Every finding on record at East Side Nursing Home

Based on observation, interviews and record during a survey, the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents for one (1) (Resident #89) of eleven (11) residents reviewed for accidents. Specifically, on 10/10/2025 facility staff (Driver #1 and Transport Aide #1) failed to ensure that Resident #89 was safely secured in the facility's wheelchair transport van when returning from a medical appointment. The resident's wheelchair was secured to the van floor; however, the transport staff did not ensure the resident was wearing the required shoulder and lap belts, which resulted in Resident #89 being thrown from the wheelchair to the front of the van during an abrupt stop. Resident #89 suffered a nasal fracture, abrasions, and had associated pain. This resulted in actual harm to Resident #89 that was Immediate Jeopardy and Substandard Quality of Care Past Non-Compliance with the likelihood of serious harm, serious impairment, serious injury or death to resident's health and safety. The findings are: The policy titled Operation of the 2011 Ford Passenger Van dated 09/2024 documented the training included viewing the public use wheelchair lift operation video, reviewing the instructions for use on the restraint system, with hands on demonstration. The policy did not include a verification check system to ensure residents were appropriately secured prior to transport or direct staff what to do if a resident refused to comply with safety requirements. A cell phone was provided for each transports use. Resident #89 had diagnoses of post orthopedic aftercare of a hip fracture (break in the bone), congestive heart failure (chronic, progressive condition where the heart muscle cannot pump blood efficiently) and chronic obstructive pulmonary disease (chronic lung disease with persistent, progressive airflow limitation). The Minimum Data Set (a resident assessment tool) dated 09/23/2025 documented that Resident #89 was cognitively intact, understands and was understood by others. The Comprehensive Care Plan undated documented Resident #89 was admitted for rehabilitation following a left femoral fracture repair (break in the upper part of the thigh bone requiring surgery). Documented interventions included the resident was dependent on staff for wheelchair mobility off the unit. Review of a Kardex (guide used by staff to provide care) dated 10/10/2025 documented Resident #89 was dependent on staff for wheelchair locomotion off unit, and transferring required extensive assist of one staff member using a rolling walker and a gait belt (an adjustable strap worn around a resident's waist to assist staff with safe standing, transfers, and walking while reducing the risk of falls and back injuries). The Accident and Incident Report dated 10/10/2025 at 11:15 AM documented that Resident #89 was in the facility's transport van on their way back from a scheduled appointment to facility when the vehicle came to an abrupt stop, causing Resident #89 to fall forward out of their wheelchair onto the van floor. Resident #89 stated, My nose and knees hurt. The transport staff called 911 (emergency services) and notified the facility. Emergency Medical Services assumed care and transported Resident #89 to the emergency room for further evaluation. The provider and the resident's responsible party were notified. The accident and incident report included statements from Driver #1 and Transport Aide #1. Driver #1 documented they were traveling 45 miles per hour when traffic in front of them stopped abruptly, causing them to brake suddenly to avoid a crash. Resident #89 was sitting upright in the wheelchair, which was securely locked, however the resident fell forward onto the floor. Transport Aide #1 documented that Driver #1 was driving and a car in front of them braked fast. Suddenly, Resident #89 was on the floor bleeding. The accident and incident report did not document that Resident #89 refused to put on the shoulder and lap safety belts. The facility's five-day investigation submission report dated 10/15/2025 documented that after review of staff statements and staff interviews it was determined that Driver #1 admitted to not securing Resident #89 with the seat belts, stating No, I forgot to put it on. During an interview and observation on 02/05/2026 at 10:20 AM, the Director of Maintenance stated all drivers were trained to ensure the wheelchair restraints were properly secured and to apply the shoulder and lap belts. Residents who refuse restraints (seat belts) should not be transported. The Director of Maintenance showed the wheelchair restraint system to the surveyor. During this observation, the Director of Maintenance stated the wheelchair was secured with four anchor points to the floor at the time of the accident, however the shoulder and lap belts were not applied, which resulted in Resident #89 being thrown from their wheelchair. They stated the signage in the van prior to the accident on 10/10/2025 was small and placed on the interior side door of the van, so it may not have been as visible. After the accident, the signage was enlarged and placed in the front interior of the van. The sign stated, For the safety of all drivers and passengers everyone is required to wear seat belts at all times while the vehicle is in motion, please buckle up. During an interview on 02/05/2025 at 10:27 AM, Transport Aide #1 stated they transported Resident #89 to an outside appointment on 10/10/2025 in the facility's van. Driver #1 had to abruptly apply the brakes to avoid an accident. Transport Aide #1 stated Resident #89 was thrown from their wheelchair and slid toward the front of the van. Resident #89 was bleeding badly and had stated their nose and knees hurt. Transport Aide #1 stated they told Driver #1 that Resident #89 was not wearing a seat belt and that the resident had refused. Driver #1 had stated it was okay to proceed with the transport. Transport Aide #1 stated this was their first day working (10/10/2025) independently, and they believed that Resident #89 was exercising their rights. They further stated they should have notified their supervisor and told Driver #1 not to proceed with the drive. Attempts were made to contact Driver #1 via telephone without success on 01/29/2026 at 3:34 PM, 02/04/2026 at 4:49 PM and 02/09/2026 at 8:53 AM. During an interview on 02/05/2026 at 10:32 AM, the Assistant Administrator stated it was the driver's responsibility to ensure that all safety restraints were applied before transport. They stated Driver #1 should have refused to transport Resident #89 and called their supervisor just as they were trained to do. They stated this could have resulted in a more serious accident, and the process to correct the issue was started immediately. During an interview on 02/06/2026 at 10:40 AM, the Administrator stated the accident that occurred on 10/10/2025 was an isolated incident. Driver #1 should have contacted them and not driven the van if Resident #89 had refused to put their seat belt on. They stated drivers were trained during orientation not to move the van until all passengers were strapped in securely. The Administrator stated additional safety measures were implemented following the incident. During a telephone interview on 02/06/2026 at 9:17 AM, Resident #89 stated they were returning from a medical appointment. The wheelchair was anchored down at the rear of the facility's van, but they did not have the shoulder and lap belts in place. The driver slammed on the brakes. They flew out of the chair and landed on their face; they had bleeding from their nose and were in pain. The driver immediately contacted emergency services, they were transported to a local hospital and diagnosed with a nasal fracture. They also stated they had some abrasions to their forehead and hands. Resident #89 stated they did not refuse to fasten their seat belt and were not sure why the transport staff did not fasten their seat belts. During a telephone interview on 02/06/2026 10:36 AM, the Medical Director stated it was important for everyone to follow the guidelines of the Department of Transportation and the facility's policy for securing safety restraints to avoid a situation like this. They stated if Resident #89 was properly restrained they would not have fallen out of their wheelchair and caused the resident harm. The resident could have potentially sustained fatal injuries. During an interview on 02/09/2026 at 8:01 AM with the Assistant Administrator and the Director of Nursing, the Assistant Administrator stated that Driver #1 and Transport Aide #1 should have known to contact their supervisor if Resident #89 had refused to put their seat belt on. The Director of Nursing agreed. Based on observations, interviews, and record review the survey team determined the facility removed immediacy as of 10/15/2025 and corrected the non-compliance. Driver #1 was terminated 10/10/2025.Transport Aide #1 was re-educated on 10/10/2025.The policy titled Operation of the 2011 Ford Passenger Van with a revised date of 10/10/2025 was updated to include a three-level safety verification process for every resident transported.The facility created transportation verification logs for each trip documenting each verification step and signature of completion.The facility enlarged and relocated safety signage inside the transport van.100 percent (%) of transportation staff were educated on 10/10/2025. 87 percent (%) of nursing, recreational, therapy, and social work staff were educated by 10/15/2025 regarding the verification system, transport policy, and resident safety. The facility continued the education and then expanded the training to include nutritional and housekeeping services staff. Transportation audits were conducted to monitor the corrective actions and to ensure the implementation of facility protocols to ensure resident safety while utilizing the facility's transportation services. These audits were reviewed weekly by the Administration and were reported during the monthly facility Quality Assurance Program (QAPI) meetings. 10 New York Code Rules and Regulations 415.12(h)(1)

Based on observation, interview and record review conducted during a survey, the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (1) (third floor) of three (3) resident use floors. Specifically, ceiling tiles were stained and there was evidence of roof leaks in resident rooms and common areas. This involved Resident #84. The finding is: The policy titled Resident Rights dated 12/19/2022, documented that the facility shall protect and promote the rights of each resident. The policy documented resident rights shall include, but not be limited to, the resident's right to a dignified existence, self-determination, and be treated in a respectful manner that supports his/her dignity in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life.During an interview and observation on 01/27/2026 at 12:58 PM, Resident #84 stated their ceiling leaks and the window leaks; it was not leaking now but you can see the ceiling and there are rags on the windowsill filled with rusty moldy water. On the windowsill there were towels rolled up, one of the towels was yellow in color, was dried and crusty in appearance. Resident #84 stated that the towels had been there since spring and that there was tape on the wall where the leak was just coming through and that the staff knew and nobody did anything about it.During an observation on 01/27/2026 at 10:03 AM, there was a discolored (grey) ceiling tile that appeared to be wet from an active leak in the hallway outside the third-floor shower room.During an observation and interview on 01/27/2026 at 10:08 AM, an approximately 10-foot-long section of the windowsill just inside the third-floor dining room was chipped and rust-colored. The Regional Maintenance Supervisor stated that it was from roof leaks when it rained.During an observation on 01/27/2026 at 10:24 AM, the third-floor hallway, in between rooms [ROOM NUMBERS], the ceiling tile had a large rust color water stain, approximately one and a half (1.5) feet by one (1) foot. There were two additional gray colored water stains in the ceiling tiles observed between the nursing station and elevator, measuring approximately 6 inches by 6 inches. During an observation on 01/28/2026 at 2:04 PM, there were brown stained ceiling tiles near the window in room [ROOM NUMBER] and there were white towels placed along the windowsill that were discolored. The resident in room [ROOM NUMBER] stated that the ceiling has leaked for more than a year, and the water comes right down the window.During an observation on 01/28/2026 at 3:15 PM, there were wet stained ceiling tiles in the hallway between rooms [ROOM NUMBERS], and just outside the shower room on the third floor. Additionally, there were brown stained ceiling tiles in resident room [ROOM NUMBER] near the corner of the window.During a further observation on 01/29/2026 at 10:20 AM, the third-floor hallway, in between room [ROOM NUMBER] and 321, a ceiling tile appeared to be replaced and now had one gray/rust colored water stain, approximately twelve (12) inches by six (6) inches. There were two smaller gray water stains in the ceiling tile in front of the stair well door in that hallway, measuring about six (6) inches in diameter, and the two gray colored water stains remained in between the nursing station and elevator.During an interview on 01/29/2026 at 10:20 AM, Licensed Practical Nurse #1 (Unit Manager of the third floor) stated there had not been an active ceiling leak in a while, and the stained ceiling tiles did not appear home-like. During an observation and interview on 01/29/2026 at 10:32 AM, two small brown stains were observed in the right-hand corner of room [ROOM NUMBER] near the window, measuring about 4 inches in diameter. The resident in room [ROOM NUMBER] stated that there had not been active ceiling leaks but their ceiling in their room and in the hallway had water stains. They stated that the water stains bothered them, and it was not homelike. During an observation on 01/29/2026 at 5:19 PM, there were eleven (11) residents in the third-floor dining room. The windowsill in the dining room was halfway painted a different color, half was white, and the other was blue, the white portion had brown stains and was peeling. 10 NYCRR 415.5 (h)(2)

