Every finding on record at Elderwood at Amherst

Based on interview and record review conducted during survey, the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for one (Resident #4) of three residents (Resident #4) reviewed for accidents. Specifically, on 11/04/2025, Certified Nurse Aide #3 failed to transfer Resident #4 using the sit-to-stand lift (a wheeled patient-handling device designed to help a person move from a seated position to a supported standing position) as per the care plan. This resulted in a laceration to the resident's left leg requiring a transfer to the emergency room and sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision). This resulted in actual harm to Resident #4 that is not Immediate Jeopardy. The findings include: The facility policy and procedure titled, Comprehensive Care Plan dated 06/18/2025 documented the comprehensive care plan was to be implemented as soon as the care plan was developed. Review and revise the care plan after each assessment and as needed based on the resident's changing needs; and ensure all staff are aware of the care plan and their roles in implementation. Review of a facility document titled, Certified Nursing Assistant (CNA) dated July 2022 documented that certified nursing assistants were to assist residents with activities of daily living, including transfers, according to the resident's plan of care. Resident #4 had diagnoses including dementia, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and abnormalities in gait and mobility. The Minimum Data Set (a resident assessment tool) dated 11/03/2025 documented that Resident #4 was mildly cognitively impaired, usually understands and was usually understood by others. The resident required maximal assistance with transfers. The Comprehensive Care Plan dated 11/01/2025 documented Resident #4 was to use a sit-to-stand lift to move the resident from the bed to the chair. The Visual/Bedside Kardex Report (guide used by staff to provide care) dated 11/04/2025 documented the resident required a mechanical lift (sit to stand) with one-person physical assist. A nursing progress note completed by Nursing Supervisor Registered Nurse #2 dated 11/04/2025 at 7:50 AM documented that Certified Nurse Aide #3 reported when they transferred Resident #4 to their wheelchair, they noticed blood on the floor. Certified Nurse Aide #3 lifted Resident #4's pant leg and saw a skin tear on Resident #4's left leg. Certified Nurse Aide #3 notified the nursing supervisor who notified the physician and the resident was sent to the emergency department. Review of a provider note dated 11/05/2025 at 12:10 PM by Nurse Practitioner #1, documented the resident sustained a full thickness laceration (a deep open wound that extends through the epidermis (outer skin layer) and dermis (middle skin layer) into the subcutaneous (layer of fat just beneath the skin) tissue that required sutures. The facility investigation dated 11/06/2025 documented that Certified Nurse Aide #3 used a one staff assist stand pivot (a mobility technique used to move a person from one seated surface to another) transfer to move Resident #4. The comprehensive care plan was updated using a sit to stand mechanical lift. When Resident #4 was transferred, their leg scraped against their wheelchair causing a full thickness tear. Certified Nurse Aide #3 did not review the updated care plan prior to initiating the transfer. The failure to follow the care plan by Certified Nurse Aide #3 resulted in the injury to Resident #4. A telephone interview was attempted without success on 08/19/2026, at 11:33 AM with Nursing Supervisor Registered Nurse #2 who assessed Resident #4's leg at the time of the accident. During an interview on 08/19/2026, at 12:33 PM, Unit Manager Registered Nurse #1 stated they expected staff to review care plans at the beginning of their shift to see if there were any changes or updates in the resident's care plan. During an interview on 08/19/2026, at 12:44 PM, the Director of Nursing stated they expected their staff to review the care plan before they provide care. They stated that if Certified Nurse Aide #3 had reviewed the care plan prior to the transfer, the skin tear probably would not have happened. During an interview on 08/20/2026, at 7:43 AM, Certified Nurse Aide #3 stated they transferred the resident with a stand-to-pivot transfer. Certified Nurse Aide #3 stated they noticed blood on the floor and when they pulled up Resident #4's pant leg they saw the skin tear, so they reported it to Nursing Supervisor Registered Nurse #2 right away. They stated they thought Resident #4 may have hit their leg on the wheelchair. They stated that they should have reviewed the care plan prior to doing the transfer and that they should have used the sit-to-stand lift. During an interview on 08/20/2026, at 10:14 AM, the Chief Nursing Officer stated they expected staff to follow the care plan and for staff to review the care plan prior to providing care to ensure they were giving the correct care. During an interview on 08/20/2026, at 10:56 AM, Nurse Practitioner #1 who examined Resident #4 on 11/05/2025 stated that if Certified Nurse Aide #3 did not follow the care plan and the resident was injured, they would consider this harm. They stated they expected certified nurse aides to follow the care plan and review it for any changes. During an interview on 08/20/2026, at 12:07 PM, the Administrator stated they expected staff to review resident care plans before providing care and to follow the plan of care. During an interview on 08/20/2026, at 1:37 PM, the Medical Director at the time of Resident #4's injury stated certified nurse aides have a Kardex care plan that they follow. They stated that if the aide did not follow the care plan and the resident was injured, then it would be considered harm. They stated they expected the certified nurse aides to follow the care plan and review it for any updates. They stated this was an avoidable accident. 10 New York Code Rules and Regulations 415.12(h)(1)

