Every finding on record at Delaware Oaks Center for Rehabilitation and Nursin

Based on observation, interview, and record review conducted during a Complaint Investigation (2598732) during the Standard survey completed on 09/19/2025, the facility failed to protect residents from resident-to-resident sexual abuse for one (1) (Resident #12) of three (3) residents reviewed. Specifically, Resident #12 was touched inappropriately by Resident #51 and both residents lacked the ability to consent. The finding is: The policy titled Prevention, Investigation & Reporting Resident Abuse, Mistreatment, Injury of Unknown Source, Neglect & Misappropriation of Resident Property Effective 5/2024 and last reviewed 7/2024 documented that it was the facility's policy to prevent sexual abuse, and documented sexual abuse was defined as non-consensual sexual contact of any type with a resident. Resident #51 had diagnoses which included dementia, depression, and type 2 diabetes mellitus. The Minimum Data Set (a resident assessment tool) dated 08/29/2025 documented Resident #51 was severely cognitively impaired, was usually understood and usually understands others. The comprehensive care plan revised on 08/29/2025 documented that Resident #51 was at risk for being a victim due to their inability to understand their surroundings related to cognitive impairment, dementia, their dependence on others and their impaired mobility. Resident #12 had diagnoses including aphasia (a language disorder that affects a person's ability to communicate), Alzheimer's disease with early onset, and Post Traumatic Stress Disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). The Minimum Data Set, dated [DATE] documented Resident #12 was severely cognitively impaired, was rarely/never understood and sometimes understands others. The comprehensive care plan revised on 08/29/2025 documented that Resident #12 was a risk of being a victim due to their inability to understand their surroundings, related to cognitive impairment and dementia. Resident #12 was severely cognitively impaired and not able to make decisions for themselves. The documented interventions dated 5/30/2024 included to provide support and ensure resident was free from abuse. The resident exhibited behaviors such as hallucinations, delusions, wandering, aversion with hands on care, and medical treatments. Documented interventions initiated on 3/31/24 included to distract and offer pleasant diversions, determine cause of behavior and remove resident, medications as ordered, psych evaluations as needed, document behaviors, ensure safe comfortable environment. Resident #61's Minimum Data Set, dated [DATE] documented they were cognitively intact. The Complaint/Incident Investigation Report 2598732 submitted by the facility to the Internet Quality Improvement and Evaluation System on 08/23/2025 at 1:15 PM documented that on 08/22/2025 at 5:34 PM, Resident #61 reported they observed Resident #12 standing in front of Resident #51, at which time Resident #51 had placed their left hand under Resident #12's shirt and rubbed Resident #12's left breast. Review of the Nursing Home Investigative Report submitted by the facility on 09/01/2025 at 8:33 PM documented that there was reasonable cause to believe that abuse occurred. Review of the facility Accident/Incident form dated 08/22/2025 at 5:34 PM documented that Resident #61 reported to facility staff that they had witnessed Resident #12 standing in front of Resident #51, who was seated in their wheelchair and that Resident #51 had their left hand under Resident #12's shirt and was rubbing Resident #12's left breast. During an observation on 09/16/2025 at 9:51 AM, Resident #51 was in bed, and was not able to be interviewed. During an observation on 09/15/2025 at 10:56 AM, Resident #12 was dressed and resting on their bed and was not able to be interviewed. During an interview on 09/18/2025, Resident #61 stated they witnessed Resident #51 touch Resident #12 in an inappropriate manner. Resident #12 was standing close Resident #51, making noises, and Resident #51 was running their hands all over Resident #12. They reported this immediately to the Administrator. Review of an Employee Statement Form completed by Certified Nurse Aide #3 and dated and signed 09/10/2025 documented that on 08/22/2025 they witnessed Resident #51 put their hand up Resident #12's bra. A call was placed to Certified Nurse Aide #3 for interview without success. During a telephone interview on 09/19/2025 at 11:44 AM, Certified Nurse Aide #1 stated they worked during the evening shift on 08/22/2025 and Resident #51 had been brought back from an activity and was seated in their wheelchair near the elevator. Resident #12 had kept approaching #51, staff would intervene. Resident #51 was then moved to a different location. During an interview on 09/19/2025 at 9:00 AM, Registered Nurse #2 Unit Manager stated on 8/22/2025 Resident #12 was especially attention-seeking with Resident #51. Resident #51 was moved to another floor. The intervention immediately implemented was to keep Resident #12 away from male residents (within arm's length) and staff education. Resident #12 was seen by the facility medical provider for an acute visit the next day related to their behaviors, as needed medications were administered, and the resident was transferred to the hospital for a psychiatric evaluation. During an interview on 09/18/2025, the Administrator stated Resident #61 came to their office and reported they had observed Resident #51 touching Resident #12. The Administrator stated they immediately called the Nurse Supervisor (Registered Nurse #5) and instructed them to separate the two residents and initiate an investigation into the allegation. 10 NYCRR 415.4(b)(4)

Based on interview and record review conducted during Complaint investigation (2598732) during the Standard Survey completed on 09/19/2025, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse, to the administrator and to other state officials (including to the State Survey Agency) for two (2) (Residents #12 and #51) of three (3) residents reviewed. Specifically, the Administrator was notified of an allegation of resident-to-resident abuse and it was not reported to the State Agency within the required time frame.The finding is:Refer to F 600 Freedom from Abuse and NeglectThe policy titled Prevention, Investigation & Reporting Resident Abuse, Mistreatment, Injury of Unknown Source, Neglect & Misappropriation of Resident Property Effective 5/2024 and last reviewed 7/2024 documented that it was the facility's policy to prevent abuse and any suspected or actual violation required immediate reporting to the Administrator, Director of Nursing, Social Worker, Nursing Supervisor or House Charge Nurse on duty. Immediate action was to be taken to report any incident to the New York State Department of Health. It further documented the New York State Department of Health required immediate reporting of suspected or actual abuse to the Administrator of the facility and, when required by law or regulation to the New York State Department of Health via the Health Commerce System Network Incident Reporting Form or the Abuse Hotline. The New York State Department of Health must be contacted about alleged abuse if someone tells you they saw abuse. When reasonable cause is established that abuse may have occurred, the incident must be reported to the New York State Department of Health within 24 hours. The investigation does not need to be completed before reasonable cause is established.The Complaint/Incident Investigation Report 2598732 submitted by the facility to the Internet Quality Improvement and Evaluation System on 08/23/2025 at 1:15 PM documented that on 08/22/2025 at 5:34 PM, Resident #61 reported they observed Resident #12 standing in front of Resident #51, at which time Resident #51 had placed their left hand under Resident #12's shirt and rubbed Resident #12's left breast. During an interview on 09/18/2025, Resident #61 stated they witnessed Resident #51 touch Resident #12 in an inappropriate manner. Resident #12 was standing close to Resident #51, making noises, and Resident #51 was running their hands all over Resident #12. They reported this immediately to the Administrator. During an interview on 09/18/2025 at 11:45 AM, the Administrator stated that Resident #61 reported what they had observed to them immediately. The Administrator stated they immediately called the nurse supervisor (Registered Nurse #5) and instructed them to go to the unit to intervene. The Administrator stated they believed the nurse supervisor informed the Director of Nursing of the allegation and was instructed to start an investigation. The Administrator stated the abuse allegation should have been reported to the State Agency immediately and thought the Director of Nursing had completed the reporting. During an interview on 09/18/25 at 12:32 PM, the Director of Nursing stated they knew these types of abuse allegations needed to be reported to the New York State Department of Health immediately and no later than two (2) hours after an allegation was made. They stated they had not reported this on time, because they had not completed their investigation and had not determined if it had happened. 10 NYCRR 415.4(b)(4)

Based on observation, interview, and record review completed during a complaint investigation (#NY000373627), the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. Specifically, Resident #1 was on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms (MDRO) including gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment (gowns) during hands-on care while dressing, changing briefs, changing linens and performing wound care. The finding is: The facility's policy titled Barrier Enhanced Precautions last reviewed 1/2024 documented Enhanced Barrier Precautions expands the use of PPE (personal protective equipment) and designates the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi- drug-resistant organisms) to staff hands and clothing. The use of gown and gloves for high-contact resident care activities is indicated for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO (multi- drug-resistant organisms) colonization as well as for residents with MDRO (multi- drug-resistant organisms) infection or colonization. High contact resident care activities include, but are not limited to dressing, bathing/showering, transferring residents that require extensive hands-on assistance, changing linens, changing briefs or assisting with toileting that requires extensive hands-on assistance, device care or use, and wound care (chronic wounds rather than skin tears and abrasions). Resident #1 had diagnoses including hemiplegia (weakness of one side of body) and hemiparesis paralysis on one side of body) following cerebral infarction (stroke), osteomyelitis (infection of the bone) of the lumbar vertebrae (back), and a chronic sacrococcygeal (area above the tail bone on right and left buttocks and the tail bone) pressure ulcer. The Minimum Data Set (a resident assessment tool) dated 2/11/2025, documented Resident #1 had mild cognitive impairment, usually understood, and usually understands. Resident #1 required partial/moderate assistance for personal hygiene, and was dependent on staff for toileting hygiene, mobility to roll from side to side, and lower body dressing. In addition, Resident #1 had two stage II pressure ulcers (a partial-thickness skin loss involving the epidermis and/or dermis. It can look like a scrape (abrasion), blister, or a shallow crater in the skin) and one stage 4 (IV) pressure ulcer (extend to muscle, tendon, or bone). The Comprehensive Care Plan initiated on 02/7/25 revealed Resident #1 was at risk for infection related to osteomyelitis (infection) of vertebra lumbar (lower back) region with plans for enhanced barrier precautions and the resident required staff assistance for toileting and personal hygiene. During an observation on 3/19/2025 at 9:28 AM a sign for enhanced barrier precautions was posted on Resident #1's door and directed staff to utilize gowns and gloves for hands on care. Two Certified Nurse Aides #1 and #2, were observed at the resident's bedside wearing gloves, but no gowns preparing to provide hands on care after setting up the wash basin and linens. At 9:34 AM Certified Nurse Aide #2 gave the resident a wet washcloth to clean their face. The resident washed their face and gave the soiled washcloth to Certified Nurse Aide #2. Certified Nurse Aide #1 adjusted an incontinence pad underneath the resident's buttocks and helped undress the resident in preparation for toileting care. Certified Nurse Aide #2 washed the resident's perineum (genitals). At 9:38 AM Certified Nurse Aide #1 turned the resident towards Certified Nurse Aide #2 and during the task both Certified Nurse Aides' uniform clothing came in contact with the resident's bed linens. There was a large, bordered gauze dressing intact and clean on the resident's sacrum and buttocks. Certified Nurse Aide #1 washed the exposed area of the resident's buttocks. At 9:40 AM the resident was rolled on their other side toward Certified Nurse Aide #1. Licensed Practical Nurse #1 entered the room without donning (putting on) a gown and applied a treatment to the resident's buttocks after washing her hands and donning gloves. During the treatment the Licensed Practical Nurse #1's uniform came in direct contact with the bed linens. At 9:52 AM Certified Nurse Aide #2 asked Certified Nurse Aide #1 if Resident #1 was on precautions. Certified Nurse Aide #1 said no. At 9:53 AM Licensed Practical Nurse #1 completed wound care on a second wound on the resident's upper thigh. At 9:56 AM the two Certified Nurse Aides removed the soiled linens and placed clean linens on the bed which required rolling the resident from side to side. During an interview on 3/19/2025 at 9:58 AM, Licensed Practical Nurse #1 stated Resident #1 was on enhanced barrier precautions because of the open wounds; however, they didn't wear a gown because they knew the resident's wounds did not have any secretions. A gown was used to protect for soilage or contamination. Licensed Practical Nurse #1 stated enhanced barrier precautions were implemented for resident care to prevent transmission of infections. During an interview on 3/19/25 at 10:15 AM, Certified Nurse Aide #2 stated they didn't realize Resident #1 was on enhanced barrier precautions that was why they asked Certified Nurse Aide #2 if the resident was on precautions. Certified Nurse Aide #2 stated that they were relatively new and still learning the facility's practices and could not recall if they had received any education regarding enhanced barrier precautions. Certified Nurse Aide #2 stated they would wear what the personal protective equipment listed on the sign and verify this with other staff members. During an interview on 3/19/25 at 1:15 PM, Certified Nurse Aide #1 stated they didn't realize Resident #1 was on enhanced barrier precautions because they didn't notice the Personal Protective Equipment (PPE) set up located to the left of the door. Certified Nurse Aide #1 stated if the resident's door was open and the sign was not visible, they usually don't look to the left of the door. Certified Nurse Aide #1 stated the Personal Protective Equipment set-up was probably just put there yesterday or today. Certified Nurse Aide #1 stated the purpose of the precautions was to prevent the spread of infection. During an interview on 3/21/2025 at 3:32 PM, the Director of Nursing stated that Resident #1 was on enhanced barrier precaution because of their wound care for a Stage IV open pressure ulcer. Residents with wounds were supposed to be on enhanced barrier precautions which required staff to wear a gown and gloves during direct hands-on care. This included wound treatments, toileting hygiene, dressing, and changing linens to prevent the spread of infections. During a telephone interview on 3/26/25 at 3:23 PM, the Registered Nurse Infection Control Preventionist stated the facility implemented enhanced barrier precautions when residents have wounds that require wound care, and that Resident #1 had been on enhance barrier precautions during their entire length of stay in the facility. Staff were required to wear a gown and gloves during hands on care, changing linens, and providing wound care to prevent transmission of potential infections for staff and other residents and it is the responsibility of the entire team to enforce these infection control measures. 10 NYCRR 415.19(a)(2)

Based on observation, interaview and record review conducted during a Standard survey completed on 8/9/24, it was determined that the facility did not ensure that they maintained an effective pest control program so that the facility is free of pests and rodents. Specifically, two (Units 2 & 3) of two Resident Units and the Main Kitchen had issues with insects including house flies, spiders, and fruit flies. The findings are: The policy and procedure titled Pest Control dated January 2024 documented the facility would maintain an effective pest control program. The policy and procedure documented the facility maintains an ongoing pest control program to ensure the facility is free of insects. A request for exterminator service inspection reports from June 2024 to August 2024 was given to the facility. The facility did not provide exterminator service inspection reports from July 2024 and August 2024. Review of the June 2024 exterminator service inspection reports dated 6/13/24 documented that the drain flies have gotten worse and recommended a treatment. During observations on 8/5/24 from 7:00 PM to 7:45 PM: Second Floor East Shower Room - three small live flies on the plastic shower chair in the shower stall. Second Floor Dining Room - a plug-in style flying insect light trap was observed unplugged and sitting on the windowsill. Further observation revealed it had at least 14 small dead flies on the sticky paper. Second Floor Nurses' Station - a plug-in style flying insect light trap was plugged into a wall outlet. Further observation revealed it had at least 20 small dead flies on the sticky paper. During observations on 8/6/24 between 9:00 AM to 3:30 PM: Unit 3 nurses' station - many house flies noted at nurses' station. Unit 3 hallway outside of Resident room [ROOM NUMBER] - six small live flies in the vicinity. At the time of the observation, Maintenance Assistant #1 removed the saturated ceiling tiles from the ceiling and at least twelve more small live flies were observed in the opening. Kitchen - a plug-in style flying insect light trap was plugged into a wall outlet. Further observation revealed it had at least 50 small dead flies on the sticky paper; several small live flies were observed in the Dish Room and the Food Storage Room adjacent to the food preparation area. Resident room [ROOM NUMBER] - four houseflies on resident's food/meal tray; houseflies flew near resident's face/mouth. During observations on 8/7/24 between 9:00 AM and 4:00 PM: Resident room [ROOM NUMBER] - five live spiders noted on the ceiling over the resident's bed; two live spiders noted in spider web on the window. Unit 3 Hallway - three live flies landed on facility computer; additional flies flew through the hallway. Resident room [ROOM NUMBER] - three houseflies noted on resident's bed linen; three houseflies flew around resident's head. Resident room [ROOM NUMBER] - flies landed on resident's lunch tray. Resident room [ROOM NUMBER] - three flies landed on resident's television. Resident room [ROOM NUMBER] - flies were noted on the wall and the resident's over the bed table. Resident room [ROOM NUMBER] - rectangular insect glue tape was attached to the corner of the door-side resident's television and a strip insect glue trap hanging from the door-side resident's lamp. There were two dead houseflies on the insect glue tape and at least four small dead flies on the strip. Resident room [ROOM NUMBER] - six to seven live houseflies on the tray table at the door-side bed. Additionally, a live housefly was observed on the door-side resident's forehead and on the blanket that covered their legs. Resident room [ROOM NUMBER] - 10 to 15 small live flies in the bathroom and six to ten additional live houseflies in the bedroom. Resident room [ROOM NUMBER] - eleven small live flies on the wall above the window-side bed. There were at least ten small live flies and two live houseflies on the wall above the door-side bed. Additionally, on the privacy curtain between the door-side bed and the door were more than 20 small live flies and five more houseflies on the ceiling tiles in this room. Resident room [ROOM NUMBER] - four live small files on the wall between the bed and the bathroom wall. Unit 3 hallway outside of Resident room [ROOM NUMBER] - at least seven small live flies were in the vicinity. During observations on 8/8/24 between 9:00 AM to 2:00 PM: Therapy Room - a housefly landed on resident. Resident room [ROOM NUMBER] - seven live spiders noted above resident's bed on the ceiling and two live spiders on spider web in window. Resident room [ROOM NUMBER] - houseflies flew around the resident in the window-side bed and the tray table over the window-side bed. The tray table contained the resident's lunch, and a housefly was observed flying around a bowl of baked beans. Resident room [ROOM NUMBER] - one housefly and two fruit flies on over the bed table with one housefly on privacy curtain. During an interview on 8/5/24 at 7:45 PM, the Director of Maintenance stated there had been an uptick in fly activity in the facility in the last few weeks and they informed their contracted licensed exterminator and added six or seven plug in style devices around the facility to help the situation. During an interview on 8/6/24 at 10:26 AM, the Director of Maintenance stated the sticky paper needed to be replaced in the plug-in device in the kitchen. During an interview on 8/7/24 at 10:47 AM, Resident #92 stated the spiders above their bed bothered them and said, wouldn't they bother you? Resident #92 also stated they did tell staff about the spiders. During an interview on 8/7/24 at 11:45 AM, Resident #40 stated they had have had flies in their room for one or two months. They stated, Flies are always in my face, it is a pain in the butt. During an interview on 8/7/24 at 12:02 PM, the Housekeeping Supervisor stated they did not know where the flies originated from. The Housekeeping Supervisor stated they were not aware of any specific issue with flies in resident rooms. During an interview on 8/7/24 at 1:27 PM, Resident #89 stated flies were always around and that was why they wanted to keep a lid on their lunch tray, so the flies did not land on their food. During an interview on 8/7/24 at 1:50 PM, Housekeeping Aide #2 stated there were many flies and told their supervisor about them. During an interview on 8/7/24 at 2:45 PM, the Director of Maintenance stated the facility had a contract with a licensed exterminator for two visits per month. They stated they were made aware that small flies were being observed in the facility around mid-July 2024. At that time, the facility increased the frequency of the exterminator's visits to weekly, and since 7/24/24, the exterminator has completed two treatments for the flies. The Director of Maintenance stated they did not have documentation for the fly treatments, but they had requested it from the exterminator. During an interview on 8/8/24 at 1:45 PM, Resident # 15 stated they saw flies every day and it annoyed them. During an interview on 8/8/24 at 1:47 PM, Resident #148 stated they had been at the facility for two weeks and noticed flies in their room earlier this week. Their spouse brought in glue traps to get the flies, which they thought were common houseflies and fruit flies. Resident #148 stated three days ago, they placed a glue trap on their tray table, and it caught eight flies. They further stated the flies were unsanitary and annoying and they could feel them on their body when they tried to sleep. Resident #148 stated they chose to eat their meals in their room and when asked if the flies bothered them while they ate, Resident #148 responded, Wouldn't they bother you? During an interview on 8/9/24 at 8:52 AM, Licensed Practical Nurse #1, they stated the flies have been in the facility at least a month. They stated the facility needed to fix the windows so that flies and other bugs don't come into the building. During an interview on 8/9/24 at 9:55 AM, Licensed Practical Nurse #2, they stated that the flies have been in the building at least the last two weeks. They stated that flies would bother the residents. During an interview on 8/9/24 at 9:07 AM, Registered Nurse Unit Manager #2, stated the flies have been here for at least two weeks ago. Registered Nurse Unit Manager #2 stated the staff try to remove food trays timely to keep food off the floor. They stated they have seen flies on residents and staff remembers trying to keep them off residents. During an interview on 8/9/24 at 9:55 AM, the Administrator, they stated were aware of insects in the building. They stated it is a team effort to keep the insects in check. They stated that staff need to throw out food or other things that may attract insects. 10NYCRR 415.29 (j)(5)