Based on observations, interviews and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #80) of three (3) residents reviewed for skin conditions. Specifically, Resident #80's arterial ulcer treatment was not completed in accordance with the physician's order. Additionally, there was no documented evidence that a provider was notified Resident #80 was refusing the ordered treatment or it was not being completed as ordered between 01/23/2026- 01/27/2026.The findings are: The policy titled Wound Treatment dated 12/19/2022 documented all residents requiring wound care should receive treatment by a licensed nurse and dressings should be changed per the physician order and documented on the Treatment Administration Record. Resident #80 had diagnoses that included a history of osteomyelitis (infection in a bone), arterial ulcers (painful deep wounds), and dementia. The Minimum Data Set (a resident assessment tool) dated 12/04/2025 revealed Resident #80 had mild cognitive impairment and rejected care one (1) to three (3) times during the lookback period of seven (7) days. The current Comprehensive Care Plan dated 07/21/2025 documented the resident had an arterial ulcer to their left medial malleolus (the bump on the inner side of the ankle) with interventions to monitor/document/report any changes in skin status and to follow the facility policy for the prevention and treatment of skin breakdown. The care plan documented that if the resident refused care to reapproach and/or have another staff attempt to complete it. Review of a physician order dated 12/18/2025 written by the Medical Director documented to cleanse the left medial malleolus with wound cleanser/normal saline, apply betadine (antiseptic) moistened gauze to the base of the wound, secure with bordered gauze and change twice daily. Review of Treatment Administration Records from 12/19/2025 to 12/29/2025 revealed there was no documented evidence the dressing had been changed for nine (9) shifts during this timeframe. Review of a physician order dated 01/02/2026 written by the Medical Director documented to cleanse the left medial malleolus with 0.25 % (percent) Dakin's solution (antiseptic solution), apply betadine moisturized gauze, Dakin's moistened fluffed gauze to base of wound, secure with bordered gauze and change twice daily. Review of the Treatment Administration Record from 01/03/2026 to 01/16/2026 revealed there was no documented evidence the dressing had been changed for seven (7) shifts during this timeframe. Review of physician orders dated 01/16/2026, the Medical Director documented to provide wound care treatment to the left medial malleolus topically every day and night shift for an arterial ulcer. The order documented to cleanse the wound with 0.25% Dakin's solution, apply iodosorb (a gel that can help kill bacteria and have the wound heal faster), use skin prep (skin barrier wipes) to the surrounding tissue, secure with bordered gauze, and change twice a day. During an observation on 01/27/2026 at 11:56 AM Resident #80 was lying in bed, there was a gauze dressing taped to their left inner ankle, was labeled with a date of 01/23 and the initials of Licensed Practical Nurse #4. There was a dime sized area in the middle of the gauze dressing that was dark red in color (strikethrough, where drainage penetrates through to the outer layer of a dressing). At the time of the observation the resident was unable to be interviewed. Review of the Treatment Administration Records dated 01/23/2026 through 01/27/2026 revealed there was no documented evidence that wound care treatment to the left medial malleolus was completed for the day shift on 01/24/2026 nor the day and evening shifts on 1/25/2026. The Treatment Administration record on the evening shifts of 01/23/2026, 01/24/2026, and 01/26/2026 was documented as Resident #80 refused treatment. The day shift on 01/26/2026 was signed off as completed by the Director of Nursing. Review of the interdisciplinary progress notes 12/01/2025 through 01/27/2026 revealed they did not document the provider was notified that Resident #80 had refused the treatment to their left medial malleolus or that it was not completed as ordered. Review of a wound assessment report dated 01/28/2026 Nurse Practitioner #1 documented Resident #80's left medial malleolus wound had thick seropurulent exudate (drainage from the wound that was watery, cloudy and yellow to tan in color), the healing had stalled and to cleanse the wound with 0.25% Dakin's solution, use skin prep to the surrounding tissue, apply calcium alginate with silver (absorbent wound dressing with antimicrobial properties) , cover with bordered gauze and change the dressing twice daily. Nurse Practitioner #1 documented to consider a wound culture if Resident #80 was agreeable to take antibiotics as the wound could turn into osteomyelitis quickly. The assessment note did not document that they were aware the residents refused treatments and that they had not been completed, nor does it document a history of refusal of wound care. During an interview on 02/04/2026 at 4:32 PM, Licensed Practical Nurse #3 stated they were not aware that Resident #80 had an ankle wound that required the dressing to be changed twice daily, and they stated they did not know why the treatment was not completed on 01/24/2026. During an interview on 02/04/2026 at 5:08 PM, Registered Nurse #1 stated that Resident #80 had a wound on their left inner ankle and that they refused a lot of things at times. Registered Nurse #1 stated that they did not recall the week of 01/23/2026 and did not know why the treatment was not completed. During an interview on 02/04/2026 at 5:20 PM, Licensed Practical Nurse Manager #1 stated that a blank on the Treatment Administration Record would indicate that the treatment was not completed and a provider should be made aware if treatments were not completed or if there were more than two refusals. Licensed Practical Nurse Manager #1 stated that a date of 01/23 on 01/27/2026 would mean that the treatment was not completed and that a provider should have been notified. During an interview on 02/04/2026 at 5:48 PM, the Director of Nursing stated a blank on the Treatment Administration Record would indicate that the treatment was not completed. If a resident refused a treatment the nurses should document the refusal and notify a provider. Nurses should be completing treatments in accordance with the provider's orders, and that not completing treatments could delay wound healing. During a telephone interview on 02/05/2026 at 3:53 PM, Nurse Practitioner #1 stated that all of Resident #80's wounds on their feet and ankle were painful. Resident #80 had a history of refusing care. Nurse Practitioner #1 stated that if they had been made aware that Resident #80 did not have their dressing changed for several days, they would not have done anything different as the wound appeared to be infected prior to 01/23/2026, as they were on comfort care and had refused antibiotics. 10 NYCRR 415.12

Based on observation, interview and record review conducted during the survey, the facility did not ensure each resident received food prepared in a form designed to meet individual needs for one (1) (Resident #43) of three (3) residents reviewed. Specifically, Resident #43 was ordered a mechanically altered diet (a diet that consists of easy to chew and swallow foods) of ground meat and was not provided ground consistency meat during a meal observation. The finding is: The policy titled Tray Pass, dated 12/19/2022, documented the purpose of the policy was to ensure residents receive the correct meals safely, timely and in accordance with the physician diet orders. The meal trays were to be checked against the diet roster prior to delivery. Nursing or designated staff verify resident identity and correct diet at the time of tray pass. The policy documented any incorrect trays are addressed immediately and report to dietary and nursing. The policy titled Altered Diets, dated 12/19/2022, documented that residents who require mechanically altered diet will receive meals modified in texture as ordered by the physician or authorized practitioner. Diet orders are based on clinical assessment and recommendations from Speech-language Pathology when applicable. It was documented that dietary staff will prepare and serve meals according to the ordered diet consistency. Resident #43 had diagnoses that included Parkinson's Disease (progressive movement disorder of the nervous system), hypertension, and anorexia (general loss of appetite). The Minimum Data Set (a resident assessment tool), dated 01/15/2026, documented the resident was cognitively intact, was understood and understands. The assessment tool documented Resident #43 required set-up assistance for eating and received a mechanically altered diet. The Comprehensive Care Plan revised on 01/15/2026, documented Resident #43 was a long-term care resident at the facility who was at risk for decline in mobility/self-care. Interventions included the resident's diet was thin liquids and regular diet textures with ground meats. Resident #43 was a potential risk for sub-optimal nutrition and dehydration due to the need for altered texture. Interventions included to provide their diet as ordered. Review of the Kardex (a guide to care) dated 02/05/2026, documented Resident #43 was independent with set up for eating and was on a regular texture diet with ground meats, may have stewed meats and meat balls. The Order Recap Report documented Resident #43 had an active physician's order, with started date of 09/23/2025, for a regular diet with ground meat texture, no mushrooms or pineapple. Review of the Speech Therapy Discharge Summary for dates of service 10/21/2025-11/19/2025, revealed Resident #43 demonstrated difficulty in efficiently masticating (chewing) regular meat with moderated prolonged mastication and oral residue. Resident #43 safely tolerated regular textures with ground meats and demonstrates increased intake with ground meals. The discharge summary documented Resident #43 was discharged from service with recommendations for regular texture and mechanical soft/ground textured meats solids and thin consistency liquids. During an observation on 01/27/2026 at 12:35 PM, Resident #43's was sitting at a dining table with Resident #33 and Resident #60 in the main dining room. Resident #60 already had their lunch meal in front of them. Activity Aide #1 walked over to the table, carrying a large tray that contained two (2) plated meals. One plate contained a full chicken breast (not chopped, cut up or ground) and the second plate contained ground chicken meat. Activity Aide #1 placed the plate containing the full chicken breast in front of Resident #43 and the second ground chicken plate off to the side but within arm's reach of Resident #43. Activity Aide #1 stated to Resident #43 to enjoy their meal and walk away. Resident #33 questioned their tablemates (Resident #43 and Resident #60) where their meal was and wondered if one (1) of the two (2) meals given to Resident #43 was really their own. Resident #60 took the ground chicken plate and placed it in front of Resident #33. After looking at the ground chicken plate in front of them, Resident #33 stated to Resident #43, I think I have your plate, and you have mine. The surveyor alerted Registered Nurse Educator/Infection Preventionist, who was monitoring the main dining room, to the situation. Registered Nurse Educator/Infection Preventionist went to the table, stating to Resident #43 you are a ground diet, right?, when Resident #43 replied yes, the Registered Nurse Educator/Infection Preventionist then exchange Resident #43's plate and Resident #33's plate, adding it was ok because no one had touched their plates. Review of Resident #43's meal ticket (a specific menu that includes what each resident should receive for meals, texture of meal, and any other resident specific interventions during mealtime), provided by Registered Nurse Educator/Infection Preventionist, dated 01/27/2026 for the lunch meal, revealed the resident had a special consistency of ground meats and could have unground stew meat and meatballs. It documented the resident was to have a ground grilled chicken breast. During an interview on 01/27/2026 at 1:19 PM, Registered Nurse Educator/Infection Preventionist stated that Activity Aide #1 was very new, and it was either their first day or two working at the facility. They stated they believe Resident #43 was given two plates because there was only one meal ticket on the delivery tray. Registered Nurse Educator/Infection Prventionist stated that they were not responsible for training Activity Aide #1, and it would have been the Director of Activities that should have been supervising them. Registered Nurse Educator/Infection Preventionist stated their role in the dining room to ensure the residents were eating safely. During an interview on 01/28/2026 at 11:55 AM, Resident #43 stated they were given the wrong meal on 01/27/2026, it was not ground but would have probably attempted to eat it anyway. They stated they are on a ground diet because due to their Parkinson's Disease, it took them so long to chew their meat making the rest of their meal get cold. Resident #43 stated they had been to swallowing therapy, they had never choked on a meal before, but the facility staff were afraid they could. During an interview on 02/05/2026 at 1:26 PM, the Speech Language Pathologist stated on 05/21/2024 they recommended Resident #43 to be on a regular diet with ground meats and on 10/30/2025 upgraded Resident #43 diet to include stew meat and meatballs. The Speech Language Pathologist stated Resident #43 was on a ground meat diet because the resident would chew their meat for a long period of time and then end up spitting it out. They suspected it was causing weight loss. The Speech Language Pathologist stated they changed Resident's #43 diet in hopes of gaining weight and solving oral difficulties. The Speech Language Pathologist stated they would expect Resident #43 to be served chicken that was ground and vegetables cooked softly fork tender. During an interview on 02/05/2026 at 3:27 PM, the Director of Activities stated that it was a normal job duty for the activities department to assist with passing trays in the main dining room for the lunch meal. They stated on 01/27/2026 it was Activity Aide #1 first or second day working in the dining room and Activity Aide #1 was only supposed to be observing. The Director of Activities stated they instructed Activity Aide #1 to observe Registered Nurse Educator/Infection Preventionist while they stepped out of the dining room to deliver a meal tray upstairs. They stated they were unsure why Activity Aide #1 did not follow their direction but wished they would have. The Director of Activities stated a resident was on a special diet for a reason and that diet should be followed. During an interview on 02/05/2026 at 3:43 PM, Nurse Practitioner #2 stated, Resident #43 was ordered to have a regular textured diet with ground meats. They stated they would expect Resident #43 to be served ground meats due to the residents' Parkinson's disease. During an interview on 02/09/2026 at 2:02 PM, the Regional Food Service Director, with Dietary Manager #1 present, stated the process for delivering trays into the main dining room was two meals are placed on one tray with the corresponding meal tickets. The tray was then handed off to nursing/activity staff serving the meals at the doorway of the kitchen. The Regional Food Service Director stated they were aware that an activity aide served Resident #43 the wrong texture meal on 01/27/2026 but was usure how it happened. They stated the error should not have occurred because residents being served the wrong texture of food could pose a potential for aspiration or worse. During an interview on 02/09/25 at 2:23 PM the Director of Nursing stated Resident #43 was ordered to have a regular diet with ground meat. They stated their expectation would be when the facility is having a chicken breast for lunch then Resident #43 chicken would be ground. The Director of Nursing stated after they became aware of the situation that occurred on 01/27/2026 they spoke with Activity Aide #1 who stated there was only one meal ticket on the tray, so they thought Resident #43 was to have both. The Director of Nursing stated Resident #43 was ordered a ground diet because the resident had difficulty chewing regular meats, but the resident did not have any swallowing issues. They stated Resident #43 would benefit when receiving the correct diet for chewing due to their Parkinson's disease. 10 NYCRR 415.14(d)(3)