Based on observation, interview, and record review conducted during a Complaint investigation (#2675690) during an Abbreviated survey completed on 12/04/2025, the facility did not ensure the resident's right to be free from physical and mental abuse for two (2) (Residents #1 and #2) of three (3) residents reviewed. Specifically, Certified Nurse Aide #1 attempted to redirect Resident #1, a wandering resident to a seated position. The physical handling during this process was observed as aggressive. Resident #1 lost their balance, fell to the floor, and sustained a small abrasion to their side. A physical struggle occurred after Resident #2 unplugged a power cord; Certified Nurse Aide #2 responded aggressively, moving the resident against a wall to recover the cord. In addition, Certified Nurse Aide #2 restricted Resident #2's movement and taunted the resident leading to continued agitation. Even though the residents did not have a reaction/recall to the staff's inappropriate interactions, it can be determined that the reasonable person would experience no actual harm with the potential for more than minimal psychosocial harm as a result of the inappropriate interactions by staff. The findings are:The policy titled Abuse Prevention, Identification, Investigation, Protection and Reporting revised 04/30/2024 documented, the facility will provide protection for the health, welfare and rights of each resident residing in the facility. The facility will have procedures to prevent and prohibit all types of abuse, mistreatment, neglect, misappropriation of resident property and exploitation. The policy titled Abuse Reporting Guide: Identification and Reporting Alleged Violations of Abuse, Neglect, Mistreatment, Injuries of Unknown Source, Misappropriation and Exploitation, undated, documented: Examples of mental / verbal conflict - include intimidation, bullying - aggressive behavior in which someone intentionally and repeatedly causes another resident mental anguish or discomfort. Examples of physical altercations willful actions include, but are not limited to the following, hitting, grabbing, shoving. 1.Resident #1 had diagnoses including dementia (the loss of cognitive functioning, thinking, remembering and reasoning to such an extent that it interferes with a person's daily life and activities), anxiety disorder (a mental health condition characterized by intense, excessive and persistent worry or fear about everyday situation interfering with daily life, work and relationships), and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 09/23/2025 documented that Resident #1 had moderate cognitive impairment, sometimes understood, sometimes understands, was able to ambulate once standing with supervision or touching assistance (helper provides verbal cues and / or touching/steadying and/or contact guard assistance as resident completes activity. Resident #1's comprehensive care plan, identified as current by Director of Nursing #1, documented the resident had a deficit in activities of daily living and mobility. Interventions included the resident walked 150 (one hundred fifty feet) with supervision or touching assistance with rolling walker and cueing for direction. The resident had the potential for alteration in their mood/behavior related to dementia, interventions included to approach resident from the front in a calm gentle manner, explain all aspects of care prior to care, if resident becomes agitated, stop, ensure safety and re-approach; monitor environment stimuli, adjust as needed; and redirect, intervene and/or provide distraction during episodes of agitation. Resident #1's Bedside Kardex Report (guide used by staff to provide care) 11/24/2025 documented the resident walked 150 (one hundred fifty) feet with supervision or touching assistance as needed, cuing for direction. There were no interventions regarding what to do if the resident has altered mood/behavior. Review of facility's incident report dated 11/21/2025 documented, Resident #1 had a witnessed fall, was observed to land on the floor while the certified nurse aide was with the resident. It was reported by staff watching the camera footage. Resident was transferred to the chair by the aide. A note on the form dated 11/22/2025 documented on the morning after the fall, staff observed a reddened area to the right flank (side) of resident. The area was noted to be superficial and not bleeding. The resident showed no signs or symptoms of pain or discomfort. Resident #1's Skin assessment dated [DATE] at 9:33 AM documented Resident #1 had a 3.5 centimeter by (x) 1.2 centimeter abrasion on their right flank, in-house acquired on 11/21/2025, new intervention included triple antibiotic ointment followed with a dry clean dressing daily. During observations on 12/03/2025 at 11:55 AM and 12:31 PM, Resident #1 was sitting in the unit dining room at table with two (2) other residents, no concerns were observed. During an interview on 12/03/2025 at 12:35 PM Resident #1 denied any concerns related to abuse, mistreatment or neglect. 2.Resident #2 had diagnoses including dementia, Parkinson's Disease (a progressive movement disorder of the nervous system), and osteoarthritis (a degenerative joint disease where joint cartilage breaks down, causing bones to rub against each other). The Minimum Data Set, dated [DATE] documented that Resident #2 was severely cognitively impaired, usually understood, sometimes understands, wandering behavior occurred daily, and was able to ambulate once standing at least 150 (one-hundred fifty) feet independently. Resident #2's comprehensive care plan, identified as current by Director of Nursing #1, documented the resident had a deficit in activities of daily living function/mobility related to dementia and Parkinson's. Interventions included they were able to walk 150 (one hundred fifty feet) independently with no physical help from staff, no assistive device, and cues for direction only. The resident had potential for alteration in their mood/behavior related to dementia and could display wandering and physical aggression. Interventions included to approach resident from the front in a calm gentle manner, explain all aspects of care. If resident becomes agitated, stop, ensure safety and re-approach; monitor environmental stimuli and adjust as needed, redirect, intervene and/or provide distraction during episodes of agitation.Resident #2's Bedside Kardex dated 11/24/2025, documented the resident was able to walk 150 feet independently, with no set up or physical help from staff, no assistive device, and cues for direction only. Staff were to monitor whereabouts due to unsafe wandering, at risk of elopement and redirect as needed. There were no interventions regarding what to do if the resident has altered mood/behavior. Review of the Nursing Home Facility Incident Report submitted to Internet Quality Improvement & Evaluation System (iQIES) on 11/21/2025 at 10:27 PM completed by Director of Nursing #1 documented an alleged incident occurred on 11/21/2025 at 8:20 PM, the building supervisor received a call from the receptionist that there was a commotion in the lounge on Unit 3. Upon the Supervisor's arrival, both certified nurse aides assigned to the unit were very agitated about the behavior of two (2) residents. There was an allegation of two (2) residents being treated in a neglectful manner that was observed on camera. Investigation was ongoing, both certified nurse aides were immediately removed from the building and suspended pending investigation. On 11/22/2025 New York Stated Department of Health contacted the reporter to gather more information about the facility-reported incident. They stated a review of the cameras showed a aide being rough with a resident during ambulation assistance, causing the resident to fall. Another resident approached the aide in an attempt to defend the resident who had fallen. Th aide picked up a wet floor sign in a threatening manner. The other aide redirected the second resident to a couch area, where they sat the resident down and then held the resident down with the aide's body weight. Both aides were sent home after the event. Aides will likely be terminated. Review of the Nursing Home Investigative Report dated 11/25/2025 at 3:20 PM, completed by Director of Nursing #1, documented the facility concluded that the incident met criteria for abuse, inappropriate physical contact resulting in injury. Inappropriate physical contact was made with two residents by both certified nurse aides, a police report was made on 11/25/2025. A skin tear was noted to Resident #1's right flank (side). It was concluded the injury was caused during the incident as there have been no other documented incidents. Findings indicate that the conduct of Certified Nurse Aide #1 and Certified Nurse Aide #2 failed to comply with established facility standards. Immediate corrective actions were taken, including removal and termination of the involved staff, resident assessments, and social work assessments for the residents. Immediate re-education for all clinical staff regarding caring for dementia population was completed. The facility video footage dated 11/21/2025 was observed on 12/03/2025 at 11:00 AM and revealed the following:At 8:22:58 PM Certified Nurse Aide #1 was observed holding on to Resident #1's left upper arm with one hand walking behind and to the left side of the resident from the hallway toward the lounge. Another camera view identified by Director of Nursing #1 as the footage from the unit entrance camera on 11/21/2025 at 8:23 PM revealed Certified Nurse Aide #1 was behind Resident #1 holding onto both Resident #1's upper arms with their hands while pushing Resident #1 forward with their body from behind and struggling to remove Resident #1's hands from the wall railing. At 8:23:15 PM video footage from the lounge view revealed Certified Nurse Aide #1 was holding onto Resident #1's upper arm from behind while pushing Resident #1 forward across the hallway toward a chair and Resident #1 tripped causing them to fall forward onto their knees and palm of hands at 8:23:18 PM. Certified Nurse Aide #1 and Certified Nurse Aide #2 were observed to pull on Resident #1's arms to a standing position and sat Resident #1 in a chair in the common area at 8:23:36 PM. Resident #2, who was seated in the area, stood up and started approaching Certified Nurse Aide #1 while they were walking back toward the nurse's station, they turned right and picked up a wet floor sign and picked it up to chest height and swung the sign in Resident #2's direction at 8:23:52 PM. At 8:23:55 PM Certified Nurse Aide #2 was observed to approach and redirect Resident #2 back to a chair in the lounge by holding onto Resident # 2's left arm and they pushed Resident #2 into the chair. Certified Nurse Aide #2 was observed to continue to have their hands on Resident #2 and held Resident #2 with their hands and body. Then Certified Nurse Aide #2 let go and continued to maintain a close proximity and was walking in front of Resident #2 appearing to be taunting Resident #2 for four (4) minutes. At 8:32:55 PM Resident #2 was observed to approach the medication cart near the wall and removed the power cord. Certified Nurse Aide #2 approached the resident, donned gloves and approached Resident #2 at 8:33:26 PM. Certified Nurse Aide #2 observed to struggle with Resident #2 to remove the power cord from Resident #2's hands, Certified Nurse Aide #2 was observed to move Resident #2 up against the wall, with their hands. Another camera view identified by Director of Nursing #1 as the footage from the unit entrance camera on 11/21/2025 at 8:33:43 PM revealed Certified Nurse Aide #2 and Resident #2 physically pushing each other, at 8:33:45 PM Certified Nurse Aide #2 was observed to have the power cord in their hand. During observations on 12/03/2025 at 11:50 AM and 12:31 PM, Resident #2 was sitting in the unit dining room at table with two (2) other residents, no concerns were observed. The resident was alert, confused and was not interviewable. During an interview on 12/03/2025 at 12:07 PM Certified Nurse Aide #5 stated they were familiar with Resident #1 and stated the resident usually wanders on the unit and not aware of any aggressive behaviors towards others and should be allowed to safely wander. During an interview on 12/03/2025 at 12:10 PM Certified Nurse Aide #6 stated they were familiar with Resident #2 and stated the resident usually wanders on the unit and not aware of any aggressive behaviors towards others and should be allowed to safely wander. During an interview on 12/03/2025 at 12:18 PM, Unit Manager Licensed Practical Nurse #1 stated they were familiar with Resident #1 and Resident #2 and stated the residents usually wandered on the unit. They stated they observed the video from 11/21/2025 regarding the actions between Certified Nurse Aides #1 and #2 with Residents #1 and #2 and stated their actions were abusive to the residents. They stated Resident #1 and Resident #2's behaviors included wandering on the unit, and it was a locked unit therefore the residents couldn't have eloped and should have been allowed to ambulate while ensuring their safety and not have forced either resident to sit down. They stated Certified Nurse Aide #1 should have walked next Resident #1 if they were guiding them to a chair, not behind them pushing while holding onto the resident's arms. They stated upon viewing the video Certified Nurse Aide #1 was forcefully pushing and holding onto Resident #1 therefore causing them to fall forward onto the floor and subsequently sustain an abrasion that was determined to be related to the fall. They stated they had reviewed the video, and that Certified Nurse Aide #2 should not have forced Resident #2 to sit down, push them preventing them from rising from the chair and believed Certified Nurse Aide #2 continued to antagonize Resident #2 by blocking them, making body motions to the resident and what appeared to be laughing at the resident. Unit Manager Licensed Practical Nurse #1 stated Certified Nurse Aide #2 should have allowed Resident #2 to hold onto the power cord if they were refusing to let go of it and reapproach later. They stated Certified Nurse Aide #2 physically abused Resident #2 by pushing them up against the wall and struggling to remove the power cord from their hands. They stated Certified Nurse Aide #1 and #2 were physically abusive towards Residents #1 and #2 by their actions.During a telephone interview on 12/03/2025 at 3:30 PM, Receptionist #1 stated they were working on 11/21/2025 and were watching the cameras on the screen at the desk and informed Nursing Supervisor Registered Nurse #1 that Resident #1 had fallen to the floor and there was a lot of commotion on the unit between staff and residents. They stated while watching the cameras they observed Certified Nurse Aide #1 to be handling Resident #1 roughly before falling to the floor and then both Certified Nurse Aide #1 and Certified Nurse Aide #2 were observed to roughly pick Resident #1 up from the floor by pulling on the resident's arms. They then stated they observed Certified Nurse Aide #2 to forcefully make Resident #2 sit in a chair and continued to interact with Resident #2 which appeared to be taunting and intimidating the resident. They stated they watched Certified Nurse Aide #2 forcefully push Resident #2 up against a wall and struggle to get something out of their hands. They stated Certified Nurse Aide #1 and #2's actions with Resident #1 and Resident #2 were physically abusive. During a telephone interview on 12/03/2025 at 2:57 PM, Certified Nurse Aide #1 stated they were hanging onto Resident #1's arms and pushing them from behind toward the chair because they didn't feel safe. They stated they should have paged the nursing supervisor or asked their co-worker to assist them if they didn't feel safe. They stated they should not have been holding onto the resident's arms and pushing them forward with their body toward the chair as it was an inappropriate manner of guiding them. They stated they wanted Resident #1 to sit down and do an activity but did not provide an activity and they should have. Certified Nurse Aide #1 stated Certified Nurse Aide #2 was forcing Resident #2 to sit down and later had pushed them up against the wall to take the power cord away which is being physically abusive. They stated now that they have thought about their actions with Resident #1, of pushing them to a chair when they didn't want to go therefore causing them to fall was also being physically abusive. During a telephone interview on 12/04/2025 at 8:50 AM, Nursing Supervisor Registered Nurse #1 stated on 11/21/2025 Receptionist #1 requested they look at the camera video of Unit 3 and they observed Resident #2 pacing in the hallway and Certified Nurse Aide #2 following them back and forth and they should have walked away to allow Resident #2 to calm down. They stated Resident #2 ambulated on the unit independently and Certified Nurse Aide #2's actions were taunting and intimidating therefore mentally abusive to Resident #2. They stated they would have expected Certified Nurse Aide #1 to have intervened and redirected Certified Nurse Aide #2 to walk away from Resident #2 to diffuse the situation and allow Resident #2 to calm themselves. They stated when they entered the unit, they observed Certified Nurse Aide #2 pushing Resident #2 up against a wall, with the resident's face towards the wall using their body and continued to aggressively struggle with Resident #2 to remove a power cord from their hands. They stated they would have expected Certified Nurse Aide #2 to have calmly attempt to retrieve the power cord from Resident #2 and if the resident refused then to reapproach later while maintaining a distance and observing to ensure their safety. They stated Certified Nurse Aide #1's actions of pushing Resident #1 across the hallway from behind and subsequently causing them to fall to the floor were physically abusive towards Resident #1 and Certified Nurse Aide #2's actions with Resident #2 were physically abusive towards Resident #2. They stated both Certified Nurse Aide #1 and #2 were immediately suspended pending the investigation and terminated after the investigation for being physically abusive to the residents. During an interview on 12/04/2025 at 10:10 AM, Inservice Educator Registered Nurse #2 stated Certified Nurse Aide #1 and Certified Nurse Aide #2 were trained on physical and mental abuse, mistreatment, resident rights, dementia care, and how to handle residents with behaviors. Upon viewing the video footage from 11/21/2025 from 8:22:33 PM through 8:33:45 PM they stated Certified Nurse Aide #1 was physically abusive to Resident #1 by holding onto the resident's arms while pushing the resident from behind with their body to force the resident to ambulate towards a chair causing Resident #1 to fall to the floor; and Certified Nurse Aide #2 was physically and mentally abusive to Resident #2 with their actions of pushing, physically preventing the resident to rise from a chair, taunting the resident in the hallway and pushing the resident up against a wall while leaning against them with their body to try to remove the power cord from their hand and continued to physically struggle with Resident #2 until they had the power cord. They stated they would have expected both Certified Nurse Aides #1 and #2 to use a calm approach from the front and assist residents from the side guiding the resident never pushing from the back and if the residents didn't want to sit down, they should not have been forced to sit down. They stated they would have expected Certified Nurse Aide #1 and #2 to have worked together to maintain a calm approach and would have expected if they could not maintain a calm approach, they should have called Nursing Supervisor Registered Nurse #1 for assistance. They stated Certified Nurse Aide #2 should not have physically attempted to remove the power cord from Resident #2's hands and should monitored resident's safety from a distance and reapproached later to retrieve the power cord. They stated Certified Nurse Aide #1 was physically abusive to Resident #1 and Certified Nurse Aide #2 was mentally and physically abusive to Resident #2. During a telephone interview on 12/04/2025 at 10:54 AM, Certified Nurse Aide #2 stated they should have walked away from Resident #2 and reapproached later to remove the power cord from their hands but believed they were protecting other residents, although they had no knowledge if Resident #2 was physically abusive towards others. Certified Nurse Aide #2 stated they had not witnessed Certified Nurse Aide #1 pushing Resident #1 from behind but stated if they were pushing from behind and the resident fell then it would be considered abuse. Certified Nurse Aide #2 stated they had not physically restrained or pushed Resident #2 into a chair, did not taunt or intimidate Resident # 2, did not physically push Resident #2 into the wall or physically struggle with Resident #2 to remove the power cord from their hands. Certified Nurse Aide #2 informed of the video footage and description of their actions from the video and Certified Nurse Aide #2 continued to deny the actions that were described. During an interview on 12/04/2025 at 11:58 AM, Nurse Practitioner #1 stated they were aware of the inappropriate staff interactions with Resident #1 and Resident #2 from 11/21/2025 and assessed each resident on 11/25/2025. They stated they agreed the abrasion that was noted on Resident #1's flank the morning of 11/22/2025 was related to the fall and because Certified Nurse Aide #1 was pushing Resident #1 from behind while holding onto their arm which contributed to their fall. They stated they viewed the video footage from 11/21/2025 from 8:22:33 PM through 8:33:45 PM and stated Certified Nurse Aide #1 physically abused Resident #1 and Certified Nurse Aide #2 was mentally and physically abusive to Resident #2. They stated Resident #1 and Resident #2 have dementia and their behaviors include wandering. They stated they would have expected the staff to monitor their safety and offer interventions such as activities if they wanted them to sit down, not physically force them to sit down. They stated they would have expected Certified Nurse Aide #2 to maintain a calm approach and if Resident #2 refused to give the power cord to them then they should have reapproached later while ensuring their and others safety from a distance. During an interview on 12/04/2025 at 3:15 PM, Director of Nursing #1 stated Nursing Supervisor Registered Nurse #1 called them on 11/21/2025 after 8:00 PM related to the physical altercation between Certified Nurse Aide #2 and Resident #2, therefore they immediately watched the video footage and suspended Certified Nurse Aide #1 and Certified Nurse Aide #2 pending an investigation. They stated they concluded the investigation based on the video footage Certified Nurse Aide #1 physically abused Resident #1 by pushing them from behind with their body while holding onto the resident's arms causing them to fall to the floor and Certified Nurse Aide #2 was physically and mentally abusive towards Resident #2 by pushing them into a chair, physically holding them in the chair, taunting and intimidating the resident in the hallway which is mental abuse and then the witnessed account and video footage of them physically pushing Resident #2 against the wall and continued to physically struggle forcefully removing the power cord from the resident's hands. They stated they would have expected Certified Nurse Aide #1 and #2 to have assisted each other to diffuse the situations and or called Nursing Supervisor Registered Nurse #1 for assistance since the unit staff nurse was on break or walk away and reapproach later while maintaining a safe environment. They stated staff were trained to guide residents from the front or side and should not have been pushing the residents from behind and should not have used any physical force towards the residents. They stated Certified Nurse Aide #2 should have walked away from Resident #2, not maintained a close proximity, blocking and waving their hands up at the resident as if to be taunting them which is mental abuse. During an interview on 12/04/2025 at 3:32 PM Administrator stated they viewed the video footage from 11/21/2025 8:22:33 PM through 8:33:45 PM and stated they concluded Certified Nurse Aide #1 was physically abusive toward Resident #1 and Certified Nurse Aide #2 was mentally abusive related to the taunting, physically restraining by holding them down in the chair, and physically abusive when they pushed and forcefully struggled with Resident #2 to remove the power cord from their hands. The Administrator stated Certified Nurse Aide #1 and Certified Nurse Aide #2 were terminated due to the abuse they afflicted on Resident #1 and Resident #2. 10 NYCRR 415.3(d)(1)(vii)

