a fall until an RN assessment was completed because a resident could be hurt by moving them without knowing if there was an injury present as a result of the fall. The DON also stated that the facility falls policy and procedure documented that an RN assessment was required before moving a resident after a fall. 10 NYCRR 483.35(a)(3)(4)(c)

Based on observations, record review and interview, during a recertification survey the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident consistent with the resident rights set forth that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for four (4) (Residents #'s 29, 92, 145 and #173) of thirty-five (35) residents reviewed. Specifically; for Resident #29 the facility did not ensure that a resident specific Comprehensive Care Plan (CCP) for the care and treatment of [REDACTED].#92, the facility did not ensure a CCP for positioning was implemented, for Resident #145, the facility did not ensure a CCP for the treatment of [REDACTED].#173, the facility did not ensure a resident specific CCP for communication deficit was implemented. This is evidenced by: Resident #29: The resident was admitted on [DATE], with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident had severe cognitive impairment. During an observation on 5/20/19 at 2:41 PM, the resident had a thick layer of white dry skin noted on the top of her head/ scalp ending on her forehead and multiple dry skin areas on her arms, legs and upper chest area. During an observation on 5/21/19 at 2:49 PM, 5/23/19 at 8:59 AM and 5/24/19 at 12:05 PM, the resident had a thick layer of white dry skin on the top of her head/ scalp ending on her forehead. During an interview on 5/24/19 at 12:49 PM, Certified Nursing Assistant (CNA) #3 stated Resident #29 has a rash all over her body and her skin peels a lot. CNA #3 stated that the CNA staff do not provide specific care to the resident's skin or scalp. A CCP for At Risk for Alteration in Skin Integrity last updated 08/01/18, did not include resident specific interventions for the care and treatment of [REDACTED]. During an interview on 5/24/19 at 1:42 PM, Licensed Practical Nurse Unit Manager (LPNUM) #3 stated the resident had psoriasis since she was admitted to the facility. LPNUM #3 stated, she was unaware of the current condition of the resident's skin. LPNUM #3 and this surveyor observed the resident together during the interview and LPNUM #3 stated the resident's skin and scalp were worse than she recalled. LPNUM #3 stated she would expect the resident to have a specific CCP in place to treat the resident's dry skin on her body and the thick white layer of dry skin on the resident's scalp. During an interview on 5/24/19 at 2:09 PM, the Director of Nursing (DON) stated she would expect a resident specific CCP for alteration in skin integrity to be in place to ensure ongoing assessment and management of the resident's scalp and skin. Resident #145: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had severely impaired cognition, required extensive assistance with most ADL's and was without pressure ulcers present. The MDS dated [DATE], documented the resident had a stage II pressure ulcer. During observations on the following dates and times, Resident #145 was in a wheelchair in various areas on the unit with bilateral lower extremities (BLE) down and [MEDICAL CONDITION] (swelling if tissue) present to left lower extremity (LLE): On 5/20/19 at 2:20 PM, 5/21/19 at 8:43 AM, 8/21/19 at 10:05 AM, 5/21/19 at 12:10 PM, 5/21/19 1:24 PM, 5/22/19 10:31 AM, and 5/22/19 at 12:02 PM. Review of physician progress notes [REDACTED].>4/8/19 - documented the resident had bilateral lower extremity (BLE) [MEDICAL CONDITION] ([MEDICAL CONDITION] is when an indentation remains after the swollen skin is pressed). 4/15/19 - an increased amount of [MEDICAL CONDITION] was noted to the resident's BLE. 4/26/19 - the resident had a blister to the left heel secondary to increased [MEDICAL CONDITION]. Nursing notes dated 4/15/19, 4/16/19, 4/22/19, noted the resident had [MEDICAL CONDITION] present. A CCP for the [DIAGNOSES REDACTED].#3 and was not provided. During an interview on 5/24/19 at 12:50 PM, CNA #3 stated the resident is able to reposition herself and is mobile. CNA #3 stated the resident remains in her wheelchair throughout the day. The CNA's do not elevate the resident's legs, or encourage her to do so. During an interview on 5/24/19 at 1:30 PM, LPNUM #3 stated she was aware the resident had [MEDICAL CONDITION] and developed a pressure ulcer to her left heel from this [MEDICAL CONDITION]. LPNUM #3 stated the resident should have a CCP in place for [MEDICAL CONDITION]. LPNUM #3 reviewed Resident #145's CCP during this interview and was unable to locate a care plan or interventions for [MEDICAL CONDITION]. During an interview on 5/24/19 at 2:12 PM, the DON stated the resident should have a CCP in place for the care and treatment of [REDACTED]. During an interview on 5/24/19 at 2:09 PM, the DON stated the care plans have been identified as not resident specific, nor inclusive of changes that occur for the resident. Facility staff training has been discussed, but has not yet been implemented. Resident #173: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had a severe cognitive impairment with minimal difficulty hearing and usually understood. A CCP for difficulty in communication related to hearing loss last updated on 6/23/15, did not include resident specific interventions for communication related to hearing loss. During an observation on 05/21/19 at 1:16 PM, the resident was seated in a common area on the unit alone, moaning in pain. A CNA approached the resident and attempted to communicate with her by speaking very loudly to the resident. The resident tried to hear what the CNA stated, however continued to repeat incorrect information as she was unable to understand what was being said to her. The CNA used hand gestures and facial expressions in addition to yelling loudly at the resident, until the resident could understand the CNA was telling her she already had pain medications. During an observation on 5/22/19 at 10:38 AM, the resident was seated in a common area on the unit, and was moaning. The resident was approached by a social worker attempting to communicate with her. The social worker had to repeat herself several times and speak very loudly and close to the resident's ear for the resident to understand part of what the social worker was stating. During an interview on 5/24/19 at 1:13 PM, CNA #4 stated the resident is very hard of hearing and it is often very difficult to communicate with her. CNA #4 stated you have to speak very loudly, almost yelling for the resident to understand. During an interview on 5/24/19 at 1:25 PM, LPN #4 stated the resident is very deaf, however she was able to make her needs known. LPN #4 stated some staff communicated with staff via writing, however that was a long time ago. LPN #4 stated the CCP in place was not resident specific and that the resident cannot usually understand verbal content. During an interview on 5/24/19 at 1:58 PM, LPNUM #3 stated that years ago a picture board was in place for communication with the resident. LPNUM #3 stated staff needed to speak very loudly, directly in the resident's face and near her ear for her to understand. LPNUM #3 stated the CCP was not resident specific and did not identify the needs of this resident. During an interview on 5/24/19 at 2:12 PM, the DON stated the facility was recently aware that care plans were not resident specific, and they were not updated when needed. The DON stated the facility was working to implement an educational inservice to correct CCPs. 10NYCRR415.11(c)(1)

Based on observation, record review and interview during the recertification survey, the facility did not maintain an infection control program to prevent the development and transmission of disease and infection for three (3) (Resident #'s 12, 174 and #299) of 7 residents reviewed. Specifically; for Resident #174, the facility did not ensure standard precautions were maintained during a dressing change to the resident's non-pressure ulcer, for Resident #12, the facility did not ensure standard precautions were maintained during a dressing change to the 3 pressure ulcers on the resident's upper and lower left hip, and for Resident #299, the facility did not ensure the resident's oxygen tubing was kept off the floor. This is evidenced by: Resident #12: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was usually understood and could usually understand with severe cognitive impairment. Wound assessments dated 5/21/19 documented: Wound #1 on the left hip measured 2.3 cm by 1.3 cm x 0.6 cm with undermining and granular tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), 5 % necrosis (cellular injury causing the death of cells in living tissue), 40 % escar (piece of dead tissue that is cast off from the surface of the skin), and [MEDICATION NAME] tissue with a small amount of purulent drainage coming from the wound. A surrounding reddened area 12.5 cm x 8.0 