Based on interviews and record review conducted during the survey, the facility did not ensure that newly admitted resident's and/or their representatives were provided with a written summary of a Baseline Care Plan that included the minimum healthcare information necessary to properly care for the immediate needs of the resident (including but not limited to initial goals, admission orders, dietary, therapy and social services) for eight (8) (Residents #7, #9, #32, #40, #57, #64, #80, and #89) of ten (10) residents reviewed. Specifically for all residents identified the facility did not provide the residents or their representative with a written summary of their Baseline Care Plan. The findings include but are not limited to: The facility policy titled Baseline Care Plan dated 12/19/2022, documented a baseline care plan would be developed within 48 hours of the resident's admission and the resident and their representative would be provided with a paper copy summary of the baseline care plan that includes but was not limited to a summary of the resident's medications, dietary instructions and any services or treatment to be administered by the facility. Additionally, the policy documented if a resident and their representative declined the paper copy, it must be documented. 1. Resident #57 was admitted to the facility on [DATE] with diagnoses including fracture of the femur (uppermost part of the thighbone), dementia, and anxiety. The Minimum Data Set (a resident assessment tool) dated 06/16/2025 revealed that Resident #57 had severe cognitive impairment. Review of Resident #57's Baseline Care Plan, dated 06/16/2025, revealed no documented evidence that a written summary of their initial care needs (that included admission orders, dietary, therapy and social services) had been provided to the resident representative. Review of interdisciplinary progress notes dated 06/16/2025 to 07/07/2025 revealed on 06/16/2025 at 3:29 PM, Social Worker #1 documented they met with Resident #57 to review their plan of care. There was no documentation that a summary of the baseline care plan was provided to the resident and their representative. 2. Resident #9 was admitted to the facility on [DATE] with diagnoses including dementia, congestive heart failure, and chronic obstructive pulmonary disease (a progressive, uncurable lung disease). The Minimum Data Set, dated [DATE] revealed that Resident #9 had severe cognitive impairment.Review of Resident #9's Baseline Care Plan, dated 10/21/2025, revealed no documented evidence that a written summary of their initial care needs had been provided to the resident representative. Review of interdisciplinary progress notes dated 10/21/2025 to 11/11/2025 revealed on 10/21/2025 at 12:36 PM, Social Worker #1 documented they met with Resident #9 and their family to discuss the plan of care. There was no documentation that a summary of the baseline care plan was provided to the resident and their representative. 3.Resident #64 was admitted to the facility 01/16/2026 with diagnoses including atrial fibrillation (irregular heart rate), schizoaffective disorder, and dysphagia (difficulty swallowing). The Minimum Data Set, dated [DATE] revealed that Resident #64 had moderately impaired cognition. Review of Resident #64's Baseline Care Plan, dated 01/16/2026, revealed no documented evidence that a written summary of their initial care needs had been provided to Resident #64 and/or the resident representative. Review of interdisciplinary progress notes dated 01/16/2026 to 02/06/2026 revealed on 01/16/2026 at 2:05 PM, Social Worker #1 documented they met with the resident and family to review the plan of care. There was no documentation that a summary of the baseline care plan was provided to the resident and their representative. During an interview on 02/04/2026 at 3:23 PM Social Worker #1 stated that baseline care plans get completed on admission and that they would verbally go over the baseline care plan with either the resident and/or the resident representative. Social Worker #1 stated that they would offer to provide a copy of the baseline care plan but most of the time the family would decline a copy and that they have never documented that a copy was offered. During an interview on 02/04/2026 at 5:48 PM the Director of Nursing stated that the social worker was responsible for providing a copy of the baseline care plan to the residents and/or the residents' representative upon admission. The Director of Nursing stated that they were aware that Social Worker #1 was verbally going over the baseline care plan but was not aware that copies were not being provided and stated that a copy should have been provided to the residents and/or resident representatives. 10 NYCRR 415.11

Based on observation, record review, and interviews conducted during the Standard Survey completed on 11/20/23, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for two (Residents #8 and #26) of 2 residents reviewed. Specifically, residents were not provided a choice to take a tub bath because there was not a functioning tub bath in the facility. The findings are: The facility's policy and procedure (P&P) titled Resident Preference and Care Planning and Care Area Assessments - C.A.A. dated 10/3/17 documented all residents will have an interdisciplinary care plan developed that shall include measurable goals and timetables to meet each individual's medical, physical, mental, and psychosocial needs as well as review and implement resident wishes/choices and goals. The facility's P&P titled Comprehensive Care Plan dated 12/19/22 documented the resident has the right to participate in the development and implementation of his/her person-centered plan of care including but not limited to; the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency and duration of care and any other factors related to the effectiveness of the plan of care. The planning process must incorporate the resident's personal and cultural preferences in developing goals of care. The facility's P&P titled Bathing - Tub Bath/Shower dated 4/17/13 documented all residents will receive a tub bath or shower at least weekly, more often if indicated or requested. Residents will be asked their preference upon admission, and this will be documented. The procedure documented to fill tub 2/3/full of lukewarm water, adjust body strap, assist resident to swing legs into tub turning chair at the same time or slide chair back into tub depending on which tub is being used. 1. Resident #8 had diagnoses that included major depressive disorder (MDD), bipolar disorder, and hypertension. The Minimum Data Set (MDS - a resident assessment tool) dated 10/12/23 documented Resident #8 was cognitively intact, was understood, and understands. The MDS dated [DATE] documented it was very important to resident to choose between a tub bath, shower, bed bath or sponge bath. Resident #8's Visual/Bedside Kardex Report (guide used by staff to provide care) undated, identified as current by Regional Quality Assurance Registered Nurse, documented Bathing - Showers Tuesday Days and Friday Days. Resident #8's comprehensive care plan dated 5/8/20 documented, allow resident to make decisions concerning own care as much as possible. During an interview on 11/14/23 at 9:47 AM, Resident #8 stated they never had choice regarding a tub bath verses a shower. Resident #8 stated they had asked for a tub bath about a year ago, but the staff said the bathtub did not work. Resident #8 stated they would prefer a tub bath over a shower. 2. Resident #26 has diagnoses that include MDD, peripheral vascular disease (PVD, decreased circulation of the lower extremities), and generalized anxiety disorder. The MDS dated [DATE] documented Resident #26 was cognitively intact, was understood, and understand. The MDS documented that it was very important to resident to choose between a tub bath, shower, bed bath or sponge bath. Resident 26's Visual/Bedside Kardex Report undated, identified as current by Regional Quality Assurance Registered Nurse, documented Bathing - Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated. Shower: Thursday Eve. Resident 26's comprehensive care plan dated 8/1/23 documented, allow resident to make decisions concerning own care as much as possible. During an interview on 11/13/23 at 1:11 PM, Resident #26 stated they have never been asked if they preferred a tub bath verses a shower because they believed the facility did not have a working tub. Resident #26 stated they would prefer a tub bath over a shower if the facility had a tub but understands from staff the tub has been broken for a long time. During an observation on 11/14/23 at 9:55 AM the 2nd floor tub room was blocked with the linen cart, upon moving the linen cart the tub was noted to have crusty white/ brown debris and rust around the drain and spout of the tub. The faucets would not turn and tub chair that maneuvers up and down to place a resident into the tub did not engage and move. During an interview on 11/16/23 at 2:00 PM, Certified Nursing Assistant (CNA) #5 stated they didn't know if the tub worked, believe residents were asked their bathing preferences upon admission. During an observation at this time CNA #5 had difficulty turning on the tub water faucet; stated the water wasn't getting warm and it appeared the tub was not working. The showering hose was clogged, and the chair lift did not function. CNA #5 stated there was not a tub on the 3rd floor and that this was the only tub in the facility. CNA #5 stated the facility was not able to provide a tub bath to residents upon their preference because the facility did not have a working tub. During an interview on 11/16/23 at 2:09 PM, Licensed Practical Nurse (LPN) #6 stated they do not know; if the facility tub was in working order, who was responsible to ask the resident's their bathing preference, and when the last time the tub was in working order. LPN # 6 stated they believed it was important for residents to choose their bathing preference, believed it was a resident's right to preferences and the facility should have a working tub. During an interview on 11/16/23 at 2:14 PM, LPN #4 Unit Manager (UM) stated residents were offered a bathing preference of showering or bed bath but not a tub bath because the facility doesn't have a working tub. During an interview on 11/17/23 at 9:50 AM, Activities Department Director #1 stated they completed the MDS section of Preferences for Routine and Activities on the annual MDS as it prompts the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?. The Activities Department Director #1 stated they did not ask residents their bathing preferences, does not have any evidence the residents were asked their specific bathing preferences. They would not offer a tub bath because the facility doesn't have a working tub. The Activities Department Director stated the facility doesn't have a process to determine the resident's bathing preference. During an interview on 11/17/23 at 9:55 AM, Maintenance Department Director #1 stated the 3rd floor tub was removed from the facility approximately 2 years ago because it was broken and was unable to be repaired. The 2nd floor tub had been broken for at least 2 years and was unable to be repaired because there were no available parts as the tub was outdated. Maintenance Department Director #1 stated Administration was aware there was not a working tub in the facility. During an interview on 11/17/23 at 10:01 AM, the Corporate Quality Assurance Registered Nurse (RN)/ Acting Director of Nursing stated were not aware the facility didn't have a working tub and did not know if staff had asked residents their preference for bathing. (Tub versus shower). During an interview on 11/17/23 at 10:18 AM, Regional [NAME] President of Operations stated they were the Administrator for the facility last year and knew the facility did not have a working tub but had not replaced it because they didn't have any residents that requested a tub bath. The Regional [NAME] President stated they did not know if staff asked residents their bathing preferences of tub bath/shower/bed bath and stated did not have evidence residents were provided a choice. The Regional [NAME] President of Operations stated it was important for residents to have a choice and the facility should have determined if a resident wanted a tub bath. Additionally, they stated at this time the facility did not have the means to provide a tub bath upon a resident's request. 10 NYCRR 415.5(b)(3)