Based on observation, interview, and record review conducted during the Standard survey completed on 4/18/25, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for one (1) (Unit One) of two (2) medication storage rooms, and one (1) (Unit One/Cart 2) of three (3) medication carts observed. Specifically, Unit One's medication room contained multiple unopened, bottles of expired medications and Unit One's medication cart (Cart 2) contained an insulin pen that was not dated when opened. The finding is: The policy and procedure titled Medication Rooms on Nursing Units dated 7/30/24 documented medication rooms on the nursing units of the facility will be the areas where medications for residents are stored. Authorized persons are allowed in the room for the purposes outlined: Licensed Nurses (Licensed Practical Nurse, Registered Nurse) for administration of medication to residents or for storage and or return of medication, Purchasing Assistant/designee under supervision of the Unit Manager/Assistant Unit Manager/Charge Nurse for storing or inventory stock medication and general supply items, and Pharmacy Consultant or Pharmacy staff to conduct inspections or re-label medication containers. The policy and procedure titled Pharmacy Consultant Responsibilities dated 7/24/2018, documented an inspection of the nursing unit medication room by the Pharmacy Consultant will occur at least three times per year. The Pharmacy Consultant removes discontinued, outdated or deteriorated medications from the current stock and alerts the Unit Manager/designee to forward them to the Director of Nursing Services for return or destruction. During an observation on 4/17/25 at 4:25 PM the Unit One medication room contained the following expired medications: -three unopened, 60 milliliter bottles of Sodium Polystyrene Sulfonate suspension 15 grams/60 milliliters (medication used to treat high potassium level) expired 3/2025, -an unopened 16 fluid ounce bottle of Iron Supplement liquid (supplement used to treat condition causing low oxygen in the blood) expired 2/2025, -an unopened bottle of docusate sodium 100 milligrams (stool softener) 100 soft-gels expired 3/2025, -three unopened bottles of aspirin 325 milligrams,100 tablets, one expired 1/2025 & two expired 3/2025, -an unopened bottle of sennosides 8.6 milligrams (medication to treat constipation) 100 tablets expired 3/2025, -an unopened bottle of magnesium oxide 400 milligrams (supplement used to treat low magnesium) 120 tablets expired 2/2025. During an interview on 4/17/25 at 4:25 PM, Registered Nurse Supervisor, #1 stated they were unsure who was responsible for checking the medication storage room for expired medications. Expired medications should not be given and could possibly be less effective. During an observation on 4/17/25 at 4:40 PM, Unit One's medication cart (Cart 2) contained an open Lantus insulin pen (medication used to control high blood sugar). The pen was labeled with a resident's name but it was not dated as to when it was opened. During an interview at the time of the observation on 4/17/25 at 4:40 PM, Licensed Practical Nurse #3 stated the insulin pen was opened and should have been dated when it was opened. During an interview on 4/18/25 at 8:33 AM, the Director of Nursing stated the overnight nurse was responsible for checking the medication rooms weekly for expired medications. All nurses were responsible for checking each medication they administer for the expiration date. Expired medications should be given to the nursing supervisor to be disposed of. They also stated that insulin pens should be dated when they were opened and stored in the refrigerator until they were in use. During a telephone interview on 4/18/25 at 10:12 AM, the Pharmacy Consultant stated all medication storage rooms should be checked routinely for expired medications and they should be removed as the medications may be less effective. They stated they had recently checked the facilities medication storage rooms, on 4/1/25 and there were a few over the counter medications that were going to expire at the end of the month but were not removed at that time. The Pharmacy Consultant stated they spoke with the Director of Nursing and reported that some medications were going to expire at the end of the month. Additionally, they stated insulin pens should be isolated in a bag and dated when opened, if not opened, utilized insulin pens should be stored in the refrigerator. 10 NYCRR 415.18 (e)(4)

Based on observation, interview, and record review conducted during a Standard survey completed on 4/18/25, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two (2) (Resident #47 and Resident #52) of three (3) residents reviewed. Specifically, palm guards (shield/protectors/splint) use for contractures (loss of joint mobility) were not provided at all times as planned and recommended by Occupational Therapy. The policy and procedure titled Splint, Brace Care dated 5/23/18 documented the need for splint or brace use is assessed by a Licensed Therapist and recommendations would be issued for the type of device to be worn and the scheduled use. The program would be designated by the therapist and carried out by nursing. The device and involvement in therapy programs (if indicated) would be listed on the Interdisciplinary Profile of Care. Additionally, the policy documented that the Nursing Assistant would document the splint/brace program in the electronic medical records for residents involved in a nursing rehab program. The Unit Manager/Assistant Unit Manager/Charge Nurse/Team Leader monitored the completion and accuracy daily. The findings are: 1. Resident #52 had diagnoses that included cerebral infarction (stroke), hemiplegia (paralysis on one side of the body), and hemiparesis (weakness of one side of the body). The Minimum Data Set (a resident assessment tool) dated 1/8/25 documented that Resident #52 was rarely understood, rarely understands and had severe cognitive impairment. The Minimum Data Set documented Resident #52 had upper and lower extremity functional limitation in range of motion on both sides and was dependent on staff for all activities of daily living. The Kardex Report (a guide used by staff to provide care) dated 4/18/25 documented under Restorative Programs, Resident #52 was to receive assistance with splint or brace: left and right palm protectors on at all times, to be removed for hygiene and range of motion (ROM). Review of the Occupational Therapy Discharge Summary dated 1/10/25 documented Resident #52 was discharge from therapy with recommendations made for a Restorative Nursing Program: assistance with splint or brace: left and right palm protectors on at all times, remove for hygiene and range of motion, hand wash and air dry weekly or if soiled. Review of the Occupational Therapy Evaluation and Plan of Treatment note dated 4/9/25, Occupational Therapist #1 documented upon evaluation Resident #52 was holding both of their hands in a fisted position, Resident #52 was care planned for use of palm guards and was not present at the time of evaluation. Occupational Therapist #1 documented Resident #52 would benefit from skilled occupational therapy services to promote improved upper extremity joint mobility for prevention of worsening joint contractures and increased pain. Review of the Certified Nursing Assistant's Task documentation in the electronic medical record revealed Resident #52 was to have left and right palm protectors on at all times, except with hygiene and range of motion. There was no documented evidence of resident refusals. During an observation on 4/14/25 at 10:26 AM, Resident #52 was observed lying in bed, right hand contractures noted to all digits (fingers) there was no palm protector in place, their left hand was covered with a blanket and unable to be visualized. Further observation of Resident #52's room revealed there was a sign posted on the wall at bedside titled Arm Range of Motion Routine and documented Resident #52 was to wear a palm protector on their left and right hand to prevent contracture of their fingers. Intermittent observations made on 4/14/25 at 12:46 PM, 4/15/25 at 11:41 AM, 4/15/25 at 4:28 PM, 4/16/25 at 9:06 AM, 4/16/25 at 12:04 PM, and 4/17/25 at 8:28 AM, revealed Resident #52 did not have palm protectors in place to either their right or left hand. Additionally, Resident #52's right hand digits were curled inwards toward their palm. Resident #52's left hand index finger and thumb were pressed together, and the remaining fingers were curled inwards touching their palm. During a care observation on 4/17/25 at 10:43 AM, Certified Nurse Aide #4 and Certified Nurse Aide #5 transferred Resident #52 from bed to their wheelchair via mechanical lift. Certified Nurse Aide #4 applied Resident #52's bilateral heel booties and then placed a wedge pillow behind their legs. No palm protectors were applied to Resident #52's left or right hand, and there was no palm protectors visualized in Resident #52's room. During an interview on 4/17/25 at 10:56 AM, Certified Nurse Aide #4 stated resident care needs and devices would be documented on their Kardex, and they would review the Kardex prior to providing care. Certified Nurse Aide #4 stated they were assigned to Resident #52, and they were care planned to have bilateral heel booties and a wedge pillow under their legs when up in their wheelchair. They stated that Resident #52's hands were contracted but had never seen them wear any palm protectors. Certified Nurse Aide #4 stated they did not see that Resident #52 was to have palm protectors on their Kardex and had not seen any in their room. During an interview on 4/17/25 at 11:12 AM, Licensed Practical Nurse #6 reviewed Resident #52's Kardex in the electronic medical record and stated that Resident #52 should have right and left palm protectors in place at all times except for hygiene. Licensed Practical Nurse #6 stated the nurses and unit manager were responsible to ensure the certified nurse aides followed the plan of care. They stated it was important for Resident #52 to have palm protectors in place to protect their skin and prevent further contractures. Licensed Practical Nurse #6 stated the certified nurse aides should have known Resident #52 required palm protectors to both hands, as it was documented on their Kardex, and they had a sign posted on the wall by their bed. During an interview on 4/17/25 at 11:46 AM, the Assistant Director of Rehabilitation stated nurses and certified nurse aides were trained how to apply splints and that positioning devices, and splints were listed on the Kardex and under the Tasks menu in the electronic medical record. The Assistant Director of Rehabilitation stated Resident #52 had bilateral arm and hand contractures, and were to have palm protectors to both their hands at all times. They stated this was recommended for maintenance and to prevent further contractures. The Assistant Director or Rehabilitation stated they would expect nursing to follow their recommendations and notify them with any changes or concerns. During an interview on 4/17/25 at 12:05 PM, Occupational Therapist #1 stated during the recent evaluation completed on 4/9/25 Resident #52 was without their palm protectors in place. They stated they expected nursing to follow the recommendations per the plan of care. 2. Resident #47 had diagnoses that included cerebral infarction, right hand contracture, and dementia. The Minimum Data Set, dated dated dated [DATE] documented Resident #47 was sometimes understood and sometimes understands and had severe cognitive impairment. The Minimum Data Set documented Resident #47 had upper and lower extremity functional limitation in range of motion both sides and was dependent on staff for all activities of daily living. The Kardex Report dated 4/18/25 documented under Restorative Programs, Resident #47 was to have a right-hand palm shield on at all times, remove for daily hand hygiene and ROM (range of motion). Hand wash and air dry weekly or as needed when soiled, and complete skin checks daily. The Occupational Therapy Discharge Summary dated 3/6/25 documented Resident #47 was discharged from occupational therapy services and recommendations included Nursing Rehab program: Right hand palm shield (splint/protector) on at all times, remove for hygiene and ROM (range of motion). Review of the Certified Nursing Assistant's Task documentation in the electronic medical record revealed Resident #47 was to have right hand palm shield on at all times, remove for hygiene and range of motion. There was no documented evidence of resident refusals. Intermittent observations made on 4/14/25 at 4:04 PM, 4/15/25 at 8:20 AM, 4/15/25 at 3:53 PM, 4/16/25 at 8:25 AM, 4/16/25 at 12:52 PM, and 4/17/25 at 8:56 AM, Resident #47's right hand was positioned as a clenched fist and there was no right-hand palm shield in place. During an interview on 4/17/25 at 10:56 AM, Certified Nurse Aide #4, stated resident care needs and position devices were documented on the Kardex which was reviewed prior to providing care. Certified Nurse Aide #4 stated they had provided care to Resident #47 and did not see on their Kardex they required a right-hand palm shield. Certified Nurse Aide #4 stated had never seen Resident #47 wear a splint/palm shield and there were no splints in their room. During an interview on 4/17/25 at 11:22 AM, Licensed Practical Nurse #6 stated Resident #47's right hand was contracted and should have a right-hand splint in place except for hygiene and range of motion. Licensed Practical Nurse #6 stated it was important for Resident #47 to have their palm shield in place to prevent further contractures and prevent skin break down. During an interview on 4/17/25 at 12:11 AM, the Assistant Director of Rehabilitation stated Resident #47 received occupational therapy services from 2/10/25 - 3/6/25 and was discharged with recommendations to continue the use of right hand palm shield at all times, remove for hygiene and range of motion. The Assistant Director of Rehabilitation stated Resident #47's use of the palm shield was to maintain skin integrity because of their closed fist. They stated they would expect nursing to follow recommendations made, document refusals, and update them with any changes. During an interview on 4/18/25 at 9:30 AM, Licensed Practical Nurse Manager #4 stated the nurses and unit manger were responsible to ensure the certified nurse aides followed the plan of care. Licensed Practical Nurse Manager #4 stated certified nurse aides were to apply splints/palm guards and would expect them to be in place if care planned. They stated they would expect staff to document resident refusals in the medical record and be notified if positioning devices were not located. During an interview on 4/18/25 at 12:28 PM, the Director of Nursing stated unit managers and nurses were responsible to make sure the resident's care plan was followed. They stated splints / palm guards were listed on the Kardex and would expect staff to review prior to providing care. The Director of Nursing stated they would have expected staff to follow the care plan and apply devices/splints as ordered to prevent injury or contractures. 10 NYCRR 415.12 (e) (2)