cm was warm to touch and boggy. Medial to wound #1 a second open area was identified that was draining purulent drainage; Wound #2 measured 1.0 cm, 0.7 cm x 1.0 cm, with undermining and; Wound #3 was below wound #2 and measured 1.5 cm by 1.5 cm. physician's orders [REDACTED]. physician's orders [REDACTED]. - for Wound #1, Upper left hip, stage 3 pressure sore, the resident was to receive wound care three times a day, cleanse wound with wound cleaner, pat dry with gauze, pack area with [MEDICATION NAME] AG (medicated packing for wound), apply Z guard (protective ointment) to surrounding skin, and cover wound with dry dressing. -for Wound #2, lower left hip, the resident was to receive wound care three times a day, cleanse wound with wound cleaner, pat dry with gauze, pack area with [MEDICATION NAME] AG, apply Z guard to surrounding skin cover wound with dry dressing. - for Wound #3, inferior to Wound #1 left hip, the resident was to receive wound care every 3 days, cleanse wound with wound cleaner, pat dry with gauze, apply skin prep, apply duoderm (wound cover), The eTAR dated 05/23/19, documented: the resident received a treatment to her left wound every day. Cleanse left hip wound #1 with 4:1 wound cleanser, pack area with [MEDICATION NAME] AG, apply z guard to surrounding skin, cover with dry dressing 3 times a day and documented the resident received a treatment to wound #2 adjacent to left hip stage 3, cleanse with wound cleaner, pack with [MEDICATION NAME] AG, cover with dry dressing. It documented the resident received a treatment to wound #3 left lower gluteal area, cleanse with wound cleaner, apply skin prep and apply small duoderm every 3 days. During an observation of a dressing change to the resident's left hip on 5/23/19 at 11:45 AM, licensed practical nurse (LPN) #6 was observed to wash her hands for less than 10 seconds, applied gloves, and gathered supplies for the wound dressing. The LPN had a dangling silver bracelet that fell to her wrist outside the gloves. As the LPN removed the old dressing with gloved hands the bracelet brushed against the wound area that was draining purulent serosanguineous fluid. She washed her hands, donned gloves and placed items on the clean field on the bedside tray. As she opened the dressing supplies and placed them on the bedside table with her gloved hands, she touched the outer package, and placed 2 q-tips and 4x4 gauze on the clean field. She picked up the wound cleaner and without changing her gloves began to squirt each wound with the wound cleaner and wiped around the wounds with a 4 x 4 blotting at first and then going back into the middle of the wound with the same gauze. As LPN #6 bent over the resident cleaning the wound her badge attached to the front of her top and dangling bracelet entered the wound area numerous times. The LPN re-gloved and without washing her hands packed the wound with the [MEDICATION NAME] AG, picked up the package of Z guard, squeezed some ointment onto her gloved right hand and smeared the ointment from the middle wound to the top wound. While doing this the resident became restless and attempted to touch the area, the LPN# 6 bent over the resident and used her left arm to sweep the residents arm away and touch the wound with her name badge and dangling bracelet. LPN #6 then covered wound #1 and #2 with a dry dressing without washing her hands or changing gloves. After cleaning the wound, LPN #6 took the bottle of wound cleaner out of the resident's room and put it back on the top of the cart outside the resident's room. The bottle was not cleansed before placing it on the cart. During interview on 5/24/19 at 11:47 AM, LPN #6 stated she hadn't realized her badge and bracelet had touched the wound during the dressing change. The badge should have been taken off and the bracelet should not be worn to work because the gloves don't cover it. No one had pointed this out to her before, but it is not good practice. During interview on 5/24/19 at 12:09 PM, the registered nurse manager (RNUM) #3 stated she had only just become the nurse manager. The nurses and staff are educated on infection control and should not be wearing jewelry that could dangle down on the resident when care is being given. It is not good practice and could spread infection from one person to another. During interview on 5/24/19 at 2:07 PM the Assistant Director of Nursing/Infection Control Nurse stated the required time for hand washing before and between resident care is 20 seconds. When doing dressing changes the nurse should wash hands either using soap and water or an alcohol-based sanitizer between glove change. No jewelry should be dangling down into the wound field as this puts the resident at a risk for infection. Nurses are educated on proper dressing procedure yearly. Once an item is brought into the residents' room and used it should not be put back into the treatment cart unless it has been disinfected. Resident #174: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact and was able to be understood by others and was able to understand. Wound assessment dated [DATE], documented a vascular wound to the resident's left foot, 4.5 cm in length and 4.5 cm in width. Serosanguinous (containing both blood and serum) drainage from the wound with slough present. Wound edges were macerated (defined as the softening and breaking down of skin resulting from prolonged exposure to moisture) and peri (surrounding) wound skin appearance was red and macerated. Physician's Progress Note dated 5/6/09, documented the resident has fluid filled cyst on left anterior foot. The cyst appears to be bigger and her foot is more [MEDICAL CONDITION] with warmth and redness. The resident will be started on [MEDICATION NAME] (antibiotic) 875 mg twice a day for 7 days. physician's orders [REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. The electronic Treatment Administration Record (eTAR) dated 05/2019, documented the resident received a treatment to her left foot every day. Cleanse wound with 4:1 wound cleanser, apply Santyl to the wound bed, and cover with ABD pad and cling gauze. During an observation of a dressing change to the resident's left foot on 5/23/19 at 10:16 AM, LPN #1 was observed to remove the old dressing with gloved hands. He washed his hands, donned a glove on his right hand and opened the dressing supplies and placed them on the bedside table. The LPN put a glove on his left hand. He picked up the spray bottle containing wound cleanser, touched the outside of the dressing package to retrieve the gauze and sprayed the gauze. He then cleansed the wound to the resident's left foot. He did not remove his gloves, wash his hands or apply a new pair of gloves after picking up the spray bottle and touching the outside of the dressing package. He cleansed the wound following this procedure with 3 pieces of gauze. He removed the fourth piece of gauze by again touching the outside of the package, dried the wound, washed his hands and donned a new pair of gloves. He opened the cotton tipped swabs with gloved hands touching the outside of the package. He held the cup of Santyl and applied the gel using the cotton tipped swab. He did not remove his gloves, wash his hands and apply a new pair of gloves after touching the outside package of the cotton tipped swabs and holding the cup of Santyl. After applying the Santyl, he removed his gloves and applied new glove to the right hand without washing his hands. He opened the dressing packages of the ABD pad and kling. He washed his hands and changed his gloves. He applied the ABD pad to the wound and wrapped it with kling. During an interview on 05/23/19 at 10:57 AM, LPN #1 stated he did not realize he should not hold the spray bottle or touch the outside packages of dressing supplies without first washing his hands and changing his gloves prior to proceeding with the dressing change. He stated he was not taught to do this. During an interview on 05/23/19 at 11:05 AM, Registered Nurse Manager (RNM) #4 stated the nurses receive weekly competencies by her and they are observed annually performing a dressing change. Also, there is a competency fair where the classroom is open for the nurses to go through and complete all the competencies including the new staff. She stated the nurses are taught not to touch the outside of dressing packages without washing their hands and changing gloves afterwards. Resident #299: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Initial Nursing assessment dated [DATE], documented the resident was cognitively intact and was able to be understood by others and was able to understand. physician's orders [REDACTED]. The following are observations of the resident's oxygen tubing on the floor in the resident's room: 05/20/19 at 09:14 AM; 05/21/19 at 01:21 PM; 05/22/19 at 10:33 AM; 05/23/19 at 09:50 AM; 05/23/19 at 04:07 PM and 05/24/19 at 08:15 AM During an interview on 05/24/19 at 08:51 AM, Registered Nurse (RN) #1 stated the staff try to keep the oxygen tubing off the floor much as possible. The tubing is very long and would not fit in the bag the tubing was normally kept in. If it was seen that the tubing was on the floor, it should have been replaced. During an interview on 05/24/19 at 08:54, RN #2 stated if staff notice the oxygen tubing is on floor, they should notify nursing and new tubing will be obtained. It should be off the floor at all times. The staff are inserviced to absolutely keep it up off floor. 10NYCRR415.19(b)(4)