Based on interviews and record reviews conducted during a Recertification Survey completed 11/20/23, the facility did not ensure they consulted with the resident's physician when medications were not administered as ordered for one (Resident #4) of two residents reviewed for notification. Specifically, the physician was not notified when the resident's insulin was being administered late multiple days on the evening shift. The findings are: The policy and procedure Medication Administration - General dated 10/29/12 documented all medications must be given at the right time and signed for after administration on the Medication Administration Record (MAR). 1.Resident #4 had diagnoses including diabetes mellitus type II, transient cerebral ischemic attack (TIA, temporary impairment of blood flow to the brain), and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 8/14/23, documented Resident #4 was cognitively intact and received insulin injections. Resident #4's physician orders dated 9/26/23 documented Levemir (insulin) FlexPen inject 28 units subcutaneous (SQ) in the morning and inject 20 units SQ at bedtime. Review of Resident #4's Medication Administration Records (MARs) for September 2023 - November 2023 documented Levemir was to be administered at 9 AM and 9 PM. Review of the Medication Admin Audit Report revealed that Levemir 20 units SQ was given after 10 PM on 19 occasions in September 2023, 16 occasions in October 2023 and 9 occasions in November 2023. Seventeen of those forty-four were administered after 11 PM. Review of progress notes from September 2023 to November 2023 revealed the physician, had not been notified of medications administered out of the 1-hour allotted timeframe. During an interview on 11/13/23 at 9:57 AM, Resident #4 stated sometimes their insulin was given very late, not until almost midnight, they do not like to be woken up so late, and that it upsets them. During an interview on 11/17/23 at 11:29 AM, Licensed Practical Nurse (LPN) #1 stated medications can be given an hour before and up to an hour after their scheduled time listed on the MAR. LPN #1 stated they have been late with administering mediations to residents, and they have never called the physician about medications being administered late. LPN #4 stated the physician should have been notified. During an interview on 11/17/23 at 12:18 PM, LPN #2 stated nurses can give medications one hour before and one hour after the scheduled timeframe. If given out of the timeframe, then the supervisor should be called so that the physician could be notified. LPN #2 was never informed of medications being given late and stated if Levemir was given late it could mess with the blood sugar reading. During an interview on 11/17/23 at 2:22 PM, the Medical Director stated if there was a problem in the medication timing, then the physicians should be notified. If receiving Levemir late, there could be an issue because Levemir was an insulin and could cause blood glucose to go low and could make it look like the resident's blood glucose was managed better than it was. During an interview on 11/20/23 at 8:05 AM, the Acting Director of Nursing (DON) stated nurses can give medications an hour before and after their scheduled time. If out of the timeframe they should be notifying the provider and ideally it would be the Nursing Supervisor on that shift notifying the physician. If the physician was notified there should be a progress note written in the resident's electronic health record. The DON would expect nurses to document medications that were given right after administering them and would expect nurses to notify supervisors if meds are late so the providers could be called and orders received. 10 NYCRR 415.3(f)(2)(ii)(b)

Based on observation, interview, and record review conducted during the Standard survey completed 11/20/23, the facility did not ensure that each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for one (Resident #72) of three residents reviewed for ADLs. Specifically, Resident #72 was observed with long dirty (dark debris) fingernails, had unkempt facial hair, and was not shaved or offered to be shaved during morning care. The finding is: The policy and procedure (P&P) titled Shaving Residents - Male and Female dated 11/14/11 documented it shall be the policy of this facility that residents shall have facial hair removed on a regular basis and/or per their request. The P&P titled Nail Care - Routine and Diabetic dated 2/14/13 documented it shall be the policy of this facility that resident nails will be kept neat, clean, and smooth to assist in injury prevention and to maintain proper hygiene. The P&P titled AM (morning) and PM (night) Care dated 7/23/13 documented every resident shall be provided with AM and PM care daily to provide cleanliness and comfort for the resident, to monitor skin, and to prevent odor. 1. Resident #72 had diagnoses that included depression, cognitive impairment (difficulty remembering, and making decisions that affect everyday life), and weakness. The Minimum Data Set (MDS- a resident assessment tool) dated 10/24/23 documented Resident #72 had severe cognitive impairment was always understood, and always understands. The MDS documented Resident #72 required moderate assistance for personal hygiene. The comprehensive care plan (CCP) dated 8/14/23 documented Resident #72 had an ADL self-care performance deficit related to activity intolerance and confusion. Interventions included to check nail length, trim and clean on bath day and as necessary. Additionally, the CCP documented Resident #72 was at risk for decline in ADLs and mobility due to muscle weakness. Interventions included extensive assist of one staff member for grooming. The Kardex (a guide used by staff to provide care) dated 11/16/23 documented Resident #72 required extensive assist of one staff member for grooming. Review of the Treatment Administration Record (TAR) dated 11/1/23-11/30/23 documented Resident #72's skin and nails were checked on 11/1/23, 11/8/23 and 11/15/23. Review of the nursing progress notes from 10/15/23 through 11/15/23 revealed there was no documentation regarding refusal of nail care or shaving. During an observation and interview on 11/14/23 at 9:34 AM, Resident #72 had long nails on both hands with dark debris under the nails. Resident #72 had unkempt facial hair. Resident #72 stated they did not like the facial hair, and they wanted someone to shave it. During an interview on 11/14/23 at 10:21 AM, Resident #72's family member stated Resident #72 never had facial hair and in the past, they would remove their own facial hair daily. The family member also stated Resident #72 always kept their fingernails trimmed short. During an observation on 11/15/23 at 3:55 PM, Resident #72 had unkempt facial hair and long nails with debris underneath them. During an observation on 11/16/23 at 9:41 AM, Certified Nursing Assistant (CNA) #3 and Licensed Practical Nurse (LPN) #2 assisted Resident #72 with morning care. CNA #3 did not attempt or offer to assist Resident #72 with shaving and nail care, before, during or after the completion of morning care. During an interview on 11/16/23 at 9:55 AM, CNA #3 stated they noticed Resident #72's long nails and facial hair. CNA #3 stated they did not shave or do nail care for Resident #72 because they always refused. CNA #3 stated they did not know what was under Resident #72's nails. CNA #3 stated they would approach Resident #72 later about their facial hair and nails. During an interview on 11/16/23 at 10:08 AM, LPN #5 stated Resident #72 usually refused care but could be persuaded when staff talked to them. LPN #5 stated Resident #72 definitely needed some hand care. During a telephone interview on 11/16/23 at 3:24 PM, CNA #4 stated Resident #72 would refuse care unless they were approached using their preferred nickname. CNA #4 stated when staff used Resident #72's preferred nickname, they would be like jelly in your hands. CNA #4 stated, that meant Resident #72 would allow all care including nail care and shaving when staff used the right approach. During an interview on 11/16/23 at 3:54 PM, LPN #2 stated shaving and nail care were part of morning care. LPN #2 stated they noticed Resident #72 had long nails that were dirty. LPN #2 stated CNA #3 should have at least offered to shave Resident #72 and should have attempted to clean Resident #72's fingernails because it was unknown what was underneath them. LPN #2 stated just because a resident might be known to refuse care, it did not mean the staff should stop attempting to complete care. LPN #2 stated each day was a new day, and residents should at least be approached daily, for shaving and nail care. During an interview on 11/17/23 at 9:20 AM, Registered Nurse (RN) #1 stated they expected staff to shave and complete nail care for residents during morning care. RN #1 stated they expected staff to cut and clean long nails when they noticed residents had long nails, not only on shower days. RN #1 stated staff should have noticed if residents needed to be shaved or nail care done when they were doing care. RN #1 stated the LPNs oversaw the CNAs so they should have made sure the CNAs were completing care every day. During an interview on 11/17/23 at 11:13 AM, the Acting Director of Nursing (DON) stated during morning care, the staff should have at least offered to shave residents unless the resident was care planned to grow a beard. The Acting DON stated, the staff should have looked at the fingernails during care and address them in any way; if the nails needed to be cleaned, trimmed, or filed. The Acting DON stated it was standard to check the fingernails on shower days, but CNAs should always check during daily care if nail care was needed. NY10CRR 415.12 (a)(3)

Based on observation, interview and record review conducted during a complaint investigation (#NY00315321) completed on 8/2/23, the facility did not ensure residents had the right to be free from sexual abuse for one (Resident #1) of four residents reviewed. Specifically, the facility did not ensure Resident #2 did not engage in non-consensual sexual contact with Resident #1. The finding is: The policy and procedure (P&P) titled Resident Abuse Prohibition revised on 3/1/18, documented sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. 1. Resident #1 had diagnoses that included depression, anxiety, and diabetes mellitus (high blood sugar levels). The Minimum Data Set (MDS - a resident assessment tool) dated 3/18/23 documented Resident #1 was understood, understands, and had moderate cognitive impairment. During an observation/interview on 8/2/23 at 10:19 AM, Resident #1 was well-kempt with a guarded, flat affect. Resident #1 stated they felt safe at the facility. The undated Facility Investigation and Findings documented that Resident #1 stated the touching was unwanted. Additionally, the investigation documented after viewing the video footage, Resident #2 had entered Resident 1's room on 4/25/23 and was in the room for 17 minutes. The Nurse Practitioner (NP) #1 Acute Visit Progress Note dated 4/25/23 documented Resident #1 stated Resident #2 entered their room and touched their breast and genital area. Resident #1 stated this was an unwanted and non-consensual encounter. The Doctor of Philosophy (PhD) #1 Behavioral Health Progress Note dated 5/1/23 documented Resident #1 was referred for an initial psychological evaluation due to concern about their decreased well-being after a fell ow resident exhibited sexually inappropriate behavior towards them. During an interview on 8/2/23 at 11:25 AM, Social Worker (SW) #1 stated on 4/25/23 Resident #1 reported that Resident #2 had entered their (Resident #1) room in the early morning and touched their (Resident #1) breasts and genital area. Additionally, Resident #1 stated to SW #1 the encounter was unwanted and non-consensual. During an interview on 8/2/23 at 11:34 AM, the Director of Nursing (DON) stated they considered unwanted, non-consensual sexual touching to be sexual abuse. The DON also stated that neither party had the ability to consent to a sexual encounter. During an interview on 8/2/23 at 11:40 AM, the Administrator stated they considered unwanted, non-consensual sexual touching to be sexual abuse. NYCRR 10 415.4(b)(1)(i)