Based on observation, interview, and record review conducted during the Standard Survey completed on 4/18/2025, the facility did not ensure it was free of a medication error rate of five percent or greater for two (2) (Residents #31 and #44) of three (3) residents observed during medication administration. Specifically, there were two (2) errors for 25 observed medication opportunities resulting in a medication error rate of 8% (percent). Medications were not administered to Resident #31 and #44 in accordance with the physician's order before breakfast. The findings are: The policy and procedure titled Medications Administration Methods dated 1/25/2024 documented the Medication Nurse must follow the five (5) rights of administration (Right Drug, Right Dose, Right Time, Right Resident, Right Route). Medication may be administered one hour before or after the routine scheduled time, unless otherwise indicated. The policy and procedure titled Medication Standardized Schedule and Terminology dated 4/25/2018 documented the time schedule will be developed in accordance with accepted medical and pharmaceutical practices, and according to needs of residents. Medications are to be administered 1 hour before to 1 hour after scheduled medication time, unless otherwise indicated by physician (before meals, after meals and immediate medications). 1. Resident #31 had diagnoses that included non-infective gastroenteritis and colitis (inflammation of the stomach and intestines), dysphagia (difficulty swallowing) and long-term use of aspirin. The Minimum Data Set (a resident assessment tool) dated 3/18/25 documented that Resident #31 was understood, understands and cognitively intact. Review of the Order Summary Report revealed an order dated 3/14/25 for Pantoprazole Sodium (Protonix) tablet delayed release 40 milligrams, give 1 tablet by mouth before breakfast for gastroesophageal reflux. The Medication Administration Record (MAR) dated 4/1/2025-4/30/2025 documented Pantoprazole Sodium (Protonix) tablet delayed release 40 milligrams, give 1 tablet by mouth before breakfast for gastroesophageal reflux. The administration time was scheduled before breakfast at 7:30 AM. During a medication administration observation on 4/16/25 at 9:30 AM to 10:07 AM, Licensed Practical Nurse #2 administered Pantoprazole Sodium 40 milligrams along with seven other morning medications. At the time of the observation Resident #31 stated they had already eaten their breakfast. During an interview on 4/18/25 at 8:49 AM, Licensed Practical Nurse #2 stated Resident #31's Pantoprazole 40 milligrams was scheduled to be given at 7:30 AM and they did not administer it until after 10:00 AM on 4/16/25 and was not administered as ordered or within timeframe allowed. During a telephone interview on 4/18/25 at 9:54 AM, the Medical Director stated Pantoprazole should be taken thirty minutes before breakfast. The Medical Director stated they would expect medication to be administered as directed/ordered. Additionally, they stated they would expect to be notified if a resident was not receiving their medications as ordered to reduce medication errors, and to review which medications are ok to be or not ok to be given after scheduled time. The Medical Director was not aware that Resident #31 was not receiving Pantoprazole as ordered. 2. Resident #44 had diagnoses that included hypothyroidism (condition where the thyroid gland does not produce enough hormone), congested heart failure, and chronic kidney disease. The Minimum Data Set, dated dated dated [DATE] documented that Resident #44 was understood, understands and had moderate cognitive impairment. The comprehensive care plan dated 1/9/25, documented Resident #44 had a diagnosis of hypothyroidism. Interventions included to administer medications per the medical doctor/nurse practitioner orders and observe for toxicity. Review of the Order Summary Report dated 4/18/25 revealed and order dated 1/8/25 for levothyroxine sodium 75 micrograms, give 1 tablet by mouth before breakfast for hypothyroidism. The Medication Administration Record dated 4/1/25 - 4/30/25, documented levothyroxine sodium 75 micrograms to be administered by mouth before breakfast for hypothyroidism. The administration time was scheduled for 7:30 AM. Review of the facility Meal Schedule revealed the scheduled breakfast time for Unit 1 was 7:30 AM, Unit 2 was 8:05 AM, and Unit 3 was 7:45 AM. During a medication administration observation and interview on 4/16/25 at 9:09 AM, Licensed Practical Nurse #6 reviewed Resident #44's medications in the electronic medical record. The order for levothyroxine sodium 75 micrograms was observed to be pink on the screen of the electronic medical record, Licensed Practical Nurse #6 stated the medication was highlighted pink because it was overdue. Licensed Practical Nurse #6 administered Resident #44's morning medications which included levothyroxine sodium 75 micrograms. Resident #44's breakfast tray was on their bedside table and had been consumed. During an interview on 4/16/25 at 9:23 AM, Licensed Practical Nurse #6 stated the order for levothyroxine sodium 75 micrograms was scheduled to be administered at 7:30 AM and that it should have been given on an empty stomach to ensure it was effective. Licensed Practical Nurse #6 stated they were behind on their med pass, because they had to stop to pass breakfast trays and help feed residents. During an interview on 4/18/25 at 9:30 AM, Licensed Practical Nurse Manager #4 stated levothyroxine sodium was to be administered before breakfast on an empty stomach and would expect nurses to follow the instruction on the physician order. They stated if levothyroxine sodium was administered after 9:00 AM and the resident had already consumed their breakfast they would consider the medication to be administered late and may not be effective. During a telephone interview on 4/18/25 at 9:52 AM, the Medical Director stated levothyroxine sodium was ordered before breakfast on an empty stomach to ensure it was absorbed effectively. They stated if the medication was administered after breakfast, they would be concerned it was not as effective and could start to see signs and symptoms of low thyroid which could be potentially harmful to the resident. The Medical Director stated if levothyroxine sodium was consistently administered late, they would expect to be notified by nursing, ensure labs were being monitored, and would adjust the hour of medication administration time. During an interview on 4/18/25 at 9:22 AM, the Director of Nursing stated they expected nurses to follow physician orders and would expect any medication ordered before breakfast be administered before breakfast. They stated typically, medications ordered before meals were to be taken on an empty stomach. The Director of Nursing stated they would expect the nurses to notify the Unit Manager and Physician when medications were not being administered as ordered. Additionally, the Director of Nursing was not sure if nursing staff were notifying the medical provider of medication being administered outside scheduled timeframe. During a telephone interview on 4/18/25 at 10:09 AM, the Pharmacy Consultant stated they would expect nurses to follow the instructions on the physician orders, if a medication was ordered to be administered before breakfast, they would expect the nurses to adhere to the rule, administer medications as ordered. 10NYCRR 415.12(m)(1)

Based on observation, interview, and record review conducted during the Abbreviated Survey (Complaint #NY00347516) the facility did not ensure they treated each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #2) of three residents reviewed. Specifically, Resident #2 was treated by Certified Nurse Aide #1 in an undignified manner during care. Resident #2 told Certified Nurse Aide #1 they were hurting their arms by rushing them; Certified Nurse Aide #1 threw their clothes at them and stated, well then put them on yourself. The finding is: The policy titled Resident's Rights, last modified 6/6/2022, documented that each staff member will be personally responsible for ensuring that the rights of each resident are respected and not violated. Staff shall ensure that all residents are afforded their right to a dignified existence, in treatment and care. The policy titled Dignity, last modified 8/1/2019, documented each resident has the right to be treated with dignity and respect. All interactions with residents by any staff must focus on assisting the resident in maintaining and enhancing their self-worth. When providing care and services, staff must respect each resident's individuality, as well as honor and value their input. Resident #2 had diagnoses including spinal stenosis of the lower back (narrowing of an area in the spine, causes back pain), need for assistance with personal care, and unspecified dementia. The Minimum Data Set (a resident assessment tool) dated 5/22/24, documented Resident #2 was cognitively intact, always understood and always understands. They did not reject care, and they required partial/moderate assistance with upper body dressing. The comprehensive care plan, dated 7/8/24, documented Resident #2 had an Activities of Daily Living functional deficit related to their spinal stenosis and required one-person physical assistance with upper body dressing. The Kardex (a guide staff use to provide care) dated 7/8/24, documented Resident # required one-person partial/moderate assistance with upper body dressing. Review of the facility investigation, dated 7/8/24, revealed the Director of Nursing (current Acting Administrator) interviewed the resident and completed a grievance/Concern/Compliment Log Form, on 7/8/24. Resident #2 stated they had been assisted onto the toilet by Certified Nurse Aide #1, they began to take their shirt off, they told the Aide they were hurting their arms, the aide proceeded to throw the clothing at them and replied, then put them on yourself and walked away. The Director of Nursing interviewed Certified Nursing Aide #1 on 7/8/24. The Aide stated the resident was difficult they apologized for hurting their arms, then walked away and let them be. Certified Nurse Aide #1 was terminated on 7/8/24 for unsatisfactory resident care, resident abuse, or failure to follow a care plan, and being insubordinate to a supervisor/manager. During an observation and interview on 1/15/25 at 3:17 PM, Resident #2 was seated in their wheelchair in their room, dressed and well groomed, watching TV. Resident #2 stated they did recall the incident with Certified Nurse Aide #1. They stated that was a while ago but recalled that they were trying to get ready for bed and the Aide was rushing them. They stated it made them feel bad for needing help. They were in a nursing home because they couldn't take care of themselves, and Certified Nurse Aide #1 made them feel like they were a burden and moved too slow. That was why they told someone about it, it just wasn't the right way to treat people. Resident #2 stated they did not feel they were physically abused but they felt it was undignified to be treated that way. They were not fearful of staff and felt safe in the facility. The facility responded quickly to their concern, and they never saw the Aide again after that. During a telephone interview on 1/16/25 at 10:41 AM, Certified Nurse Aide #3 stated they worked on the unit where Resident # 2 lived, but they did not recall the incident with Certified Nurse Aide #1. They stated it would not be right to toss a resident's clothing at them and tell them to dress themselves. That would be very undignified. Most of their residents were in the nursing home because they couldn't dress themselves. They shouldn't make them feel bad about that. During a telephone interview on 1/16/25 at 1:07 PM, Certified Nurse Aide #1 stated they recalled caring for Resident #2, they stated Resident #2 was always difficult to deal with because they wanted things done their way. Certified Nurse Aide #1 stated they were new to the resident and didn't know how they liked things done yet. They stated that when the resident got frustrated with them, they thought they should walk away and re-approach later, after they calmed down. They did not feel they mistreated the resident. They stated they did return to the resident after they calmed down, got them dressed and into bed. They felt the Director of Nursing wanted them fired, so that was a good excuse to do it. During an interview on 1/16/25 at 1:20 PM, Certified Nurse Aide #2 stated they never witnessed Certified Nurse Aide #1 being physically abusive but thought Certified Nurse Aide #1 was not patient with the residents and got frustrated easily. They were taught to treat residents like this was their home and they were a guest, that was not how Certified Nurse Aide #1 acted. During an interview on 1/16/25 at 1:25 PM, Registered Nurse #1 stated it would be very undignified to toss a resident's clothing at them and tell them to dress themselves. The residents were there because they couldn't care for themselves, it was terrible to make them feel bad about that. During an interview on 1/16/25 at 1:40 PM, The Acting Administrator (previous Director of Nursing) stated Certified Nurse Aide #1 did not treat Resident #2 with dignity and respect. The Certified Nurse Aide was terminated for their mistreatment of Resident #2. 10NYCRR 415.5 (a)