Based on observation, interview, and record review conducted during Complaint investigations (#NY00336247 and #NY00319578) during a Standard survey completed on 8/9/24 the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior were provided for one (Unit 3) of two resident units. Specifically, the facility roof was in disrepair and actively leaking resulting in stained and wet ceiling tiles. Additionally, there were walls and floors in disrepair, urine odors, a soiled privacy curtain and a broken window. The findings are: The policy and procedure titled Maintenance Service dated 1/24 documented that maintenance service shall be provided to all areas of the building, grounds, and equipment. a. Observation on the Third Floor on 8/5/24 at 6:40 PM revealed the walls of the shower stall in the [NAME] Shower Room were in disrepair. Further observation revealed the bottom of the plastic shower surround panels were soft and speckled with a brownish-black substance. There was no caulk or sealant between the walls and the shower floor. During an interview on 8/6/24 at 8:55 AM, the Director of Maintenance stated the bottom of the shower stall was caulked about three months ago, and it needed to be scrubbed and caulked again. b. During observations on 8/6/24 between 8:00 AM to 12:35 PM on Unit 3: Resident room [ROOM NUMBER] - a two foot by two-foot ceiling tile brown, bowed, and wet. Resident room [ROOM NUMBER] - urine smell in the room. Resident room [ROOM NUMBER] - urine smell in the room. Resident room [ROOM NUMBER] - wall across from bathroom with molding was removed, multiple gouges in the walls exposing drywall, and a wallpaper border at the top of the walls torn and in disrepair. Nurses Station - strong urine odor. Resident room [ROOM NUMBER] - water actively dripping into a garbage can below. Further observation revealed two ceiling tiles were saturated and bowed downward. At the time of the observation, Maintenance Assistant #1 removed the saturated ceiling tiles from the ceiling which easily fell apart. Additional observation revealed three floor tiles below this area in the corridor were curled up on the edges. Resident room [ROOM NUMBER] - the wall at the head of the bed had a large piece of fabricated white material approximately two feet by two feet screwed to the wall all the way around. The corner seam adjacent to the closet was in disrepair from floor to ceiling with cracked chipped drywall. The floors in the room were sticky throughout and the room had a urine odor. During an interview on 8/6/24 at 8:07 AM, Resident #47 stated that sometimes the staff would put a bucket underneath a leaking ceiling tile to catch the water. They also stated that the ceiling was still leaking, and they wish it would stop. During a telephone interview on 8/6/24 at 8:12 AM, Resident's #76's representative they stated that the hallways smell like urine and feces when they visit the facility. During an interview on 8/6/24 at 9:10 AM, the Director of Maintenance stated Maintenance staff patched the roof with a silicone product at the end of summer or beginning of fall in 2023. The Director of Maintenance stated the patch held until spring 2024. They further stated this area actively leaked when it rained. Additionally, they stated the floor tiles in the area had already been replaced, but new water damage had occurred. During an interview on 8/8/24 at 9:48 AM with Housekeeping Aide #1 stated that housekeeping was responsible for cleaning resident rooms. During an interview on 8/9/24 at 10:21 AM, Resident #51 stated that the hallways smell like urine. During an interview on 8/8/24 at 3:20 PM, the Director of Maintenance stated there was an active leak from the roof above Resident room [ROOM NUMBER]. They stated they were told the roof was patched four years ago in this area. The patch held until about two weeks ago when it began to leak again. The Director of Maintenance stated Maintenance staff were keeping an eye on the area and changed ceiling tiles every time they showed brown rings, which meant they were wet. They also stated if there was a hard rain, they would likely have to move the resident out of the room. The Director of Maintenance further stated they were waiting for corporate personnel to go ahead with one of the five contractor's estimates that they submitted, and in the meantime, they did not think adding another layer of silicone patch would be effective, as the whole roof needed to be re-surfaced. Review of the Maintenance Work Order dated 7/31/24, it documented a roof leak in Resident room [ROOM NUMBER]. Review of additional Maintenance Work Orders dated 8/5/24 and 8/6/24, it documented a roof leak in Resident room [ROOM NUMBER]. c. During observations and interviews on 8/7/24 between 9:00 AM and 2:00 PM on Unit 3 revealed the following: Shower Room - black spots and debris along the bottom of the wall where the floor molding was missing; and rust stain dripping from a shower grab bar with a brownish substance on the shower wall. Resident room [ROOM NUMBER] - Privacy curtain with brownish tan debris splattered on it and a cracked window. The resident in the room at the time of the observation stated the privacy curtain was disgusting and the window was broken. Corridor outside of Resident room [ROOM NUMBER] - two ceiling tiles in the corridor outside of Resident room [ROOM NUMBER] had brown water stains that appeared to be fresh. During an interview on 8/7/24 at 12:35 PM, the Director of Maintenance stated the ceiling tiles outside of Resident room [ROOM NUMBER] had been replaced this morning (8/7). They also stated it hadn't rained in twelve hours, but water puddled in this area of the roof and some water was still leaking through after the rain ended. During an interview on 8/8/24 at 3:12 PM, the Director of Maintenance stated they were not aware of a cracked windowpane in Resident room [ROOM NUMBER]. d. During an interview on 8/5/24 at 7:07 PM, Resident #42 stated they were moved to another room when the ceiling tiles fell because of the leaking roof. During an observation on the Third Floor on 8/8/24 at 10:10 AM revealed a drain hose ran from the ceiling into the sink in the bathroom of Resident room [ROOM NUMBER]. Further observation revealed a five foot long by five-foot-wide tarp was installed above the ceiling tiles, above the area of the door-side bed in Resident room [ROOM NUMBER]. The drain hose that was observed in the bathroom sink originated at the center of the tarp. During an interview on 8/8/24 at 10:10 AM, the Director of Maintenance stated there was an active roof leak in the area above the door-side bed in Resident room [ROOM NUMBER] and the tarp was added around March 2024 to control the leaking. They also stated every few days, and especially after rain, Maintenance staff checked the tarp in this room and cleared any water that may still be in the drain hose. During an interview on 8/9/24 at 9:55 AM, the Administrator stated that they expect housekeeping to clean the rooms according to the cleaning schedule and they expect the housekeeping supervisor to do clean room audits. The Administrator stated they were aware of the ceiling/roof issues, there were estimates for the repairs, and that they were waiting for corporate to approve the repair. Review of roof repair estimate dated 1/16/24 documented that a new roof flashing and a new roof membrane was needed to repair the roof. Review of a roof repair estimate dated 5/28/24 documented that a new roof was needed for the building. NYCRR 10 415.5(h)(2)

Based on observation, interview, and record review conducted during a complaint investigation (Complaint #NY00330109) during the Standard survey completed on 8/9/24, the facility did not ensure the resident's right to be free from abuse for one (Resident #72) of 7 residents reviewed for abuse. Specifically, Resident #72 wandered into Resident #61's room on two separate occasions where a resident-to-resident altercation occurred that resulted in minor injuries to Resident #72. Additionally, care plan interventions (stop signs in doorway) to keep Resident #72 out of the room, were not in place. The finding is: The policy and procedure titled Abuse Prohibition Protocol, Types of Abuse, Response/Reporting dated 1/24 documented every resident has the right to be free from abuse and the facility would do all that is in their control to prevent such occurrences. Physical abuse includes acts of violence like striking (with or without an object), hitting, and shoving. 1. Resident #72 had diagnoses including dementia, hypothyroidism, and vitamin D deficiency. The Minimum Data Set (a resident assessment tool) dated 5/8/24 documented the resident had severe cognitive impairment and had wandering behaviors that significantly intruded on the privacy of others. The comprehensive care plan dated 12/20/23 documented the Resident #72 was at risk for being taken advantage of related to cognitive impairment and dementia. Interventions included a second stop sign was added to Resident #61's doorway to prevent Resident #72 from wandering into that room. Resident #61 had diagnoses including schizophrenia, major depressive disorder, and chronic pain. The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact and had verbal behaviors directed toward others. The comprehensive care plan dated 12/20/23 documented Resident #61 had a second stop sign added to their doorway. An undated Care Plan Detail report documented Resident #61 interventions/tasks included a second stop sign was added to their doorway. The Event Summary Resident report dated 12/18/23, completed by the Regional Clinical Director, documented that Resident #72 wandered into Resident #61's room. Resident #61 then hit Resident #72 in the head with a bed remote. Staff responded immediately when they head yelling and removed Resident #72 from Resident #61's room. Resident #72 had a small bump on the back of their head. Per staff Resident #72 sometimes removes the stop signs or goes under them to get into rooms. An intervention for a second, lower stop sign was to be placed on Resident #61's doorway. Review of an untitled, unsigned document dated 5/26/24, documented Resident #72 was found with two hematomas (collection of blood under the skin) on their head that were bleeding. The supervisor was directed to review camera footage which showed the Resident #72 entered Resident #61's room and was in there for five minutes. When Resident #72 exited the room, they were holding their head. Upon initial approach Resident #61 denied anything happened, but then admitted they hit Resident #72 with their television remote because the resident entered their room and started going through their things. The accident and incident report dated 5/26/24 at 9:48 PM documented interventions for the resident-to-resident altercation between Residents #72 and #61 were to place Resident #72 on 15-minute checks for 48 hours and a room change to promote safety. During an observation on 8/5/24 at 7:41 PM, 8/6/24 at 9:52 AM and 8/7/24 at 8:09 AM, there were no stop signs across Resident #61's doorway. There were no stop signs in the area at all. Resident #61 was lying in their bed. During an observation on 8/8/24 at 7:39 AM, two stop signs were hanging down the left side of Resident #61's doorway, they were not across the doorway, there were no staff in the room at this time. Resident #61 was lying in their bed. During an interview on 8/8/24 at 3:21 PM, Certified Nurse Aide #9 stated Resident #72 always wandered and staff would try to redirect them. There have been a couple incidents between Resident #72 and #61. The Certified Nurse Aide stated they put two stop signs up, but Resident #61's roommate takes them down when they go in and out of the room without putting them back up. Also, Resident #72 was known to take the stop signs down. During an interview on 8/8/24 at 3:36 PM, Certified Nurse Aide #10 stated they found Resident #72 walking down the hall holding their face and bleeding on 5/26/24. Certified Nurse Aide #10 stated Resident #72 tends to want to wander down that specific hallway more than the other hallways and the stop signs weren't working. Certified Nurse Aide #10 stated the incidents between the residents were considered physical abuse. During an interview on 8/8/24 at 4:22 PM, Licensed Practical Nurse #8 stated the incident in May was unwitnessed. They frequently checked placement of the stop signs but Resident #72 has taken them down in the past. Staff redirect the resident, but someone isn't with her one on one. During an interview on 8/9/24 at 8:50 AM, Registered Nurse Unit Manger #2 stated Resident #72 wanders, goes up and down the hallways and was easily redirected. Registered Nurse Unit Manager #2 stated they thought the stop signs were working and nobody had reported that Resident #72 had taken down the stop signs since they had started working in the facility two weeks ago, but they have heard this was something the resident has done in the past. The stop signs can be easily removed, they are a visual deterrent and not a barricade. Registered Nurse Unit Manager #2 stated they didn't know if the stop signs were up on Monday or Tuesday. There was no schedule for checking the stop signs. They just do it on rounds or when walking by the room because of the roommate taking them down. Registered Nurse Unit Manager #2 stated they wouldn't comment on whether the resident-to-resident incidents were considered abuse because they didn't work at the facility during those times. During an interview on 8/9/24 at 10:08 AM, the Director of Social Work stated in the instances of the resident-to-resident incidents involving Resident #72 and Resident #61, Resident #72 wandered into Resident #61's room and got into the resident's personal space. Resident #61 then lashed out. Resident #72 does seem to be drawn to that specific room, so stop signs were placed and black tape was placed in front of the doorway. The Director of Social Work stated they considered Resident #61 hitting Resident #72 to be abuse and the resident's right to be free from abuse was not maintained. They stated there were periods of time that the stop signs were successful and there were no incidents, then unsuccessful. They do ask staff their opinions for interventions because they were with the residents all the time, Resident #61 refused a move or bed change. During an interview on 8/9/24 at 10:58 AM, the Director of Nursing stated the supervisor called them the evening of 5/26/24 and reported the resident had some bleeding and they thought they fell . The Director of Nursing directed the supervisor to watch the camera footage with the security guard. When they watched footage the Resident #72 wandered into Resident #61's room and when they exited, they were holding their head. When they interviewed Resident #61 about it, they eventually admitted they hit Resident #72 with a television remote because they were messing with their things. They moved Resident #72's room down the opposite end of the unit. The Director of Nursing stated they didn't think this was an abuse situation because the residents don't really know what they were doing most of the time and Resident #61 had a psych disorder. During an interview on 8/9/24 at 12:42 PM, the Administrator stated they would consider the incidents that involved Resident #61 and Resident #72 to be abusive and that Resident #72 had the right to be free from abuse. 10 NYCRR 415.4(d)(1)(vii)

Based on observation, interview, and record review conducted during a Complaint investigation (NY00345819) during a Standard survey completed on 8/9/24, it was determined the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for two (Residents #61 and #63) of nine residents reviewed. Specifically, the residents did not have a stop sign/s across their doorway to deter other residents from entering their room as planned. The finding is: The policy and procedure titled Care Plan, Comprehensive Person-Centered dated 1/24 documented that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Resident #63 was admitted to the facility with diagnoses of schizoaffective disorder and bipolar disorder (mental health conditions.) The Minimum Data Set (MDS - a resident assessment tool) dated 4/25/24 documented the resident was understood, understands and was cognitively intact. The comprehensive care plan with a revision date of 6/18/24 documented there were safety concerns related to Resident #63's impulsive behaviors at times and involvement with resident-to-resident altercations. Interventions included Resident #63 was to have a stop sign across doorway of their room. The Kardex (a guide used by staff to provide care) dated 6/19/24 documented Resident #63 was to have a stop sign across their doorway. During an observation on 8/5/24 at 8:16 PM, Resident #63's doorway did not have stop sign in place across their door. During an observation on 8/6/24 at 9:01 AM, Resident #63 was sitting up in bed, there was no stop sign in place across their doorway of Resident #63's room. During an observation on 8/7/24 at 8:43 AM, Resident #63 was not in room and there was no stop sign in place across their doorway. During an observation and interview on 8/8/24 at 9:43 AM, Resident #63 was observed in their room, and there was no stop sign across their doorway. Resident #63 stated they had never had a stop sign on their doorway. During an interview on 8/8/24 at 9:55 AM, Certified Nursing Assistant #3 stated they were not aware if Resident #63 had a stop sign for their doorway and if it was on the Kardex. They stated the nurses would communicate to them what residents had stop signs. During an interview on 8/8/24 at 3:44 PM, Licensed Practical Nurse #6 could not recall if a stop sign had been implemented for Resident #63 after a resident-to-resident altercation. During an interview on 8/9/24 at 9:15 AM, Certified Nursing Assistant #6, stated they had not seen a stop sign on Resident #63's door. During an interview on 8/9/24 at 9:35 AM, Registered Nurse Supervisor #1 stated they placed a stop sign on Resident #63's doorway 6/18/24 after a resident-to-resident altercation to prevent other resident's from entering Resident #63's room. They stated they updated the care plan and documented the intervention in the electronic medical record. Registered Nurse Supervisor #1 stated they were not aware if Resident #63's still had the stop sign in place. During an interview on 8/9/24 at 9:46 AM, the Director of Nursing stated that stop signs were used to deter other residents from entering another resident's rooms. They stated stops signs should be documented on both the care plan and Kardex. The Director of Nursing stated that if a resident's stop sign was not in place, they would expect staff to report it to the Nurse Manager, Supervisor, or the Director of Nursing and have it replaced. 2. Resident #61 had diagnoses including schizophrenia, major depressive disorder, and chronic pain. The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact and had verbal behaviors directed toward others. The comprehensive care plan dated 12/20/23 documented Resident #61 had a second stop sign added to their doorway. An undated Care Plan Detail report documented Resident #61 interventions/tasks included a second stop sign was added to their doorway. During an observation on 8/5/24 at 7:41 PM, 8/6/24 at 9:52 AM and 8/7/24 at 8:09 AM, there were no stop signs across Resident #61's doorway. There were no stop signs in the area at all. Resident #61 was lying in their bed. During an observation on 8/8/24 at 7:39 AM, two stop signs were hanging down the left side of Resident #61's doorway, they were not across the doorway, there were no staff in the room at this time. Resident #61 was lying in their bed. During an interview on 8/8/24 at 3:21 PM, Certified Nurse Aide #9 stated they put two stop signs up, but Resident #61's roommate takes them down when they go in and out of the room without putting them back up. Also, other residents may take them down. During an interview on 8/8/24 at 4:22 PM, Licensed Practical Nurse #8 they frequently checked placement of the stop signs, but residents take them down. During an interview on 8/9/24 at 8:50 AM, Registered Nurse Unit Manger #2 stated the stop signs can be easily removed, they are a visual deterrent and not a barricade. Registered Nurse Unit Manager #2 stated they didn't know if the stop signs were up on Monday or Tuesday. There was no schedule for checking the stop signs. They just do it on rounds or when walking by the room. NYCRR10 415. 11 (c) (1)

Based on observation, interview, and record review conducted during a Standard survey completed on 8/9/24, the facility did not ensure that when the use of a restraint was indicated, the facility used the least restrictive alternative for the least amount of time for one (Resident #76) of one resident reviewed. Specifically, the resident's seatbelt restraint was not released every two hours as ordered. The finding is: The policy and procedure titled Use of Restraints dated 1/24 documented a physical restraint was defined as any manual method or mechanical device attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement. The opportunity for motion and exercise is provided for a period of not less than 10 minutes during each two hours of restraint use. Resident #76 had diagnoses including cerebral palsy (abnormal brain development that affects ability to control muscles), seizures, and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 6/14/24 documented Resident #76 had severe cognitive impairment, and they used a physical restraint when in their chair. The Restraint Evaluation dated 7/29/24 documented Resident #76 used a wheelchair seat belt, the resident was unable to release it, and it was considered a restraint. Review of the Order Summary Report revealed a provider order dated 4/25/24 for a seatbelt in the resident's chair related to muscular weakness/cerebral palsy. Staff were to release the restraint every two hours and as needed for safety. The comprehensive care plan dated 6/3/24 documented Resident #76 used a physical restraint for positioning related to cerebral palsy. Interventions included to release the seatbelt every two hours for toileting or repositioning. The Bedside Kardex Report (a guide used by staff to provide care) dated 8/8/24 documented the seatbelt was supposed to be released every two hours for toileting or repositioning. During a continuous observation on 8/8/24 from 7:35 AM to 10:33 AM Resident #76 sat in their wheelchair with their seatbelt in place. The seat belt restraint was not released during this timeframe. During an interview on 8/8/24 at 10:47 AM, Certified Nurse Aide #7 stated they arrived to work at 9:00 AM, were told to stay with Resident #76 and that their seatbelt needed to be released at 11:00 AM. Certified Nurse Aide #7 stated restraints needed to be released every two hours and wasn't sure why. During an interview on 8/8/24 at 10:53 AM, Licensed Practical Nurse #1 stated the resident got up at 6:45 AM that morning and restraints were supposed to be released every two hours. The seatbelt was for positioning but was considered a restraint. During an interview on 8/8/24 at 12:29 PM, Certified Nurse Aide #8 stated they didn't release the seat belt that morning during breakfast because that was when Resident #76 was most grabby and jumpy and after that (meal) another aide was with the resident. During an interview on 8/9/24 at 8:47 AM, the Registered Nurse Unit Manager #2 stated the seatbelt wasn't considered a restraint and Resident #76 can reposition themselves in their chair. The Registered Nurse Unit Manager #2 stated the seatbelt was supposed to be released periodically, every two hours by the assigned Certified Nurse Aide. Staff know to do this because it was on the care plan, and it was important to release it to make sure the resident could move freely and for safety. During an interview on 8/9/24 at 10:54 AM, the Director of Nursing stated the seatbelt was supposed to be released every two hours when the resident was out of bed, and it was used for positioning in their chair. Either the assigned certified nurse aide or the nurse could remove it. 10 NYCRR 415.4(a)(5)(i)