Based on interview and record review completed during the Standard survey completed on 1/28/22, the facility did not ensure that all alleged violations of abuse including injuries of unknown origin were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury for three (Resident #4, #34, #226) of seven residents reviewed for alleged abuse. Specifically, a bruise of unknown origin (Resident #226) and an allegation of resident-to-resident abuse (Resident #4 and #34) were not reported to the New York State Department of Health (NYSDOH) within the two-hour timeframe as required. The findings are: The facility policy and procedure (P&P) titled Resident Abuse Prohibition revised 3/1/18 documented to prohibit resident abuse. Upon the receipt of a complaint, if there is reasonable case to believe abuse has occurred, Administration will be immediately notified, and the Department of Health will be notified as soon as possible, but not to exceed 24 hours. The P&P defined reasonable cause to include statements that physical abuse, mistreatment, or neglect occurred. An investigation shall be initiated immediately after administrative notification, staff will be interviewed, and written statements obtained. Section titled Resident to Resident documented that all resident complaints/concerns will be referred to Administration and upon the receipt of a complaint, Administration shall conduct an investigation into allegations. The facility P&P titled Accidents & Incidents (A&I) revised 7/31/17 documented that all accidents, potential accidents, incidents, reported abuse, suspected abuse shall be investigated and reported to the Administration. It is the responsibility of all staff members to report any accident/incident, potential accident/incident and any suspected abuse issues to the charge nurse immediately - including resident-to-resident altercations. When the floor nurse receives report of an accident/incident, they are to immediately notify the nursing supervisor and the floor nurse or supervisor is to complete the A&I report. The supervisor needs to immediately start the investigation. Once the A&I and all required paperwork has been reviewed by the supervisor, it shall be given to the DON or RN designee for review. 1. Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 1/16/22 documented Resident #4 understood, understands and had moderate cognitive impairment. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #34 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #34 understood, understands and had moderate cognitive impairment. The resident had no history of verbal or physical behavioral symptoms towards others. Review of the Progress Notes dated 11/4/21 at 7:44 PM documented that Director of Nursing (DON) was notified at 5:55 PM via phone by Registered Nurse (RN) #1 Nurse Supervisor that Resident #34 alleged that Resident #4 hit Resident #34 in the buttocks, and hit Resident #34 in the jaw earlier the same day. DON documented an assessment that revealed there was no injury to Resident #34 and statements from both residents and staff who were present at the time of the alleged abuse. The DON notified Resident #34's family and documented that after investigation of the allegations by Resident #34, there was not credible evidence that abuse occurred. Review of A&I reports provided by the facility revealed there was no documented A&I investigation into Resident #34's allegations of abuse reported on 11/4/21. Review of the NYS DOH Automated Complaint Tracking System Complaint/Incident Investigation Report revealed there was no documented investigation into Resident #34's allegations of abuse reported on 11/4/21. During a phone interview on 1/26/22 at 12:28 PM, RN #1 Nurse Supervisor stated that they were notified of the alleged incident between Resident #4 and Resident #34 later during the shift that it allegedly occurred and spoke to both residents regarding the allegation. RN #1 then spoke to the DON about the allegations, at which point RN #1 and the DON concluded that the allegation did not require an incident report or reporting to NYSDOH because Resident #34 was a bad historian, without injuries from alleged altercation and stated they were not fearful of Resident #4 when asked by RN #1. During an interview on 1/27/22 at 11:37 AM, the DON stated that there was no further investigation on the allegation made by Resident #34, beyond what was documented in the resident's progress notes. The DON stated that they were aware of alleged violation reporting requirement and the allegation was not reported to the NYSDOH because they investigated the allegation and ruled out that abuse occurred. 3. Resident #226 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief Interview for Mental Status (BIMS) assessment documented on 1/10/22 by the Social Worker revealed Resident #226 had moderately impaired cognition. The Comprehensive Care Plan, (CCP) dated 1/24/22 documented Resident #226 was at risk for falls related to history of falling and confusion. Planned interventions included: Anticipate and meet the resident's needs, call light within reach and encourage to call for assistance, ensure non-skid footwear when out of bed (OOB), follow facility fall protocol, physical therapy evaluate and treat as ordered or as needed. On 1/25/22 at 10:38 AM Resident #226 was observed laying on their bed in their room with a purple bruise above the right eyebrow approximately 2 inches x 2 inches. During an interview at the time of the observation Resident #226 stated they didn't know how they got the bruise. Review of the Progress Notes revealed the following: - 1/19/22 at 8:39 PM Registered Nurse (RN) #4 documented, staff noted a bruise on right temple area. Resident #226 did not know where it came from or how it happened. The transport aide did not notice it yesterday. - 1/20/22 at 2:54 AM Registered Nurse (RN) #4 documented, HCP, daughter called and was with resident during the appointment and saw the bruise and was concerned. - 1/20/22 at 1:26 PM Licensed Practical Nurse (LPN) #2 documented, Aide notified writer that resident had a bruise on the right side of the forehead, 2 centimeters (cm) x 2.1 cm. Writer attended and noted the same, purple in color with red blood vessels in the middle. This was not present when resident left the facility with her daughter on 1/19/22 at 2:15 PM for an appointment. Resident didn't know what happened to cause it. - 1/20/22 at 2:04 PM the Director of Nursing (DON) documented, it was discovered by this resident's daughter while out of facility at medical appointment that resident has a quarter sized bruise over the right eyebrow. Review of the Facility Accident / Incident (A/I) Reports provided by the facility dated 1/20/22 at 1:20 PM documented It was discovered on 1/19/22 while out of facility at an appointment that resident had a quarter sized bruise above their right eye. Review of the on-line submission Health Emergency Response Data System (HERDS) documented the incident dated 1/19/22 with an incident time 3:00 PM, submitted on 1/20/22 at 2:39 PM. During an interview on 1/28/22 at 10:14 AM, LPN #1 Unit Manager (UM) stated they were not aware of the bruise above resident #226's eyebrow until interviewed by the DON on 1/20/22. LPN #1 UM stated when an injury of unknown origin was noted the DON should be notified immediately to rule out abuse. During an interview on 1/28/22 at 12:37 PM, the DON stated the Nursing Supervisor should have informed the covering DON on 1/19/22 when the staff reported the bruise above the resident's right eyebrow immediately to rule out abuse. The DON stated the were not aware of the bruise above Resident #226's right eyebrow nor was the covering DON until the morning of 1/20/22. The DON stated a report should have been filed within 2 hours of the noted bruise on 1/19/22 according to the regulations to New York State Department of Health (NYS DOH) because it was an injury of unknown origin on the resident's forehead. During an interview on 1/28/22 at 1:52 PM, the Administrator stated a report to NYS DOH should have been filed within 2 hours of the noted bruise on 1/19/22 because it was an injury of unknown origin on the resident's forehead. 415.4(b)(4)

Based on interview and record review conducted during the Standard Survey completed on 1/28/22, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (Resident #226) of seven residents reviewed for abuse. Specifically, there was a lack of a thorough investigation to include the previous shifts staff members statements according to facility practices to rule out abuse, neglect or mistreatment when a bruise of unknown origin was identified above the resident's right eyebrow. The finding is: Review of a facility policy and procedure (P&P) titled Accident/Incidents revised date 7/31/2017 documented, all accidents, potential accidents, incidents, reported abuse, suspected abuse, unexplained bruising shall be investigated and reported to the administration as indicated (see P&P Abuse Prohibition). The supervisor needs to immediately start an investigation as to what happened and the cause, making sure all staff scheduled on the unit complete the staff observation sheet. The supervisor will also fill out observation/ investigative sheets for the past 72 hours for any injury of unknown origin or until area was not noted. Review of a facility P&P titled Resident Abuse Prohibition revised date 1/18/2017 documented the facility prohibit resident abuse, neglect by staff, volunteers, consultants, family members/friends/legal guardians or other individuals. Definitions included: injuries of unknown origin to be classified as an injury of unknown origin both of the following conditions must exist; the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma). 1. Resident #226 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief Interview for Mental Status (BIMS) assessment documented on 1/10/22 by the Social Worker revealed Resident #226 had moderately impaired cognition. Review of the Facility Accident/Incident (A/I) Report provided by the facility dated 1/20/22 at 1:20 PM documented It was discovered on 1/19/22 while out of facility at an appointment that resident had a quarter sized bruise above their right eye. Witness statements included were Resident 226's daughter, Transport Aide, Training Nurses Aide (TNA) #7 and Licensed Practical Nurse (LPN) #1 Unit Manager (UM). Review of the investigation provided by the Director of Nursing (DON) revealed there was no documented evidence staff members working the day shift on 1/19/22, or the previous night and evening shift were interviewed to rule out abuse. During an interview on 1/28/22 at 10:14 AM, LPN #2 stated the bruise noted above the resident's right eyebrow was an injury of unknown origin and should have been thoroughly investigated. LPN #2 stated she doesn't know how the resident obtained the bruise. During an interview on 1/28/22 at 11:25 AM, LPN #1 UM stated a bruise of unknown origin should be thoroughly investigated to rule out abuse, including obtaining statements from all staff working on the day shift on 1/19/22 and does not know if previous shift employees should have been interviewed. LPN #1 UM stated the DON investigated the bruise. During an interview on 1/28/22 at 11:25 AM, the DON stated they had stopped interviewing staff after two staff members stated they had not seen the bruise on 1/19/22 on the day shift. The DON stated a bruise could appear hours after an incident and they should have interviewed the previous shifts to rule out abuse. The DON stated they had not completed a thorough investigation. During an interview on 1/28/22 at 1:52 PM, the Administrator stated they had stopped interviewing staff when a staff member stated they had not seen it on the day shift of 1/19/22 but should have continued to interview staff on the previous shift to rule out abuse. 415.4(b)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 1/28/22, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, one (Resident #36) of one resident reviewed for quality of care of prosthetic eye did not receive eye care as ordered by the physician and was inaccurately documented in the treatment record. The facility policy and procedure (P&P) titled Maintenance of Prosthetic Eye dated 2/4/21 documented that routine cleaning of prosthetic eye is to be performed in effort to maintain comfort, reduce secretions, extended life of prosthetic eye and aide in the prevention of [CONDITION(S)] (eye infection). Any licensed nursing staff is able to perform maintenance of prosthetic eye. All residents possessing a prosthetic eye shall have it removed, cleansed and inserted once monthly unless otherwise specified by a doctor. Equipment included: Sterile water, clean gloves, baby shampoo, prosthetic eye suction cup and a clean towel. The finding is: 1. Resident #36 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/29/21 documented Resident #36 was severely cognitively impaired with short-term and long-term memory problems. The facility's physician Order Summary Report documented an order dated 1/24/21 as follows: Remove and clean right eye prosthetic weekly then replace. Rinse with sterile saline and replace with the use of suction adaptor. Check eye for any discoloration, drainage or redness everyday shift on Thursday. The facility's Treatment Administration Record (TAR) dated 12/1/21 through 1/28/22 revealed an order: Remove and clean right eye prosthetic weekly then replace. Rinse with sterile saline and replace with the use of suction adaptor. Check eye for any discoloration, drainage or redness ever day shift every Thursday for right eye prosthetic. The following was documented: -12/2/21, 12/30/21, 1/13/22 and 1/27/22 the treatment was initialed as completed -12/9/21 and 1/6/22 was blank, with no documented evidence the prosthetic eye was removed and cleaned -12/16/21, 12/23/21 it was documented that Resident #36 refused the treatment to their prosthetic eye -1/20/22 documented as NA Review of Referral and Consult Report Resident #36 for prosthetic eye dated 3/1/21 documented, Patient came in with ocular prosthesis upside down, checked socket and polished ocular prostheses. There is no crack or chip in prostheses. Attached to consult, Artificial Eyes - Eye maintenance instructions included how to remove the eye and cleaning of the eye. Review of the Comprehensive Care Plan dated 2/4/21 documented Resident #36 has an artificial right eye. Interventions included: treat eye prosthetic as ordered, provide eye care as ordered, notify physician of any eye concerns, monitor for eye drainage, arrange consultation with eye care practitioner as required, follow up with eye specialists as indicated, and monitor for discomfort or pain in eyes and notify physician. During an interview on 1/24/22 at 10:47 AM, the resident's daughter-in-law stated the prosthetic eye remover was missing for approximately 4 weeks. During an interview and observation on 1/28/22 at 10:18 AM, Licensed Practical Nurse (LPN) #2 stated the resident has not allowed her to remove and clean the eye in a long time, months. LPN #2 identified they had documented the resident refused eye care on the TAR dated 12/23/21. LPN #2 stated the suction cup adapter to remove the prosthetic eye should be in the top drawer of the treatment cart and had not seen it in a while. LPN #2 searched for the prosthetic suction cup adapter in treatment cart, both unit medication carts and in the resident's room; unable to locate it. During an interview on 1/28/22 at 10:48 AM, LPN #3 reviewed the TARs 12/2021 and 1/2022 and identified they documented the resident refused eye care on 12/16/21 and the resident received eye care on 12/2/21, 12/30/21, 1/13/22 and 1/27/22. LPN #3 stated she had not seen the suction cup adaptor, had not removed and cleaned the resident's prosthetic eye as ordered. The LPN documented in the TAR inaccurately. LPN #3 stated they should have asked the Unit Manager, a nursing supervisor or the Director of Nursing (DON) where to obtain the adaptor and informed them they were unable to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 1/28/22 at 11:32 AM, LPN #1 Unit Manager stated they were unaware the prosthetic eye suction cup adapter to remove the glass eye was missing and the glass eye was not being cleansed as ordered. LPN #1 stated they would have expected the staff nurses to report the adaptor was missing and it would have been ordered. During an interview on 1/28/22 at 12:52 PM, the DON stated they were unaware the prosthetic eye suction cup adapter to remove the glass eye was missing and would have expected the staff nurses to inform the UM to ensure the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/28/22 at 2:51 PM, the Medical Director stated it is very important to follow the orders, it was a clinical recommendation to remove and clean the prosthetic eye. The Medical Director stated they expect the nurses to document accurately and notify the DON to obtain the adaptor and if necessary, notify medical personnel. 415.12