Based on record review and interviews conducted during an Extended Recertification survey started on [DATE] and completed on [DATE], the facility failed to initiate cardiopulmonary resuscitation (CPR) to an unresponsive resident who had a full code status and advance directives in place for one (Resident #79) of three residents reviewed. Specifically, on [DATE] Resident #79 was found unresponsive, without a pulse, respirations, or blood pressure. Facility staff failed to check the resident's code status, failed to initiate emergency response, failed to activate the 911 (emergency medical response) system, and failed to provide cardiopulmonary resuscitation (CPR) for the resident who was a full code. Resident #79 expired on [DATE]. This resulted in actual harm to Resident #79's health and safety with the likelihood to affect all residents with full code status in the facility that is immediate jeopardy and substandard quality of care. There were 33 full Code residents in the facility. The finding is: The policy and procedure titled Basic Life Support, dated [DATE], documented basic life support procedures including cardiopulmonary resuscitation (CPR), rescue breathing, and defibrillation (controlled electric shock) will be initiated on all appropriate residents unless advance directives documenting the exclusion of these procedures are on file in the medical record. Staff are to initiate cardiopulmonary resuscitation (CPR) when cardiac arrest occurs for residents who have requested cardiopulmonary resuscitation (CPR) in their advance directives. The policy documented if a resident is unresponsive, immediately confirm status. The EMR (electronic medical record) will be utilized as the initial method of immediate identification. Send another staff member to obtain the medical record and the medical record will be brought to the area when basic life support is being provided or considered. 1. Resident #79 had diagnoses including congestive heart failure, hypertension, and diabetes mellitus. The Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #79 was cognitively intact, understands, was understood, and did not have a do not resuscitate (DNR) order. The comprehensive care plan dated [DATE] (current at the time of the resident's death) documented Resident #79 had advanced directives in place which included Medical Orders for Life-Sustaining Treatment (MOLST). The goal documented the resident's wishes would be honored and interventions documented that those wishes would be followed per the provider's order. The Medical Orders for Life-Sustaining Treatment (MOLST), reviewed and signed by Resident #79's Attending Physician #1 (Medical Director) on [DATE], documented a cardiopulmonary resuscitation (CPR) order. The physician's Order Summary Report printed [DATE] with a date range of [DATE]- [DATE] documented that Resident #79 had an active cardiopulmonary resuscitation/full code status order. The New York State Department of Health Certificate of Death documented Resident #79 expired on [DATE] at approximately 10:45 AM. The immediate cause of death was documented as respiratory failure. The Nurses Note dated [DATE] and timed 9:15 AM, authored by Registered Nurse Nursing Supervisor #1 documented activities staff (Memory Care Program Specialist #1) noticed the resident was unresponsive and not breathing and notified primary nurse to assess and writer called to confirm had expired. Resident was without pulse, unresponsive, without breaths, was motionless, no chest palpation or heartbeat, pupils are fixed and dilated. During an interview on [DATE] at 7:34 AM, Licensed Practical Nurse #1 stated, Memory Care Program Specialist #1 alerted them on [DATE], that Resident #79 was unresponsive. Licensed Practical Nurse #1 stated they could not recall what time they found the resident unresponsive and that they immediately called Register Nurse Supervisor #1 from Resident #79's room. Licensed Practical Nurse #1 stated they did not check Resident #79's code status, did not activate the emergency response system, and did not initiate cardiopulmonary resuscitation (CPR). During an interview on [DATE] at 7:47 AM, Registered Nurse Supervisor #1 stated they were called to Resident #79's room on [DATE], but was unsure of the time, to confirm Resident #79 had expired. Registered Nurse Supervisor #1 stated they confirmed Resident #79 had expired as the resident had no breaths, no pulse, no blood pressure and was motionless. Registered Nurse Supervisor #1 stated they did not check Resident #79's code status prior to pronouncing the resident expired. Registered Nurse Supervisor #1 stated when they returned to their office, after five to ten minutes, to document their assessment they realized Resident #79 had advance directives for a full code status. Registered Nurse Supervisor #1 stated cardiopulmonary resuscitation (CPR) should have been initiated when the resident was found unresponsive, but too much time had elapsed to initiate cardiopulmonary resuscitation (CPR) at that point. During a telephone interview on [DATE] at 8:07 AM, Certified Nurse Assistant #1 stated they provided morning care to Resident #79, on [DATE], five to ten minutes prior to Memory Care Program Specialist #1 finding Resident #79 unresponsive. During an interview on [DATE] at 8:42 AM, the Director of Nursing stated when a resident was found unresponsive staff should check for signs of life, check the resident's code status, and if needed call a Code Blue if the resident had a full code status. The Director of Nursing stated cardiopulmonary resuscitation (CPR) should have been initiated for Resident #79. During an interview on [DATE] at 9:04 AM, Memory Care Program Specialist #1 stated they were preparing for an activity and went into check on Resident #79. The resident did not respond, and they notified the nurse immediately the resident was unresponsive. Memory Care Program Specialist #1 stated they did not recall the exact time they found the resident. On [DATE] at 12:19 PM, Memory Care Program Specialist #1 stated they were trained in cardiopulmonary resuscitation (CPR) but were instructed to tell the nurse first. Additionally, they stated they did not check Resident #79's code status. During a telephone interview on [DATE] at 10:21 AM, Resident #79's Attending Physician #1 (Medical Director) stated when a resident was found unresponsive staff should determine the resident's advance directive/code status. If a resident was a full code, cardiopulmonary resuscitation (CPR) should be initiated immediately. Additionally, Attending Physician #1 stated they were unaware cardiopulmonary resuscitation had not been initiated when Resident #79 was initially found unresponsive, nor were they notified when the code status was identified as full code, to give direction to staff. Immediate Jeopardy was identified, and the facility Administrator was notified on [DATE] at 1:53 PM. Based on staff interviews and record review the survey team verified the facility made the following corrective actions to remove the immediacy as of [DATE] at 2:00 PM. - 87 percent of licensed staff (licensed practical nurses, registered nurses, physical therapists, occupational therapists, and speech therapists) were educated on the facility's Code Blue procedures. 10 NYCRR 400.21

Based on interview and record review during the Extended survey completed on 12/15/23, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (two Certified Nurse Aides, one Housekeeping Aide, and one Dining Service Associate) of six employees reviewed that worked in the facility and were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their first date worked at the facility. The findings are: The policy and procedure titled, Abuse Prevention, Identification, Investigation, Protection and Reporting, modified 6/19/23, documented the facility will provide protection for the health, welfare and rights of each resident residing in the facility. The Administrator of the facility is responsible for the development and implementation of written policies and procedures that prohibit and prevent abuse, mistreatment, neglect, exploitation of residents, and misappropriation of resident property. Additionally, the policy and procedure documented prior to hire, all prospective staff will be screened for a history of abuse, mistreatment, neglect, exploitation, and misappropriation of resident property per state and federal regulations. Appropriate licensing boards and registries will be checked per federal and state requirements. The policy and procedure titled, Onboarding Policy, modified 9/1/23, documented a new employee is not authorized to begin work until onboarding criteria has been met. Listed onboarding criteria includes, Nurse aide registry has been reviewed for all staff. 1a. Review of Employee A's (Dining Service Associate) automated timecard revealed Employee A worked in the facility from 8/31/23 to present on the 6:00 AM to 2:00 PM shift. Review of Employee A's personnel file revealed it contained no documentation that the New York State Nurse Aide Registry was checked for Employee A. During an interview on 12/14/23 at 8:15 AM, the Food Service Director stated all Dining Service Associates, including Employee A, delivered food trays to and from the resident units and the resident dining rooms for each meal and occasionally re-stocked nourishment refrigerators located on the resident units. 1b. Review of Employee B's (Housekeeping Aide) automated timecard revealed Employee B worked in the facility from 8/30/23 to 9/27/23 on the 6:00 AM to 2:00 PM and 12:00 PM to 8:00 PM shifts. Review of Employee B's personnel file revealed it contained no documentation that the New York State Nurse Aide Registry was checked for Employee B. During an interview on 12/14/23 at 8:45 AM, the Director of Facilities Services stated Employee B mainly worked in the Laundry department and their tasks included the delivery of clean laundry to the resident units, including personal laundry into each resident room, and picking up soiled laundry from the resident units. They stated Employee B also could have been assigned to prepare a resident room for a new resident. 1c. Review of Employee C's (Certified Nurse Aide) automated timecard revealed Employee C started working in the facility on 9/11/23. Review of Employee C's personnel file revealed it contained documentation that the New York State Nurse Aide Registry was checked for Employee C on 9/26/23. Between 9/11/23 and 9/26/23, Employee C worked eight shifts between the hours of 6:00 AM and 6:30 PM. 1d. Review of Employee D's (Certified Nurse Aide) automated timecard revealed Employee D started working in the facility on 9/18/23. Review of Employee D's personnel file revealed it contained documentation that the New York State Nurse Aide Registry was checked for Employee D on 9/22/23. Between 9/18/23 and 9/22/23, Employee D worked three shifts between the hours of 6:00 AM and 10:00 PM. During an interview on 12/14/23 at 8:10 AM, the Scheduler stated Certified Nurse Aides are usually assigned to the same resident unit each time they work, but could pick up shifts and be assigned to any resident unit. The Scheduler stated Employee C and D worked mainly on Memory Lane Unit. During an interview on 12/8/23 at 2:25 PM, the Recruitment Coordinator stated they were new to the job in August and September and the Nurse Aide Registry checks were missed. They also stated some were caught during an audit done by the Human Resources Manager in September. During an interview on 12/12/23 at 4:15 PM, the Human Resources Manager stated the Onboarding Policy says the Nurse Aide Registry must be reviewed for all staff, and review means to look at the entire thing, including the resident abuse findings section. The Human Resources Manager further stated the Recruitment Coordinator was responsible for checking the Nurse Aide Registry for all new staff before they started working at the facility, as part of the onboarding process, and the Recruitment Coordinator had received adequate training before taking on the responsibility for this task. Additionally, they stated Employees A, B, C, and D should have had the Nurse Aide Registry checked before they started working and documentation kept in their personnel files. During an interview on 12/14/23 at 9:05 AM, the Director of Nursing stated Human Resources was responsible for checking the Nurse Aide Registry as part of the facility's onboarding process and it must be done prior to hire. During an interview on 12/14/23 at 11:05 AM, the Administrator stated the Nurse Aide Registry was supposed to be checked to make sure a Certified Nurse Aide's certification was current and to make sure there were no abuse findings for all new employees. They also stated this was to be done before a new employee started working at the facility. 415.4(b)(1)(ii)(a)(b)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00301447) during an Extended Recertification survey completed on 12/15/23, the facility did not ensure the resident's right to be free from abuse for two (Residents #20 and 52) of five residents reviewed. Specifically, on 8/29/22 at 8:40 PM, Resident #52 wandered into Resident #20's room without staff knowledge and were found lying in Resident #20's bed, naked, and engaged in sexual intercourse. The finding is: The policy and procedure titled Abuse Prevention, Identification, Investigation, Protection and Reporting dated 6/27/23 documented the facility will provide protection for the health, welfare and rights of each resident residing in the facility and the Administrator was responsible for development and implementation of written policy and procedures that prohibit and prevent abuse. Abuse prevention included establishing a safe environment, identifying, and monitoring of residents with needs and behaviors that might lead to conflict or neglect including wandering into other's rooms/space. The document titled Your Rights as a Nursing Home Resident in New York State documented residents have the right to be free from sexual abuse. Resident #20 had diagnoses including dementia, diabetes, and chronic kidney disease. The Minimum Data Set, dated dated dated [DATE] documented Resident #20 had severe cognitive impairment and did not exhibit wandering behavior. The comprehensive care plan dated 5/21/22 documented Resident #20 had the potential for alteration in their mood/behavior related to dementia and change in their environment. The resident had inappropriate sexual behavior 8/29/22 with another resident. The Determination of Incapacity for Medical Decision-Making form dated 7/1/22 documented Resident #20 did not have capacity to make their own medical/health care decisions. This form was signed by a Nurse Practitioner and Attending Physician #2. The untitled kardex (tool used by staff to provide care) dated 8/31/22 documented Resident #20 was understood, usually understands, and walked independently. Resident #20 was independent with dressing. Resident #52 had diagnoses including dementia, lupus (long term disease that can inflammation and pain in the body), and osteoporosis (brittle bones). The Minimum Data Set, dated dated dated [DATE] documented Resident #52 had severe cognitive impairment and did not exhibit wandering behavior. The comprehensive care plan dated 10/12/21 documented Resident #52 was at risk or have been the recipient of verbal or physical altercations with other residents. Interventions included to assess for inappropriate behavior, and unmet needs such as hunger, thirst, fatigue, pain and need to toilet; move away from other residents who are at high risk to become physically or verbally aggressive. The untitled kardex dated 8/31/22 documented Resident #52 walked independently, and they were rarely/never understood. Safety interventions included to not leave the resident alone in the bathroom and to redirect, intervene or provide distraction during episodes of agitation or fidgetiness. Resident #52 required extensive assist of one staff member for dressing. Review of the provider Progress Note dated 8/8/22 documented Resident #52 had no decisional capacity related to their dementia diagnosis. The Progress Note, written by Registered Nurse #3 dated 8/29/22 at 8:40 PM, documented staff found Resident #52 in bed naked with Resident #20's genitalia inside of them. Staff took Resident #52 to their room for an assessment. There was no redness or bleeding noted from their genital area, the supervisor was updated, provider and family were contacted. The Progress Note, written by Registered Nurse Supervisor #4 dated 8/29/22 at 10:03 PM, documented staff reported they observed Resident #52 in bed with Resident #20, both the residents had no clothes on. Staff separated them immediately, examined Resident #52, no bleeding or redness was noted. The Medical Doctor/Nurse Practitioner was updated, a psychiatry consult was ordered, and the physician would see them in the morning. The Facility Investigation for the occurrence on 8/29/23 at 8:40 PM, documented a Certified Nurse Aide #2 was rounding and found Resident #52 and #20 laying unclothed in bed together. Certified Nurse Aide #2 approached the edge of the bed and witnessed the residents engaged in sexual activity. Certified Nurse Aide #2 immediately called for the Registered Nurse (#3) on the unit, who arrived at the room and observed the residents laying unclothed in bed. Certified Nurse Aide #2 dressed the Resident #52 and was escorted to their room. A Registered Nurse assessment was completed and found no obvious signs of injury. The investigation documented that camera footage was reviewed for 8/29/22 and revealed the following timeline: -At 7:04 PM, Resident #52 was wandering in and out of rooms -At 7:14 PM, Resident #52 entered Resident #20's room and exited right away -At 7:32 PM, Resident #52 re-entered Resident #20's room -At 7:40 PM and 8:40 PM, two Certified Nurse Aides were in the hallway, going in and out of rooms near Resident #20's room, but did not enter that room. -At 8:40 PM, the residents #20 and #52 were discovered by Certified Nurse Aide #2 The investigation summary documented both residents reside on the secured memory care unit and have severe cognitive impairment. On 8/29/22 both residents were discovered engaged in probable sexual activity. They were immediately separated. Neither resident seemed distressed or harmed or displayed any signs of fear or psychological harm. Review of the Witness Accounts of Accident/Incident written by Certified Nurse Aide #2 dated 8/29/22 at 8:40 PM, revealed Residents #20 and #52 were laying naked in bed on their sides. Resident #20 was behind Resident #52 and penetrated them. Certified Nurse Aide #2 asked what they were doing, and Resident #20 stated nothing. During an observation on 12/7/23 at 1:30 PM, Resident #20 was sitting in their room, alert and oriented to themselves. Resident #20 didn't know the date, city, or who the president was. During an observation on 12/11/23 at 8:35 AM, Resident #52 was seated in the dining room with staff assisting them. The resident was alert and nonverbal. During a telephone interview on 12/13/23 at 10:28 AM, Certified Nurse Aide #2 stated they couldn't remember the exact positions the residents were found, but knew it was inappropriate and that Resident #20 was more of the person in control. The Witness Account of Accident/Incident statements dated 8/29/22 were read to Certified Nurse Aide #2 and they confirmed what was written. and stated they last saw Resident #52 at 7:30 PM. Certified Nurse Aide #2 stated the last time they had seen Resident #52 was 7:30 PM. They said were looking for Resident #52 to put them to bed, that's when they opened Resident #20's door and saw the clothing on the floor in the room, that's why they walked over to the bed and found the residents together. Certified Nurse Aide #2 stated they went and got the nurse immediately. Certified Nurse Aide #2 stated neither resident was on safety checks prior to this incident and that Resident #52 had wandering behaviors. Certified Nurse Aide #2 stated they knew Resident #52 did not have capacity to consent to sexual relations and didn't really know Resident #20's cognitive level. During a telephone interview on 12/13/23 at 11:13 AM, Registered Nurse #3 stated they remembered the incident with Residents #52 and #20, and they were working on the medication cart that evening. Registered Nurse #3 stated Certified Nurse Aide #2 went to look for Resident #52 and they called them down to Resident #20's room. Registered Nurse #3 stated they saw the residents in bed together, Resident #20 was sitting up in the bed and Resident #52 was laying on their left side toward the wall with their legs bent up, and both were naked. Registered Nurse #3 stated Resident #52 couldn't undress themselves, so Resident #20 must have undressed them. Registered Nurse #3 stated Certified Nurse Aide #2 said Resident #20 was in Resident #52. Registered Nurse #3 stated they assessed Resident #52 for any injuries and found none. There were no fingermarks, bruising, red areas anywhere on the resident and that included the genital area. Registered Nurse #3 stated there was no evidence of ejaculation and that these residents were unable to consent to the sexual contact. Registered Nurse #3 stated they would consider this sexual abuse because Resident #52 was unable to consent and that it could be harmful if a resident was unable to consent to sexual contact. During a telephone interview on 12/13/23 at 3:15 PM, Registered Nurse Supervisor #4 stated they were told about this incident after Residents #20 and #52 were already separated. They remembered they contacted the Director of Nursing that evening but didn't remember specifics. Registered Nurse Supervisor #4 stated neither resident had capacity to consent to sexual relationships and this would be considered sexual abuse in the real world. The Registered Nurse Supervisor #4 stated that this could be considered harmful to someone who couldn't give consent. During an interview on 12/14/23 at 11:48 AM, the Director of Nursing stated staff discovered Resident #52 in Resident #20's bed and per Certified Nurse Aide #2 statements, penetration happened. The residents were not able to give consent for this type of relationship. The Director of Nursing stated this was considered sexual abuse and Resident #52's right to remain free from abuse was not maintained. The Director of Nursing stated this situation was harmful for the resident, but the resident did not seem like they were in distress after the incident. The Director of Nursing stated the police were not called in this situation. During a telephone interview on 12/14/23 at 12:59 PM, Resident #20 and #52's Attending Physician #2 stated they were notified right away about the incident and examined the resident's the next morning. Attending Physician #2 stated they did a physical exam and saw no evidence of any trauma, or any concerns that indicated trauma. Resident #52 at the time of the exam had no change in their demeanor, they have dementia, were nonverbal with a flat affect. Attending Physician #2 stated the residents had no capacity to make complex medical decisions. During a telephone interview on 12/14/23 at 3:01 PM, the Psychiatrist Consultant stated they didn't have their notes available, so they may be limited in their responses. Several paragraphs of Resident #52's Psychiatry Consult dated 9/3/22 was read to the Psychiatrist Consultant. The Psychiatrist Consultant stated with a fair amount of certainty, the residents lacked capacity to give consent. The Psychiatrist Consultant stated for a reasonable person who had intact cognitive functioning it was plausible that this situation (non consensual sex) could have caused harm. 10 NYCRR 415.3(d)(1)(vii)