Based on observation, interview, and record review conducted during a Standard survey completed on 8/9/24, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #49) of one resident reviewed. Specifically, the Physician Wound Consultants recommendations for an air mattress were not implemented. The finding is: The facility policy and procedure titled Consultations, last revised 1/24, documented the facility is responsible to provide consultation services for any residents as needed. The facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility, and the timeliness of the services. Nursing will notify physician of consultation and any recommendations if physician is not at facility. Physician will approve any orders he/she agrees with on consult. Physician will document if he/she agrees on consult. The facility policy and procedure titled Weekly Wound Assessment/Rounds, last revised on 1/24, documented the physician will help staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop. The physician will authorize pertinent orders related to wound treatments. If the resident is not responding to established regimen, the nurse/medical professionals shall evaluate need for treatment change or reassess need for interdisciplinary services. Resident #49 had diagnoses that included chronic obstructive pulmonary disease (COPD, lung disease), type 2 diabetes mellitus, and peripheral vascular disease (poor circulation of lower extremities). The Minimum Data Set (a resident assessment tool) dated 6/26/24 documented Resident #49 was cognitively intact, was understood and understands. Additionally, the Minimum Data Set documented that Resident #49 had three Stage 3 pressure ulcers (full thickness tissue loss). The comprehensive care plan (identified as current) dated 7/21/2020 with a revision date of 8/9/24 documented Resident #49 had a pressure ulcer to right thigh with a goal that ulcer will heal prior to next review. The care plan documented the resident had a history of being verbally aggressive towards staff and refusing treatment recommendations. The comprehensive care plan did not include the use of an air mattress as recommended. Review of wound assessment and plan dated 5/31/24 revealed Resident #49 had a Stage 3 pressure ulcer on the left posterior (back) thigh that required additional preventative treatment. An air mattress was recommended by Physician Wound Consultant. Review of additional Wound Consults dated 7/7/24, 7/12/24, 7/19/24, 7/28/24 and 8/2/24 revealed an air mattress continued to be recommended. The 7/12/24 note documented the pressure ulcer on the left thigh was healing and decreased in size. Physician Progress Note dated 6/10/24 at 1:16 PM completed by Physician Assistant #1 documented they were asked to review Resident #49's wound team evaluation and recommendations. Physician Assistant #1 documented they agree with current wound team comprehensive evaluation and recommendations. Physician Wound Consultants input is greatly appreciated, wounds evaluated and treated appropriately per Physician Wound Consultants recommendations. There were no follow up physician or nursing progress notes that documented the recommendation was carried out. During intermittent observations made on 8/7/24 at 8:24 AM and 1:36 PM, and 8/8/24 at 11:07 AM, Resident #49 was in bed and there was no air mattress present on bed. During an observation on 8/7/24 at 1:40 PM Licensed Practical Nurse #5 provided pressure ulcer care to Resident #49's pressure ulcers. At this time, there was no air mattress present on the bed. Resident #49 was observed a quarter sized open area on their left posterior thigh. During an interview on 8/8/24 at 12:10 PM, Certified Nurse Aide #5 stated Resident #49 did not have an air mattress on their bed and was not aware that they may have needed one. During an interview on 8/8/24 at 12:11 PM, Registered Nurse Unit Manager #3 stated were aware of Resident #49's pressure ulcer. Registered Nurse Unit Manager #1 reviewed the wound consults and stated they could not say why the recommendations made by the Physician Wound Consultant were not followed. During an interview on 8/8/24 at 12:17 PM, Licensed Practical Nurse #5 stated they were aware Resident #49 had a pressure ulcer and were unaware of the recommendation for an air mattress for Resident #49's bed. During an interview on 8/8/24 at 2:00 PM, the Director of Nursing stated when recommendations for wound care were made, the consults were placed in the providers mailbox by the nurse. The provider comes in and reviews the consults and carries out (writes order) any recommendations made. During an interview on 8/9/24 at 10:24 AM, the Physician Wound Consultant stated they recommended an air mattress for Resident #49 on 5/31/24. The Physician Wound Consultant stated they had not noticed and was not aware the air mattress was not placed on Resident #49's bed. Physician Wound Consultant stated Resident #49 would benefit from having the air mattress. During an interview on 8/9/24 at 11:13 AM, the Director of Nursing stated that if a recommendation was made by the wound consultant, they would expect the facility provider to be updated by the Unit Manager and the recommendation to be carried out. 10NYCRR 415.12 (c) (1)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/9/24, the facility did not ensure that a resident with limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion for one (Resident #5) of one resident reviewed for positioning and mobility. Specifically, Resident #5 had a contracture (loss of joint mobility) and was not provided a device to prevent further contracture. The finding is: The facility policy and procedure titled Contracture Management, last revised on 1/24, documented the facility will engage residents as appropriate in contracture management interventions to improve, maintain and prevent the deterioration of mobility of joints, flexion (bending of a joint) and extension of extremities. A joint contracture is characterized by chronically reduced range of motion secondary to structural changes in non-bony tissues, including muscle, tendons, ligaments, and skin. Prolonged immobilization of joints or trauma are the most common causes of joint contractures. Additionally, all residents will be assessed for range of motion of resident joints and muscles. Upon examination, recommendations are made to the medical professional for treatments and/or orthotics as appropriate. Resident #5 had diagnoses that include hemiplegia (paralysis on one side of body) and hemiparesis (weakness of one side of body) following cerebral infarction (stroke). The Minimum Data Set (a resident assessment tool), dated 6/12/24, documented Resident #5 had severe cognitive impairment, rarely/never understood, and sometimes understands. The Minimum Data Set documented that Resident #5 and was totally dependent on staff for all activities of daily living and had functional limitation in range of motion of both upper extremities. The comprehensive care plan dated 8/6/2020, with a revision date of 6/23/24, documented Resident #5 was at risk for impaired skin integrity related to decreased mobility with an intervention added on 3/2/21, to prevent resident from scratching and keep hands and body parts from excessive moisture, keep fingernails short. There was no rolled washcloth to left hand documented on comprehensive care plan. Review of a physician progress note dated 3/12/19 revealed Resident #5 had an admitting diagnosis of contracture of the left side of the body. The Task List Report (guide for staff) for Resident #5 dated 8/9/24 at 9:26 AM, documented Resident #5 had an intervention in place to have rolled washcloth in left palm to be worn at all times except for hygiene and report any abnormal observations to the nurse initiated on 12/30/21 and cancelled on 11/1/22. Review of Certified Nurse Aide task schedule for August 2024, dated 8/9/24 at 9:30 AM, documented Resident #5 had a task for a rolled washcloth in left palm to be worn at all times. This task was grayed out indicating it was not active and there were Xs in the boxes indicating staff did not complete this task. An Occupational Therapy note dated 10/17/23, documented Resident #5 was referred for skilled therapy evaluation for potential improvement with grooming/hygiene and to address bilateral upper extremity hand contractures. There was no functional limitation due to contractures. An Occupational Therapy Discharge Summary, dated 11/16/23, documented long-term goal met on 11/16/23 that Resident #5 will tolerate 15 minutes of passive range of motion to reduce risk of worsening contractures. An Occupational Therapy note dated 6/11/24, documented Resident #5 was referred to therapy by nursing to manage bilateral hand contractures and positioning for hand range of motion and comfort to prevent worsening of contractures and skin breakdown. There was a functional limitation present due to contractures in bilateral hands, worse on left side. Recommendations were documented as splint/orthotic recommendations: to be determined. Risk factors were documented that Resident #5 was at risk for muscle atrophy (the partial or complete wasting away of a body part or tissue). An Occupational Therapy Discharge Summary, dated 7/9/24, documented Resident #5 met long-term goal that occupational therapy would determine appropriate orthotic device that promotes neutral wrist and digit positioning for bilateral hand placement and positioning to prevent contractures. Rolled washcloth because this provides patient with most hygienic and optimal hand positioning. The discharge recommendations documented to follow care plan as directed and reach out to therapy with questions or concerns. During intermittent observations on 8/7/24 at 8:29 AM, 11:56 AM, 1:36 PM, and 8/8/24 at 7:58 AM and 1:22 PM, Resident #5 was lying in bed with no rolled washcloth present to left hand. During an interview on 8/8/24 at 9:23 AM, Certified Nurse Aide #4 stated they have seen rolled washcloths in Resident #5's hands prior but was not sure if they were supposed to have them. During an interview on 88/24 at 9:43 AM, Licensed Practical Nurse #5 stated they were not aware of any rolled washcloth order to Resident #5's left hand. During an interview on 8/8/24 at 9:54 AM, Rehab Aide stated they thought Resident #5 had a palm guard or rolled washcloth in place to their left hand. During an interview on 8/8/24 at 9:57 AM, Occupational Therapist stated they worked with Resident #5 recently and noticed that Resident #5's left hand was contracted. Occupational Therapist stated that if there wasn't a washcloth in place to Resident #5's left hand then there should be. Resident #5 had used the rolled washcloth in the past and it had been effective for them. If the rolled washcloth wasn't in place it could lead to worsening contractures, skin break down, and pain. Occupational Therapist stated they were going to add a rolled washcloth to Resident #5's Certified Nurse Aide tasks for Resident #5. During an interview on 8/8/24 at 10:35 AM, Occupational Therapist stated they made a clerical error after Resident #5's evaluation in June and forgot to add the rolled washcloth as a task for the Certified Nurse Aide to apply. During an observation and interview on 8/8/24 at 10:57 AM, Occupational Therapist measured the flexion (bending of a joint) and extension (opening of joint) of Resident #5's upper extremity joints. Occupational Therapist stated according to the measurements, Resident #5 has a contracture in the proximal (closer to the point of attachment to the body) joint of left hand. During this observation, Occupational Therapist opened Resident #5's left hand and there were 3 indentations from the fingers in the palm of the hand. Occupational Therapist stated moisture and bacteria could build up and cause infection. During an interview on 8/8/24 at 12:07 PM, Certified Nurse Aide #3 stated they have seen rolled washcloths in Resident #5's hand before and they were used so that their hand does not get contracted and to keep it clean. During an interview on 8/8/24 at 12:16 PM, Certified Nurse Aide #5 stated sometimes Resident #5 had rolled washcloths in their hand but does not know why. During an interview on 8/8/24 at 2:01 PM, Occupational Therapist stated when there were changes made to a resident's plan of care after an evaluation the therapist will place an order for the change, enter a progress note and verbally communicate to nursing staff the change. During an interview on 8/8/24 at 2:08 PM, the Director of Nursing stated they would expect therapy to care plan any interventions for residents if new ones were added or one was continued and update nursing staff on the intervention. During an interview on 8/9/24 at 8:42 AM, Director of Therapy stated Resident #5 had a rolled washcloth in place in the past as an intervention for contracture in left hand, as well as for hygiene purposes. Director of Therapy stated the Occupational Therapist forgot to add it as a task and back to Resident #5's plan of care after their most recent evaluation. Director of Therapy stated Resident #5 needed the rolled washcloth to their left hand to prevent worsening contractures and to prevent skin breakdown. 10NYCRR 415.12 (e) (2)

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00330919) during the Standard Survey completed on 8/9/24, the facility did not ensure each resident received food that accommodated their allergies, intolerances, and preferences for one (Resident #89) of one resident reviewed. Specifically, Resident #89 received a meal tray with foods that did not accommodate their documented preferences. The findings include: The facility policy and procedure titled Food and Nutrition Services, undated, documented each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Additionally, food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. Resident #89 had diagnoses that include protein-calorie malnutrition, dysphagia (difficulty swallowing), and chronic diastolic heart failure. The Minimum Data Set (a resident assessment tool) dated 7/16/24 documented Resident #89 had mild cognitive impairment, understood, and understands. The comprehensive care plan dated 12/6/23 documented Resident #89 had a potential nutritional problem and was at risk for malnutrition related to therapeutic diet with an intervention to identify and honor food preferences. The Dietary Progress note dated 5/1/24 at 1:31 PM, Registered Dietician documented they spoke with Resident #89 and obtained preferences. Resident #89 stated they do not want meat at meals. The Meal tracker and care plan was updated. The Dietary Progress note dated 7/15/24 at 2:08 PM, Registered Dietician documented Resident #89 preferred to eat vegetarian (a person who does not eat meat, and sometimes other animal products) This writer reviewed food preferences with Resident #89 and discussed the limitations of dislike of meat. Recommend continue current plan of care with updated preferences. Review of Resident #89's meal tickets dated 8/1/24 through 8/5/24 documented resident was a vegetarian. Vegetarian was documented in all capital letters in red at the top of each meal ticket. During an observation and interview on 8/7/24 at 8:48 AM, Resident #89's breakfast meal was on the tray table with the lid covering it. Resident #89 lifted the lid and 2 sausage links cut up into small pieces were observed on the meal tray, untouched. Resident #89 stated they won't eat it because they were a vegetarian. Resident #89 stated they receive meat products all the time on their meal trays, and it bothered them. Vegetarian was written at the top of Resident #89's meal ticket in capital red letters. During an interview on 8/8/24 at 10:04 AM, Registered Dietician stated Resident #89 was very adamantly a vegetarian and it was written on their meal ticket. Registered Dietician stated they were not aware Resident #89 was served sausage on their meal tray and they would expect the food service staff to follow the tickets and notes written on the tickets. During an interview on 8/8/24 at 1:42 PM, Licensed Practical Nurse #2 stated Resident #89 states they cannot eat certain things so the staff will do their best to accommodate their preferences. During an interview on 8/8/24 at 1:52 PM, Dietary Director stated they expected the dietary staff to look at the meal tickets before going up to the units. There was a supervisor who checks all the trays before they leave the kitchen, and they expected the supervisor to catch anything before the tray was sent. Dietary Director stated dislikes were written at the top of each meal ticket in capital red letters. Dietary Director stated the meal tray with sausage should not have been served to Resident #89 and the dietary staff should have caught it. During an interview on 8/8/24 at 2:09 PM, the Director of Nursing stated they would expect dietary staff to read the meal tickets and make sure they were correct before sending them up to the units. The Director of Nursing stated they would expect the nursing staff to look at the meal tickets to make sure they were correct before serving them to the residents. During an interview on 8/9/24 at 8:00 AM, Certified Nurse Aide #11 stated they were aware that Resident #89 was a vegetarian. Certified Nurse Aide #11 stated before the tray is brought to the resident staff should check to make sure there wasn't anything wrong with it. 10 NYCRR 415.14(d)(4)

Based on observation, interview, and record review conducted during a Standard survey completed 3/24/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues: dirty hoods over the ovens/stoves; the light over the stove was out, pipes along the ceiling had a build- up dust; the griddle was soiled with a thick layer of black a greasy dried substance; the wall next to the griddle and behind the ovens/stoves and floor under the ovens/stove were soiled with a black greasy substance; floors throughout the kitchen were soiled with debris black greasy substance; the ice cream freezer had ice build-up; garbage cans were over- flowing with garbage and had no lids. There were multiple crates of outdated milk in the refrigerator; walk-in refrigerator and freezer floors were soiled food drippings/spills. The walk-in refrigerator's condenser had a build of mold and containers of food under the condenser also had spots of mold. There were multiple containers of food that where unlabeled, undated, or outdated, and food that was rotten. The walk- in freezer had boxes of food on the floor and boxes stacked 2 to 3 inches from the ceiling. Inside/outside of microwave was soiled with dried food splatter. The Counter- top of microwave and coffee maker had debris and stain marks. The dry storage area had multiple empty boxes in the corner, an open bag of sugar and containers and racks were covered with a white powdery substance. The vent to ice machine had layer of dust build-up and the outside had food splatter/greasy build-up. In addition, two (Second Floor and Third Floor) of two nourishment kitchen refrigerators contained unlabeled, undated, and outdated foods and one (Activity Room) of one refrigerator/ freezer contained unlabeled, undated, and outdated foods, no thermometers and dried sticky substance on the door. The findings are: The undated policy and procedure (P/P) titled Food Receiving and Storage documented foods shall be received and stored in a manner that complies with safe food handling practices. Food services, or other designated staff, will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/ walk-ins will not be overcrowded. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. Food items and snacks kept on nursing units must be maintained. All food belonging to residents must be labeled with resident's name, the item and the use by date. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. Opened containers must be dated and sealed or covered during storage. The undated P/P titled Sanitization documented the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas shall be kept clean from litter and rubbish. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The undated P/P titled Refrigerators and Freezers documented the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. All foods shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. Refrigerators and freezers will be kept clean, fee of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. 1. During an observation of the main kitchen on 3/20/23 between 8:09 AM and 8:55 AM revealed the following: - The hoods over the ovens/ stoves had a thick build- up of caked on brownish/ grayish dust and one of the lights over the stove was not in working condition. - The pipes along the ceiling had caked on grayish dust build up which was directly above the tray line where food was being served. - The griddle had a thick build up layer of black greasy dried substance over the entire surface and the wall next to the griddle had thick black greasy build up streaming down the wall and onto the floor. - The wall behind the stove had grease splatters and grime build up and the floor under the stove had debris and grease build up on it. - The floor throughout the kitchen had debris all over it, the grout had a caked on black substance and the floor was sticky and unclean looking. - The ice cream freezer had ice build-up around the outside walls approximately 1-2 inches thick. - Two garbage cans sitting in the kitchen by the breakfast tray line, and hand sink were overflowing with garbage and had no lids on them. - There were two crates of 1/2 pint cartons of 2% milk with the sell by date of 3/16/22 and 3/17/22. There was one crate of 1/2 pint cartons of whole milk with the sell by date of 3/16/22. - The refrigerator was tightly packed with food which did not allow for free movement and access to some foods. - The walk-in refrigerator had packages of ground hamburger on the bottom shelf with no drip proof pan/ container under it and red liquid drippings were on the floor directly under the meat. - There were multiple areas on the condenser of small circular gray/ black fuzzy spots that appeared to be mold build-up. In addition, food containers under or near the condenser had the same gray/ black fuzzy spots on the outer part of the containers. - There were three plastic containers filled with a creamy food substance unlabeled, undated, and not properly covered. One had an onion on top of it that was touching the creamy substance. - There was a case of celery that was rotting and a 1/2 bag of opened lettuce unlabeled and undated with a red sticky substance on the bag. - There was an undated open bucket of hard-boiled eggs and a plastic container of red sauce with the date of 2/17/23. - The floor of the refrigerator was sticky and had debris under the racks of food. There were multiple amounts of creamer containers on the floor and a broken opened yogurt container in the corner. The walls had multiple food splatters on them. - The walk-in freezer floor had buildup of dirt, food drippings/ spills. - The walk-in freezer was tightly packed with boxes of food stacked on the ground in the middle between the shelves 3 to 4 feet deep touching the back wall and 3 to 4 feet high making it difficult to reach or see any boxes/ food in the back of the freezer. In addition, the top shelves to the right had boxes of food stack approximately 2 to 3 inches from the ceiling. It was noted on the left side of the freezer, there were multiple empty shelves. - The freezer contained an unidentified unlabeled piece of freezer dried meat approximately 5 inches by 10 inches. - The dry storage area had approximately 15 empty boxes in the corner of the room. -The dry storage area had a large exposed opened bag of sugar placed in a plastic container. The top of the sugar in the bag had multiple pieces of black debris on it. -The dry storage area had a plastic container with a package of pudding in it. The container was dirty and had caked on white powder both on the inside and outside. The rack it was sitting on also had thick white powder on it. - The area/ counter by the microwave and coffee maker had a build-up of debris, food splatters and stains. Inside/ outside of the microwave had build-up on dried splatter and dirt on it. - The ice machines vent had a thick layer grayish dust build-up and the outside had food splatter/ greasy build-up. 2. During an observation on the Third Floor on 3/20/23 at 8:38 AM revealed the nourishment refrigerator contained the following items: - Open half-gallon container of orange juice, about half full, with no date opened and no resident name. - One peanut butter and jelly sandwich in clear plastic wrap, labeled PJ with no date and no resident name. - Black bag that contained one slice of salami, the store label indicated it was packed on 2/28/23 and sell by 2/28/23, also two slices of ham, the store label indicated it was packed on 2/28/23 and sell by 2/28/23, there was no resident name on the bag or inside the bag. - One slice of cheese in a store brand package, with no date opened and no resident name. During an observation on the Second Floor on 3/20/23 at 9:45 AM revealed the nourishment refrigerator contained the following items: - Large cardboard pizzeria pizza box that contained two pizza slices, the receipt attached to the box revealed it was ordered on 2/25/23, the box was not labeled with a resident name. - Plastic leftover container of approximately six ounces of cooked ground beef with no date or resident name. - Pint of Chinese food restaurant take-out inside a brown paper bag, no date or resident name on the bag or inside the bag. At this same time, a brown and red spill was observed in the freezer that spanned across the width of the freezer. During an interview at the time of the observation, Maintenance Aide #1 stated the freezer needed to be cleaned. During a second observation on the Second Floor on 3/24/23 at 1:03 PM revealed the nourishment refrigerator contained the following: -A clear plastic container 1/2 full of brownish/ red ground meat in it, unlabeled and undated. -A large pizza box in the refrigerator labeled with resident's name and dated 3/21/23, 12 AM. -Unidentified food wrapped in a paper towel, unlabeled and undated. -The bottom shelf had brown smears of food debris on it. In addition, the nourishment room floor had a large number of debris and caked on black substance under and behind the refrigerator and along the sink cabinets. At this time there was a paper sign taped to the refrigerator that had the following written on it, ALL ITEMS MUST BE LABELED WITH NAME AND DATE. ANY ITEM WITHOUT A DATE WILL BE DISCARDED. ALL DATED ITEMS WILL BE DISCARDED AFTER 3 DAYS. 3. During an observation in the Activities room on 3/20/23 at 9:00 AM the refrigerator/ freezer contained the following: - An opened package of butter with nothing covering it, unlabeled and undated. - An opened package of sliced cheese with 15 slices left, unlabeled and undated. - One opened package of bologna, unlabeled and undated, with use by date 6/16/23 and once opened use withing 7 days. - Two opened packages of oven roasted turkey breast, unlabeled and undated when opened, one had use by date 4/21/23 and the other 5/6/23. - Two opened 20-ounce plastic bottles of soda, unlabeled and undated. - One 1/2 pint carton of whole milk dated sell by 3/2/23. - One zip lock bag containing six frozen sausage links and two zip lock bags containing two to three pieces of frozen breaded meat, both unlabeled and undated. - The refrigerator door had a large brown dried substance on it. - Both the refrigerator and freezer did not have thermometers. At this time, during an interview with the Activities Director they stated all the food in the refrigerator and freezer should be labeled and dated. Both Housekeeping and Activities will clean the refrigerator and freezer. We should have thermometers in which are supplied by dietary.' During an interview on 3/20/23 at 9:15 AM, the Food Service Director (FSD) stated all foods should be labeled and dated. Any foods after three days should be thrown away. They stated there was a cleaning schedule for the kitchen, but they have not been using it because it was too complicated to follow. They stated they just recently started up a new cleaning schedule for the supervisors and dietary staff to use but they do not have any to review, as they just started it. They stated the hoods over the ovens/stoves and pipes near the ceilings were taken care by maintenance. They stated maintenance would need to call a contractor in to take care of them. They stated the hoods should be cleaned once a month but does not know when the last time they were cleaned. They agreed the hoods and pipes along the ceiling needed to be cleaned and taken care of. The FSD stated the refrigerator, freezer and dry storage should have not looked the way they did and had no excuse for it. They stated they do not put anything in the refrigerators on the units except the tray of nourishments and that anything in them should also be labeled and dated and thrown away after 3 days. They stated all the refrigerators and freezers should have a thermometer in them. 10 NYCRR 415.14(h) 14-1.43(e), 14.1-44, 14-1.170, 14-1.171(a)(b)(d)