Based on observation, record review, and staff interviews, during abbreviated survey (Case #NY 152) the facility did not ensure that based on the comprehensive assessment of a resident, that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 (Resident #6) of 4 residents reviewed. Specifically, for Resident #6, the facility did not ensure the Speech Language Practitioner's (SLP) recommendation dated [DATE] for close supervision for eating due to the resident's risk for choking was implemented. Additionally, the facility did not ensure that interventions for the resident's difficulty swallowing were documented on the resident's meal card. On [DATE], during dinner, the resident nonverbally indicated he could not breathe. The [MEDICATION NAME] maneuver and cardiopulmonary resuscitation (CPR) were initiated, 911 was called and the resident was transferred to the hospital. This is evidenced by: Resident #6 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had long and short-term memory loss and had severe cognitive impairment. During a dining observation on [DATE] at 5:50 pm, dinner was being served. Staff were comparing meal tickets with the food on the tray to ensure residents were receiving the correct diet. The residents who needed to be fed, or needed extensive assistance, were seated in the back of the dining room at three tables that had been placed together to make one long table. Two Certified Nursing Assistants (CNA) were at the tables assisting and feeding the residents. There were CNAs, Licensed Practical Nurses (LPN), and a Dietician walking throughout the dining room and assisting residents as needed. Meal tickets for several residents were reviewed and they matched the residents' prescribed diets. The undated Therapy Recommendation Process policy and procedure (P&P), documented that when there was a diet change, speech therapy was indicated, changed, or discontinued, or there were other nursing recommendations, a Speech Therapy (ST) order/recommendation form was completed. The form was given to the nurse on the unit, or the Registered Nurse Supervisor (RNS) on evenings and weekends, who then notified the practitioner and placed the form in the Medical Doctor (MD) book for his/her signature. A copy of the form was also given to the dietary department. The Registered Nurse (RN) updated the care plan. The Resident Nutrition File System P&P revised ,[DATE], documented that feeding strategies, per Occupational Therapy (OT)/Speech Language Pathologist (SLP)/Nursing recommendations were to be listed under Alerts on the meal tickets. The Mayo Clinic website information dated [DATE] defined choking as; When food becomes impacted, choking can occur. If food completely blocks the airway, and no one intervenes with a successful [MEDICATION NAME] maneuver, death can occur. The MD Orders dated [DATE], documented the resident was on a mechanical soft texture diet with thin liquids. The Comprehensive Care Plan (CCP) for impaired swallowing related to dysphagia (difficulty swallowing) initiated on [DATE], documented the resident was at risk for dysphagia and aspiration (inhaling a foreign substance such as food or fluids into the lungs). Interventions were in place to alternate liquids and solids, offer pureed food as needed, to ensure the resident was eating at a slow rate, and to take small sips and bites. The CCP for nutritional risk related to dementia, difficulty chewing, and difficulty swallowing initiated on [DATE], documented that his food was to be cut into small pieces, he required supervision when eating, and was prescribed a mechanical soft diet with thin liquids. The CNA Care Card dated [DATE], documented the resident was at risk for aspiration and dysphagia. He was to alternate liquids and solids, have his food cut into small pieces, be supervised when eating, eat a mechanical soft diet with thin liquids, and could be provided with pureed foods as needed. Staff were to ensure he was eating at a slow rate and taking small sips and bites. The Speech Language Pathologist's (SLP) evaluation dated [DATE], documented the resident had clinical signs and symptoms of dysphagia, could be quite impulsive and had a history of [REDACTED]. She recommended a mechanical soft diet, thin liquids, and close supervision to monitor the rate at which the resident was eating, and the amount of food he was putting into his mouth. There was a risk for choking if not given close supervision. The resident's meal ticket dated [DATE], for the evening meal, documented food choices consistent with a mechanical soft diet. The Alert section of the meal ticket was blank. A Nurses' Progress Note dated [DATE] at 6:20 pm, written by Registered Nurse Supervisor (RNS) #3, documented the resident was assessed. The resident had been observed in the dining room by CNA #5 having difficulty breathing. The charge nurse started the [MEDICATION NAME] Maneuver, and was assisted by other nurses. The RNS initiated CPR, 911 was called, and the resident was transferred to the hospital. The Emergency Medical Services (EMS) chart dated [DATE] at 6:44 pm, documented that Paramedic #1 checked the resident's airway with a laryngoscope (a device used to enable visualization of the airway), found, and removed volumes of food from (the resident's) airway, equivalent in size to a couple of golf balls. Air exchange was greater after removal of food. The emergency room MD note dated [DATE] at 7:23 pm, documented the resident was intubated (a flexible plastic tube was inserted into the windpipe to maintain an open airway). The MD suctioned a large amount of undigested food and had to pull food out of the resident's throat, using her fingers that included a large triangular shaped piece of bread. The [DIAGNOSES REDACTED]. The resident was admitted to the critical care unit. A hospital nursing note dated [DATE] at 6:46 pm, written by the Registered Nurse (RN), documented the resident was placed on comfort care and started on [MEDICATION NAME] (for pain) and [MEDICATION NAME] (for anxiety). He had been taken off life support that afternoon and died at 5:51 pm. The hospital discharge summary dated [DATE], documented the discharge [DIAGNOSES REDACTED]. During an interview on [DATE] at 12:35 pm, LPN #4 stated that residents who were at risk for choking were seated at tables where a nurse or CNA was sitting for monitoring based on the SLP's recommendations. During an interview on [DATE] at 1:43 pm, the SLP stated the resident needed to sit at a table that was supervised by staff for safety and to ensure the strategies to prevent choking were used. The resident had a history of [REDACTED]. She recommended close supervision, and a mechanical soft diet with ground or pureed foods as desired. Close supervision for dining meant that an LPN or CNA needed to sit with the resident at the table. The resident could feed himself, but was rather impulsive. During an interview on [DATE] at 2:26 pm, LPN #5 stated she was by the dining room when CNA #5 called her over to the resident. The CNA told her he looked like he was having trouble breathing. His lips were blue. She stated the resident was not his usual self, so she hit his back and did the [MEDICATION NAME] maneuver. No food was expelled. LPN #6 came over and did the [MEDICATION NAME] maneuver. She could see the resident's mouth, and again, no food was expelled. An emergency code was called. He was breathing at that time. He then became unresponsive, CPR was started and 911, the MD, and the family were notified. LPN #5 stated that supervision included ensuring the resident had the right diet, cutting up their food, encouraging the resident to drink fluids, etc. She was not sure if supervision meant somebody needed to sit with the resident. During an interview on [DATE] at 3:00 pm, LPN #6 stated a CNA told her the resident was choking. She did the [MEDICATION NAME] maneuver. No food was expelled. She stated the resident responded, and was breathing. The RNS told her to call the MD. While she was on the phone, she heard a commotion, yelled around the corner to check on what was happening, and was told the resident had coded (gone into [MEDICAL CONDITION]). The code was called, she called 911 and the resident's daughter. She stated supervision meant keeping an eye on the resident to ensure they were not eating too fast. It also meant checking to see that the resident had the right diet and fluid consistency. She stated the resident was at a supervision table; staff walking around the dining room kept an eye on residents who sat at supervision tables. He was not at a table where residents needed to be fed. During an interview on [DATE] at 3:09 pm, CNA #5 stated she had been passing meal trays