Based on observation, interview, and record review conducted during the Standard survey completed on 1/28/22, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three, (Resident #47, #56, & #224) of four residents observed for pressure ulcers. Specifically, there was a lack of treatment initiation for residents with pressure ulcers (#47, #224), treatments were not completed as recommended by the Wound Consultant Physician (#56), a wound culture was not obtained as ordered (#224), and pressure reducing devices were not provided as recommended by the Wound Consultant Physician (Resident #56 & 224). The findings are: The facility policy and procedure (P&P) titled Pressure Ulcer Prevention and Treatment Protocol revised July 2013 documented any resident entering the facility without pressure ulcers will remain free from pressure ulcers unless the residents' clinical condition demonstrates that it was unavoidable. Any resident having a pressure ulcer will receive the necessary treatments and services to promote healing, prevent infection and prevent new ulcers from developing. Floor staff will follow the following preventative procedures: Use positioning devices such as, but not limited to, pillows, foam wedges, bolster rolls, etc. to prevent bony prominences from contact with each other: Use pressure relieving devices such as, but not limited to, foam pads, air or gel cushions, and pressure relieving mattresses. Review of Mattress Systems for Pressure Management provided by the facility document; Group 2 support surfaces can prevent pressure ulcers, and help treating existing pressure sores while helping control pain, enhance the quality of sleep and life, and make care giving for bed-bound patients easier. Group 2 support surfaces include: alternating - pressure, low-air loss, lateral-rotation, mattress overlays. 1. Resident #47 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 12/13/21 documented Resident #47 was understood, understands and was at risk for the development of pressure ulcers. Review of the Order Summary Report dated 11/4/20 revealed an active Physician's Order for skin checks once per week on Tuesday. The Comprehensive Care Plan dated 12/20/21 documented Resident #47 was at risk for pressure skin breakdown. Interventions included to administer treatments as ordered, educate resident on causes of skin breakdown, follow facility policies and procedures for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a range of motion (ROM) observation on 1/27/22 at 2:39 PM, the PTA (Physical Therapy Aide) #2 completed ROM. Resident #47's right heel was observed to be red and there was a small stage 2 pressure ulcer with surrounding redness was on the bottom of the left heel. Resident #47 requested the PTA to apply lotion to the left heel and Resident #47 stated both heels had been sore for over one month and that Certified Nurse Aide (CNA) #4 was aware and notified Licensed Practical Nurse (LPN) #6. During interview on 1/27/22 at 3:00 PM, the PTA #2 stated they informed LPN #6 one month ago of potential skin breakdown to Resident 47's heels and LPN #6 instructed the PTA to apply barrier cream to the heels. Review of Resident #47's Medication/Treatment Administration Record (MAR/TAR) dated 1/1/22 through 1/27/22 revealed there was no documented evidence a treatment was ordered for the resident's the right and left heels. Further review of the Order Summary Report dated 1/2022 revealed there were no Physician's Order for a treatment to Resident #47's right and left heels. During an interview on 1/27/22 at 3:40 PM, LPN #6 stated nurses were responsible to visually inspect resident's skin once weekly on bath days. LPN #6 stated they signed the weekly skin check on 1/25/22 in the TAR without visually inspecting Resident # 47's skin. During observation on 1/27/22 at 4:05 PM, Registered Nurse (RN) #2, Unit Manager in the presence of LPN #6 measured the reddened area (stage 1, red, non-blanchable area) to Resident's #47 right heel as 1.5 cm (centimeter) x 1 cm and stated it was boggy (soft). The left heel was staged at a 2 (superficial shallow crater) and measured 0.5 cm x 0.5 cm x 0.1 cm and was boggy. During an interview on 1/27/22 at 4:10 PM, RN #2 Unit Manager stated that the nurses were expected to visually inspect the resident's skin on bath days. When concerns were identified the nurses were to inform the unit manager or RN supervisor. RN #2 stated they were not aware Resident #47 had pressure ulcers to their heels. During a telephone interview on 1/28/22 at 12:00 PM, CNA #4 stated that Resident #47 heels had been red for over a month and had informed LPN #6 and RN #2 Unit Manager. CNA #4 was instructed by LPN #6 to apply barrier cream to Resident #47 heels. CNA #4 applied lotion to the heels during morning care as resident requested. During an interview on 1/28/22 at 1:35 PM, the Director of Nurses (DON) stated it was not in the scope of practice for CNA's to be performing skin assessments. The CNAs should notify the nurse on duty of the skin concern and then nurse should notify the RN. The RN would then assess and notified the provider for an appropriate treatment. 2. Resident #56 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #56 was cognitively intact, at risk for the development of pressure ulcers (PU) and had one stage 3 (full thickness tissue loss) PU. The Comprehensive Care Plan dated 12/31/21 documented Resident #56 had a stage 3 PU to the right heel. Interventions included to follow facility policies and procedures for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Order Summary Report dated 1/27/22 documented an order dated 1/6/22 to cleanse right heel with wound cleanser, pat dry, apply nickel thick dab of Santyl (sterile ointment used to remove dead tissue) and to apply alginate, gauze, foam dressing and kerlix. The Wound Evaluation & Management Summary documented by the wound physician dated, 10/2/21 11/4/21, 12/2/21, 12/23/21, 1/6/22, 1/13/22, and 1/20/22 revealed a recommendation for a Group 2 bed mattress and air boot for the right heel. In addition, a recommendation to add collagen powder to the treatment was documented on 12/23/21, 1/6/22, 1/13/22, and 1/20/22. Intermittent observations on 1/24/22 through 1/27/22 between 8:09 AM and 1:35 PM revealed Resident #56 was in bed and did not have a Group 2 bed mattress and did not have an air boot as recommended from the Wound Consultant Physician. During an observation and interview on 1/26/22 at 10:54 AM LPN #2 completed the treatment as written in the orders with LPN #1 Unit Manager present. Observation and interview on 1/27/22 at 8:26 AM Wound Consultant Physician completed the treatment to resident's right heel as followed; cleansed with wound cleanser, pat dry, mixed collagen powder into the Santyl ointment, applied nickel thick dab to right heel, applied alginate, and covered with a foam dressing. Wound Consultant Physician stated the nurses should be adding collagen powder to the Santyl to assist with the healing process as recommended. Upon review of the physician orders, the Wound Consultant Physician verified collagen was not in the treatment order and stated the nurse manager was responsible review their recommendations and write the treatment orders according to their recommendations. Additionally, a Group 2 bed mattress and air boot was also recommended, and they expected their recommendations to be followed. During an interview on 1/28/22 at 10:03 AM, LPN #2 stated they do not review the wound consultant recommendations, did not know collagen was recommended in the treatment order and does not know what a Group 2 bed mattress is. LPN #2 stated it is the responsibility of the Unit Manager to review the recommendations and write the orders. During an interview on 1/28/22 at 11:03 AM, LPN #1 UM stated they were responsible to review the recommendations from the wound consultant and write the orders. LPN #1 stated they did not see the recommendation for the air boot or Group 2 bed mattress. LPN #1 stated they did not write the order for the collagen powder because the pharmacy said it was not available and did not inform the Director of Nursing (DON) and should have because it was a recommendation. 3. Resident #224 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #224 was moderately cognitively impaired and was at risk for the development of pressure ulcers. The Comprehensive Care Plan dated 1/5/22 documented Resident #224 admitted with an unstageable (slough and/or eschar (black tissue) unable to be stageable due to coverage of wound bed) PU to their sacrum, the sacral PU had been debrided and the cultures were positive for infection. After debridement the PU was restaged at Stage 4, and the resident follows with the Wound Consultant Physician in house for wound care. Interventions included to follow facility P&P for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Order Summary Report dated 1/27/22 documented an order dated 1/5/22 to consult with the wound specialist, off-loading boots to both heels when in bed every shift for red boggy heels with breakdown. There was no documented evidence of a treatment to the right heel. Review of the Treatment Administration Record dated 1/1/22 through 1/31/22 revealed an order dated 1/21/22 to obtain a sacral wound culture. There was no evidence the sacral wound culture was obtained as ordered. There was no evidence of a treatment to the right heel. Review of Wound Evaluation & Management Summary documented by the Wound Physician dated, 1/6/22, 1/13/22, and 1/20/22 revealed a recommendation for a Group 2 bed mattress. Intermittent observations on 1/25/22 through 1/27/22 between 8:14 AM and 2:54 PM revealed Resident #224 was not on a Group 2 bed mattress as recommended from the wound consultant physician. During a morning care observation and interview on 1/26/22 at 10:33 AM with the DON present; CNA #6 stated Resident #224 did not have any pressure ulcers on their heels. CNA #6 removed the resident's bilateral heel booties, and their right heel had a black unstageable ulcer that measured approximately 1 centimeter (cm) x 1 cm area. During an observation and interview on 1/27/22 at 9:03 AM, the Wound Consultant Physician stated Resident #224 was wearing heel float booties for protection and the resident's heels were intact without skin breakdown. The Wound Consultant Physician observed Resident #224's right heel and stated the resident's right heel had a black area measuring 1 cm x 1.1 cm and stated they would have expected the nursing staff to have identified the area and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/28/22 at 7:39 AM, CNA #6 stated they didn't know Resident #224 had a black area on their right heel and didn't look at the resident's heels during care on 1/26/22 and should have. During an interview on 1/28/22 at 10:03 AM, LPN #2 stated they were not aware there was a blackened area on Resident #224's right heel. LPN #2 stated they rely heavily on the CNAs to inform them of skin changes. During an interview on 1/28/22 at 11:21 AM, LPN #1 Unit Manager stated they were responsible to review the recommendations from the Wound Consultant and write the orders. LPN #1 stated they did not see the recommendation for the Group 2 bed mattress. In addition, LPN #1 stated CNAs should be observing all areas of the resident's skin every shift during care for changes and would have expected the nursing staff to observe and report the blackened area on Resident #224's right heel and a treatment to be initiated immediately. During an interview on 1/28/22 at 1:04 PM, the DON stated LPN #1 Unit Manager was responsible to read the Wound Evaluation & Management Summary and follow the recommendations. The DON stated Resident #56 and #224 should have had a Group 2 bed mattress. Resident #56 should have had an air boot for their right heel, pressure reducing devices, and the collagen order should have written and completed according to the recommendations. The DON stated they would have expected LPN #1 Unit Manger to have informed them if the pharmacy was unable to provide the collagen, so they could have called other suppliers to obtain the collagen. Additionally, the DON stated the wound culture was not obtained as ordered on 1/21/22 and should have been. The nurses were expected to follow the physician orders. During an interview on 1/28/22 at 1:35 PM, the Administrator stated they would have expected the wound consultant to have identified the pressure reducing devices were not in place according to their recommendations and follow up with LPN #1 Unit Manager. During an interview on 1/28/22 at 2:46 PM, the Medical Director stated it was important the facility follow the Wound Consultant Physician's recommendations. 415.12 (c)(1)(2)