Based on observation, interview, and record review during the Standard survey completed on 3/24/23, the facility did not maintain the resident call bell system in working order. Specifically, call bells in resident rooms, resident bathrooms and shower rooms did not activate the call light above the residents' room doors and did not activate the master station located at the Nurses' Station. This affected one (2nd floor) of two resident units. This involves Residents #35, 59 and 54. The finding is: The policy and procedure titled, Answering the Call Light reviewed 2/2023, documented a general guideline was to report all defective call lights to the nurse supervisor promptly and nursing must notify maintenance department of the defective call light. Review of the Visual Nurse Call System Operating Instructions revealed routine calls are indicated by simultaneous operation of illumination of the associated station selector LED (light-emitting diode) , which indicates origin of call, illumination of call lamp at master station, and slow pulsing audible tone. Emergency calls are indicated by simultaneous flashing of the associated station selector LED, which indicates origin of call, flashing of call lamp at master station, and a pulsing audible tone. 1. Observation of the 2nd floor on 3/20/23 from 2:53 PM to 3:26 PM revealed the call bell stations in the following resident rooms (23 rooms and 2 shower rooms), bathrooms, and shower rooms did not have an audible tone, illuminate above the doorframe or at the master station panel, located at the nurse's station, when activated: 200 (bathroom only), 201, 202 (bathroom only), 203 (bathroom only), 205 (bathroom only), 206 (bathroom only), 207, 208 (bathroom only), 209, 210, 211, 212, 213 (bathroom only), 214 (bathroom only), 215, 216 (bathroom only), 216 Private (P) (bathroom only, 217, 218, 219 (bathroom only), 221, 222, 223, the shower room near room [ROOM NUMBER] and the shower room across from the nurse's station. Review of the audit tool called, Call Bell Preventative Maintenance dated 1/27/23 revealed call bells were working except three rooms on the Second Floor and a service technician will repair. Manual bells were placed in affected rooms. Review of the audit tool called, Call Bell Preventative Maintenance dated 2/13/23 revealed four rooms had issues and a service technician serviced the disabled call bells, but the same issues returned. The Corporate Maintenance and Engineering Coordinator was notified. During an interview on 3/20/23 at 3:08 PM, Resident #35's call light was not working, and the resident stated they had a tap bell to use but didn't think it worked very well. During an observation and interview on 3/20/23 at 3:10 PM, Resident #59's call light was not working, and the resident stated their call light had not worked since the big storm around Christmas. During an observation and interview on 3/20/23 at 3:20 PM, Resident #54 stated they wished someone would check their call light because they didn't think it worked. There was no tap bell in the room. During an interview on 3/20/23 at 3:16 PM, Certified Nurse Aide (CNA) #1 stated the call bells haven't been working for about a month and the residents use tap bells for assistance. During an interview on 3/20/23 at 3:23 PM, Registered Nurse (RN) #1 Unit Manager (UM) stated the call bells not working had been a problem and that administration and ownership knew about it. During an interview on 3/20/23 at 3:35 PM, the Administrator stated in early February 2023, four resident rooms were identified with non-functioning nurse call bell stations. The Administrator stated an outside contractor came to the facility to provide an estimate for repairs, but they had not yet received the estimate. The Administrator stated the Corporate Maintenance and Engineering Coordinator identified a faulty controller and a new controller was ordered and was received today. After identifying the issue, an audit was performed, and the Administrator stated they were not sure if the audit included checking of nurse call bell stations inside resident room bathrooms. Tap bells were distributed to residents with non-functioning nurse call bell stations at that time. The Administrator also stated the nurse call bell systems on the Second Floor and the Third Floor were two independent systems. During an interview on 3/22/23 at 8:10 AM, the Administrator stated the Corporate Maintenance and Engineering Coordinator did replace the controller and found that it did not correct the issue and they were still waiting for the estimate from the outside contractor. During an interview on 3/23/23 at 2:45 PM, Maintenance Aide #1 stated when a resident activated their bedside nurse call button, the light above their door frame should light up and the light at the Nurses' Station panel for that particular room should also light up. Maintenance Aide #1 also stated when a resident activated their bathroom nurse call button, the light above their door frame should blink and the light at the Nurses' Station panel for that particular room should also blink. When any nurse call button is activated, there should be a chirping noise at the Nurses' Station panel to alert staff. During an interview on 3/24/23 at 11:20 AM, Maintenance Aide #1 stated maintenance staff performed monthly audits of the nurse call bell system, both bedside and bathroom stations. During an interview on 3/24/23 at 11:27 AM, the Director of Nursing (DON) stated the call bell system hadn't been functioning for a couple months and they had been trying to get it fixed. The DON stated they should have a functioning call bell system and that maintenance was responsible to make sure it was working. During an interview on 3/24/23 at 2:25 PM, the Administrator stated the facility did not have a policy and procedure specific to the maintenance of the nurse call bell system, but they referred to the manufacturer's information. NYCRR 415.29

Based on observation, record review, and interview conducted during a complaint investigation (Complaint #NY00298668) during the Standard survey completed on 3/24/23, the facility did not ensure residents had the right to be free from sexual abuse for four (Resident #s 1, 21, 67 and 246) of 11 residents reviewed for abuse. Specifically, the facility did not ensure Resident #246 did not engage in non-consensual sexual contact with Resident #1. Resident #246 was found touching Resident #1's exposed genitals. Additionally, Resident #67 had non- consensual contact with Resident #21 and was found touching Resident #21 on their breast and inner thigh in the dining room. The findings are: The policy and procedure (P&P) titled Abuse Prevention Program/Abuse and Neglect-Clinical Protocol/Abuse Investigation and Reporting revised on 1/2022, documented sexual abuse was defined as non-consensual sexual contact of any type with a resident, sexual contact with any person incapable of giving sexual consent. This included, but was not limited to unwanted touching. 1. Resident #1 had diagnoses including schizoaffective disorder, depression, and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 5/5/22 documented Resident #1 had moderately impaired cognition and had no physical or verbal behaviors directed toward others. The untitled comprehensive care plan (CCP) revised 7/7/22, documented Resident #1 lacked capacity for medical decision making as of 5/25/21, had potential for alteration in mood and behavior for possible trauma from an incident on 7/7/22. During an observation and interview on 3/21/23 at 10:48 AM, Resident #1 was lying in bed under the blankets. The resident stated they didn't have any issues with any other residents and felt safe at the facility. Resident #246 has diagnoses including dementia with behavioral disturbance, hypertension (HTN-high blood pressure), and history of falling. The MDS dated [DATE] documented Resident #246 had severe cognitive impairment and had physical behavioral symptoms directed towards others. The untitled CCP dated 9/7/21 documented Resident #246 exhibited behavioral symptoms such as socially inappropriate, verbal and physical aggression towards staff and other residents, racial slurs, wandering, and cognitive impairment. The Event Summary completed by the Administrator documented on 7/7/22 at approximately 4:30 AM, Resident #246 touched Resident #1 in the private area and was later laying on top of Resident #1 naked. Certified Nurse Aide (CNA) #2 walked into the residents' room and saw Resident #246 sitting in a chair next to Resident #1's bed touching Resident #1's naked private area. CNA #2 immediately separated them and placed Resident #246 back into their bed and went to go report the situation to the nurse. CNA #2 went back into the room, which took approximately two minutes and saw Resident #246 lying naked on top of Resident #1. Only groping and no penetration occurred during this event. CNA #2 immediately removed Resident #246 and wheeled them to the dining room. Resident #246 then put back in the bed and placed under constant supervision until further notice. The Administrator, Director of Nursing (DON), Physician (MD), and Regional Clinical Director were immediately notified. Registered Nurse (RN) assessment was completed with no injuries to either resident. Facility's Director of Social Work (DSW) met with Resident #1 and there appears to be no signs of any psychological distress due to either resident not being able to recall incident. Review of the Incident and Accident Statement Form: Certified Nurse's Aide Statement revealed date of incident 7/7/22, time 4:30 AM. CNA #2 saw Resident #246 sitting in a chair next to Resident #1's bed. Resident #246 with their hand was foundling Resident #1's private area. CNA #2 pulled Resident #246 hand away from Resident #1 and put Resident #246 back to bed and went to report it to the nurse. CNA #2 came back, and Resident #246 had climbed on top of Resident #1. CNA #2 went over and got Resident #246 off Resident #1 and took Resident #246 to the dining room. During an interview on 3/23/23 at 12:18 PM, the DSW stated Resident #1 had no recollection of the incident when the DSW went to speak to them a few hours after the incident happened. The DSW stated that neither resident had capacity for decision making and that if someone can't give consent the inappropriate touching would be considered abuse. During a telephone interview on 3/23/23 at 1:36 PM, CNA #2 stated they saw Resident #246 in their wheelchair by Resident #1's bed with their hand on Resident #1's naked private area. They immediately removed Resident #246's hand and thinks they either moved Resident #246 to the other side of the room by their bed or just outside the door. They stated they did not put Resident #246 back to bed and that Resident #246 was in a wheelchair. CNA #2 then went to get the supervisor who was just around the corner. They stated they were gone less than a minute and when they came back, they found Resident #246 trying to climb on top Resident #1 which at that time CNA #2 stopped Resident #246 and put them back in their wheelchair and took them out of the room down to the dining room. CNA #2 stated Resident #246 was in a brief when they were trying to climb on Resident #1 who was naked in bed. CNA #2 stated Resident #246 had never done anything like that before. During an interview on 3/23/23 at 3:56 PM, the RN Supervisor #2 stated they were notified that CNA #2 found Resident #246 groping Resident #1's genitals. The residents were separated right away, and the incident was over by the time the RN Supervisor #2 arrived on the unit. The RN Supervisor #2 stated they notified the DON, Administrator, and the corporate DON between 4:30 AM and 5:00 AM, right after this incident happened. The RN Supervisor #2 stated they would consider this incident sexual abuse and that was how they documented it on the incident report. During an interview on 3/24/23 at 9:37 AM, the DON stated that they would consider the incident that occurred on 7/7/22 between Resident #246 and Resident #1 a form of sexual abuse. 2. Resident #21 had diagnoses including Alzheimer's dementia, depression, and anemia. The MDS dated [DATE] documented Resident #21 had severe cognitive impairment and had no verbal or physical behaviors directed toward others. The untitled CCP revised 7/26/22, documented Resident #21 was at risk for being taken advantage of related to cognitive impairment, extremely relevant due to incident on 7/24/22. Resident #67 had diagnoses including dementia, conduct disorder, and HTN. The MDS dated [DATE] documented Resident #67 had moderately impaired cognitive impairment and no verbal or physical behaviors directed toward others. The untitled CCP revised 7/25/22, documented Resident #67 had behavior symptoms including on 7/24/22 was found groping another resident. The Event Summary completed by the Administrator documented on 7/24/22 at 11:45 AM, a CNA (#3) found Resident #67 rubbing Resident #21's breast and inner thigh. The CNA (#3) went into the dining room and saw the residents sitting in the corner. The CNA (#3) witnessed Resident #67 with their hand on Resident #21's breast and their other hand in between their legs on top of their clothes. The General Statement dated 7/24/22, written by Licensed Practical Nurse (LPN) #1, documented they were informed by a CNA (#3) that Resident #67 was touching Resident #21 in a sexual manner. When LPN #1 went to speak to Resident #21 after the incident, the resident was startled with a worried look on their face. Resident #21 said that Resident #67 was standing in front of them looking at them like they were trying to find a spot they could touch them, like they were a piece of meat. During a telephone interview on 3/21/23 at 10:28 AM, Resident #21's family member stated there was an incident a while back where the resident was molested by another resident. Resident #21 didn't remember that they were inappropriately touched. During a telephone interview on 3/22/23 at 2:02 PM, CNA #3 stated they brought another resident into the dining room and that was when they saw Resident #67 touching Resident #21 inappropriately. CNA #3 stated they separated the residents right away and told the nurse. CNA #3 stated Resident #21 was scared for a little bit after the incident, but they have Alzheimer's and didn't remember much later in the shift. During an interview on 3/23/23 at 10:27 AM, the RN UM #1 stated this incident was considered abuse because the resident was touched inappropriately without giving consent. The RN UM #1 stated staff didn't prevent the abuse from happening, but staff didn't expect it to happen. During an interview on 3/23/23 at 12:04 PM, the DSW stated they remembered an incident of inappropriate touching occurred between Resident #s 21 and #67. The DSW stated both residents did not have capacity for decision making and would not consider this sexual abuse because neither party can give consent and neither remembered the incident happened. The DSW stated this was a reportable incident, but they didn't think the intent part was there. During an interview on 3/24/23 at 12:32 PM, the Director of Nursing (DON) stated they considered this incident inappropriate touching and didn't think it was maliciously intended. The DON stated inappropriate touching was not considered abusive because of the resident's cognition. When asked if the act was deliberate because Resident #67 was not touching Resident #21 on their arm or head, the DON stated Resident #67 lacked capacity for decision making, safety awareness, and impulse control. NYCRR 10 415.4(b)(1)(i)

Based on interview and record review conducted during a complaint investigation (NY00298668) completed on a Standard survey completed 3/24/23, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made to the appropriate officials (including the State Survey Agency). Specifically, two (#1 and #246) of eleven residents reviewed for abuse were involved in an allegation of sexual abuse and was not reported timely to the New York State (NYS) Department of Health (DOH) as required. The finding is: The policy and procedure titled Abuse Prevention Program/ Abuse and Neglect-Clinical Protocol/ Abuse Investigation and Reporting dated 1/2022 documented all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or designee, to the State licensing/ certification agency responsible for surveying/ licensing the facility. An alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but not later than: two hours if the alleged violation involves abuse. Resident #1 had diagnoses including schizoaffective disorder, depression, and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 5/5/22 documented Resident #1 had moderately impaired cognition and had no physical or verbal behaviors directed toward others. The untitled comprehensive care plan (CCP) revised 7/7/22, documented Resident #1 lacked capacity for medical decision making as of 5/25/21, had potential for alteration in mood and behavior for possible trauma from incident on 7/7/22. Resident #246 has diagnoses including dementia with behavioral disturbance, hypertension (HTN-high blood pressure), and history of falling. The MDS dated [DATE] documented resident #246 had severe cognitive impairment and had physical behavioral symptoms directed towards others. The untitled CCP initiated 9/7/21, documented Resident #246 exhibited behavioral symptoms such as socially inappropriate, verbal, and physical aggression towards staff and other residents, racial slurs, wandering, cognitive impairment. The Event Summary completed by the Administrator documented on 7/7/22 at approximately 4:30 AM, Resident #246 touched Resident #1 in the private area and was later laying on top of Resident #1 naked. Certified Nurse Aide #2 walked into the residents' room and saw Resident #246 sitting in a chair next to Resident #1's bed touching Resident #1's naked private area. CNA #2 immediately separated them and placed Resident #246 back into their bed and went to go report the situation to the nurse. CNA #2 went back into the room, which took approximately two minutes and saw Resident #246 lying naked on top of Resident #1. Only groping and no penetration occurred during this event. CNA #2 immediately removed Resident #246 and wheeled them to the dining room. Resident #246 then put back in the bed and placed under constant supervision until further notice. Administrator, Director of Nursing (DON), Physician (MD), and Regional Clinical Director were immediately notified. Registered Nurse (RN) assessment was completed with no injuries to either resident. Facility's Director of Social Work met with Resident #1 and there appears to be no signs of any psychological distress due to either resident not being able to recall incident. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/ Incident Investigation Report revealed the date/ time of occurrence was 7/7/22 at 4:30 AM and submitted by the facility on 7/7/22 at 6:24 PM. During an interview on 3/23/23 at 12:18 PM, the Director of Social Work (DSW) stated Resident #1 had no recollection of the incident when the DSW went to speak to them a few hours after the incident happened. The DSW stated that neither resident had capacity for decision making and that if someone can't give consent the inappropriate touching would be considered abuse. During an interview on 3/24/23 at 9:37 AM, the DON stated that they would consider the incident that occurred on 7/7/22 between Resident #246 and Resident #1 a form of sexual abuse. They stated they were aware of the reporting regulations and that this incident should have been reported to the NYS DOH within 2-hours. 10 NYCRR 415.4(b)(4)