and then sat down at the resident's table to feed the other resident. She saw the resident, waving his arms. She went over to him to check if he was okay. When she looked at him, his lips were bluish. The resident couldn't speak, but when asked if he was having trouble breathing, he shook his head yes. She hit his back and called for the nurse. LPN #5 came right over, started patting his back, and did the [MEDICATION NAME] maneuver. LPN #6 came to assist. She did not see anything come out of his mouth. She stated supervision meant the right diet and fluids were provided to the residents and to monitor them to be sure they weren't eating too quickly, etc. There was always a nurse and other staff in the dining room during meals to supervise the residents. During a phone interview on [DATE] at 10:32 am, the Dietary Supervisor stated the resident had been served a grilled cheese sandwich. She spoke with the resident after he was served. He was eating a grilled cheese sandwich. He only had about a bite left. About 15 minutes later, a code was called. She did not know if his sandwich had been cut into small bites because that wasn't done at the time the trays were being served from the kitchen area. It was done by staff when the residents were served. She was not sure if anyone was sitting at the table prior to her seeing CNA #5 sitting there when she approached the table to ask the resident if his meal was okay. During a phone interview on [DATE] at 1:30 pm, the DON stated there was no written policy and procedure in place for implementing therapy recommendations. She stated the process was that when therapy made a recommendation, they completed a Functional Status Change Form and submitted it to the Registered Nurse Unit Manager (RNUM), or the RNS if it was a weekend. Effective [DATE], Speech Therapy was also providing a copy of the form to dietary. The recommendation for close supervision should be on the Functional Status Change From and given to an RN. She would have expected nursing to follow the SLP's recommendation for close supervision. Close supervision would mean the resident would sit at a table with a staff member to closely supervise the resident. Supervision meant that staff were in the dining room, supervising all residents, not just one specific table. There was always a nurse in the dining room. During a phone interview on [DATE] at 3:49 pm, the DON stated if the SLP had sent a Functional Status Change Form to nursing, then nursing could have added close supervision to the CCP and on the CNA care card. There was no record that the SLP had completed the form recommending the resident have close supervision. If the form had been completed, there may have been a different outcome for the resident. During an interview on [DATE] at 5:50 pm, Dietician #1 stated the residents who needed assistance were seated at the back of the dining room. At the time of the incident, there were only two assisted tables at the back of the room for the unit the resident resided on. There was a space between them; they were not pushed together. The resident was seated at the table on the left side of the dining area with his back facing the other assisted table located at the right side of the dining area. During an interview on [DATE] at 6:05 pm, CNA #6 stated the residents who sat in the back of the dining room were the ones who needed the most assistance, and aides sat at those tables. The nurses stay in the front of the dining room where the more alert residents were seated and assist them as needed. The remainder of the aides circulated throughout the dining room to supervise and offer assistance to the residents while they ate. During a phone interview on [DATE] at 11:40 am, the Medical Director stated he felt that some food was stuck in the resident's esophagus that triggered the choking incident. The resident's muscle tone was not the best for swallowing. Close supervision meant a resident was seated closer to an aide who could quickly intercede if there was an issue. The entire dining room was supervised by staff during meals. It would have been crucial for the speech therapist to communicate to nursing that the resident needed close supervision. If she did not, she should have. Close supervision should have been documented in the CCP and on the CNA care card. During a phone interview on [DATE] at 9:46 am, regarding the [DATE] incident, CNA #8 stated she was sitting at a table at the other end of the assisted feeding section. The resident's back was to her, so she was unable to observe him while he was eating. She stated that residents who needed cueing to alternate solids with liquids, take small sips and bites, and to eat slowly, would almost have to have somebody sitting next to them to ensure they were eating and drinking that way. During a phone interview on [DATE] at 10:42 am, LPN #5 stated the resident was done eating and his plate was empty when CNA #5 sat down at the table to feed the other resident. She did not know if anyone had been sitting with the resident prior to CNA #5 sitting with him. The residents at the back tables were the last to be served. During a phone interview on [DATE] at 1:27 pm, CNA #5 stated after she had finished passing trays that evening, she sat down at the resident's table. He had already finished his meal. When she did supervise him, she would make sure his food was cut up, that he had the right diet, that he didn't put too much food in his mouth at one time, and that he did not eat too fast. She did not know if anyone was sitting at that table while she passed trays. Being at a back table, she would assume he needed supervision while eating. During a phone interview on [DATE] at 2:16 pm, LPN #6 stated the LPNs and CNAs knew the residents' diet interventions. They were written on their meal tickets. She stated most of the residents with dysphagia sat at the back tables for feeding and supervision. The residents at the back tables were not served until a staff person could sit at the table with them. When she sat with the resident at meal time, she needed to remind him to swallow before he talked. The resident's preference was to have his sandwiches cut into quarters by the staff. During a phone interview on [DATE] at 10:34 am, the SLP stated that at the time she evaluated the resident, there was not a form for ST to communicate changes and recommendations. After the [DATE] incident occurred, she spoke with administration and recommended a system be put in place for ST to notify other disciplines of diet changes and recommendations. She did not have access to the Functional Status Change form that was utilized by PT/OT, and nursing. When she evaluated a resident, and there was not a diet change, she would make recommendations, if any, to nursing, who would then communicate them to dietary. A copy of her evaluation was printed and provided to nursing and the MD. When ST was recommended, or if there was a diet change, she would complete an ST order form to initiate therapy, the type of therapy required, type of diet, and interventions. She spoke with the Registered Nurse Unit Manager (RNUM) following the resident's evaluation (done on [DATE]) and told her that the resident could functionally chew, but because of his choking history and impulsivity, he needed to sit at a supervised table where either a nurse or CNA sat with the resident to ensure the resident was following the interventions put in place for his safety. The Alerts on the meal tickets could be provided to dietary by PT/OT or nursing. Dietary added them to the meal ticket. The interventions for dining were also in the resident's CCP and on the CNA care card. During a phone interview on [DATE] at 3:19 pm, Dietician #2 stated Nursing or ST would provide a slip for dining strategies the residents needed. That could include such things as alternating fluids and solids, small bites and sips, no straws, etc. The recommendations are put on the meal ticket in the section for Alerts. Nobody notified her there were supposed to be alerts for feeding strategies to be used with the resident. During a phone interview on [DATE] at 9:21 am, the RNUM stated the SLP completed a ST therapy recommendation form for every evaluation she did and gave it to the RNUM. She completed the form even when therapy was not indicated for the resident, to provide any recommendations she had. She could not recall if she received one for the resident. She could not recall what the SLP told her about the resident, but he was seated in the back of the dining room at an assisted table, so he needed some type of supervision. She defined supervision as; staff were seated at a table with residents where they could observe and assist them. Close supervision meant a staff member was seated right next to a resident to observe and assist that resident. The residents' care plans for dysphagia were based on the recommendations from the SLP. The dietician puts the alerts for feeding strategies on the residents' meal tickets based on the SLP's recommendations. She did not know why there were no alerts for the resident's dining strategies on his meal ticket. During a phone interview on [DATE] at 1:38 pm, the DON stated the alerts for ST interventions should be on the meal tickets. Everybody in the dining room was supervised. There was no difference between supervision and close supervision. The resident was placed on limited assistance when first admitted to the facility pending the SLP evaluation. That meant a staff person would need to be within arm's length of the residents sitting at assisted tables. Following the SLP's evaluation, the resident was placed on close supervision and remained at the assisted table. The incident occurred because of a process problem. There needed to be specific definitions of the levels of supervision and interventions. Administration was looking at the SLP recommendation process. A check box was added to the ST order/recommendation form for assisted table. There was currently a full-house audit being conducted to compare the ST recommendations against the CCP, the CNA care card, the meal ticket, and the seating in the dining room to ensure everybody was getting the level of assistance needed. New ST recommendations were being brought into the morning meeting, which the entire team attended, to ensure the recommendations were in place. 10 NYCRR 415.12(h)(1)