Based on interview and record review conducted during a Standard survey completed on 1/28/22, it was determined that the facility did not arrange for the provision for physician services 24 hours a day, in case of emergency. Specifically, one (Resident #124) of one resident reviewed for hospitalization the facility did not ensure the provider responded promptly to notification for resident with critically high and high laboratory values. The finding is: 1. Resident #124 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 10/17/21 documented Resident #124 was moderately cognitively impaired, understands and was understood. An undated facility document titled Team Health documented that staff are to call the on call medical provider between the hours of 8:00 AM and 5:00 PM and to use option #2 unless it is a code situation then staff are to press option #1. Additionally, staff are to contact the Medical Director after hours. A review of chronological nursing progress notes dated 12/11/21 documented the following: 9:19 AM - Resident #124 was observed slurring their words, not using words but saying letters, and confusion. A phone call was made to the on call medical provider service at 8:30 AM to report the issue with the resident. A second phone call was made to the on call medical provider at 9:00 AM to report the same issue. The on call medical provider returned the phone call and ordered labs including basic metabolic panel (BMP blood test including basic chemistry studies of the blood), complete blood count (CBC), urinalysis (U/A a test of urine, that provides important clinical information on kidney function), and a COVID-19 test. The COVID-19 test was negative. 12:45 PM - a phone call from the lab who performed the tests reported that Resident #124 had critical lab values of potassium (high potassium level can cause muscle weakness, tiredness, and heart rhythm issues) of 6.2 (normal range 3.2 to 5.2) and a BUN level of 100 (normal range 7 to 21 milligrams per deciliter; a high value can indicate possible kidney failure). A phone call was made to the on call medical provider and a message was left. 3:05 PM - a phone call from the lab reported that the resident had high white blood cells (WBC) of 17 (normal range 4.5 to 10) and the mean platelet volume of 12 (normal range 7.2 to 10.2). A phone call was made to the on call medical provider, a message was left, and waiting for a return call. 5:06 PM - Resident #124 was observed to be moving slow, confused, and removing clothes. A call was placed to the on-call medical provider at this time and return call was pending. The Director of Nursing (DON) was notified of the concerns. 5:33 PM - The family of Resident #124 was notified about the resident's condition. They agreed to send the resident to the hospital. 6:40 PM - The Medical Director of the facility was notified by phone of Resident #124's condition. The Medical Director gave the order to send the resident to the hospital. The ambulance service was called at 6:11 PM and arrived at 6:30 PM to transfer Resident #124 to the hospital. During an interview on 1/26/22 at 11:26 AM, LPN #2 Unit Manager stated that they left messages for the on-call provider to receive direction for Resident #124 but did not receive any return calls. During an interview on 1/26/22 at 12:41 PM, RN #4 stated that nursing staff must notify someone before sending a resident to the hospital. RN #4 stated that Resident #124 didn't look right, and they were concerned and contacted the DON. RN# 4 stated residents the labs were concerning, and they called the family to ask if the resident could be sent to the hospital. RN #4 stated that they asked the DON for permission to call the Medical Director. Once the Medical Director was contacted an order was obtained and Resident #124 was sent to the hospital. During an interview on 1/26/22 at 1:07 PM, the Nurse Practitioner stated that if staff couldn't get a hold of the on-call medical provider then yes, the resident should be sent to the hospital for evaluation. During an interview on 1/27/22 at 8:21 AM, the DON stated that they expected their nurses to keep calling the on-call provider, if they do not hear back from them. The DON stated that they expect their nurses to trust their instincts and, after 60 minutes if they have not gotten a hold of the on-call provider, to call the Medical Director. During an interview on 1/27/22 at 9:07 AM, the Medical Director stated that the expectation was for the nurses to call them if they were not able to get a hold of the on-call provider. The Medical Director stated that the expectation was for the nurses to send a resident to the hospital for an evaluation if they feel the resident needs to be sent, and they cannot get a hold of the on-call provider. 415.15(b)(3)

Based on interview and record review conducted during the COVID-19 Infection Control Focus Survey completed on 12/31/20, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility did not ensure one out of one employee (Certified Nurse Aide (CNA) #1) reviewed was screened for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks every 12 hours while on duty. The finding is: Executive Order 202.11, dated March 27, 2020, as codified at 9 NYCRR 8.202.11, documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The NYS DOH DAL (Dear Administrator Letter) NH-20-07, Required COVID-19 Testing for all Nursing Home and Adult Care Facility Personnel, dated May 11, 2020, documented: This Directive supplements the prior (DOH) Advisory concerning hospital discharges to nursing homes (NHs), as well as the DAL sent on April 29, 2020. The directive documented: With respect to COVID-19, state and federal rules and regulations require that NHs adhere to appropriate safety measures including, but not limited to: Requiring all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. The facility policy and procedure (P&P) titled [MEDICAL CONDITION] (COVID-19) revised 12/2/20 documented All staff members will be questioned at the beginning of every shift (if working a shift over 8 hours, staff will be screened at the beginning of the next oncoming shift) at the reception desk re: crowds, travel to high-risk area, symptoms, and have their temperature taken at the beginning of each shift prior to going to their designated area/department. During an interview on 12/31/20 at 9:10 AM the Administrator stated the facility census was 61 residents. This included 31 COVID-19 residents on contact and droplet precautions on Floors 2 and 3. Review of CNA #1's 12/22/20 through 12/28/20 Time Card included the following: - 12/22/20: 6:27 AM to 9:03 PM. 14.5 hours. - 12/26/20: 6:26 AM to 9:00 PM. 14.5 hours. - 12/28/20: 6:32 AM to 9:00 PM. 14.5 hours. During an interview on 12/31/20 at 10:06 AM, CNA #1 stated he has worked overtime and double shifts. He stated employees get screened when they enter the facility at the start of their shift and do not get re-screened or have temperature re-taken when working a double shift (which are two 8-hour shifts, totaling 16 hours). CNA #1 was not aware they needed to be re-screened every 12 hours while on duty. Review of the facility Staff Screening Log dated 12/22/20, 12/26/20, and 12/28/20 documented one screening for CNA #1 on each date. During an interview on 12/31/20 at 11:04 AM the receptionist on duty stated when staff enter the building screening questions are asked and temperature is taken, staff then have a rapid COVID-19 test prior to starting their shift. Additionally, the receptionist stated staff is to be re-screened if working over their 8-hour shift. During an interview on 12/31/20 at 12:23 PM the Infection Preventionist stated staff is screened at the beginning of their shift and are not re-screened unless symptomatic. During an interview on 12/31/20 at 12:00 PM the Administrator stated staff are screened for COVID-19 at the beginning of their shift, and staff are not re-screened if working a double shift unless they were to develop symptoms. 415.19(a)(1) 400.2

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for nine ( Residents #9, #17, #28, #33, #34, #37, #50, #58 and #220) of ten residents reviewed for Baseline Care Plans, the facility did not develop a Baseline Care Plan within 48 hours of admission that included the minimum required information, and/or the resident and/or resident's representative were not provided with a written summary of the plan. This is evidenced by, but not limited to, the following: The facility policy, Baseline Care Plan, revealed a Baseline Care Plan (BCP) will be developed for each resident within 48 hours of admission. The interdisciplinary team will review the physician orders [REDACTED]. The resident and their representative will be provided a summary of the BCP that includes, but is not limited to, the initial goals, a summary of the medications, dietary instructions, and any services or treatments to be administered. 1. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 4/5/19, revealed the resident had moderately impaired cognition and clear comprehension. 2. Resident #9 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/19/18, revealed the resident had moderately impaired cognition, clear comprehension, and used oxygen and a [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) machine. 3. Resident #17 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 7/4/18, revealed the resident was cognitively intact and used oxygen. Review of the medical records for each resident revealed an undated BCP which did not include the minimum healthcare information necessary to properly care for the resident immediately following admission including initial goals, dietary orders, therapy services, social services, physician orders, and/or instructions to provide person centered care. There was no documented evidence that the BCP was reviewed and/or a copy was provided to the resident and/or their representative. Interviews conducted on 5/28/19 included the following: a. At 2:08 p.m., the Registered Nurse Manager (RNM) said that the BCP was developed by the interdisciplinary team and each discipline (Nursing, Social Work, Dietary, and Therapy) was responsible for completing their own section. She said the BCP should be completed within 48 hours of admission. The RNM said she was not aware of the minimum requirements that should be included in the BCP. The RNM said she did not know who was responsible for providing a summary of the BCP to the resident and/or representative. b. At 3:15 p.m., the Social Worker (SW) stated she was responsible for reviewing the BCP with the resident and/or their representative. The SW said she would ask the resident and/or representative if they wanted a copy of the BCP. She stated there was a place on the BCP for the resident and/or representative to sign that the BCP had been reviewed with them. She stated if it was not signed, then it was not done. When interviewed on 5/29/19 at 11:00 a.m., the Director of Nursing stated the BCP was developed within 48 hours of admission, and a summary of the BCP and medication list was supposed to be provided to the resident and/or representative.