Based on observation, interview, and record review conducted during the Standard survey, completed on 3/24/23, the facility did not ensure that a resident's drug regimen was free from unnecessary psychotropic medications for one (Resident #70) of five residents reviewed for antipsychotic medications. Specifically, an antipsychotic (AP) medication was restarted without behavioral documentation or psychotic features to support its use and physician progress notes documented the resident was stable with no indication to restart psych meds. Additionally, there was lack of monitoring for side effects after the medication was initiated. The finding is: The facility policy and procedure titled Antipsychotic Medication Use reviewed 1/2022, documented AP medications may be considered for residents but only after medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. Residents will only receive AP medication when necessary. The attending physician and other staff will gather and document information to clarify a resident's mood, behavior, function, medical condition, specific symptoms, risks to the resident and others that may warrant the use of AP medications. Residents who are admitted from the community or transferred from hospital that are already receiving AP medications will be evaluated for the appropriateness and indications for use. Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing AP medication. Diagnoses alone do not warrant the use of AP medication. AP medications will generally only be considered if the behavioral symptoms present a danger to the resident, or others, and the behavioral symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia, or grandiosity). 1.Resident #70 was admitted with diagnoses including schizophrenia, extrapyramidal and movement disorder (EPS-side effects such as involuntary muscle contraction, tremor, stiff muscles, and involuntary facial movements that can occur from taking AP medications), and diabetes. The Minimum Data Set (MDS- a resident assessment tool) dated 12/22/22 documented the resident was cognitively intact, received AP medication on a routine basis, had a mood severity score of zero, no psychosis or behavioral symptoms, and no rejection of care. Review of the hospital discharge summary dated 9/8/22 documented resident was treated for drug induced acute dystonia (abnormal muscle tone resulting in painful muscle spasm or abnormal posture due to side effect of AP medication) and multiple psych meds had been discontinued while inpatient at the hospital. The note documented, pre -hospitalization , the resident was receiving injection of Invega (extended-release injectable AP medication) every (q) four weeks with last dose given in 8/2022. The discharge recommendations documented resident would need to follow up with psychiatry for re titration of psych meds and continuation of Invega. Review of physician orders tab in the electronic medical record (EMR) documented an order for Invega Prefilled Syringe 234 milligrams (mg)/1.5 milliliters (ml) inject 1.5ml intramuscularly (IM) one time a day q 28days dated 12/16/22 with a start date of 12/17/22. The comprehensive care plan (CCP) dated 9/9/22 documented the resident required assist with activities of daily living due to EPS and was at risk for drug related complications related to (r/t) black box warnings (warnings on medications intended to bring the consumer's attention to the major risks of the drug assigned by the FDA). Interventions included monitor for changes in status, notify interdisciplinary team (IDT) as needed (PRN); ensure medications are reviewed by MD/NP/PA (Medical Doctor, Nurse Practitioner, Physician Assistant) on admission and PRN; monitor for adverse reactions; monthly review of medications by pharmacy consultant. Review of Resident #70's physician progress notes documented the following: -On 9/8/22, the resident denied anxiety, depression, or mood changes. Mood is normal. Meds reviewed in EMR. Assessment/Plan: schizophrenia was on multiple psych meds all discontinued in hospital. Will have psych follow and monitor for re-titration. -On 9/26/22, the resident denied anxiety, depression, or mood changes. Mood is stable. Meds reviewed in EMR. Assessment/Plan: schizophrenia very stable since arrival no indication to restart any meds at this point. -On 10/25/22, the resident denied anxiety, depression, or mood changes. Mood is stable. Meds reviewed in EMR. Assessment/Plan: schizophrenia very stable since arrival no indication to restart any meds at this point. -On 11/21/22, the resident denied anxiety, depression, or mood changes. Attitude is cooperative and appropriate. Meds reviewed in EMR. -On 12/11/22, the resident denied anxiety, depression, or mood changes. Attitude is cooperative and appropriate. Medication reconciliation completed. Assessment/Plan: schizophrenia very stable since arrival no indication to restart any meds at this point. -On 1/26/23, the resident denied anxiety, depression, or mood changes. Attitude is cooperative and appropriate. Meds reviewed in EMR for indication and use. Assessment/Plan: schizophrenia stable no indication to restart any meds at this point. -On 2/21/23, the resident denied anxiety, depression, or mood changes. Attitude is cooperative and appropriate. Meds reviewed in EMR for indication and use. Assessment/Plan: schizophrenia stable no indication to restart any meds at this point. -On 3/20/23, the resident denied anxiety, depression, or mood changes. Attitude is cooperative and appropriate. Meds reviewed in EMR for indication and use. Assessment/Plan: schizophrenia stable no indication to restart any meds at this point. The interdisciplinary (IDT) Progress Notes dated 9/8/22 through 3/22/23 lacked documented evidence of behavioral symptoms or documentation indicating psychosis. No documentation of hallucinations, delusions, paranoia, or grandiosity. The Progress Notes lacked documented evidence of indication for restarting or monitoring for side effects r/t Invega injection ordered on 12/16/22. Review of Medication Administration Records (MAR) dated 9/1/22 through 3/31/23 documented Invega was signed off as administered on 12/17/22, 1/14/23, 2/11/23 and 3/11/23. Review of Monthly Medication Review completed by Consultant Pharmacist dated 9/2022 through 2/7/23 documented no irregularities were identified. The Third Floor, Team Two 24- hour report dated 12/1/22 through 12/20/22 lacked documented evidence of Resident #70's new order of Invega on 12/16/22 or monitoring for any behaviors or side effects r/t new medication order. Intermittent observations from 3/20/23 through 3/24/23 between 9:25 AM and 3:00 PM, revealed Resident #70 was pleasant, friendly, and smiling on all observations. The resident was in their room, per preference, in bed/out of bed to wheelchair, dressed and well kempt, listening to music, watching TV, and/or eating meals. The resident answered questions and held conversation appropriately. During an interview on 3/23/23 at 9:34 AM, Certified Nurse Aide (CNA) #4 stated they were very familiar with Resident #70 and the resident was very vocal and able to make their needs known. The resident would let staff know what they wanted to do, whenever they wanted to do it. Somedays they prefer to rest in bed, other times they get out of bed. Resident #70 never had behavioral issues, hallucinations, or delusions. They were always cooperative with care. During an interview on 3/23/23 at 9:39 AM, Licensed Practical Nurse (LPN) #2 stated the resident had been on their assignment since the resident was transferred from the 2nd floor. LPN #2 stated Resident #70 never had any behavioral issues, hallucinations, or signs of psychosis. During an interview on 3/23/23 at 1:39 PM, Registered Nurse (RN) #1 Unit Manager (UM) 2nd floor, (previously UM on 3rd floor) reviewed Resident #70's EMR and stated the resident was stable and never had behavioral concerns or signs of psychosis that they were aware of. RN #1 UM stated LPN #1 had put the order in for the Invega but was not sure why as there was no supporting documentation in the progress notes and should have been. That (Invega order) was never communicated to me. RN #1 UM stated the resident should have been on report for behavior and side effect monitoring for the first 14 days of being on a new medication. On follow up interview 3/23/23 at 1:50 PM, LPN #2 stated they did not know why the Invega was ordered on 12/16/22. LPN #2 stated they can only assume when the resident transferred from the 2nd floor maybe someone reviewed the chart, or the discharge summary, and saw that a medication was missed so they restarted it. During an interview on 3/23/23 at 4:30 PM, the Medical Doctor (MD) stated the facility tried to get psych follow up but had recently been in between psych providers. The MD stated the resident had all AP medications discontinued in the hospital, prior to admission. The MD stated they were aware of Resident #70 being on Invega, prior to admission, but felt the resident had been very stable since admission with no signs of psychosis and no indication for restart of AP's. The MD stated it was not their intention to have Invega restarted after having been off of it for several months and the resident remained psychiatrically stable. The MD stated they would have to look into that today. During an interview on 3/24/23 at 10:41 AM, the Director of Social Work (DSW) stated the facility had been in between psychiatric consultants due to credentialling issues. DSW stated the MD would follow residents psychiatrically in the interim. Resident #70 had been stable in discussion with nursing and MD. DSW stated they thought that Resident #70 prior assisted living residence, psych services/provider, called and spoke with the 3rd Floor Unit Manager, that was no longer employed at the facility, inquiring about continuing the monthly injection. The DSW stated they hoped that there was documentation in the record indicating those discussions. During interview on 3/24/23 at 12:52 PM, the Consultant Pharmacist stated residents were discussed at GDR (gradual dose reduction) meetings every other month. The Consultant Pharmacist stated they were aware Resident #70 AP medications had been discontinued while hospitalized . Usually, behavioral documentation and progress notes were reviewed, but with the long history and diagnosis of schizophrenia it makes sense that the medication was restarted. The Consultant Pharmacist stated it may have been unnecessary to restart the Invega, after being off of it for a while, without behavioral documentation and/or indicators of psychosis to support it being reinitiated. During a telephone interview on 3/24/23 at 1:08 PM, LPN #1 stated they remembered Resident #70 wasn't eating very well, losing some weight, and one of the RN's reviewed the chart and realized the resident had not been receiving Invega since admission. LPN #1 stated they couldn't recall who it was, but I was just doing what the RN told me to do. I should have put it on 24 -hour report. Then it would have been discussed at morning report. The resident should have been monitored for at least 14 days after restarting a (new) medication. LPN #1 stated I would have been responsible for that since I put the order in. It was an honest mistake. Resident monitoring and follow up is a group effort. During an interview on 3/24/23 at 12:10 PM, the Director of Nursing (DON) stated they did not work at the facility at the time, but they would have expected to see behavioral documentation/monitoring and Resident #70 should have been on 24 -hour report for 14 days for monitoring and follow up and this was not done. 10 NYCRR 412.12 (l)(1)(2)(i)(a)