Based on observation, interview and record review during the Standard survey conducted from 4/27/22 through 5/3/22, the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Three (Units 1, 2, and 3) of three resident units reviewed for dignity with dining had an issue involving meals served on disposable plates. This involved Resident #s 9, 17, 48 and 72. The finding is: The facility policy and procedure titled Dignity dated 8/1/19 documented each resident has the right to be treated with dignity and respect. Examples of treating residents with dignity and respect include but are not limited to: promoting resident independence and dignity while dining, such as avoiding daily use of disposable cutlery and dishware. 1. During an observation on 4/27/22 at 10:38 AM, Resident #48 had a breakfast tray on tray table in front of them. The egg on the paper plate was noted absorbed into the plate. During Unit 1 meal observation on 4/27/22 at 11:48 AM, staff served resident's lunch trays with the entrée on disposable plates covered with plastic wrap. During Unit 3 meal observation on 4/27/22 at 12:01 PM, staff served resident's lunch trays with the entrée on disposable plates. During Unit 2 meal observation on 4/27/22 at 12:13 PM, staff served resident's lunch trays with the entrée on disposable plates covered with plastic wrap. During an observation and interview on 4/27/22 at 12:06 PM, Resident #72 was eating their lunch and the entrée was on a disposable plate. The Resident stated the disposable plates were terrible and once they had mashed potatoes that made a hole in the bottom of the plate. Now they knew to leave the plastic wrap under the plate to avoid a mess. During an observation and interview on 4/27/22 at 12:47 PM, Resident #48 stated the facility used paper plates and they were horrible especially in the morning when trying to eat eggs, it was hard to get the egg on the fork from the paper plate. Resident #48 stated they hated paper plates and would prefer a plate that had a hard surface. During an interview on 4/27/22 at 03:43 PM, Resident #17 stated the disposable plates were a mess and they preferred a real plate. The resident stated when they tried to remove the plastic wrap from the plate, the food got all over the place and was annoyed by it. During Unit 2 dinner observation on 4/28/22 at 6:02 PM, resident's entrées were observed to be served on disposable paper plates. During an interview on 4/28/22 at 6:25 PM, Resident #9 stated my paper plate dissolved into my food. I couldn't eat it. Then stated they did not like the paper plates. Observation in the Main Kitchen on 4/29/22 at 11:40 AM revealed residents' food trays contained hard re-usable plastic drinking cups and soup bowls and metal utensils, but the entrée and dessert were plated on paper plates and the food on each plate was covered with disposable clear plastic wrap. During an interview on 4/29/22 at 11:40 AM, the Food Service Director stated paper plates were used for resident meals because of kitchen staffing. They further stated residents who were care planned for re-usable adaptive plates have their food served on them, but the majority of residents received their food on paper plates. The Food Service Director stated the facility had re-usable heated plate bases with re-usable hard plastic covers that helped keep the food hot during transport, but they were not currently used in order to save the kitchen staff the time it would take to wash them. During a test tray observation on 4/29/22 at 11:56 AM, the entrée and dessert were served on disposable plates with a tight plastic wrap covering. While removing the plastic wrap, the plate was bending, and it was difficult to remove the plastic wrap without the plate being bent. During an interview on 4/29/22 at 12:09 PM, the Food Service Director stated at the start of the COVID-19 pandemic in 2020, the facility started using all single-service food containers and utensils to serve the residents' meals for breakfast, lunch, and dinner. They further stated during Resident Council meetings, the residents voiced that they preferred metal re-usable utensils over plastic utensils, so the facility switched back to metal re-usable utensils. Additionally, the Food Service Director stated in the time since the start of the COVID-19 pandemic, the facility had switched back to re-usable cups, but had not yet transitioned back to re-usable plates. During a telephone interview on 5/3/22 at 11:50 AM, the Registered Dietician (RD) stated the residents had received paper products since they started working at the facility at the end of March last year. The RD stated they switched to full glass with the hotplates under the plates and regular trays last summer but then staffing got bad, so they moved back to paper products. The RD stated there were a few residents that have complained, so they had offered regular glass to them. The RD stated there were no issues with getting the meals out on time from the kitchen. The RD stated the facility policy was to use reusable items and they were not aware of the facility policy regarding dignity with dining and to avoid using disposable items. During an interview on 5/3/22 at 1:54 PM, the Administrator stated they had used all disposable products during COVID-19 pandemic and now they were using only disposable plates. The Administrator stated they received complaints from resident council about the plastic utensils but not the disposable plates. The Administrator stated they never got back to using full reusable items, and they had regular plates available for resident use. During an interview on 5/3/22 at 2:39 PM, the Director of Nursing (DON) stated they did not know the facility dignity policy specifically documented to avoid the use of disposable dishware but that it made sense. The DON stated now that they knew it was upsetting some residents they needed to go back to regular plates. 415.5(a)

Based on observation, interview, and record review conducted during the Standard survey completed from 4/27/22 through 5/3/22, 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 for one (Resident #121) of one resident reviewed for quality of care related to venous access devices. Specifically, there was no documented evidence of monitoring or care of the resident's accessed Mediport (needle inserted into the central venous access device). The finding is: The facility policy and procedure titled, Huber Needle Termination dated 8/26/19, documented needles being used for continuous intravenous (IV) therapy will be changed on a weekly basis unless otherwise specified in the attending physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Resident #121 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Set) dated 4/19/22 revealed the resident was cognitively intact. During an observation and interview on 4/27/22 at 1:04 PM, Resident #121 had an access device (Mediport) in their right chest. The Mediport had a Huber needle (specially designed hollow needle) inserted and a dressing dated 4/10 that was loosened and lifted exposing the needle and insertion site. At this time Resident #121 stated nobody at the facility had used the Mediport, checked or changed the dressing since they were admitted 12 days ago. The SNF (skilled nursing facility) Admission/Readmission Form dated 4/15/22 documented Resident #121 had a Mediport in their right chest. Review of the Order Summary Report dated 4/15/22 revealed there were no documented physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing Progress Notes, and the Provider Visits dated 4/15/22 through 4/28/22 revealed there was no documentation regarding the resident's accessed Mediport. During an interview on 4/29/22 at 9:18 AM, Registered Nurse (RN) #2 stated Resident #121 had a permacath (catheter used for hemodialysis) in their chest that was used for [CONDITION(S)]. The RN #2 stated they were not sure if the resident had a Mediport and had to ask the manager. RN #2 talked to the Registered Nurse Unit Manager (RN UM) #1, then stated Resident #121 had a Mediport and that they checked the resident's orders, but there was nothing listed for it. The RN #2 stated the dressing was supposed to be changed as needed or every 7 days. RN #2 stated they didn't change the dressing and didn't know who was supposed to change the dressing. During an observation and interview on 4/29/22 at 9:22 AM, RN Unit Manager (UM) #1 stated Resident #121 was admitted with the Mediport de-accessed and that it was not being used for any treatments. RN UM #1 observed Resident #121's right chest Mediport, which had a clear dressing with a white border dated 4/10 that had peeled away exposing the needle insertion site and stated they didn't know what the apparatus was on the resident's right chest and stated, I guess its accessed. The RN UM #1 stated they didn't know what the process was for caring for the Mediport and had to review the facility policy. The RN UM #1 stated they didn't know the Mediport was accessed and should have been made aware. The RN UM #1 stated whoever did the admission assessment would usually write a note about the Mediport and document that a resident had one. The RN UM #1 stated the DON completed the resident's admission assessment and documented the resident had a right chest Mediport. During an interview on 4/29/22 at 9:34 AM, the Director of Nurses (DON) stated they competed Resident #121's admission assessment and the resident did have a Mediport in their right chest. The DON stated they remembered there being a dressing on it but didn't know the date of the dressing or that a needle was inserted. The DON stated they had to review the facility policy to determine what care should be done for the Mediport. The DON stated the Mediport should be on the care plan and there should be orders for it. The DON stated there were no orders for the care of Resident #121's Mediport and it was not care planned. During an interview on 4/29/22 at 10:53 AM, the DON stated if a Mediport was accessed, it should be flushed weekly, and the dressing should be changed weekly. The DON stated whoever does the admission assessment should add orders and add the Mediport to the care plan to let staff members know that the resident had a Mediport. The DON stated it was their mistake and it was overlooked upon the resident's admission. During an interview on 5/3/22 at 1:04 PM, the Medical Director stated their policy was to flush and complete a dressing change weekly for accessed Mediports. The Medical Director stated if the staff didn't know or were unsure about whether the Mediport was accessed they should have brought it to the provider's attention and would've recommended de-accessing it. Monitoring of the site and dressing changes should have been done to visualize the site for signs of infection. 415.12