Based on record review, and staff interview during an abbreviated survey (Case #'s NY 677 and NY 159), the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for two (Residents #2 and #4), of three residents reviewed. Specifically, for Resident #2, the facility did not ensure the mattress to be put on the floor at the resident's bedside, as documented on the care card, was in place when the Certified Nursing Assistant (CNA) left the room. The resident fell out of bed and sustained an abrasion and small laceration on her forehead. In addition, for Resident #4, the facility did not ensure the resident was wearing the Derma-saver leggings (worn to protect against skin tears) that were documented on her care card. This resulted in a skin tear to her left lower extremity. This is evidenced by: Finding #1 The facility did not ensure a mattress was on the floor at the resident's bedside. Resident #2: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The Certified Nursing Assisatant (CNA) Care Card Policy and Procedure revised in (MONTH) 2012, documented the purpose was to structure and guide CNA's in providing care to residents. The CNA was to review the care card at the beginning of his/her shift. The CNA Care Card dated 8/25/17, documented the resident was to have a mattress on the floor. The Comprehensive Care Plan (CCP) initiated on 12/1/17, documented the resident was to have a mattress on the floor. A Nursing Progress Note dated 5/21/18 at 5:45 am, written by Licensed Practical Nurse (LPN)#2, documented the resident was observed on the floor, face down next to her bed, with the nurse call light on and the alarm sounding. The floor mattress was not in place. A Nursing Progress Note dated 5/21/18 at 5:45 am, written by RNS #4, documented the resident had fallen and sustained a small abrasion on the left side of her forehead and a slit on the front of her forehead. During an interview on 6/27/18 at 7:52 am, RNS #4 stated LPN #2 notified her sometime between 5:00 am- 6:00 am on 5/21/18, that the resident was on the floor. When she walked into the room, the resident was on the floor and the mattress was not. She assessed the resident and assisted in getting the resident off the floor. CNA #3 had dressed the resident and left her in bed because she had complained of pain. She then went to get the nurse, but did not put the mattress back on the floor. During an interview on 6/27/18, LPN #2 stated the resident fell sometime between 5:00 am- 6:00 am. She had just entered the hallway where the resident's room was and heard the bed alarm sounding. She stated CNA #3 passed her and went into the resident's room. The CNA called for her and said the resident was on the floor. When she arrived at the room, she saw the resident on the floor. The resident had a laceration on her upper forehead at the hairline. The resident was supposed to have a mattress on the floor by the bed, but it was not there. During an interview on 6/28/18 at 1:35 pm, the Director of Nursing (DON) stated the resident had expressed pain, so CNA #3 went to get the nurse. The CNA should have stayed with the resident and put on the call light, or she could have put the mattress back on the floor before going to get the nurse. During an interview on 7/30/18 at 9:59 am, CNA #3 stated she had worked the 11:00 pm- 7:00 am shift on 5/21/18. The resident was on her assignment and was scheduled to be bathed and dressed prior to the start of the 7:00 am- 3:00 pm shift. When she was done providing the resident's care, she put the bed in the low position and went into the bathroom to empty the basin. When she came back out to get the resident out of bed, she expressed she had a headache. The CNA left the room to tell the nurse about the resident's headache, and then went to a different hallway to answer lights. She stated it was busy and several lights were going off. Once she was done there, she went back to the resident's hallway, saw her call light on, and went to the room. When she entered, she saw the resident on the floor. She yelled for the nurse. She stated she had forgotten to put the mattress back on the floor by the resident's bed. Finding #2 The facility did not ensure the resident was wearing the Derma-saver leggings. Resident #4: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The CNA Care Card policy and procedure revised in (MONTH) 2012, purpose was to structure and guide CNAs in providing care to residents. The CNA reviews the care card at the beginning of his/her shift. The Comprehensive Care Plan initiated on 2/28/17, documented the resident was to wear Derma-Saver leggings (worn to protect against skin tears) to both lower legs and arms at all times. They could be removed for care. The CNA Care Card documented that beginning on 2/28/17, the resident was to wear Derma-Saver leggings (worn to protect against skin tears) to both lower legs and arms at all times. They could be removed for care. A Nursing Progress Note dated 1/16/18 at 11:44 am, written by LPN #3, documented the resident had a skin tear on the left shin. The Medical Doctor (MD) and family were notified. A Nursing Progress Note dated 1/16/18 at 1:12 pm, written by the Registered Nurse Assistant Manager, documented the resident was assessed for a skin tear to the left lower extremity. The resident denied pain or discomfort. Staff were to monitor for signs and symptoms of infection. During an interview on 6/28/18 at 3:38 pm, the Director of Nursing (DON) stated the facility standard was that the CNAs follow the plan of care. Failure to do so could lead to negative outcomes for the resident or the CNA. During an interview on 7/26/18 at 8:52 am, LPN #3 stated she saw the resident being pushed up to her table at breakfast time. She stated she was near the resident's table and saw drops of blood on the floor. That was when she noticed the skin tear on the resident's right lower leg. She stated the resident was not wearing her Derma-savers on her legs. They were supposed to be worn at all times. She stated CNA #4, who brought the resident to the table was the resident's aide that day. During an interview on 7/27/18 at 8:29 am, CNA #4 stated the resident had been added to his assignment that morning (1/16/18). He provided her personal care, got her out of bed into her geri-chair and took her to the dining room for breakfast. The unit was very busy that day and he did not look at the resident's care card prior to providing her care. He stated the aides were supposed to look at the residents' care cards every day. 10 NYCRR 415.12(h)(1)