Based on observations, interview, and record review during an Abbreviated survey (Complaint #NY00307500) started and completed on 01/03/23, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, in advance of and during a blizzard emergency, the natural gas fueled emergency generator was not tested and maintained and failed to supply emergency power to the facility for the duration of the storm. During the blizzard emergency, person(s) knowledgeable of the emergency generator were not onsite to monitor essential equipment, specifically the emergency generator. This affected three (First, Second, and Third Floors) of three resident use floors and one of one Basement. The finding is: Observation on 1/3/23 revealed the building's natural gas emergency generator was installed at the exterior South side of the building. On 1/3/2023 at 8:32AM, the facility's Administrator stated they were not at the facility during the entirety of a blizzard that impacted the City of Buffalo from 12/23/22 - 12/25/22. There were no maintenance staff working in the building during this time. The Maintenance Director had been on leave since 12/22/22. The Administrator stated no one was regularly checking the emergency generator during the blizzard. During this interview the Administrator stated they did not check the building's emergency generator during the blizzard emergency. The Administrator further stated the facility's natural gas fueled emergency generator failed when wind from the storm pushed snow into the generator housing and froze the generator. On 1/3/23 at 8:38 AM the Administrator stated the facility lost electrical grid power to the building on 12/23/22 at 4:05 PM. At that time, the facility's emergency generator turned on, and the facility was running on electricity provided by the emergency generator. The Administrator further stated that the emergency generator failed on 12/23/22 at 11:30 PM. At that time the building had no heat or power. The Administrator stated the facility's grid power was restored around 10:30 AM on 12/25/22. 1) During an interview on 1/3/23 at 2:53 PM the Administrator stated that in advance of the blizzard, the facility conducted a Code Brown Disaster Drill in-service for the facility's department heads on 12/22/22. The Administrator further stated Code Brown was a response to many different types of disasters, including a snow emergency. The Administrator stated the following staff attended the Code Brown in-service: Administrator, Director of Nursing, Director of Rehabilitation, Director of Admissions, Staff Development, Maintenance Director, Food Service Director, Director of Social Work, Activities Director, Concierge and Unit Manager #1. The Administrator stated the Department Heads were supposed to in-service their staff about the Code Brown in-service, the facility had no documentation for the in-services conducted by the Department Heads and the Department Heads did not in-service their staff about the Code Brown in-service. During an interview on 1/3/23 at 1:45 PM Maintenance Worker #2 stated that they were not at the facility during the blizzard and received no training from the Code Brown in-service. During an interview on 1/3/23 at 1:46 PM Maintenance Worker #1 stated they were not at the facility during the blizzard and received no training from the Code Brown in-service. A Review of the 12/23/22 - 12/25/22 Power/ Generator Outage timeline provided by the Administrator documented: At 11:40PM the service contractor for the emergency generator was contacted by the facility. The contractor was unwilling to come out during the storm until they knew it was not a simple issue that needed to be fixed. A facility employee facetimed representatives from the service contractor to try to diagnose the malfunction but were unsuccessful. On 12/24/22 at 3:45 AM the technician from the service contractor advised that that due to high winds and snow, the wind pushed snow into the generator housing and ultimately froze the alternator. An interview with the Administrative Assistant on 1/3/23 at 11:19 AM revealed they checked the emergency generator one time during the blizzard on 12/23/22 at 7:00 PM or 8:00 PM, they were not sure of the time, but it was at night. The Administrative Assistant facetimed with a technician from the contractor that inspected and tested the generator and the technician told them to pour the small bottle of oil into the generator. The Administrative Assistant stated there was snow on and around the generator, and snow inside of the generator's enclosure housing. The Administrative Assistant also stated no other facility staff checked the generator during the blizzard. 2) During a telephone interview on 1/3/23 at 12:49 PM the Maintenance Director stated they were not at the facility during the blizzard, that they were on extended leave. The last day they were at the facility was 12/22/22 and were not aware of any issues with the generator at that time. The generator was last inspected by an outside contractor during August or September of 2022. A record review on 1/2/23 confirmed that 8/15/22 was the most recent planned inspection and testing of the facility's emergency generator, with full service preventative maintenance performed by a contractor. The Maintenance Director further stated they conducted the monthly load tests on the emergency generator. The Maintenance Director also stated they knew they were supposed to run the emergency generator for 30 minutes a month under load, but they did not always do that. A record review of Monthly Generator Testing reports revealed the emergency generator was not consistently run under load for at least 30 minutes every month during 2022. December 2022- There were no load tests conducted. November 28, 2022, load test lasted 25 minutes (Start: 1335 -Stop: 1400). October 2022- There were no load tests. September 22. 2022, load test last 30 minutes (Start 1200- Stop:1230) August 5, 2022, load test lasted 10 minutes ( Start: 1124 AM-Stop: 1134 AM) July 6, 2022, load test lasted 10 minutes (Start: 0943- Stop: 0953) June 23, 2022, load test lasted 10 minutes (Start: 1018- Stop: 1028) 483.90(d)2)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 468) completed from [DATE] through [DATE], the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #1) of eleven residents reviewed for quality of care. Specifically, there was a delay in notification to the physician when Resident #1 had a significant change in their health status which included a blood sugar of 31 (normal 60- 110) and unresponsiveness. Resident #1 went into cardiac arrest; emergency response was initiated, the resident was intubated (a tube placed down the patient's throat or connect to a breathing machine that pumps air into and out of lungs) and received cardio-pulmonary resuscitation and intubation (CPR, chest compressions and artificial breathing) despite having a Do Not Resuscitate (DNR, allow natural death/Do Not Intubate (DNI)) order. Resident #1 was transferred to the hospital and expired 5 days later. This resulted in actual harm for Resident #1 that was not immediate jeopardy. Additionally, Resident #1's blood sugars (BS) were not consistently monitored per the physician's orders. The finding is: The facility policy and procedure (P&P) titled Change in Resident Condition with review date of ,d+[DATE] documented a nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/mental condition; need to alter the resident's medical treatment significantly. The facility P&P titled Nursing Care of the Resident with Diabetes Mellitus with review date of ,d+[DATE] documented residents taking insulin may require more frequent monitoring, severe [CONDITION(S)] (confusion/lethargy, decreased blood sugar) range was less than (<) 40 milligrams (mg)/ (per) decaliter (dL), for symptomatic and unresponsive residents with [CONDITION(S)] (<70 mg/dL) immediately administer oral glucose paste or intramuscular (IM) [MEDICATION(S)] (hormone used to treat severe low BS) per facility protocol and notify the physician for further orders. The facility P&P titled Emergency Procedure-Cardiopulmonary Resuscitation (CPR) with a review date of ,d+[DATE] documented if an individual was found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiated CPR unless: it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. The facility P&P titled Advance Directives with a review date of ,d+[DATE] documented information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Nurse Supervisor will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented the resident had moderate cognitive impairment. Resident #1's MOLST (Medical Order for Life Sustaining Treatment) signed and dated [DATE] by Medical Doctor (MD) #1 documented Resident #1's responsible party gave consent for a DNR/DNI order. The form was also signed by the Director of Social Work (DSW #1) and the Director of Nursing (DON). The comprehensive care plan (CCP), identified as current by the Regional Administrator, documented Resident #1 had insulin dependent DM. Documented interventions included to administer medications per physician order, monitor BS per MD orders, and report to nurse signs and symptoms of [CONDITION(S)]. Additionally, the CCP documented advance directives which included DNR, DNI, HCP (health care proxy), and a hard MOLST was on file. The documented goal was that advance directives would be regarded and respected. Review of the Order Review History Report dated [DATE]-[DATE] revealed there were no parameters for physician notification related BS results and no documented evidence [MEDICATION(S)] IM was ordered. The order report documented a DNR/DNI order dated [DATE]. There was no order end date for the advanced directives. The Progress Note dated [DATE] at 2:58 PM, written by DSW #1 documented Resident #1 had a DNR/DNI order in place. Review of the Weights and Vitals Summary report dated [DATE]-[DATE] revealed on [DATE] at 6:27 PM Resident #1 had a BS of 31. The Progress Note dated [DATE] at 8:51 PM, written by Licensed Practical Nurse (LPN) #1 documented Resident #1 was observed at 6:00 PM, pale with vital signs ,d+[DATE] (normal), pulse ox (oxygen saturation level - amount of oxygen in the blood) 94% on room air (normal 90 to 100%), respirations of 16 (normal ,d+[DATE]), heart rate of 73 (average 80). Registered Nurse Supervisor (RNS) #1 was called to the floor to assess Resident #1 as the resident was not responsive to verbal or tactile stimuli. RNS #1 to floor, the Resident #1's BS at this time was 32, sugar was placed under the resident's tongue. RNS #1 was present, and another BS was obtained with a result of 47. Three minutes later RNS #1 gave another sugar sub lingual (under tongue). Three minutes later Resident #1's BS was 69. Resident #1's vital signs were stable with no signs of respiratory distress or shortness of breath. The writer (LPN #1) continued monitoring Resident #1 at this time. Around 6:30 PM, Resident #1's breathing appeared to be in distress, RNS #1 was called to the floor, the supervisor assessed Resident #1, called an ambulance, and a code was called. This writer (LPN #1) started CPR with code called. Resident #1 had a significant change in condition reported to LPN #1 at dinner time (approximately 5:30 PM). There was no documented evidence of Resident #1's cognitive response after receiving the [MEDICATION(S)] IM. , the MD was not contacted until 9:33 PM after the resident went into cardiac arrest and was transferred to the hospital. The ambulance report titled Patient Care Report dated [DATE] documented they received a call at 8:31 PM for a patient in cardiac arrest and arrived at Resident #1's side at 8:40 PM. Resident #1 was in bed, staff and fire department were on location and CPR was in progress. Staff reported resident was found lethargic and altered 3 hours ago, BS was checked, was 31, and they administered [MEDICATION(S)]. After 20 minutes the resident was rechecked and the BS was 71, however was still lethargic and slow to respond. Three hours later was found in cardiac arrest. Initial rhythm showed asystole (no heart rate), CPR continued, then attempted to insert bilateral IV (intravenous) unsuccessfully. They were able to start an IV in the tibia (leg) and administered [MEDICATION(S)] (medication used to restore cardiac rhythm). Compressions continued, and the resident was intubated. After 3 more rounds of CPR and 2 more doses of [MEDICATION(S)], the resident had strong pulses. The undated facility documented titled Event Summary completed by the Administrator, documented on [DATE] at approximately 6:00 PM LPN #1 found Resident #1 unresponsive, initial set of vitals were taken and a BS of 32. LPN #1 immediately notified RN Supervisor #1, who immediately administered [MEDICATION(S)] to the resident. The LPN (#1) noted the resident's BS began to continually rise to a range between ,d+[DATE] and the resident appeared to be responsive and stable. Approximately 20 minutes later, LPN #1 went to reassess the resident's condition and witnessed the resident unresponsive and gurgling. LPN #1 called the supervisor back to the unit. The supervisor stated they were unable to obtain a pulse for four to five seconds and made the decision at that time to call a code. 911 was called before LPN #2 arrived and placed the AED (automatic external defibrillator). The AED indicated no shockable rhythm. At that time the supervisor was still unable to feel a pulse and conducted four to five chest compressions. EMTs (emergency medical technician) arrived almost immediately and took over the code at that time. The facility concluded CPR was provided against the resident's wishes. Resident #1 had a significant change in condition reported to LPN #1 at dinner time (approximately 5:30 PM). There was no documented evidence of Resident #1's cognitive response after receiving the [MEDICATION(S)] IM. EMS was contacted at 8:31 PM the resident was in cardiac arrest and the MD was not contacted until 9:33 PM after the resident was transferred to the hospital. During an interview on [DATE] at 9:28 AM, LPN #1 stated around dinner time Certified Nurse Assistant (CNA) #1 alerted them that Resident #1 was unresponsive. LPN #1 stated they looked in the paper chart and in the EMR (electronic medical record), but the code status wasn't in there and did not know there was a separate MOLST binder. The LPN #1 stated they alerted RN Supervisor #1 that they couldn't find the MOLST or the resident's code status. LPN #1 stated RN Supervisor #1 said they would look up the code status and then alerted LPN #1 that Resident #1 was a full code and decided to call a code (overhead paged) and called the ambulance. The LPN #1 stated they did not know what RNS #1 looked at to determine the code status. LPN #1 stated they grabbed the crash cart and suction machine and brought it to Resident #1's room. LPN #1 stated they put the board under the resident and initiated chest compressions. LPN #1 stated they didn't know how many compressions were given. LPN #2 arrived to the room with the AED and applied it; the RNS #1 suctioned the resident. LPN #1 stated right after that the ambulance arrived and LPN #1 left the room because the Emergency Medical Technicians (EMTs) took over. LPN #1 stated the RNS #1 came out and asked LPN #1 to get another BS and the result was 118. LPN #1 stated at that point the EMTs were giving IVs and medications to Resident #1. During an additional interview at 12:17 PM, LPN #1 stated they did not know if Resident #1 had BS parameters for physician notification, and did not know if the physician was contacted by RNS #1. During a telephone interview on [DATE] at 10:30 AM, RNS #1 stated around 5:00 PM LPN #1 called them to Resident #1's room STAT (right away). RNS #1 stated when they arrived on the unit, LPN #1 stated the resident looked terrible and was not responding, their vitals were fine, and the resident was a full code. RNS #1 asked LPN #1 to obtain a BS and the result was 31. RNS #1 stated they gave Resident #1 IM [MEDICATION(S)] at that time and the BS went up to 77 but the resident wasn't responding to verbal or tactile stimuli. The RNS #1 stated later in the shift they got a call that the resident had secretions, the RNs #1 assessed the resident and asked LPN #1 to bring the crash cart down because they needed the suction machine. RNS #1 stated they used the [MEDICATION(S)] (tube used to suction secretions) to clear the upper airway, Resident #1 was still not responding to verbal or tactile stimuli and the BS was holding at 77. RNS #1 stated they looked for the MOLST which were traditionally kept in the first page of the chart, but it wasn't there, and LPN #1 had said they couldn't find the MOLST either. RNS #1 stated they did not know there was a MOLST binder but stated they knew the MOLST was in the EMR somewhere but didn't know where. RNS #1 stated the LPN #1 saw that the face-sheet said full code and that's what they went by. RNS #1 stated they called LPN #2, to print off the face-sheet (demographics), MARS (medication administration record) and TARS (treatment administration records) to get the transfer paperwork and to bring the AED. RNS #1 stated they had called 911. RNS #1 stated initially they couldn't find the brachial (antecubital, mid arm) pulse, and LPN #1 gave 4 compressions but then RNS #1 found a femoral pulse (top of thigh) and said to stop compressions. EMS (emergency medical services) had arrived quickly and took over. About ,d+[DATE] minutes later, after their arrival Resident #1 went into cardiopulmonary arrest. During further telephone interview on [DATE] at 12:55 PM, RNS #1 stated they did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1's BS of 31 and could not recall how much was given. RNS #1 stated for Resident #1's initial BS of 31, the physician should have been called. RNS #1 clarified and stated that they did call a code blue overhead, after they had asked LPN #2 for the AED. RNS #1 stated they called MD #1 right after they called the ambulance and told MD #1 that Resident #1 was in critical condition, not responding to verbal or tactile stimuli and had to call an ambulance for transport to the hospital. During an interview on [DATE] at 1:15 PM, LPN #2 stated they worked on the 2nd floor on [DATE], and RNS #1 called and asked them to print out documents from the EMR because Resident #1 was being sent to the hospital. About 10 minutes later RNS #1 called a code blue overhead to the 3rd floor. LPN #2 stated this was sometime between 8:00 PM and 8:30 PM. LPN #2 stated they grabbed the AED and went to the 3rd floor. When LPN #2 arrived at Resident #1's room, there was a back board under the resident, and RNS #1 was suctioning the resident. LPN #1 stated that Resident #1 was a full code, so LPN #2 hooked up the AED to the resident, and it indicated not to shock. Right after that EMTS arrived in the room. LPN #2 stated they did not know what occurred prior to their arrival. LPN #2 did not look for the resident's MOLST or code status. During an interview on [DATE] at 2:03 PM, the DON stated the MOLST binders were in place prior to their start date in December. The DON stated it was not ok for the staff to go by the face-sheet to ascertain a resident's code status. The DON stated LPN #1 and RNS #1 had worked in the facility for a long time and didn't know why they said they weren't aware of the MOLST binder. The DON stated Resident #1 had a couple hospitalization s, was readmitted on [DATE], then went back out on [DATE] and was discharged out of their EMR system. The DON stated whoever readmitted Resident #1 did not check the advance directives; the admitting nurse or supervisor were responsible to put in the advance directive orders. The MOLSTs also get scanned into the EMR, and Resident's #1's MOLST was scanned in on [DATE]. The DON stated the nursing supervisors, nurse managers and social worker double check the orders when a resident was admitted or readmitted and should address advance directives. The DON stated that they were getting away from having a paper chart because everything was in the EMR. During an interview on [DATE] at 2:40 PM, Director of Social Work (DSW) #1 stated they had started working in the facility at the end of February and the MOLST binders had been in place and to their knowledge had been in place a long time. DSW #1 stated when a MOLST was completed, with signatures and MD signature, nursing staff will put an order in the EMR. The MOLST gets uploaded to the EMR and the original goes into the binder on the unit. DSW #1 stated Resident #1 was just readmitted from the hospital and nursing staff were to make sure an order was added back into the EMR. The DSW #1 stated they did not know there was code status on the face-sheet, but they don't look at that anyway to check for code status, they were to look at the MOLST. During a telephone interview on [DATE] at 10:46 AM, MD #1 stated they didn't receive a call from RNS #1 regarding Resident #1 until 9:33 PM. The delay in the nursing staff calling them when the resident's BS was low contributed to the resident's decline and they would have wanted to see the Resident's BS brought up higher to the 200s after this instance of [CONDITION(S)]. MD #1 stated the RNS #1 administered [MEDICATION(S)], which was an appropriate thing to do in this situation. MD #1 stated the resident's BS did come up, so their altered mental status was likely from an infection rather than the low BS. MD #1 stated Resident #1 should not have received CPR because of their DNR status. The MD #1 stated staff should have known where to find the resident's code status or they could have called MD #1 as they were very familiar with Resident #1 and their code status. MD #1 stated Resident #1 was unconscious and then died , the treatment probably prolonged things. During an interview on [DATE] at 12:50 PM, LPN Unit Manager (UM) #4 stated if a resident's BS was low the nurse should call the supervisor immediately, then the supervisor should call the physician. LPN UM #4 stated for a BS of 31 they expected that the physician be notified immediately to get further orders to treat the low BS and that nurses weren't supposed to order medications for residents themselves. LPN UM #4 stated there was a MOLST binder at the nurses' desk by the telephone and if a resident didn't have a MOLST they were considered a full code. The LPN UM #4 stated Resident #1's DNR order may not have been put into the EMR upon readmission from the hospital, but someone is supposed to check, they have a few failsafe's that are supposed to be done. The nurse was to check, then SW was supposed to check for advance directive orders. In this situation, these checks failed. LPN UM #4 stated they did put orders from Resident #1's readmission into the EMR, they did a basic run through of the medications and thought the evening supervisor completed the rest of it. LPN UM #4 stated a follow up medication reconciliation also gets done to make sure all the orders were in the EMR to check if a resident was on a medication prior to their hospitalization was still needed and believed the RN UM #2 completed that check. LPN UM #4 stated it was more of a medication check, but it should be a double check of everything including advance directives. LPN UM #4 stated the efforts done by EMS were not comfortable for Resident #1 and were likely painful for the resident. During an interview on [DATE] at 1:37 PM, RN UM #2 stated when a resident had low BS, nurses used judgement and were able to give orange juice, food and stay with the resident until they stabilized, then the nurse should update the physician right away. Additionally, upon Resident #1's readmission from the hospital they did the medication reconciliation but did not look at the advance directives. When they completed the medication reconciliation they focused on the medications, but really should have looked at any orders that were already in the EMR (from the previous admission). During an interview on [DATE] at 2:45 PM, the Regional Administrator, facility Administrator and the DON were present. The DON stated RNS #1 should have called the doctor sooner and would have expected the nurse to have talked to the physician on the phone to get an order, while they retrieved the [MEDICATION(S)] for Resident #1's BS of 31. The DON stated RNS #1 said they called the physician afterwards because it had all happened so fast. During the same interview on [DATE] at 2:45 PM, the Regional Administrator stated they were not aware that the MD #1 wasn't updated about the situation until 9:30 PM. The Regional Administrator stated staff were supposed to look at the MOLST and EMR to determine a resident's code status. The Regional Administrator stated when a resident was readmitted every order could be reactivated except for the code status and when Resident #1 was readmitted it just got missed. All new admissions and readmissions were reviewed the next day in morning report and department heads attended those meetings, including nursing and SW, where advance directives were discussed. The Regional Administrator stated Resident #1 should not have received CPR and if the physician was called sooner Resident #1 would not have received CPR. During further interview on [DATE] at 4:02 PM, the DON stated Resident #1's MOLST they had on file was valid and reviewed quarterly. b. Review of the Order Review History Report dated [DATE]-[DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Check BS before meals and at bedtime. Review of the Medication Administration Record (MAR) dated [DATE] to [DATE] revealed [MEDICATION(S)] insulin 10 units was scheduled for 7:30 AM, 11:30 AM, and 4:30 PM along with a BS. The [DATE] through [DATE] 7:30 AM and 11:30 AM doses were initialed as given but the BS result was documented as NA (not applicable). During an interview on [DATE] at 10:05 AM, LPN #3 stated they did not check Resident #1's BS when they worked [DATE]-[DATE] day shift because there was no physician's order for it. LPN #3 reviewed the MAR and stated the BS on it meant blood sugar, but the resident only had a standing order to give 10 units of insulin. LPN #3 stated monitoring of resident's BS varied, and it depended on the individual, and usually there was a separate order to monitor BS before meals or at bedtime. During an interview on [DATE] at 12:50 PM, LPN Unit Manager (UM) #4 stated BS checks were ordered, and they put that order into the EMR when the [MEDICATION(S)] insulin was re-ordered. LPN UM #4 stated the BS was added to the [MEDICATION(S)] and [MEDICATION(S)] insulin orders as supplementary documentation that alerted the medication nurses that a BS was needed prior to administering the insulin. The only time the medication nurses should override that BS documentation was when a resident was out of the building. LPN UM #4 reviewed Resident #1's MAR for [DATE] to [DATE] and stated they could see the day shift BS were not completed and they did not know why. During an interview on [DATE] at 4:02 PM, the DON stated Resident #1's BS should have been checked [DATE] through [DATE] by the medication nurse. During further interview on [DATE] at 9:52 AM, the DON stated when an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated they did not know why LPN #3 did not complete the BS. 415.12

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 082) completed on 4/12/22, the facility did not ensure that all alleged violations involving abuse were reported immediately but no later than two hours after the allegation is made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) for one (Resident #1) of one resident reviewed for abuse reporting. Specifically, the facility did not report an allegation of abuse to the New York State Department of Health (NYS DOH) within the two-hour required time frame. The findings are: Review of the untitled and undated Policy and Procedure (P&P) documented all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. A. All personnel, residents, visitors, etc. are mandated to report incidents of resident abuse or suspected incidents of abuse. Such report may be made without fear of retaliation from the facility or its staff. B. Staff members are to immediately attempt to stop the actual or suspected abuse, then report the abuse/neglect/mistreatment or exploitation of the residents. Remove the resident from the immediate area of the alleged occurrence or possible causative factor, if applicable. 1. Resident #1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 3/20/22 documented Resident #1 was cognitive intact, was understood and understands. Review of the undated Event Summary completed by the Administrator documented on 4/8/22 at approximately 7;20 PM the resident called the police to accuse a CNA of inappropriately touching them during a shower a couple weeks ago. The Event Summary further documented the conclusion revealed there was no evidence sexual abuse according to the New York State Department of Health (NYSDOH) Reporting Manual. During an interview 04/12/2022 at 11:53 AM with Licensed Practical Nurse (LPN) #1stated resident went to the hospital this morning for psychiatric evaluation. Was unsure if they were admitted yet. During an interview on 04/12/2022 at 2:03 PM with the Social Worker (SW) stated the resident was in a very manic state hearing voices and having delusions, they called the police saying we stole $20,000.00 and stating they were assaulted in the shower a couple weeks ago by a staff member. The SW also stated they believe the facility started an investigation but was not involved in the process. During an interview on 04/12/2022 at 2:17 PM with the Director of Nursing (DON) stated they were aware of the allegation the resident had been very paranoid and delusional. An investigation was completed and reported by the Administrator. Abuse has to be reported within two hours. During an interview on 04/12/2022 at 2:19 PM with the Administrator stated they were aware of the allegation and did not call the allegation to the NYSDOH due to (d/t) the investigation proved the resident was in a manic state and allegations were unfounded. The Administrator was unaware all allegations of abuse must be called within 2 hours to the NYSDOH. 415.4(b)(2)

Based on observation, interview, and record review conducted during a COVID-19 Focused Infection Control Survey conducted 11/5/21, the facility did not maintain an infection prevention and control program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility Covid Tracker (full time COVID-19 specimen collector) #1 did not utilize appropriate PPE (personal protective equipment) while collecting COVID-19 specimens for one of one employee observed (Director of Therapy). The finding is: The Centers for Medicare and Medicaid Services (CMS) QSO-20-38-NH revised 9/10/21, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, documented: During specimen collection, facilities must maintain proper infection control and use recommended PPE, which includes an N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. The facility policy and procedure (P&P) titled Nasopharyngeal and Oropharyngeal Swab Collection dated 4/2021 documented it was facility policy to collect swab specimens as recommended by Public Health. The procedure included to don (put on) PPE (gown, N-95 if available, eye protection, gloves). During an interview on 11/5/21 at 8:30 AM, the Assistant Director of Nursing (ADON) stated the facility had three confirmed COVID-19 positive residents. During an observation on 11/5/21 at 9:54 AM Covid Tracker/Specimen Collector #1 completed a COVID-19 nasal swab specimen collection on the Director of Therapy wearing a surgical face mask, eye protection, gloves, and gown. During an interview on 11/5/21 at 10:06 AM, Covid Tracker/Specimen Collector #1 stated they have been employed, full time, with the facility for two and a half months and was hired just to perform COVID-19 swabbing of facility staff, visitors, and vendors. Covid Tracker #1 stated they were educated by the facility on proper technique of performing COVID-19 swabbing, testing, and the use of PPE. The Covid Tracker stated N-95 masks were available at the facility and they had one in their desk, but when things started to loosen up the Covid Tracker #1 thought it was ok to wear just a surgical mask. If someone wasn't feeling well, had symptoms, or had been working with the COVID-19 positive residents in the facility they would wear their N-95 mask while performing specimen collection. The Covid Tracker stated Oh yea, I did not even think about it. I should have been wearing my N-95 mask when I was swabbing. On 11/5/21 at 12:55 PM an attempt was made to reach the facility Infection Preventionist, via telephone, was unsuccessful. During an interview on 11/5/21 at 1:09 PM, the Regional Clinical Director and the Director of Nurses (DON) both stated the expectation of PPE to be worn by staff, performing COVID-19 specimen collection, was to wear gown, goggles/face shield, N-95 respirator, and gloves. A N-95 mask was to be worn, at all times, by the specimen collector when anyone was getting swabbed for COVID-19. Additionally, the DON stated appropriate PPE should be worn, for infection control purposes, to prevent the spread of COVID-19, and/or the swabber themselves getting contaminated with COVID-19. 415.19 (a)(1)