Based on interview and record review during the Standard survey conducted from 4/27/22 through 5/3/22, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries. Specifically, for one (Resident #125) of three residents reviewed for beneficiary protection notification, the facility did not provide the resident or responsible party (RP) with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- a letter given to residents who are terminated from Medicare coverage and remain in the facility) at the termination of Medicare Part A benefits. The finding is: The facility policy and procedure titled, Room and Care Medicare Part A Billing dated 10/11/21 documented for revision of Medicare Part A coverage a Medicare Denial Memorandum Notice of Medicare Non-Coverage (NOMNC) and a SNF ABN are presented in person to the resident or telephone contact is made to a RP notifying of non-coverage. The resident or RP are asked to sign the forms, acknowledging the estimated costs of services received but not covered by Medicare. (This must be completed at least 48 hours prior to non-coverage.) 1.Resident #125 was admitted to the facility on [DATE] under Medicare Part A services with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS- a resident's assessment tool) dated 1/18/22 revealed the resident had severe cognitive impairment. Review of the facility Admin Census/Rates revealed Medicare Part A was the primary payor for Resident #125 from 1/14/22 through 1/26/22 and the resident remained in the facility from 1/27/22 until 2/2/22 with private pay as the primary payor. There was no evidence the SNF ABN was given to the resident or their RP. Review of the SNF Beneficiary Protection Notification Review form revealed Medicare Part A services started 1/14/22 and ended on 1/26/22. The facility initiated the discharge from Medicare part A services when benefit days were not exhausted. The form included that the SNF ABN, CMS (Centers for Medicare & Medicaid Services)- was not provided to the resident. During an interview on 5/2/22 at 8:44 AM, the Business Office Coordinator stated at the time the NOMNC was issued, the resident was not expected to stay, was at the facility a couple extra days and was previously cut from Medicare Part A. The Business Office Coordinator stated the resident or resident's RP did not get the SNF ABN and should have. The Business Office Coordinator stated the resident used 13 days of the Medicare Part A stay and had more days left to use. The Business Office Coordinator stated the resident was responsible to cover that part of their stay from 1/27-2/2/22. The Business Office Coordinator stated when they are not in the facility their backup is the Administrator or MDS person and they were not sure if they were aware the resident or RP should have received the SNF ABN when they were not discharged as planned. During an interview on 5/3/22 at 1:36 PM, the Administrator stated they were the backup when the Business Office Coordinator was not available, and they didn't know Resident #125's discharge was held up and from now on they will give a SNF ABN along with the NOMNC forms to residents. 415.3 (h)(2)(iv)

Based on observation, interview and record review during a Standard survey conducted from 4/27/22 through 5/3/22 the facility did not ensure that each resident who was unable to carry out activities of daily living (ADL) receives the necessary services to maintain grooming and personal hygiene for one (Resident #50) of four residents reviewed for ADL's. Specifically, Resident #50 had long jagged and dirty fingernails on both hands and thick coarse chin hair. The finding is: Review of the facility policy and procedure (P&P) titled ADL Assistance and Supervision dated 1/8/2018 documented the Unit Manager/designee will ensure that a plan of care for receiving ADL assistance and/or supervision is incorporated into the daily nursing care of each resident. The nursing assistant provides ADL assistance/supervision to assigned residents and assists other nursing assistants in giving ADL care as needed. Review of the facility P&P titled Hygiene and Grooming dated 7/24/2018 documented nursing staff will ensure that residents are clean and appropriately groomed at all times. Nails are cleaned and trimmed as part of the bath/shower routine and whenever needed. Review of the facility P&P titled Hand and Nail Care dated 1/25/2019 documented residents will receive nail care for cleanliness and to prevent infection. Nursing Assistant: If procedure cannot be completed, report reason to immediate supervisor. Nurse: If procedure cannot be completed, document reasons in appropriate records. 1) Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 3/27/22 documented Resident #50 was moderately impaired cognitively, was understood and understands. In addition, Resident #50 required extensive assist for personal hygiene. During intermittent observations on 4/27/22 at 10:25 AM, 4/28/22 at 2:29 PM, 4/29/22 at 8:36 AM, 10:16 AM, 11:38 AM and 1:15 PM revealed Resident #50's fingernails on both hands were long (over the tips of the fingers), jagged and dirty with brown debris under them. Additionally, thick coarse long facial hair was noted to Resident #50's chin. Review of the Care Plan focus, ADL Function/Mobility/Restorative Care, documented interventions/tasks of Personal Hygiene-Extensive Assistance/One-person physical assist, date initiated 3/17/2022. Review of Kardex report dated 4/29/22 documented keep nails kept short to reduce risk of scratching or injury. Review of Treatment Administration Record (TAR) dated April 2022, documented skin examination every day shift every Tuesday and Saturday were completed 4/16, 4/19, 4/23 and 4/26. Review of the Progress Notes dated 4/22/22 through 4/29/22 for Resident #50 revealed there was no documented evidence of nail care provided or that Resident #50 refused care. During an interview on 4/27/22 at 10:25 AM, Resident # 50's daughter stated that Resident #50 would not like having chin hair and was not sure when and if staff trim, clean Resident #50's nails. During an interview on 4/29/22 at 11:16 AM, Certified Nurse Aide (CNA) #2 stated aides are responsible to perform nail care and grooming (shaving) to the residents. Nail care is provided on their shower days. CNA #2 stated, additionally if not completed on their shower day, then when aides have free time. If unable to complete or if resident refuses it should be reported to the charge nurse. During an interview and observation on 4/29/22 at 1:20 PM, Licensed Practical Nurse (LPN) #1 stated they did not think it was acceptable for females to have facial hair. That it was a dignity issue when facial hair was present. Additionally, LPN #1 stated that nail care should be done in the morning when residents are being bathed and would expect CNA to report refusals. At 1:26 PM upon observing Resident #50's nails LPN #1 stated their nails had grit and grime under them and should have absolutely been cleaned as it was a dignity issue. During an interview and observation on 4/29/22 at 1:33 PM, Registered Nurse (RN) #3 Unit 2 Unit Manager (UM) stated Resident #50 needed nail care, that Resident #50's nails had brown debris under the nails and had jagged edges. RN #3 stated that nail care should be done on bath days. During an interview on 5/3/22 at 8:17 AM, Director of Nursing (DON) stated nail care and shaving should be done with showers and as needed as it is important for resident dignity. Additional, DON stated it was unacceptable for debris to be under residents' nails as this was a sign that residents weren't cared for. 415.12 (a)(3)

Based on interview and record review conducted during the COVID-19 Infection Control Focused Survey completed on 10/27/2021, the facility did not ensure facility staff were tested and documented that testing was complete with the results of each test for COVID-19 that is consistent with current infection control measures during staff testing for COVID-19 while the facility was in outbreak testing. Specifically, three (Certified Nursing Assistant (CNA) #1, Registered Nurse (RN) #5 and RN Unit Manager #6) of four employees the facility had no documented evidence that COVID-19 testing was completed accordingly while in an outbreak. The findings are: The Centers for Medicare & Medicaid Services (CMS) guidance with Reference Number QSO-20-38-NH, dated 8/26/20, revised 4/27/2021, titled Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool, documented: Upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that all other residents and staff are tested , the dates that staff and residents who tested negative are retested , and the results of all tests. The facility is required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility's testing frequency. The CMS guidance further documented: An outbreak is defined as a new COVID-19 infection in any staff or resident, and For outbreak testing, all staff and residents should be tested , and all staff and residents that tested negative should be tested , regardless of vaccination status, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. The New York State Department of Health Dear Administrator Letter, NH-21-17, titled Revised Nursing Home Covid 19 Testing Requirements, dated 6/25/21, documented: Testing of Staff and Residents in Response to an Outbreak. An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any HCP or residents, all HCP and residents, regardless of vaccination status, should be tested immediately (see CMS QSO38-NH), and all HCP and residents who test negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among HCP or residents for a period of at least 14 days since the most recent positive result. Review of the facility policy and procedure (P&P) titled COVID-19 Resident & Staff Testing Requirements dated 09/20/2021 documented the facility will test residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19 as directed by state and federal requirements. The facility policy further stated if individual State Requirements differ, the more stringent will be followed. The findings are: During an interview on 10/27/21 at 9:01 AM, the Administrator stated the facility was in outbreak testing due to staff members testing positive for COVID-19 and staff were being tested on a weekly basis. The Administrator stated they sought out guidance from the NYS epidemiologist on the frequency of testing required for staff. Review of an email provided by the Director of Nurses dated 10/26/21 at 2:50 PM from the NYS Epidemiologist revealed protocols for out-break testing that included: Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents, regardless of vaccination status, should be tested immediately, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of 14 days. 1. Review of [CONDITION(S)]-CoV2 Rapid [MEDICATION(S)] test results from 10/1/21 through 10/27/2021 revealed that there was no documented evidence CNA #1 was tested during this time. Review of an untitled document, identified by the Director of Nursing (DON) as CNA #1's timesheets, dated 10/1/2021 through 10/31/2021 revealed: -week of 10/3/2021 - 10/9/2021, CNA #1 worked two shifts (10/6/2021 and 10/8/2021) -week of 10/10/2021 - 10/16/2021, CNA #1 worked one shift (10/14/2021) -week of 10/17/2021 - 10/23/2021, CNA #1 worked one shift (10/20/2021) During a telephone interview on 10/27/2021 at 1:29 PM, CNA #1 stated they had not been tested for COVID-19 since their employment start at the facility on 10/6/2021. CNA #1 stated they had not received notification by the facility of the need to test for COVID-19. During an interview on 10/27/2021 at 11:56 AM with the Director of Nursing (DON) and the Administrator, the DON stated CNA #1's start date was 10/6/2021 and CNA #1 was never tested for COVID- 19 by the facility. The DON stated that they communicate with staff through email or text messages when COVID-19 testing was needed. The DON stated there has been no education or in-servicing provided to staff on COVID-19 testing. In addition, the Administrator, stated that overhead pages are made, and the department heads were also updated in morning report of staff testing days. During an interview on 10/27/2021 at 2:35 PM, the DON stated that CNA #1 was not tested , should have been tested and that the facility had no test results for CNA #1. In addition, the DON stated they could not provide any evidence (email or text) to show that CNA #1 was notified of the need to be tested for COVID-19. 2. Review of [CONDITION(S)]-CoV2 Rapid [MEDICATION(S)] test results from 10/1/21 through 10/27/2021 revealed that RN #5 was tested on e time on 10/27/2021. Review of an untitled document, identified by the DON as RN #5's timesheets, dated 10/1/2021 through 10/31/2021 revealed: -week of 10/17/2021 - 10/23/2021, RN #5 worked one shift (10/23/2021) -week of 10/24/2021 - 10/30/2021, RN #5 worked one shift (10/27/2021) During an interview on 10/27/2021 at 1:37 PM, RN #5 stated they worked for the cooperation's float pool and received emails when they were to be tested . RN #5 stated they do not recall if they received an email to be tested from this facility because RN #5 usually worked at a sister facility. RN #5 stated the last time they were tested for COVID-19 about two weeks ago. During an interview on 10/27/2021 at 2:35 PM, the DON stated that the Unit Manager or the Nursing Supervisor were to verify that float RN's have been tested . The Licensed Practical Nurse (LPN) Supervisor #4 and RN #7 were the day shift supervisors. During an interview on 10/27/2021 at 2:39 PM, the Administrator stated that float RNs were tested like everyone else when facility was in the testing window. During a telephone interview on 10/27/2021 at 3:23 PM, LPN Supervisor #4 stated it was their responsibility to make sure staff working in the building have been tested for COVID-19 and used the schedule to track people down and make sure they were tested and verbally reminded staff that it was a testing day. An attempt on 10/27/21 at 3:34 PM RN #7 Day Shift Supervisor was attempted via telephone to be contacted without success. During an interview on 10/27/21 at 3:25 PM, the DON stated there were no COVID-19 test results for RN #5. RN #5 should have been tested on [DATE] at the beginning of the shift and RN #5 was not in compliance with outbreak testing. 3. Review of [CONDITION(S)]-CoV2 Rapid [MEDICATION(S)] test results from 10/1/21 through 10/27/2021 revealed that RN #6 was tested on [DATE] and 10/26/2021. During an interview on 10/27/2021 at 11:56 AM, the Administrator stated that RN #6 Unit Manager was a salaried employee who worked Monday through Friday and would not have a time sheet. During a telephone interview on 10/27/2021 at 1:04 PM, RN Unit Manager #6, stated they tested for COVID-19 on 10/21/21 or 10/22/21 and then most recently on 10/26/21. During an interview on 10/27/2021 at 11:56 AM, the Administrator stated they had no evidence of RN #6's COVID-19 test results for the week of 10/17/2021, the results were never reported to ECLRS (Electronic Clinical Laboratory Reporting System) or entered into the entered into the facility COVID Testing Tracker Log. 415.19(a)(1)