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #28) of eight residents reviewed for unnecessary medications, the facility did not ensure orders for as needed [MEDICAL CONDITION] medications were limited to 14 days. This is evidenced by the following: Resident #28 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/1/19, revealed that the resident was cognitively intact. The facility policy, [MEDICAL CONDITION] Medication, dated 4/17/17, revealed that no resident will remain on an as needed [MEDICAL CONDITION] medication greater than 14 days without the prescribing practitioner documenting the rationale. Time frames for continued as needed [MEDICAL CONDITION] medication use must be documented in the medical record. Pharmacist will send a written report to Medical Director, Director of Nursing (DON), and attending physician listing the resident's name, relevant drug, and irregularity identified. The physician will document in the medical record the review of the irregularity and what if any action has been taken to address it. If no action is taken, document rationale in the medical record. Physician orders, dated 5/15/19, [MEDICATION NAME](hypnotic used as a sleep aid) 10 milligrams (mg) at bedtime as needed. The medication was originally ordered on admission (11/30/18). Review of the medical record since admission revealed that the physician documented the resident's [DIAGNOSES REDACTED]. The Consultant Pharmacist Medication Regimen Review forms, dated 3/26/19, 4/27/19, and 5/22/19, revealed that the resident had been [MEDICATION NAME] (MONTH) (YEAR). Recommendations had been made to re-evaluate the use of Ambien, document the rationale for using [MEDICATION NAME] more than 14 days in the medical record, and possibly adding a maintenance hypnotic due to frequent use. When interviewed on 5/29/19 at 9:41 a.m., the Registered Nurse Manager (RNM) stated that the resident has had an order for [REDACTED]. She said there was discussion with the physician regarding making medication changes, but nothing had changed with [MEDICATION NAME]. During an interview on 5/29/19 at 2:14 p.m., the DON stated that the physician's signature and date on the 4/27/19 Monthly Summary Consultant Pharmacist Medication Regimen confirmed that the physician had reviewed the pharmacist recommendation. (10 NYCRR 415.12)

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #12) of three residents reviewed for accidents, the facility did not develop a thorough Comprehensive Care Plan (CCP) that included measurable goals and interventions based on the resident's assessment to ensure the services were provided to maintain the resident's highest practicable physical well-being. The issue involved the lack of care planning for wandering and exit seeking behaviors. This is evidenced by the following: Resident #12 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/8/17, revealed that the resident had moderately impaired cognition and wandered daily. The facility policy and procedure Elopement Evaluation, dated 12/29/14, directed that all residents deemed an elopement risk shall have an appropriate care plan and care profile to address said risk. The Elopement/Unsafe Wandering Risk Assessment, last reviewed on 11/8/17, revealed a score of 10, indicating the resident was at risk. Interventions included frequent monitoring, recreational activities, the use of visual barriers, and music. The section for the application of the Wander Guard and the use of a red band or lanyard was blank. The questions for the use of individualized interventions on the care plan and the Master Care Sheet were not circled yes or no. A Psychiatric Evaluation, dated 11/24/17, revealed that the resident wanted to meet with his girlfriend and/or his wife, becomes very focused and very difficult to redirect, and tries to elope so that he can see people. The CCP, dated 12/4/17, the Resident Care Profile and Behavioral Plan, both dated 12/14/17, did not address the resident's elopement risk or exit seeking behaviors. The resident's name and photo were included in a red binder as an elopement risk at the nursing station and in the Nurse Manager's Office. Progress Notes, reviewed from 9/4/17 through 1/4/17 included, but are not limited to the following: attempts to get on the elevator or use the stairway, looking for the door/exit, looking for his wife, going to the first and second floors unassisted, asking for directions to his home, asking to go to the doctor's office across the road, and/or to leave to go to work. During an observation on 1/3/18 from 2:52 p.m. to 3:52 p.m., the resident was self-propelling in a wheelchair near the elevators and nursing station, stating he needed to leave to babysit his kid brother. Interviews conducted on 1/3/18 included the following: a. At 3:22 p.m., Licensed Practical Nurse (LPN) #1 said that staff would look at the Care Profile Sheets to determine if a resident was at risk for wandering/elopement. b. At 3:41 p.m., LPN #2 said a Registered Nurse (RN) would complete the Wandering/Elopement Risk Assessments. She said the Interdisciplinary Care Team would review the assessment then develop a CCP, if needed. c. At 3:59 p.m., LPN #3 said that the resident asks to go to East Eden but has not tried to get on the elevator in months. LPN #3 showed the surveyor a red rubber bracelet on the back of the resident's wheelchair and said that indicated that he was an elopement risk. d. At 4:09 p.m., Certified Nursing Assistant (CNA) #1 said the resident will occasionally push the buttons for the elevator, but staff will discourage him and redirect him to an activity. Interviews conducted on 1/4/18 included the following: a. At 8:38 a.m., CNA #2 said that the resident will talk about leaving and wanting to go home when he sundowns. CNA #2 said the resident does not exit seek all the time, but when he does the CNAs and the Unit Helper will keep an eye on him. CNA #2 said that wandering residents and residents at risk for elopement were identified by the use of a red band on their wrist or wheelchair, pictures at reception and nursing station, and documentation on the Resident Care Profile. b. At 8:47 a.m., the RN Manager (RNM) said that an initial Wandering/Elopement Risk Assessment would be completed by an RN and reviewed quarterly. She said the assessment was then discussed with the Interdisciplinary Care Team. The RNM said if the resident has exit seeking behaviors then interventions would be put in place. She said the Social Worker (SW) would complete the CCP section regarding mood and behaviors including wandering and elopement risks. The RNM said the resident would have a red band placed on his arm, or in this resident's case on the wheelchair. She said the resident's picture would go in the elopement binder at the nurses' station, manager's office, and the front desk. The RNM said the resident does look for his brother and his wife. She said it should be documented on the Care Profile and a CCP should be in place to address his exit seeking behaviors. The RNM said she was unable to locate that information in either document. She said that the Risk Assessment was incomplete. She said that the use of the red band should have been checked and individualized interventions should have been documented in the care plan, and updated on the Master Care Sheet. c. At 9:12 a.m., the RN MDS Coordinator said that she completed the Wander/Elopement Risk Assessment. She said it was an oversight that the boxes were not checked for the red band or that a care plan was not completed. She said that the SW will usually type up the CCP regarding elopement/wander risk. d. At 9:16 a.m., the SW said that the resident displays exit seeking and wandering behavior. The SW said she completes the CCP section for wandering and elopement risks but could not locate one in the resident's record. (10 NYCRR 415.11(c)(1))

Based on observations, interviews, and record reviews, it was determined that for 2 (Residents #73 and #74) of 24 residents reviewed for Minimum Data Set (MDS) Assessment accuracy, the facility did not ensure the MDS Assessments accurately reflected the residents' status. Coding issues included resident interviews and mood interviews not attempted per the instruction user's manual. This is evidenced by the following: 1. Resident #73 has [DIAGNOSES REDACTED]. The MDS Assessments, dated 5/9/16 and 7/11/16, both indicate under Section B0700 that the resident is usually understood and usually understands. Section C0100 Should Brief Interview for Mental Status (BIMS) Be Conducted? instructions include: the interview should not be attempted if the resident is rarely/never understood (check No), and this area is to be coded Yes if the resident is at least sometimes understood. Both MDS Assessments are coded No, revealing the BIMS was not attempted with the resident. During an interview on 9/30/16 at 10:06 a.m., the Registered Nurse (RN)/MDS Coordinator said the Social Worker (SW) usually does the BIMS and mood interviews, but she does complete Section B. The RN/MDS Coordinator said she bases her information and decision on talking with the resident and staff, and believed the BIMS interview should have been conducted because the resident is sometimes understood and sometimes understands. During an interview with the SW on 9/30/16 at 10:25 a.m., the SW said the BIMS interview should have been attempted with the resident as she is sometimes understood. 2. Resident #74 has [DIAGNOSES REDACTED]. The MDS Assessments, dated 4/25/16 and 6/27/16, both indicate under Section B0700 that the resident is sometimes understood and sometimes understands. Section C0100, Should Brief Interview for Mental Status (BIMS) Be Conducted? instructions include: The interview should not be attempted if the resident is rarely/never understood as No, and this area is to be coded, Yes if the resident is at least sometimes understood. Both MDS Assessments are coded No. The BIMS was not attempted with the resident. Section D0100 Should Resident Mood Interview Be Conducted? instructions include: No should be selected for residents who are rarely/never understood, and Yes should be selected for residents who are able to be understood. Both MDS Assessments are coded No for this resident. The Mood Interviews were not attempted. During an observation on 9/29/16 at 8:30 a.m., the resident was in the dining room being assisted with breakfast. The resident was offered a drink, and clearly said, I don't want it. During an interview on 9/30/16 at 10:10 a.m., the RN/MDS Coordinator said the SW usually completes the BIMS and mood interviews, but she does complete Section B. She said she bases her information and decision on talking with the resident and staff, and believed the BIMS interview should have been conducted because the resident is sometimes understood and sometimes understands. During an interview with the SW on 9/30/16 at 10:25 a.m., she said the BIMS interview should have been attempted with the resident, as she is sometimes understood. During an interview on 9/30/16 at 10:22 a.m., the SW said she has attempted to interview the resident before and the resident could not answer the questions. She said sometimes she can be understood, so her part that says she rarely is understood is incorrect, and she should have attempted the interview. (10 NYCRR 415.11(b))

Based on observations, interviews, and record reviews, it was determined that for 2 of 24 residents reviewed for care planning revisions, the facility did not ensure that a resident's care plan was reviewed or revised to reflect the resident's current condition. Issues involved lack of care plan revisions for meal refusals (Resident #66), and activities (Resident #31). This is evidenced by the following: 1. Resident #66 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 8/22/16, described the resident's cognitive skills for daily decision making as moderately impaired and had exhibited behavior symptoms, both physical and verbal. Review of the Comprehensive Care Plan (CCP), dated last evaluated 8/23/16, revealed the resident's nutritional problems included variable intake by mouth and medications may cause shift in appetite. The CCP did not include a plan to address the resident's refusals with measureable goals and approaches. Review of the resident's weight from 3/2/16 through 9/23/16 revealed that the resident weighed 100 pounds on 3/5/16 and 96 pounds on 9/23/16. Review of the current Care Card Sheet revealed that the resident is able to eat independently after set up and intake should be encouraged. The Nursing Care Flow Sheet for September 2016, reflects that the resident has refused meals consistently. Review of the Medication Administration Record [REDACTED]. Review of the dietary note, dated 9/23/16, revealed the resident is receiving a gluten-free diet and consumes very little. She does accept ice cream and supplement. She has also been receiving fortified starches and protein at lunch and dinner. It was recommended to provide encouragement and cueing at mealtimes to promote optimum intake. During an interview on 9/29/16 at 2:20 p.m., the Registered Dietician (RD) stated that care plans are updated quarterly and any significant changes can be handwritten on the care plan. She stated that the facility is providing gluten-free products on the resident's meal tray, but the resident has consistently refused her meals. She stated that the resident is offered additional supplements. The RD stated that if a resident refuses to eat, approaches might include a supervised setting during the meal period to provide constant cueing and supervision. Review of the facility's policy, Resident Care Planning and Care Area Assessments, dated 10/3/12, revealed that all residents will have an interdisciplinary care plan developed that shall include measurable goals and time tables to meet each individual's medical, physical, mental and psychosocial and will be updated as needed for any changes in care needs. 2. Resident #31 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/25/16, revealed the resident is severely cognitively impaired. Review of the Activities CCP, dated 5/6/16, revealed that the resident is non-verbal and has severe cognitive decline. Interventions included the resident enjoys country music and enjoyed pets, reading and crafts in the past. Review of an Activity Note, dated 8/3/16, documented the resident is alert and nonverbal. She attends cocktail hour and crafts. The staff use touch activity and props to engage in activities such as music listening, musical instruments and hand movements. The staff read short stories to the resident. During an observation on 9/27/16 at 10:45 a.m., the resident was sitting in a chair in her room behind the privacy curtain. The resident did not have a radio/cd player or television in her room. During an interview on 9/29/16 at 12:22 p.m., the Certified Nursing Assistant said sometimes the resident listens to music. She said the resident does not have anything in her room but she listens to her roommate's television. During an interview on 9/30/16 at 10:15 a.m., the Activities Directory (AD) said the resident goes to group activities but she did not know if the resident attended any this week. She said the resident does not have a radio/cd player because the family did not provide one. She said she does not know if the family was asked to bring in a radio/cd player. She said the resident is also provided 1:1. The AD said the resident's care plan interventions need to be updated. The 9/26/90 Activity Department Policy includes the purpose for activities is to maintain prior interests and social contacts as well as establish new interests and hobbies. (10 NYCRR 415.11(c)(2)(i-iii))