Based on observation, interview, and record review conducted during the Standard Survey completed on [DATE], it was determined that the facility did not have a consistent system in place to identify residents' wishes regarding Advanced Directives. Specifically, facility policy and procedure specified different indicators of resident's code status that included: the CNA (certified nurse aide) Closet Care Plan; color coded stickers in resident charts; code status list kept in the Medication Administration Record (MAR) book, at the facility front desk, and in the therapy department; physician orders; and advanced directives/MOLST (Medical Orders for Life Sustaining Treatment) form. Eight (Residents #30, 63, 64, 73, 80, 83, 99, 102) of 29 residents were identified as having their advance directives improperly documented in these areas; including inconsistencies with the physician's order. Further concern was revealed with direct care staff interviews that included inconsistent responses when asked how to identify residents' code status; including the failure to verify the Resident #83 Advance Directive orders and/or the physician orders prior to initiating cardiopulmonary resuscitation (CPR- emergency resuscitation measures, including artificial ventilation and chest compressions) when the resident had a physician's order for a DNR (Do Not Resuscitate - allow natural death) in place. The lack of properly documented Advance Directive status resulted in a pattern of IMMEDIATE JEOPARDY with actual harm to Resident #83 and the potential for serious harm to RESIDENT HEALTH AND SAFETY. The IMMEDIATE JEOPARDY was removed on [DATE], prior to the completion of the survey. The findings include but are not limited to: 1. Resident #83 was admitted to the facility for rehabilitation on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated [DATE] revealed the facility did not assess the resident's cognitive status. Review of the physician's History & Physical (H&P) dated [DATE] revealed the resident was oriented to person, place, and time. In addition, the H&P documented the resident's judgment was intact, insight was intact, and decisional capacity was present. Review of a Resident Admission/Readmission Evaluation dated [DATE] revealed the following Advance Directive was checked - DNR. Review of an undated Admission Intermin (sic) Care Plan, revealed a green FULL CODE (designation that means to start CPR if a patient's heart stops beating or if the patient stops breathing) sticker on the lower right hand corner of page 1. Review of the Physician's Orders, signed [DATE] revealed the resident had a DNR order. Review of the entire medical record revealed there were no Social Work Progress Notes and there was no documented evidence that advance directives were addressed with the resident. Review of a Nurses Progress Notes dated [DATE], timed 9:05 - 9:45, written by the Director of Nursing (DON) revealed the following: - Called to 2nd (second) floor STAT (immediately). Resident was observed slumped in wheelchair, unresponsive with shallow agonal (gasping) breathing. + (positive) RT (right) femoral (femoral artery - situated at, in or near the thigh) pulse. Unable to assess pupil response due to [MEDICAL CONDITION] (clouding of the normally clear lens of the eye) B/L (bilateral). Rescue breathing with O2 (oxygen) started after the resident was put back into bed. 911 called. Rescue breathing and frequent pulse checks. Resident was noted not to have a pulse and CPR was started prior to 911 coming in. 911 arrived and resumed CPR and ACLS (advanced cardiac life support - clinical interventions for the urgent treatment of [REDACTED]. She was transported by emergency services. Family was called but was unable to be reached. Daughter came in at 9:50 AM and a staff member drove her to the hospital. Review of the MDS Death in facility tracking record revealed the resident expired [DATE]. During an interview on [DATE] at approximately 1:25 PM, the DON stated, I remember the incident when I was called to the unit and the resident coded. The resident was slumped in her chair, we got her into the bed, and checked the Closet Care Plan (guide used to provide care). The Closet Care Plan had a Full Code sticker, so CPR was initiated and 911 was called. Interview with the DON on [DATE] further revealed, staff is instructed to look at the Closet Care Plan and/or the Resident face sheet to determine code status when someone is found unresponsive. In addition, the DON stated, The code status stickers (on the Closet Care Plan and Resident face sheet) should absolutely match the Physician's orders. It's a huge problem if you go against a residents' wishes. Review of the facility policy and procedure entitled Emergencies/Safety: Basic Life Support/C.P.R. dated [DATE] revealed the following: - Residents who require basic life support (B.L.S.) (want to be resuscitated) will have a green FULL CODE sticker on the plastic sheet covering the face sheet in the front of the chart. Residents who request not to be resuscitated will have a red DNR sticker on the plastic sheet covering the face sheet in the front of the chart. - A list of all full code residents will be listed in the MAR and will be located at the front desk on the 1st floor. The lists will be updated every shift by the Registered Nurse (RN) Supervisor. - The Social Worker or Nursing Supervisor will be responsible to identify advanced directives or resuscitation status on admission, readmission or change in status during a continued stay, and will update their resuscitation status in the front of each MAR and at the front desk. Interview with the Activities Leader on [DATE] at approximately 10:51 AM revealed, There is no list that I'm aware of. I go to care plan meetings, so I do know the residents code status, especially the regulars. Interview with the Physical Therapy Director on [DATE] at approximately 10:54 AM revealed that the therapy department has access to resident Closet Care Plans on an excel spreadsheet. If a resident were to code in therapy the Director would expect a member of the therapy staff to refer to the excel spreadsheet to determine code status. In addition, the interview revealed there is a code status list that is kept in the therapy department. Observation and review of an untitled code status list posted on the wall in the Therapy Department (located on the first floor) on [DATE] at approximately 10:54 AM revealed the list was dated [DATE] and did not accurately reflect the code status of all the residents listed on the document. Observation and review of an untitled code status list located at the front desk on [DATE] at approximately 11:02 AM revealed the sheet was dated [DATE] and did not accurately reflect the code status of all the residents listed on the document. During an interview on [DATE] at approximately 1:12 PM, Licensed Practical Nurse (LPN #6) stated, When someone codes, I check the face sheet for a sticker, but there's not always a sticker on the face sheet. If there's no sticker, I guess I would check the Closet Care Plan. Interview further revealed, There is no code status list in the MAR's, I don't ever remember a code list in the MAR's. Observation of the LPN #6's MAR revealed there was no code status list in the MAR. Interview with LPN #5 on [DATE] at approximately 1:18 PM revealed, I would check the face sheet when someone codes, there is no list in my MAR. Observation of LPN #5's MAR revealed there was no code status list in the MAR. During an interview on [DATE] at approximately 3:00 PM, with the Administrator and the Social Worker, The Administrator stated, issues regarding Advance Directives and discrepancies with Advance Directives were brought up in the [DATE] Quality Assurance (QA) meeting. The interview further revealed the Social Worker and the Assistant Director of Nursing (ADON) were in the process of conducting audits and correcting any identified issues and had a few more to correct. The Social Worker then stated that all audits of residents' Advance Directive status had not been completed and corrections to the resident's Advance Directive status had not been completed. During a telephone interview on [DATE] at approximately 2:45 PM, the Medical Director stated, If there is a Physician's order for DNR, that order needs to be honored. Everything regarding a residents' Advance Directives should match the Physician's order. CPR should not be initiated on a resident with a DNR. 2. Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands and is understood. Review of the Physician's Order, signed [DATE], revealed Advance Directive orders dated [DATE] for DNR, DNI (do not intubate- do not place tube down throat or connect to breathing machine). Review of the medical record revealed a Health Care Proxy (HCP), dated [DATE] with no Advance Directives. Further review revealed two Physician Orders Health Care Proxy Activation forms signed [DATE] and [DATE]. Review of the Admission Record face sheet did not identify the resident's Advance Directive status. Further review of the medical record revealed the most current Social Services Care Plan Progress Note, dated [DATE]. The Advance Directive section checked: MOLST/DNR and HCP activated. Review of the Closet Care Plan, dated [DATE] documented the resident Advance Directive status as Full Code. Review of an untitled code status list, dated [DATE] revealed the resident was listed as a Full Code. 3. Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, understands and is understood. Review of the Physician Orders, created by the Assistant Director of Nursing (ADON, RN #1), confirmed with the physician on [DATE] and signed by the Nurse Practitioner on [DATE] documented the resident's Advance Directive status as Full Code. Further review of the medical record revealed an unsigned Physician Telephone order, written [DATE] with instruction that Per Advance Directive resident code status is DNR. Review of the physician's history and physical examination [REDACTED]. Further review of the medical record revealed a Durable Power of Attorney to Communicate Health Care Decisions, a Health Care Proxy and a Health Care Decisions Declaration, all dated [DATE] that documented that the resident did not want CPR to be administered. Review of the Social Services Care Plan Progress Note, dated [DATE], revealed in the Advance Directive section that HCP (Health Care Proxy) was checked but did not document that the resident had a Living Will. Review of an untitled code status list, dated [DATE] revealed the resident was listed as a Full Code. During an interview with the Licensed Practical Nurse (LPN #3) Unit Manager on [DATE] at 9:37 AM, the Unit Manager stated that when physician orders are created, the HCP and Advance Directive would be checked. The Unit Manager further stated, I would have confirmed the orders and the ADON (Assistant Director of Nursing) would check them and sign them. If I had reviewed the Advanced Directives at admission, I would have made the resident a DNR. During an interview with the ADON (RN #1) on [DATE] at 11:50 AM, the ADON stated the facility received eight admissions from their sister facility on the day the resident arrived at the facility. The ADON stated she cannot not remember if she saw the resident's Advance Directive on the day of admission. The ADON stated that she was traveling between both facilities, that day, to assist with the move of the eight residents. The ADON stated that paperwork was being faxed from the resident's previous nursing home and receipt of the paperwork was very fragmented. The ADON stated that other personnel in the nursing home may have received the resident's paperwork from the fax machine and it would be placed in the wrong staff member's mailbox. Review of facility policy and procedure entitled Advanced Directives revised [DATE] revealed that upon admission, Social Work staff will determine whether a resident has advance directive or a designated Health Care Agent. Further review of the policy revealed Social work and/or Nursing are responsible for documenting the existence of all advance directive on the Medical Alert form in the front of the resident's medical record. Social Work will document in the Social Work Progress Notes in the medical record. 4. Resident #73 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident had was cognitively intact. Review of the MOLST form dated [DATE] revealed the resident completed the form and chose not to be resuscitated. Review of the Physician's Orders dated [DATE] revealed an order for [REDACTED]. Indicating more than a four-month delay in obtaining a Physician's order for a DNR. During an interview on [DATE] at 10:19 AM, the DON stated the [DATE] date on the Physician's Orders indicates the origination date of the Physician's Order. Review of the Comprehensive Care Plan (CCP) dated [DATE] revealed The resident is a Full Code with no HCP in place at this time. Review of the resident's face sheet revealed it did not have a sticker indicating the resident's code status. 5. Additional interviews revealed the following: - [DATE] at approximately 2:10 PM - LPN #3 Unit Manager stated she would look at the Closet Care Plan or check the resident's face sheet. - [DATE] at approximately 2:25 PM - LPN #10 stated she wasn't sure what she would do and has only worked at the facility for a few weeks. -[DATE] at approximately 2:30 PM - LPN #2 stated she would look at the resident's face sheet. LPN #2 also stated she would not look at Physician's orders. - [DATE] at approximately 2:35 PM - LPN #1 Unit Manager stated if a resident was unresponsive she would go to the MOLST to determine the resident's status. If there is no MOLST the resident would be considered a full code. - [DATE] at approximately 4:34 PM - LPN # 9 stated that if a resident was unresponsive she would go to the advance directives section of the chart to check the MOLST. If there is no MOLST then the resident is a full code. - [DATE] at approximately 4:37 PM - LPN # 7 stated if a resident is found unresponsive she would check the sticker on the face sheet. If there is no sticker she would check the Physician's orders. There is also a list posted on the Unit Manager's door. - ,[DATE] /17 at approximately 4:40 PM - LPN #8 stated she would go to the chart, check the face sheet if the resident was a full code she would call Dr. Fast. If the resident was a DNR, she would call the Supervisor. LPN #8 also stated if she was off the unit she would go to the reception desk and check the code status list. 6. Review of a letter to the New York State Department of Health, signed by the Administrator, dated [DATE] revealed the following: - Resident Advance Directives and Basic Life Support policy and procedure (P&P) was reviewed and revised - All nursing, clinical and medical staff were educated on the revised Resident Advance Directives and Basic Life Support policy - Advanced Directive audits were performed and deficient practices identified were corrected - Facility Medical Director met with the Administrator and Corporate Director of Nursing and approved the revised policy and procedure 7. The Immediate Jeopardy was removed on [DATE] because of the following: a). Review of the revised Resident Advance Directive and Basic Life Support P&P, dated [DATE] revealed specific steps to obtain or change a residents' Advance Directive status: communicate and document the resident's Advance Directive status; and methods to implement the resident's Advance Directive in an emergency response. b). Review of facility In-service Records dated [DATE] through [DATE] confirmed all clinical and medical staff received education on the facility's revised Advance Directives and Basic Life Support policy. Training consisted of specific steps to obtain or change a residents' Advance Directive status, communication of code status, and the methods used to identify the resident's wishes in an emergency response. Provisions were made for education and training to continue on an on-going basis. c). Observations and reviews on [DATE] of three resident records on the 2nd floor nursing unit and three resident records on the 3rd floor nursing unit revealed the following: Resident face sheet, Advance Directive; Physician Orders; facility lists in the 24-hour report book and Therapy Department and room door tag all correctly documented the resident's Advance Directive status. Additional observations and reviews on [DATE] of nine residents' records revealed that the resident code status was accurately identified, communicated and documented based on the resident's wishes. d). Based on interviews with: Director of Nursing, Assistant Director of Nursing, ,[DATE] Shift RN Supervisor, RN MDS Coordinator, LPN #1 Unit Manager, LPN #3 Unit Manager, LPN #4, LPN #6, LPN #7, LPN #8, LPN #9, LPN #11, and LPN #12, on [DATE] between 2:30 PM and 4:30 PM revealed the staff were educated on the facility Advance Directives and Basic Life Support policy and procedure. This included specific steps to obtain or change a residents' Advanced Directive status, how the residents' wishes are identified, documented, communicated and located. In addition, the methods used to implement the resident's Advanced Directives in an emergency response, including what to do if there were to be a discrepancy with the identifiers. 415.3 (e)(2)(iii)

Based on interview and record review conducted during the Standard Survey completed on 1/24/17, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain, or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility administration failed to ensure that the facility had an effective system in place to identify residents' wishes regarding Advanced Directives. The Administrator did not follow up with the Social Worker once problems were identified with system failures to establish mechanisms for accurately documenting and communicating each resident's advance directive choices to the interdisciplinary team. The lack of properly documented Advance Directive status resulted in a pattern of IMMEDIATE JEOPARDY WITH ACTUAL HARM TO RESIDENT HEALTH AND SAFETY. The IMMEDIATE JEOPARDY was removed on 1/22/16, prior to the completion of the survey. In addition, the Plan of Correction (POC) for the Life Safety Code (LSC) survey completed on 3/8/16 identified the Administrator as the individual responsible for the correction of two repeat Life Safety Code deficiencies cited during the LSC survey completed 3/8/16. The Administrator did not ensure corrective actions identified in the POC were completed as evidenced by two (K161 and K918) deficiencies identified during the LSC survey completed 1/24/17. The findings are: REFER TO: F 155 - Right to Refuse: Formulate Advance Directive -scope/severity = K F 250 - Provision of Medically Related Social Service- scope/severity = E K 161 - LSC- Building Construction - (formerly K12) - scope/severity = E K 918 - LSC- Electrical Systems Maintenance and Testing- (formerly K 144)- scope/severity = E 1. Specifically, eight (Residents #30, 63, 64, 73, 80, 83, 99, 102) of 29 residents were identified as having their Advanced Directives improperly documented in the CNA (Certified Nurse Aide) Closet Care Plan; color coded stickers in resident charts; code status list kept in the Medication Administration Record [REDACTED]. During an interview with the Administrator and Social Worker (SW) on 1/18/17 at 3:00 PM, the Administrator stated that residents' Advance Directive status was recently discussed at the facility's Quality Assurance (QA) meeting. The Administrator stated that the Social Worker completed an audit after finding some errors at the end of December 2016. The Administrator stated that the Social Worker was correcting the residents' Advance Directive status and had a few more to correct. The Social Worker then stated that all audits of residents' Advance Directive status had not been completed and corrections to the resident's Advance Directive status had not been completed. During further interview with the Administrator on 1/24/17 at 8:25 AM, the Administrator stated that the Social Worker had made her aware of problems with residents' DNR status on 12/20/16 at the facility QA meeting. The Administrator stated that she did not have follow up meetings with the Social Worker to determine if the Social Worker had corrected problems identified with residents' Advance Directives. The Administrator stated I thought she had taken care of it. 2. Review of the approved POC, submitted by the facility following the LSC Survey completed on 3/8/16, revealed the facility identified a correction date of 5/16/16 for LSC deficiency K 12 (now K 161) and a correction date of 4/20/16 for LSC deficiency K 144 (now K 918). Based on observations, interviews and record reviews conducted from 1/13/17 through 1/20/17, the deficiencies cited under K 12 (now K161) and K 144 (now K 918) were not corrected. Furthermore, the Administrator was identified as the person responsible for the correction of these deficiencies. Additional review of the approved POC revealed the following: a). K 12 (now K 161) - The Outside Contractor administering the Fire Safety Evaluation System (FSES) was to be contacted to complete the inspection and pass the certification once the sprinkler system fire pump was hooked up to the new emergency generator. Once the Outside Contractor approved and certified the FSES, a copy of the document was to be sent to the Department of Health (DOH). A weekly maintenance audit was to be added and conducted by the Environmental Services Director to ensure that maintenance issues were corrected in a timely manner. Results of audits were to be reported to the administrator. The Administrator was to in-service maintenance and management staff about the FSES and how it ensures Fire Safety for the building and residents. Interview with the Administrator on 1/18/17 at approximately 1:31 PM revealed that no changes were made to the unprotected steel web trusses, unprotected steel beams, and non-fire rated lay-in style ceiling assemblies located on the First, Second, and Third floors pertaining to K 12 (now K 161). Further interview with the Administrator at this time revealed a Fire Safety Evaluation System (FSES) was not completed for the building. Continued interview with the Administrator on 1/18/17 at approximately 1:31 PM revealed that she had left a message for the Outside Contractor approximately two weeks ago, in an attempt to schedule an appointment to have an FSES conducted on the building and the Outside Contractor had not called her back. Additional review of the POC revealed the facility previously requested a Time Limited Waiver with a completion date of 12/1/14 for the purpose of conducting, completing, and passing an FSES for this deficiency. As of 1/24/17, a passing FSES for the building was not completed or submitted to the survey team or the New York State (NYS) DOH. b). K 144 (now K 918) - The POC documented that the required emergency testing of the generator was to resume. The weekly generator inspection/exercise was to be completed and documented by the Environmental Services Director or designee and the monthly full load test was to be conducted and documented by Environmental Services Director or designee. A new generator log was to be established for proper documentation and this log was to be audited by the Administrator monthly. Review of generator logs revealed the facility did not have documentation for weekly inspections of the emergency generator from 5/22/16 through 7/31/16 and from 12/4/16 and 12/31/16. Further review of the logs revealed the facility did not have documentation for monthly load tests for the emergency generator for March, April, May, June, July August, September, and November of 2016. Interview with the Environmental Services Director on 1/18/17 at approximately 9:10 AM revealed she has worked at the facility since March of 2016 and that the facility's previous Maintenance Supervisor was in charge of the emergency generator. 415.26

Based on interview and record review conducted during the Standard survey completed on 1/24/17, the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee effectively identified and corrected quality deficiencies with the potential to cause serious harm to residents and did not develop and implement appropriate plans of action. Specifically, the facility QAA failed to ensure complete and accurate documentation of the residents' Advance Directive status was communicated to the interdisciplinary team. The lack of properly documented Advance Directive status resulted in a pattern of IMMEDIATE JEOPARDY WITH ACTUAL HARM TO RESIDENT HEALTH AND SAFETY. The IMMEDIATE JEOPARDY was removed on 1/22/16, prior to the survey exit. In addition, the facility did not ensure that the QAA committee effectively identify and correct Life Safety Code (LSC) deficiencies and did not implement the Plan of Correction; to ensure monitoring was conducted, to prevent the continuation of five Life Safety Code deficiencies that were identified during the Life Safety Code surveys completed on 3/8/16 and 4/25/15. The findings are: REFER TO: F 155 - Right to Refuse: Formulate Advance Directive -scope/severity = K F 250 - Provision of Medically Related Social Service- scope/severity = E K 161- LSC- Building Construction (formerly K 12) - scope/severity = E K 351 - LSC- Sprinkler System Installation (formerly K 62) -scope/severity = D K 353 - LSC- Sprinkler System- Maintenance and Testing (formerly K 62) - scope/severity = E K 363 - LSC- Corridor Doors (formerly K 18) - scope/severity = E K 918 - LSC- Electrical Systems Maintenance and Testing (formerly K 144) - scope/severity = E 1. Eight (Residents #30, 63, 64, 73, 80, 83, 99, 102) of 29 residents reviewed for Advance Directives were identified as having their Advance Directives improperly documented in the CNA (Certified Nurse Aide) Closet Care Plan; color coded sticker in resident chart; Code Status list kept in the Medication Administration Record [REDACTED]. Subsequently, the facility failed to provide a consistent process to identify residents' wishes regarding Advance Directives. During an interview with the Administrator and the Social Worker (SW) on 1/18/17 at approximately 3:00 PM the Administrator stated that residents' Advance Directive status was recently discussed at the facility's December 2016 Quality Assurance (QA) meeting. The Administrator stated that the Social Worker completed an audit after finding some errors at the end of December 2016. The Administrator stated that the SW was correcting the residents' Advance Directive status and had a few more to correct. The SW then stated that all audits of residents' Advance Directive status had not been completed and corrections to the resident's Advance Directive status had not been completed. Review of the SW Advance Directive audits revealed the audits were dated 12/29/16. Review of the Facility Survey Report (FSR), signed by the Administrator on 1/18/17, revealed that the facility's QAA committee meets monthly and the most recent meeting was held on 12/20/16. The FSR documented that the Administrator, Director of Nursing (DON) and Social Worker are members of the QAA committee. During the QAA review meeting with the Administrator and the DON on 1/24/17 at 8:25 AM, the Administrator stated that after the Social Worker identified the inconsistency in Advance Directive information in resident medical records, the Social Worker began to complete audits of all current resident's Medical Records. The Administrator stated that the QAA did not meet again to follow up on the inconsistencies in Advance Directives. The DON stated that the SW did not realize the urgency in correcting the inconsistencies of the residents' Advance Directive information. When asked what QA audits of resident medical records had been completed prior to SW identifying the concern with Advance Directives, the DON stated, We haven't done any recently. We have gotten off track, but we need to start doing audits again. 2. Repeat Life Safety Code deficiencies were identified during Life Safety Code surveys completed on 1/24/17 and 3/28/16, that were initially identified during the 4/25/15 Life Safety Code survey. The four repeat deficiencies were cited in the following areas: - K 161 (formerly K 12): Structural steel beams and structural steel web trusses, located above the non-fire rated lay-in style ceiling assembly of resident use floors were not protected to meet the minimum fire rating of building construction type II (111) or type II (222). - K 363 (formerly K 18): Corridor doors were not designed to resist the passage of smoke and/ or were obstructed from closing. - K 351 and K 353 (formerly K 62): Sprinkler piping was hung from an electrical conduit instead of from the building's structure, various items were stored less than 18 (inches) from sprinkler heads, sprinkler heads were obstructed, and the fire pump was not tested under emergency power. - K 918 (formerly K 144) : The facility did not have documentation that the emergency generator was continuously tested under load for at least 30 minutes per month. In addition, the facility did not have documentation that the emergency generator was continuously inspected on a weekly basis. Review of the accepted Plan of Correction (POC) for the 3/8/16 Life Safety Code survey revealed the alleged compliance date for the 3/18/16 Life Safety Code survey was 5/16/16. Review of the Plan of Correction (POC) for the 3/8/16 Life Safety Code survey revealed that Results will be reported to the Quality Assurance(QA) Committee. The FSES (Fire Safety Evaluation System) and any recommendations of the FSES will be reviewed at QA. The QA Committee may modify reporting requirements depending on the success and consistency of these measures. Audits identified in the POC are as follows: a) K 12 (now K 161) LSC: Weekly maintenance audits, to be conducted by the Environmental Service Manager (ESM) to ensure that maintenance issues are corrected in a timely manner. Results of audits will be reported to the administrator. b) K 18 (now K 363) LSC: Weekly maintenance audits, to be conducted by Environmental Service Manager (ESM) or designee will include checking for door obstructions, door latching and penetrations in doors. c) K 62 (now K 351) LSC and K 353 LSC: Environmental Service Manager's 100 % (percent) audit of the building for 18 clearance form sprinkler heads and exit signs, sprinkler pipes to ensure they are hung properly, and that all inspections are completed. The fire pump inspection/testing and will be added to the sprinkler inspection sheet. The fire pump churn test will be added to the generator inspection/test sheet. ESM or designee will in-service all staff on the 18 clearance requirement. ESM will in-service maintenance staff on proper inspection reporting. ESM will audit paperwork for compliance and report to the QA committee. d) K 144 (now K 918) LSC: Weekly generator inspection/exercised. Monthly full load test documentation. New generator log to be audited by the administrator monthly. The ESM in-serviced all maintenance staff on how to properly run the generator load test and how to properly read the generator gauges and document. Effective 11/1/16, The Centers for Medicare & Medicaid Services adopted both the 2012 Edition of NFPA (National Fire Protection Association) 101 Life Safety Code and the 2012 Edition of NFPA 99 Health Care Facilities. Due to the adoption of these codes, the K tag identifying numbers of the Life Safety Code deficiencies were changed. Review of the Facility Survey Report (FSR) signed by the Administrator on 1/18/17 documents that the facility has monthly QA meetings and the last meeting held was 12/20/16. Further review revealed that the Administrator and the Director of Environmental Services Department are members of the Quality Assessment and Assurance Committee. An interview with the Administrator on 1/18/17 at approximately 1:31 PM revealed a Fire Safety Evaluation System (FSES) had not been conducted on the building. The FSES is a grading system, designed to demonstrate an atlernative method of compliance of LSC regulations, that a facility may use in lieu of making a physical correction. The FSES was initiated by the facility as a result of findings from the LSC survey completed on 4/25/15, and has yet to be completed. 415.27(a-c)