Based on record review and staff interviews during a complaint investigation (#NY 938), the facility did not ensure that the residents environment remained as free of accident hazards as is possible and that each resident received adequate supervision and assistive devices to prevent accidents for three (3) of seven (7) residents reviewed (Resident #1, #2 and #3). Specifically, Resident #1 and Resident #2 were care planned for a safety mat, however the type of safety mat, the presence of multiple mats, and verbiage, specifically "may leave down" on the care card resulted in confusion among staff responsible for the placement of a safety mat. Subsequently, Resident #1 sustained a cervical fracture and a facial laceration requiring sutures and Resident #2 sustained a laceration requiring sutures. This resulted in actual harm that is not immediate jeopardy. For Resident #3, the facility did not ensure that the resident received adequate supervision to prevent accidents, or potential safety risks to the resident and other residents. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This requirement is not met as evidenced by: Resident #1 This resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Brief Mini Mental Status (BIMS) dated 7/18/14 assessed this resident with severe cognitive impairment. Comprehensive Care Plan for activities of daily living (ADLs) last revised on 8/27/14 documented that Resident #1 was non-ambulatory and required assistance of two caregivers and a mechanical lift for transfers. Comprehensive Care Plan for Falls initiated on 10/16/13 documented Resident #1 at high risk for falls and initiated interventions on 10/16/13 to include; Floor mat FOAM - may leave down and a low bed. On 4/15/14 a pad alarm in bed was initiated. Visual/Bedside Kardex Report (Care card, used by care givers to know the resident's care needs) with a print date 9/22/14 documented Resident #1's transfer status of a total assist of two with a mechanical lift and documented safety devices including; Floor mat FOAM - may leave down, a low bed and a pad alarm in bed. Incident Report dated 9/21/14 at 4:30 pm documented that Resident #1 was observed lying on the floor by bed on the left side bleeding from forehead. No floor mat in place. The incident report documented that Certified Nurses Assistant #1 (CNA #1) assigned to the resident stated "I washed her up, got her dressed. Went to get help and when I came back she was on the floor". Nurse's note dated 9/21/14 at 4:30 pm signed by Licensed Practical Nurse (LPN) #1 documented that the resident was observed on the floor on the left side, bleeding from her forehead, kept in stable position until the paramedics arrived and transferred the resident off the floor onto the stretcher to the hospital. The resident sustained [REDACTED]. Nurse's note dated 9/21/14 at 4:30 pm signed by the Registered Nurse Supervisor (RNS) documented that the resident sustained [REDACTED]. Hospital Computerized Tomography (CT) report for Resident #1 dated 9/21/14 documented a fracture of the DENS (a small portion of the neck bone), type 2 with prevertebral soft tissue swelling. Nurse's note dated 9/22/14 at 3:31 am documented that Resident #1 returned from the hospital, neck brace in place and twelve (12) stitches to the forehead. An unsigned Facility Investigation Report dated 9/22/14, documented that on 9/21/14 Resident #1 was found in her room lying on her left side bleeding from the left side of her forehead. CNA #1 stated that she washed the resident up in her bed and went to get help for transferring and when she returned the resident was on the floor. The report documented that LPN #2 provided first aide to the resident and 911 was called. The report documented that the Registered Nurse Manager (RNM) and the Assistant Director of Nursing (ADON) investigated the incident which revealed that the resident was care planned to have a floor mat in place while in bed and that the floor mat was not at the bedside. The findings further documented that the CNA stated she forgot to replace the floor mat, but had placed the bed in low position when she went to find help for the mechanical transfer of the resident from the bed to the chair. The report documented that the resident was treated in the hospital for a cervical fracture at the C2-C3 level and a 4-5 centimeters laceration to the left forehead. The report documented the care team reviewed and concluded that CNA #1 did not replace the floor mat before leaving the room, was spoken to by the RNS and given a disciplinary action for not following the care plan. During an interview on 10/6/14 at 3:15 pm, LPN #2 stated that he was called to Resident #1's room and observed the resident on the floor bleeding. LPN #2 stated he immediately assisted the resident by applying first aide. LPN #2 stated that when he entered the room, the resident's fall mat was not on the floor and there was no bed alarm sounding. LPN #2 stated that LPN #1 did respond to the room, however, he directed her to prepare the paperwork to transfer the resident to the hospital. LPN #2 was asked to review Resident #1's care card, "Floor mat FOAM - may leave down" and LPN #2 stated "that's strange, it should say "when in bed". During an interview on 10/6/14 at 3:50 pm, the Director of Nursing (DON) and ADON stated that during the investigation into the incident, they determined that the wrong mat was in the resident's room at the time of her fall. The DON stated that the dense, folded mat was in Resident #1's room and the wording on the care card was causing confusion with the staff. The DON stated that after the incident the facility initiated a change to the care card wording to include "non-skid floor mat" to replace the "Floor mat FOAM" to mean the 1 inch tapered edge fall mat. During an interview on 10/6/14 at 4:10 pm, RNM #1 stated that the gray fall mats do not have to be picked up before providing care which is why the care card says "may leave down." After Resident #1's fall, RNM #1 stated she updated all of the resident's care cards on her unit to change the wording from FOAM mats to Non-skid mats for the gray mats, however, made no changes to the notation "may leave down". RNM #1 stated that the other mats used by the facility are blue, thicker mats and the care card notation was "regular" to denote that mat. RNM #1 stated she believed the changes were made facility wide but was not sure. During an interview on 10/6/14 at 4:40 pm, LPN #1 stated the night of Resident #1's fall, she observed a mat in the resident's room by the head of the bed and believed it was blue. During an interview on 10/6/14 at 4:50 pm, CNA #2 stated when she entered Resident #1's room after her fall, she observed the blue cushiony mat folded up at the head of Resident #1's bed. During an interview on 10/6/14 at 4:55 pm, CNA #3 stated he responded to Resident #1's fall, she was on the floor bleeding and there was no bed alarm going off. CNA #3 stated he did not remember if he assisted the resident to bed but had assisted her earlier in the day. CNA #3 stated that Resident #1 normally had a blue mat, it folds in two and he would place it in the bathroom. CNA #3 stated gray mats have to be left down at all times, "we are not suppose to pick up a gray mat." During an interview on 10/7/14 at 9:40 am, the RNS stated that she responded to Resident #1's room, observed the resident bleeding on the floor and directed staff to call 911. The RNS stated that she questioned CNA #1 about a fall mat and CNA #1 stated that she had stepped out for a minute to get help for the resident's transfer and did not replace the mat. The RNS stated that the bed alarm was not sounding and she observed the gray mat by the head of the bed. The RNS stated that she did believe that CNA #1 had violated the care plan, however, did not suspend her and allowed CNA #1 to continue to work for the remainder of her shift. During an interview on 10/30/14 at 2:30 pm, CNA #1 stated on 9/21/14 Resident #1 was on her assignment and was in bed. CNA #1 stated that when she entered the resident's room, there were two mats beside the resident's bed; a foam mat (gray) and a "sponge" mat. CNA #1 stated that she knew the resident needed a mat down but she was not sure about having two. CNA #1 stated that she moved the mats, washed and dressed the resident and left the room to find another aide to assist in the 2-person transfer. CNA #1 stated by the time she got back into the room, Resident #1 was on the floor. CNA #1 reviewed the resident's care card "Floor mat FOAM - may leave down" and stated "may...its not like always or must be down. I would take it up for care, but its not clear". CNA #1 stated that she removed both mats so that she had a clear space for the hoyer lift. Resident #2 This resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. Resident #2's Brief Mini Mental Status (BIMS) dated 7/28/14 assessed the resident with severe cognitive impairment. Comprehensive Care Plan initiated on 6/13/14 documented the resident is at high risk for falls and on 9/24/14 an intervention, "Floor Mat FOAM - May leave down" was initiated. Kardex Report (Care Card) dated 9/24/14 documented a safety device, "Floor Mat FOAM - may leave down" Nurse's note dated 10/1/14 at 11:50 pm signed by LPN #3 documented that Resident #2's bed alarm was sounding and resident was found on the floor in the middle of her room with a hematoma over her right forehead and bleeding from her left brow. The note further documented the resident's bed was in low position and her floor mat was on the floor covered with a falleze mat. Nurse's note dated 10/1/14 at 11:50 pm signed by RNS #2 documented Resident #2's fall with a hematoma to the right side of the forehead and a laceration to the left forehead and resident transferred to the hospital for evaluation and repair. Nurse's note dated 10/2/14 at 11:05 am documented that Resident #2 returned from the hospital at 8:15 am with four (4) stitches to the left eye. Facility Investigation Form dated 10/2/14 documented Resident #2's fall on 10/1/14 at 11:30 pm. Investigation Findings documented that the resident is care planned for a foam fall mat. Resident had soft regular fallez mat on top of foam fall mat and the CNA stated both were in the room so he used both. Care team reviewed and concluded that the "care card language