CONTINUING DEFICIENCY Based on interview and record review conducted during an onsite post-survey revisit completed on 7/30/13, the facility did not ensure that residents are free of any significant medication errors. One (Resident #1) of three residents reviewed for pain medication administration did not receive two doses of "around the clock" narcotic pain medication as ordered by the physician. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data set (MDS - an assessment tool) dated 6/5/13 revealed the resident has severe cognitive impairment. Review of the (comprehensive) Care Plan last updated 4/2/13 revealed the resident was identified with an alteration in comfort related to [MEDICAL CONDITION] joint disease, neck arthritis, pseudogout (a form of arthritis that causes sudden attacks of joint pain and swelling) and corns of the left foot. Care plan approaches include monitoring for signs and symptoms of pain and discomfort; reviewing the pain regimen and assessing effectiveness, and providing a soft neck collar for comfort. Review of a "physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The RN Night Supervisor stated during a telephone interview on 7/25/13 at 9:00 AM that she recently began employment at the facility on 6/26/13. The RN stated that she received general orientation to supervisory duties and did not receive orientation for general floor duties. The RN stated that on 7/21/13 and 7/22/13 she was scheduled to work as the Night Supervisor but due to a nursing staff shortage, she had to cover the Second Floor Unit including passing medications for the entire unit, as well as perform her supervisory duties. She stated that she had recently worked as an RN in Home Care and has not passed medications on a unit in many years. During the interview, the RN stated that she must have missed Resident #1's 12:00 AM medication "simply due to being busy". She further stated that while passing meds and doing rounds on the unit, there were no residents ringing call bells requesting pain medications. She stated that all residents appeared to be resting or sleeping comfortably. Resident #1 stated during an interview on 7/24/13 at approximately 11:30 PM that she has no complaints regarding receiving pain medications and that her pain is controlled. She stated that her neck pain improved after completing physical therapy. 415.12(m)(2)

Based on observation, interview and record review conducted during a complaint investigation (complaint #NY 773) during the Standard survey completed on 6/17/13, the facility did not ensure that residents are free of any significant medication errors. One (Resident #69) of one resident reviewed for pain medication administration did not receive five doses of "around the clock" narcotic pain medication as ordered by the physician causing "unbearable pain" to the resident. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #69 has [DIAGNOSES REDACTED]. Review of a hospital Discharge Summary Report dated 6/3/13 revealed the resident sustained [REDACTED]. The Discharge Summary documented that the resident was discharged on [MEDICATION NAME] (narcotic medication used to relieve moderate to severe pain) 7.5/500 one tablet every six hours as needed and [MEDICATION NAME] opioid [MEDICATION NAME] for the relief of moderate to severe pain) 0.5 milligrams (mg) subcutaneously (injection beneath the skin) every 6 hours as needed. Review of the Minimum Data Set (MDS - assessment tool) dated 6/10/13 revealed the resident is understood, understands and is independent in daily decision making. The MDS documented that the resident requires two person extensive assist for bed mobility, transfer and toilet use, has an external catheter and is totally dependent for dressing and personal hygiene. Further review of the MDS revealed the resident was assessed for pain, received a scheduled pain medication and an "as needed" pain medication, has occasional pain and rated the pain as "4/10" (severity of pain rated on a scale of zero (no pain) to 10 (severe pain)). Review of a Pain Management Flow Sheet dated 6/9/13 revealed the location of the resident's pain was described as "all over" with a pain rating of "8/10" which the sheet indicated as it "hurts a whole lot". The Flow Sheet documented that the resident receives [MEDICATION NAME] (narcotic pain medication used to treat moderate to severe pain) 10 mg which relieves the pain to "3/10" on a pain level between mild and moderate. Review of the (comprehensive) Care Plan dated 6/12/13 revealed the resident was identified with an alteration in comfort related to the fractured left tibia and fibula and cervical/ spinal cord injury. The Care Plan documented a goal for the resident's pain and regime to be evaluated to promote pain relief daily. Care Plan approaches include plans to monitor for signs and symptoms of pain or discomfort, review (resident's) pain regimen and assess effectiveness, medicate prior to treatments, Occupational and Physical Therapy as needed, notify Primary Medical Doctor if no relief (of pain) after administration of medications, therapy as indicated, and float heels in bed. a). Observation and interview with the resident on 6/17/13 at approximately 8:40 AM revealed the resident was lying in bed. The resident stated that he gets his pain medication and it is not working - "I am still in a lot of pain and it is not helping at all. I hurt all over and it is really unbearable". The resident also stated "it has been really bad over the last day, day and a half". The resident stated the nurse gave him some Tylenol last night but "it didn't help at all". Further observation of the resident with the Licensed Practical Nurse (LPN) Medication Nurse (MN), on 6/17/13 at 9:05 AM revealed the resident stated "it hurts a lot" and was observed grimacing and flinching when he was touched or moved by the LPN MN. During the observation, the LPN MN was asked if the resident had received any pain medication that morning and she replied "Yes". Interview with the LPN Resident Care Coordinator (RCC) on 6/17/13 at approximately 9:15 AM revealed the resident is cognitively aware and he receives scheduled [MEDICATION NAME] pain medication every 4 hours. The resident was observed again on 6/17/13 at approximately 10:30 AM sitting in his wheelchair and he stated he was returning from therapy. The resident was observed slumped in his wheelchair with a grimace on his face. The resident stated he was in terrible pain, his pain medication was not enough and needed more. The resident rated his pain through the weekend and today as an "8/10". The resident was asked why he went to therapy if he was in so much pain. The resident replied that he wanted to go home and he would push himself through the pain in therapy so he could be discharged . b). Review of admission physician's orders [REDACTED]. In addition, there was an order for [REDACTED]. Review of Physician's Telephone Orders dated 6/4/13 revealed orders to discontinue the [MEDICATION NAME] and [MEDICATION NAME] 20 mg every 6 hours as needed and change to scheduled [MEDICATION NAME] 10 mg every 4 hours around the clock (ATC). In addition, the physician ordered [MEDICATION NAME] 10 mg every 2 hours as needed. Review of the Medication Administration Record [REDACTED]. Additional review of the MAR indicated [REDACTED]"unavailable". The 6/13 MAR indicated [REDACTED]"general discomfort". Review of the Narcotic Back Up Reconciliation Log Book sheets for [MEDICATION NAME] 5 mg dated 6/16/13 revealed two tablets were taken from the Emergency Box at 9:30 AM and 5:30 PM for Resident #69. Interview with the LPN RCC on 6/17/13 at 10:10 AM revealed that the facility has a "pharmacy run" on weekends; medications leave the pharmacy at 11:00 AM and are delivered to the facility around 6:00 PM. The LPN RCC stated if "we run out of controlled medications" then we notify the DON, he gets a prescription for the medication and then we can get it from the pharmacy. During an interview on 6/17/13 at approximately 11:30 AM, the LPN MN stated that she thought she had given the resident pain medication that morning but after the surveyor brought it to her attention, she checked and saw that the resident was out of his [MEDICATION NAME]. The LPN MN stated that she called the Director of Nursing (DON) about 11:15 AM to tell him (DON) that the resident did not have any [MEDICATION NAME] left. Interview with the Pharmacist on 6/17/13 at 11:45 AM revealed the pharmacy did receive a call to fill the [MEDICATION NAME] for the resident but could not fill it without a prescription from the Physician. The Pharmacist stated there were notes in the computer that the Physician was paged several times without a response. The Pharmacist stated that they finally spoke to someone in the Physician's office and that person told the pharmacy to call the NP as she was the person on call. The pharmacist stated there were notes in the computer that the NP was called but they did not receive a response from her so the prescription could not be re-filled. Interviews with the DON on 6/17/13 at approximately 11:50 AM and 12:20 PM revealed the resident's primary Physician was on vacation out of the country and the NP was "on-call" for coverage. The DON stated he spoke with the NP "just a few minutes ago" and the NP stated she was not on call but another physician from the facility was on call. The DON stated he was off from 6/14/13 to 6/16/13 and was called by the Registered Nurse (RN) Day Supervisor on 6/16/13 that Resident #69 was out of his [MEDICATION NAME]. The DON stated he did give permission for the RN Supervisor to take one dose of [MEDICATION NAME] 10 mg out of ER box. The DON stated that he was just notified this morning (6/17/13) at approximately 11:15 AM by the LPN MN that the resident still did not have his pain medication. The DON stated the "old" pharmacy would send a report of the residents who would need new prescriptions from the Physicians/ Nurse Practitioners and then he would obtain new prescriptions. The DON stated the "new" pharmacy does not do it that way and a Narcotic Need List was created for the Unit RCCs to place the residents' names who needed new prescriptions for narcotics. The DON stated that no one has been designated to check the Narcotic Need List when he is not there; therefore, Resident #69's [MEDICATION NAME] was not refilled and the resident did not receive 5 doses of his pain medication. Review of an undated Pharmacy Policy entitled "Medication Ordering and Prescribing Reorders" revealed that the nurse will examine the supply of medication remaining to ascertain when a reorder/refill is needed for the resident. As a guideline, medications are to be reordered when a four day supply remains. Resident #69 was not administered his pain medication as ordered by the physician which resulted in "unbearable" pain for the resident. 415.12(m)(2)

Based on observation, record review and staff and resident interview, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being in accordance with the comprehensive assessment and care plan. One (Resident #24) of one resident reviewed for pain management did not receive effective and timely interventions to address the resident's complaints of pain during care and barrier cream was not applied following incontinence care as planned. This resulted in actual harm that is not immediate jeopardy. The findings are: 1. Resident #24 has a [DIAGNOSES REDACTED]. Additional review of the MDS revealed the resident is always incontinent of urine and bowel and requires extensive staff assistance for toilet use and personal hygiene. The MDS documented that the resident has a Stage 2 pressure ulcer which was present on admission, and receives Skin and Ulcer Treatments including the use of a pressure reducing device for the chair and bed, turning and positioning program, a nutritional or hydration intervention, application of non-surgical dressings, and application of ointments/ medications. Review of the comprehensive Care Plan printed on 6/26/12 and last reviewed on 7/11/12 revealed the resident had intermittent episodes of pain related to multiple fractures with planned interventions to evaluate the resident's pain; administer pain medication as ordered; monitor for worsening of pain; and review the pain regimen and assess its effectiveness. There was no documentation in the Care Plan that the resident had pain/discomfort of her buttocks. Review of the Closet Care Plan dated 6/26/12 revealed the resident requires extensive assistance for personal care and documentation that the resident has special needs and requires protective barrier cream after each incontinent episode. Review of Wound Evaluation Forms dated 6/11/12 to 7/11/12 revealed the following: - 6/13/12 - the resident had a Stage 2 pressure ulcer on the sacral slit measuring 3 centimeters (cm) in length (L) x 0.5 cm in width (W) and an "excoriation" on the right ischium (lower, back part of the hip bone) - 7/2/12 - The Stage 2 pressure ulcer on the sacral slit decreased in size to 1.2 (L) x 0.2 (W) and the right ischium excoriation had no signs or symptoms of infection. - 7/9/12 - The sacral slit Stage 2 pressure ulcer decreased in size to 1.2 (L) x 0.1 (W) and there was a "decreased amount of excoriation" on the right ischium. - 7/11/12 - The sacral slit pressure ulcer healed and had "surrounding excoriation". The size of the excoriation was not measured. A new order was obtained for [MEDICATION NAME] (antifungal cream used to treat yeast infections). Review of physician's orders [REDACTED]. In addition, the resident had an order for [REDACTED]. Observation on 7/11/12 at 7:27 AM revealed a certified nurse aide (CNA #1) provided morning care to Resident #24. The CNA was observed removing a soiled incontinence pad which was soiled with a small amount of urine and liquid stool and the resident's "treatment"/ dressing had fallen onto the incontinence pad and was discarded. The resident's buttocks were observed to be extremely reddened and excoriated. The CNA washed and rinsed the resident's buttocks with a washcloth, liquid cleanser and water and with each wipe of the washcloth (approximately 8 to 10 wipes), the resident cried out, "Ooh; Ow"; or "It hurts, it hurts". The CNA was observed to place a brief on the resident without applying barrier cream. Continued observation on 7/11/12 at 8:00 AM revealed the Registered Nurse (RN) Skin Nurse informed the Licensed Practical Nurse (LPN) Treatment Nurse that the resident's dressing came off. The LPN Treatment Nurse was observed to continue to pass medications, including to Resident #24 at 8:20 AM. Interview with the resident on 7/11/12 at 8:00 AM revealed when staff put cream on her buttocks, it helps the discomfort. Observation on 7/11/12 at 1:00 PM revealed the resident put her call light on to go to the bathroom. CNA #1 entered the room and ambulated the resident to the bathroom. As the CNA removed the brief, the resident stated repeatedly "oh, that's sore; it hurts so". The brief was soiled with a large amount of urine and a moderate amount of stool and the resident had loose stool while sitting on the toilet. The CNA washed and rinsed the resident using a washcloth, liquid cleanser and water. The resident was observed to wince, grimace and pull her buttocks away slightly with each wipe, crying out "ow it hurt, it hurts". The resident's bilateral buttocks were reddened and excoriated. The sacral dressing was loosened and slightly soiled with stool and the CNA left it in place. The CNA asked the resident if she wanted her to stop and the resident, who had visible stool on her buttocks, stated "I have to get cleaned". The CNA did not apply any barrier cream, placed a brief on the resident, and dressed the resident. The CNA transferred the resident into a wheelchair to her bedside to visit with her family. Interview with the resident on 7/11/12 at 1:00 PM revealed her "fanny" pain is terrible during incontinent care. The resident explained that she has burning pain in her buttocks with each exposure to urine and stool. Interview with CNA #1 on 7/11/12 at approximately 1:10 PM revealed the LPN Treatment Nurse provided a treatment to the resident's buttocks just prior to therapy at 9:00 AM. Interview with the LPN Treatment Nurse on 7/11/12 at 1:16 PM revealed just prior to therapy on 7/11/12 at approximately 9:00 AM, she cleansed the area with normal saline, applied Solan (a Zinc oxide product) and put a [MEDICATION NAME] dressing treatment onto the buttocks. Interview with CNA #1 on 7/11/12 at 2:40 PM revealed she told the LPN Treatment Nurse that the dressing came off after morning care. The CNA stated that the resident had to be in therapy at 9:00 AM so she took the resident to the toilet and the LPN Treatment Nurse did the buttocks treatment then. After lunch, the CNA stated she responded to the resident's call light and provided incontinence care after the resident had loose stool in the toilet. The CNA stated she wasn't sure if she told the nurse about the resident's discomfort and she didn't use barrier cream because if you put cream on the resident, her treatment will come off. Interview with the LPN Treatment Nurse on 7/11/12 at approximately 2:53 PM revealed CNA #1 informed her that Resident #24 had nausea and wasn't sleeping, however she (the CNA) did not inform her that the resident was incontinent during morning care and in the afternoon after lunch. The LPN stated she was not informed that the resident had any discomfort during incontinence care and she stated if she had known the resident was incontinent and in pain, she would have applied the Solan and provided the resident with any requested pain medication. The LPN stated the only treatment she provided to the resident was in the morning just prior to therapy at 9:00 AM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with the RN Resident Care Coordinator (RCC) on 7/11/12 at 3:00 PM confirmed that the resident should have received barrier cream after each incontinent episode. At the surveyor's request, the resident's skin was observed in the presence of the RN RCC and the RN Skin Nurse, on 7/11/12 at approximately 3:15 PM during routine toileting. During the observation, the resident told the RN Skin Nurse that her "fanny was uncomfortable; it's a little sore". The resident was ambulated to the bathroom and had loose stool prior to and while sitting on the toilet. As CNA #1 provided incontinence care, the resident whimpered, winced and/or cried out "oh, ow it hurts" with each wipe of the washcloth (approximately 10 to 14 wipes). The LPN Treatment Nurse applied Solan and the RN Skin Care Nurse stated she would call the physician for a treatment change. Observation on 7/12/12 at 9:00 AM revealed the resident was in the bathroom and was incontinent of a moderate amount of stool. CNA #1 was cleansing the resident with baby wipes. The resident was observed to moan and wince with each cleansing motion, approximately 10 to 14 wipes. The skin on the resident's bilateral buttocks was red and denuded (the removal of the upper layer of skin). The LPN Treatment Nurse entered the bathroom and applied [MEDICATION NAME] and [MEDICATION NAME] (zinc oxide) to the resident's buttocks. Following incontinence care, the resident requested to go to bed and did not want to go to therapy. Interview with the resident on 7/12/12 at 9:30 AM revealed that her bottom was too painful for her to go to therapy and sit for two to three hours. Intermittent observations on 7/12/12 from 9:30 AM to 11:00 AM revealed the resident remained in bed. Interview with the Physician on 7/12/12 at approximately 1:15 PM revealed the resident has a "chemical burn" due to [MEDICAL CONDITION] ([MEDICAL CONDITION] - bacterial infection in the bowel which causes diarrhea). The Physician stated the goal is to keep the loose "stool away from her buttocks". 415.12