is not clear enough to staff regarding which fall mat to use. Care Plan stated Floor Mat FOAM - May leave down. Care plan and care card description of 2 different mats changed to: Floor Mat FOAM - non-skid-may leave down and Fallez. During an interview on 10/7/14 at 10:00 am, LPN #3 stated that on 10/1/14 Resident #2 was up and down and CNA #4 attempted to put the resident to bed, however a short time later, Resident #2 was found sitting on her mats. LPN #3 stated there was a blue foam mat on top and a gray mat under it. LPN #3 stated that she and the CNA #4 spoke about the two mats, the care card was confusing so they left both mats down. LPN #3 stated a short time later, Resident #2 was found on the floor with a laceration to her head and sent to the hospital. LPN #3 stated the RNS #2 was notified and because the care plan documented foam mat, it was hard to determine which mat was suppose to be down. During an interview on 10/7/14 at 10:15 am, RNS #2 stated she was called to Resident #2's unit because she was bleeding from her head. RNS #2 stated that when she arrived to the resident's room, she had a regular mat she was suppose to have, the gray one, and then she had a blue one over the gray one. RNS #2 stated that she does not know why both mats were down but CNA #4 had told her that is what was in her room. RNS #2 stated she reviewed the care card and noted floor mat - foam, and stated "to me it was confusing, now what are we calling the non-skid type, the blue mats we used to call falleze mats." RNS #2 stated she spoke with the RNM #2 about the need to clarify the language on the care cards. During an interview on 10/8/14 at 9:00 am, CNA #4 stated Resident #2 is usually up and down throughout the night and he usually keeps the resident with him during the shift to keep and eye on her. CNA #4 stated that on 10/1/14, he placed the resident in bed, when he went into her room and there were two mats down and he asked the LPN why they were there, the LPN didn't know why they were there either so they just left both mats in place. Resident #3 This resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Brief Mini Mental Status dated 8/20/14 assessed the resident with moderate cognitive impairment. Resident #3's Comprehensive Care Plan initiated on 8/11/14 documented that the resident is an elopement risk/wanderer as evidenced by: resident wanders aimlessly, impaired safety awareness, ability to mobilize independently and has the potential for mood and behavior issues. On 8/15/14 an update to the care plan included that the resident significantly intrudes on the privacy of others. Incident and Accident Report dated 9/17/14 at 3:38 pm documented the resident was observed laying face down in her bedroom with a chair behind her and next to a falleze mat. The report documented that the resident sustained [REDACTED]. Incident and Accident Report dated 9/18/14 at 6:00 am documented that the resident was found in her room lying on her back with legs stretched in front of her. Incident and Accident Report dated 9/19/14 at 4:00 am documented that the resident was found in her room lying on the right side, blood around resident's head and on right arm. The report further documented that the resident sustained [REDACTED]. The resident was transferred to the hospital. Nurse's note dated 9/21/14 at 2:07 pm documented that the resident was returned from the hospital at 1:45 pm with bilateral facial bruises, seven sutures above her right eye and a hematoma to the left side of her forehead and bruising to the bridge of her nose. Incident and Accident Report dated 9/21/14 at 4:14 pm documented at 3:55 pm resident was observed lying on the floor on her right side behind the nurses station. The report further documented a note on 9/23/14 "care plan changed to reflect clip belt...for safety." Nurse's note dated 9/22/14 at 3:44 pm documented a team meeting with a family member present. The note documented the family member's concern of the resident's recent falls and questioning the need for one on one care as per the hospital recommendation to him. The family member was informed that the facility does not provide one on one care but the family member was given pamphlets from agencies that do offer this service at additional charge. The family prefers to wait on this due to cost. The team discussed interventions thus far and discussed a physical restraint clip belt and family was in agreement to try at this time. Nurse's note dated 9/24/14 at 5:53 am documented that the Resident #3 was found in her bedroom, with several alarms sounding and several alarms disarmed, and was brought to the lounge. The note documented that while the nurse was doing rounds and returned to the resident within 5 minutes, the "resident was observed 'adjusting' the oxygen setting on the concentrator of another resident in the lounge as high as the dial would go." Review of facility documents revealed no Incident and Accident Report related to the 9/24/14 5:53 am incident. Nurse's note dated 10/4/14 at 10:50 am signed by LPN #4 documented that Resident #3 found scissors and cut her belt off. Review of facility documents revealed no Incident and Accident Report related to the 10/4/14 at 10:50 am incident. During an interview on 10/7/14 at 1:45 pm, the Director of Nursing was asked about the incidents documented in the resident's nursing notes on 9/24/14 and on 10/4/14 and the DON stated that she was unaware of the incidents. During an interview on 10/7/14 at 1:50 pm, the Assistant Director of Nursing (ADON) was asked about the incidents documented in the resident's nursing notes on 9/24/14 and on 10/4/14. The ADON stated that she was unaware of the incidents and would need to ask the Registered Nurse Manager (RNM) about the incidents. The ADON stated that a meeting was held with the resident's family in which the family was concerned about the resident's falls and had requested one on one supervision for the resident, however, "we are not a one on one facility, we do not provide one on one supervision, the family is responsible for that." During an interview on 10/7/14 at 2:00 pm, the Registered Nurse Manager (RNM) stated the Resident #3 had fallen many times, with interventions in place, and she added a clip belt alarm to the resident's plan of care but the resident continued to fall because she was able to disassemble or remove the alarms. The RNM stated on 9/22/14 a meeting was held with the family regarding the resident's falls and the family was concerned about the resident's safety, and we were concerned. The RNM stated during that meeting, the family agreed to a belt that would serve as a restraint to try to keep the resident safe, however, the resident continued to have behaviors. The RNM stated that she had read the note related to the resident 'adjusting another resident's oxygen' but was unaware of who the other resident was and did not report the incident because the resident was only out of the nurse's sight for five minutes when she was found. The RNM stated that she just read the "scissor note' and was unaware of that incident. The RNM stated that had she known about that incident, she would want to know how the resident obtained the scissors because the resident had poor safety awareness and poor impulse control and she would be concerned for the resident's safety. NYCRR 415.12 (h) (1)

Based on medical record review and interviews conducted with staff, oral surgeon, and family the facility did not ensure that the resident received and was provided the necessary care and services to attain or maintain the residents highest practicable physical and medical well-being for one ( #169) of one residents reviewed during the standard recertification survey. Specifically, the facility did not ensure that the resident, who was being treated with blood thinning medications, was medically cleared by the primary physician prior to receiving surgical tooth extractions. Less than twenty four hours after the extractions the resident experienced large amounts of bleeding from the mouth. Over the following forty-eight hours the resident continued to have bleeding from the mouth, experienced vomiting and had blood in the stool. The resident was transferred to the hospital (on the third day) after the extractions and was admitted and treated with blood [MEDICAL CONDITION]. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident # 169 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ( MDS) dated 1/2/13 assessed the resident had moderate cognitive impairment, was able to understand and be understood. During an interview on 2/14/13 at approximately 11:00am the resident stated she went to the dentist and had teeth pulled. She stated she tried to tell them she was on [MEDICATION NAME] but they said she would be okay. The resident stated she became very sick after and went to the hospital. The Comprehensive Care Plan (CCP) did not include documentation that the resident was receiving [MEDICATION NAME] ( blood thinning medication) and Aspirin (measures used to prevent blood clotting and clumping of platelets) for the [DIAGNOSES REDACTED]. There was no CCP that addressed the resident was to undergo oral surgery to remove three teeth while receiving the [MEDICATION NAME] and Aspirin. The resident was seen by a private oral surgeon on 3/20/12. The report sent back to the facility with the resident documented that the resident had certain health factors for which medical clearance was requested. The specific documented was "stroke" and [MEDICATION NAME] use. A hand written notation was attached to this consult which documented " per family physician going to observe, no surgery scheduled at this time". The resident was seen on 8/20/12 by a private dentist. The documented recommendation was for extractions of four teeth by an oral surgeon. The resident was seen on 9/25/12 by an oral surgeon. The consult documented that the resident had certain health factors for which medical clearance was requested. A hand written notation on the form documented " patient and her son state that patient's International Ratio ( INR, used to measure clotting time) runs around 2.3. She is scheduled for oral surgery. We like to keep the INR less than 3. Please recommend ." The bottom half of this form contained printed information to be completed by the medical physician for clearance. This area was not completed or signed off by the attending physician. There was no evidence found that the facility's physician medically cleared the resident for oral surgery. On the same form there were two handwritten notations documented, "oral surgeon wants INR less than 3" and " dentist [DATE] @ 10:00 am." The facility nursing staff confirmed to the surveyor that these notations were documented by a nursing home staff nurses. The Nursing Note ( N/N) dated 9/25/12 documented that the resident had returned from an oral surgeon appointment and was to be scheduled for oral surgery. There was no evidence found that the resident was seen again by the dentist or oral surgeon on 11/11/12 or prior to the scheduled extractions. The Physician Order's dated 11/20/12 to 1/15/13, documented orders for [MEDICATION NAME] 3.5 milligrams (mg) once daily Monday - Friday and [MEDICATION NAME] 3 mg on Saturday & Sunday, and Aspirin 81 mg once daily. There was no evidence that the [MEDICATION NAME] or Aspirin were placed on hold prior to the dental surgery/ tooth extractions. The Medication Administration Record (MAR), dated 11/1/12-11/30/12, documented the resident received Aspirin 81 mg everyday from 11/1/12 through 11/26/12. The same MAR documented that the resident received [MEDICATION NAME] 3.5 mg Monday - Friday and 3 mg on Saturday & Sundays from 11/1/12 - 11/26/12. The residents INR's ran between 1.7 and 2.8 from 11/1/12 -11/26/12. The consult report, signed by the oral surgeon and dated 11/26/12, documented multiple infected teeth were surgically extracted. A notation on the consult report documented " Patient alerted that she will have bleeding due to high INR. " There were no progress notes documented on 11/26/12 indicating that the resident left the facility for the oral surgery. The INR documented on the MAR for 11/25/12 at 5:00 pm was 2.5. The INR documented for 11/26/12 at 5:00 pm was 2.5. The Nurse Note (N/N), dated 11/26/12 at 8:44 pm, documented the resident had moderate blood from the extraction site. The next N/N, dated 11/27/12 at 6:24 am, documented that the nursing supervisor was called to the unit in the earlier part of the shift to assess the resident who was having dental bleeding. The physician was notified and orders were received to hold Aspirin and [MEDICATION NAME] until seen by the physician, give Vitamin K ( used to clot blood) 5 mg by mouth one time and obtain Complete Blood Count (CBC) and [MEDICATION NAME] (PT) and INR in the morning. The laboratory results dated [DATE], documented a hemoglobin (Hgb) of 11.8 ( normal range 11.0-15.0) and hematocrit (Hct) of 36.5 ( normal range 34.0-45.0), and a INR of 2.4 ( therapeutic range 2.0-3.0). The N/N, dated 11/27/12 at 4:30 pm, documented that the resident continued to have bleeding from the tooth extractions. The N/N dated 11/27/12 at 10:00 pm, documented the resident continued with large amounts of bleeding from three extractions of teeth. The physician was notified and a repeat CBC was ordered. The note further documented that the resident was not able to take fluids and solids by mouth because of the bleeding. The N/N dated 11/28/12 at 2:41 am, by the nursing supervisor, documented that shortly after midnight she was was summoned to assess the resident after the resident experienced a brief unresponsive episode after she sat upright. The resident skin was reported to be moist and cool and resident reported she had gotten dizzy. The vital signs were stable and the residents' fingerstick did not indicate [DIAGNOSES REDACTED]. The resident was assessed by the physician that morning and laboratory work was ordered. The laboratory report dated 11/28/12, documented the Hgb was 8.8, Hct was 27.3 and the INR was 1.7. The potassium level was 5.6 ( normal range 3.5-5.1) . The N/N dated 11/28/12 at 3:56 pm, documented that at the end of the shift the Certified Nursing Assistant (CNA) reported the resident had blood noted in the stool and that the resident had one episode of vomiting. The next note, dated 11/28/12 at 11:36 pm documented the resident had three episodes of bloody stool and one episode of vomiting. The resident had pale colored skin and complained of being weak while ambulating. The N/N note, dated 11/29/12 at 3:52 pm, documented the resident had blood in stool one time that day. The laboratory report obtained that day documented a Hgb of 7.6, Hct of 23.8, INR 1.2 and a fasting glucose of 668. The physician was notified and the resident was transferred to the hospital for a blood transfusion of one unit of packed cells and was administered 10 units of [MEDICATION NAME]and the resident was to return to the nursing home after the blood transfusion was complete. The N/N note , dated 11/30/12, documented that the resident had been admitted to the hospital. The hospital discharge summary, dated 12/5/12, documented that the resident was admitted on 11/29/12 due to melena and acute [MEDICAL CONDITION] secondary to acute bleeding following tooth extractions done while the resident was receiving [MEDICATION NAME] . During an interview on 2/15/13 at 11:25 am, the Register Nurse Manager (RNM) stated that she was aware of the resident pending surgery and that the oral surgeon and the family made the decision to not have the [MEDICATION NAME] and Aspirin held. The RNM stated that the resident and family did not want the medications held due to the fear of the resident having a stroke. The RNM stated she could not confirm if the family and/or resident was educated on the risks versus the benefits of having the medications held prior to the surgical extractions. During an interview on 12/15/13, the residents primary care physician at the nursing home stated that he was not aware that the resident was to have tooth extractions . He stated he first became aware after the extractions were done and the resident began to have the heavy bleeding. The physician stated that the family was very reluctant in the past to have the [MEDICATION NAME] and Aspirin held . The physician stated that in the past he had spoken with the son regarding [MEDICATION NAME] therapy. There was no evidence found that the resident and/or the son received education on the risks and benefits of surgical procedures while receiving blood thinning medications. During an interview on 2/15/13 at 2:30 pm and again on 2/19/13, the Licensed Practical Nurse ( LPN) stated that she did review the consult report from the oral surgeon and noted that the surgeon documented to keep the INR less than 3. The LPN was not able to confirm if the recommendation or request for medical clearance was placed in the physician communication book. The LPN stated the usual protocol , if the consult report had recommendations that required immediate attention, would be to notify the physician for telephone orders, then the report would be placed in the physicians communication book to be signed off. The LPN stated that the physician had not signed off on the medical clearance so she believed it was not reviewed by him. During an interview on 12/19/13 at 11:00 am, the family member stated that he did not receive education on the risks of the blood thinning medication not being held prior to the procedure. The family member further stated that he voiced his concerns to the surgeon, who informed him that he had performed this same procedure many of times without any problems. During an interview on 12/20/12 at 11:39 am, the oral surgeon stated that he had not received medical clearance from the facility physician. He stated he was aware of the resident current medication list. He stated he made the decision to perform the extractions because he received a verbal report from the facility that the resident's INR was 2.3 on 11/26/12. There was no evidence found that the resident's INR was 2.3 prior to the extractions. NY10CRR415.12