Based on interview, and record review conducted during the COVID-19 Infection Control Focus Survey completed on 10/8/20, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility did not ensure staff were checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks every 12 hours while on duty. The finding is: Executive Order 202.11, dated March 27, 2020, documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The NYS DOH (New York State Department of Health) Commissioner of Health letter to Nursing Home (NH) Administrators, dated 4/29/20, documented As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Requiring all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. The NYS DOH DAL (Dear Administrator Letter) NH-20-07, Required COVID-19 Testing for all Nursing Home and Adult Care Facility Personnel, dated 5/11/20, documented This Directive supplements the prior DOH Advisory concerning hospital discharges to 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 Preventing the spread of COVID-19 dated 9/4/2020 documented it is the policy of our company to comply with Center for Disease Control (CDC) and State Department of Health (DOH) guidelines regarding awareness and prevention of the spread of Coronavirus 2019 (COVID-19). Preventing the introduction of respiratory germs into the facility will include screening of individuals entering the facility (employees, contract staff, medical staff, operators, volunteers, vendors, etc.). Everyone will be screened prior to entry into the facility. Screening will include assessment of travel history, exposure history, fever and respiratory symptoms (cough, shortness of breath, or sore throat) and a temperature assessment. The policy did not include re-screening of employees every 12 hours while on duty. During an interview on 10/8/20 at 8:45 AM, Registered Nurse (RN) #2 stated that facility census was 51 residents including two COVID-19 positive residents on Unit Three. During an interview on 10/8/20 at 9:35 AM, Certified Nurse Aide (CNA) #2 stated she has worked overtime and double shifts. She stated employees get screened when they enter the facility at the start of their shift and do not get re-screened or have temperature re-taken when working a double shift (which are two 8-hour shifts, totaling 16 hours). During an interview on 10/08/20 at 2:13 PM, CNA #1 stated she has worked double shifts and worked one the previous night. The facility does not rescreen her after working 12 hours and this is the first she heard of the requirement. During an interview on 10/8/20 at 2:16 PM, RN #1 stated she works two 16- hour shifts and one eight -hour shift per week. She stated she doesn't get re-screened or have her temperature re-checked when working a 16-hour shift because she does not leave the building. RN #1 further stated she doesn't get re-screened if she stays in the building the whole shift and was never told she had to do that. During an interview on 10/8/20 at 2:00 PM, the Director of Nursing (DON) stated she was unsure but would have to check on the process for how often staff are screened for signs or symptoms of COVID-19 and have temperatures taken when working a double shift or over 12 hours. During an interview on 10/8/20 at 2:10 PM, the Regional Consultant RN Infection Preventionist (IP), in the presence of the DON, stated they do not log temperatures or re-screen staff when they work a double shift and it is not logged anywhere. They stated there was no additional documentation of screening of staff or temperature re-checks when staff work a double shift or overtime. During an interview on 10/8/20 at 2:55 PM, the Regional Consultant RN IP and DON stated they were not aware of the NYS DOH Directive 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. They stated they were going to review the directive so the requirement could be implemented. 415.19(a)(1) 400.2

Based on interview and record review conducted during the Standard survey completed on 7/2/19, the facility did not in response to allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations are thoroughly investigated for one (Resident #44) of three residents reviewed for abuse. Specifically, the facility did not have a complete and thorough investigation conducted for an alleged resident abuse. The finding is: Review of a facility policy titled Abuse Prevention, Identification, Investigation, Protection and Reporting date last modified 4/17/19 revealed the following: -All residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, exploitation and involuntary seclusion. The Administrator will be responsible for the development and implementation of policies and procedures to prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property through appropriate screening of potential staff members and volunteers; training upon hire and throughout employment; and through identification, correction and intervention in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. -The facility Administrator/ designee will be responsible for the identification, investigation, protection of residents during investigative procedures and reporting of any alleged or substantiated incidences of abuse, neglect, involuntary seclusion and misappropriation of resident property. The Director of Nursing Services and other department heads as appropriate will assist as necessary in the process. -All instances of alleged and/ or substantiated resident abuse, neglect, involuntary seclusion or misappropriation of property will be investigated by the facility as appropriate. Review of the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev.173, 11-22-17) included mental abuse is the use verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. 1. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 5/27/19 documented the resident was cognitively intact, understood and understands. During an interview on 6/26/19 at 9:48 AM, Resident #44 stated, Certified Nurse Aide (CNA) #2 yelled in my ear a couple of weeks ago, I told her not to yell, I have tinnitus (ringing in the ears). She kept yelling. I reported it, they know about it. Apparently, CNA #2 has done this before. I think she was suspended after that. When she came back she strolled by my door, looking straight at me and stuck her tongue out at me. I just ignore her now. Resident #44 stated she felt the CNA was harassing her when she (CNA) stuck out her tongue at her. During an interview on 7/1/19 at 12:18 PM, the Director of Nursing (DON) stated, This is the first I'm hearing of these allegations. Once an allegation is reported to me, we get statements, fill out grievances, and start an investigation. The DON stated the allegations needed to be investigated. During an interview on 7/1/19 at 12:33 PM, CNA #1 stated, Resident #44 said that CNA #2 stuck her tongue out at the resident. Resident #44 said she was going to cut CNA #2 if she came into the room. CNA #1 stated this occurred about two weeks ago. During an interview on 7/1/19 at 12:38 PM, Licensed Practical Nurse (LPN) #1 stated that the nursing supervisor Registered Nurse (RN) #1 reported to her that CNA #2 could not take care of Resident #44 because of disagreement they had. A couple days later, RN #1 said Resident #44 had threatened to stab CNA #2 if she came into the room because CNA #2 had stuck her tongue out at the resident. During an interview on 7/1/19 at 1:03 PM, LPN #1 stated, I reported what was going on that morning to the DON. It was a couple weeks ago, I believe. During an interview on 7/2/19 at 10:32 AM, RN #1 stated, LPN #1 and I were in the DON's office a couple weeks ago when LPN #1 reported to the DON that Resident #44 was saying CNA #2 stuck her tongue out at the resident. During an interview on 7/1/19 at 12:48 PM, the Administrator stated, Once the DON is aware of an allegation an investigation is started. The Administrator stated she was unaware of the allegations and that an investigation had not been completed. 415.4(b)(3)

Based on interviews and record review conducted during an Abbreviated survey completed on 3/5/19 (Complaint #NY 675) the facility did not maintain acceptable parameters of nutritional status such as electrolyte balance unless the resident's clinical condition demonstrates that this is not possible, or the resident's preferences indicate otherwise for one (Resident #1) of three residents reviewed for hydration. Specifically, a resident with a history of dehydration and urinary tract infections [MEDICAL CONDITION] was not monitored closely or evaluated to determine adequate fluid intake resulting in repeat visits to the hospital. The finding is: A facility policy entitled Assessment of Needs - Dietary dated 9/24/18 documented each resident will have an assessment of dietary and nutritional needs completed by a Registered Dietitian (RD) or a Dietetic Technician within 48-hours following admission when pertinent to medical conditions/ reason for admission; otherwise within 5 days following admission. Assessment of needs by a RD or designee will be ongoing and documented at least every 90 days or whenever the nutritional needs of the resident changes significantly. Upon readmission to the facility from the hospital, the resident's dietary needs are reassessed in the Progress Notes within 48-hours if a significant change in condition has occurred. 1. Resident #1 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 12/11/18 revealed the resident was severely cognitively impaired and required one-person physical assist with eating. A Nutritional Services Note dated 12/6/18 completed by the dietician documented laboratory data from 12/5 that is indicative of hydration status; Blood Urea Nitrogen (BUN) 12 (normal 5-31 mg/dl), Creatinine (Cr) 0.56 (normal 0.40-1.60), Sodium (Na) 144 (normal 133-147), and Potassium (K) 3.8 (normal 3.5 -5.6). Review of an initial Nutritional assessment dated [DATE] revealed the resident's fluid needs were estimated at 1650 milliliters (ml) with 2160 ml of fluid provided every day. The note documented the resident's intake from meals was approximately 740 ml from meals and supplements in addition to a medication pass supplement. Her average meal intake was documented at 48 % (percent). Review of the fluid intake documentation revealed the resident's fluid intake from 12/4/18 through 12/14/18 was fair to good with overall intake of fluid approximately 1200 ml to 1620 ml a day. Review of the Medication Administration Record [REDACTED]. Review of fluid intake documentation that included fluids as needed, fluids from meals, nutritional medication pass, hydration pass fluids and supplemental fluids from 12/15/18 through 1/10/19 revealed the following days at sub-optimal intake for fluids:12/15/18 = 1060 ml,12/16/18 = 1320 ml,12/17/18 = 1090 ml;12/18/18 =725 ml;12/19/18 = 1180 ml;12/20/18 = 960 ml;12/22/18 = 1440 ml;12/23/18 = 1170 ml;12/27/18 = 840 ml;12/28/18 = 1020 ml;12/26/18 = 720 ml;12/31/18 = 720 ml;1/1/19 = 720 ml;1/2/19 = 1200 ml;1/3/19 = 600 ml;1/6/19 = 840 ml;1/7/19 = 300 ml;1/8/19 = 960 ml;1/9/19 = 360 ml. Review of a nurse note dated 1/10/19 revealed the resident was transported to the hospital and admitted with [MEDICAL CONDITION] (high sodium in the blood) and pneumonia. Review of the hospital admission laboratory results dated [DATE] revealed the resident's BUN was 67 milligrams/ deciliter (mg/dl), Na was 153 millimoles (mmol)/ Liter (L). Review of the Final Report from the hospital dated 1/12/19 revealed the resident had been found unresponsive at the nursing home. In the emergency room (ER) she was borderline hypotensive (low blood pressure), hypoxic (low oxygen level in the blood) and blood work revealed [MEDICAL CONDITION] (low potassium), [MEDICAL CONDITION]ly due to dehydration and acute kidney injury. The acute kidney injury, [MEDICAL CONDITION] and [MEDICAL CONDITION] had improved with IV (intravenous)fluids. Review of a nursing Admission/Readmission Initial note dated 1/15/19 revealed the resident was readmitted to the facility. Review of a Nutritional Service Note dated 1/16/19 revealed the resident's diet on admission was pureed with nectar thick liquids. The note documented a full nutrition assessment was to follow. Review of fluid intake documentation that included fluids as needed, fluids from meals, nutritional medication pass, hydration pass fluids and supplemental fluids from 1/16/19 through 1/29/19 revealed the following days at sub-optimal intake for fluids:1/16/19 = 750 ml, 1/17/19 = 240 ml, 1/18/19 = 1420 ml; 1/19/19 960 ml; 1/20/19 = 1500 ml; 1/21/19 = 600 ml; 1/22/19 = 1220 ml; 1/23/19 = 1020 ml; 1/24/19 = 780 ml; 1/25/19 = 920 ml; 1/26/19 = 780 ml; 1/27/19 = 1320 ml; 1/28/19 = 960 ml; 1/29/19 = 510 ml Review of the Nurse's Notes dated 1/29/19 to 1/30/19 revealed the resident had an overall decline in status with weakness, lethargy and use of accessory muscles for breathing. The resident was sent to the hospital and admitted with [MEDICAL CONDITION], acute [MEDICAL CONDITION] and a urinary tract infection. Review of Routine Chemistry results (laboratory data) dated 1/29/19 from blood work drawn prior to sending to the hospital revealed the resident's sodium was at a critical level of 188 mmol/L, BUN was high at 119 mg/dL and Cr level was high at 5.58 mg/dL. During an interview on 3/5/19 at 2:00 PM, the Registered Dietetic Technician stated she does look at the fluid intake sheets when she completes her assessments of the residents, however does not review them weekly. She stated the resident was placed on hydration protocol after she was initially admitted and was on supplements with the medication pass. When a resident is readmitted to the facility she has 14 days to complete a nutritional assessment. In this case, the resident was re-admitted on [DATE] but went back to the hospital on [DATE]. During an interview on 3/5/19 at 3:00 PM, the Registered Dietitian (RD) stated dietary is responsible for reviewing the resident's fluid intake. However, it is the responsibility of the entire team to review the resident's fluid intake and not solely dietary's responsibility. If a resident's fluid intake is not enough the resident is placed on the hydration protocol with extra fluids passed by nursing. In addition, dietary can adjust the meal pattern to accommodate more fluids. During an interview on 3/5/19 at 2:45 PM, the Director of Nursing (DON) stated the entire interdisciplinary team is responsible for monitoring the resident's fluid intake. The resident's intake was poor throughout most of her stay and staff did attempt to get her to eat and drink with little success. Additionally, she stated the computer notifies staff when a resident's intake is 25% or less but that is overall intake and not just fluids. 415.12(i)(1)

Based on interview and record review during the Standard survey completed on 4/4/18, the facility did not implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility did not provide documentation that verified five (Employee #1, Business Office Coordinator, Employee #2, Supervisor of Housekeeping and Laundry, Employee #3, Unit Clerk, Employee #4, Activity Leader, and Employee #6, Activity Leader) of seven facility employees that were not Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs), worked in the facility during the last four months, and were subject to the New York State Nurse Aide Registry; had been reviewed through the New York State Nurse Aide Registry prior to their employment. The findings are: 1a.) Interview with the Human Resources Coordinator on 3/29/18 at approximately 8:10 AM revealed: - The Human Resources Coordinator was not conducting New York State Nurse Aide Registry checks on all of the facility's employees prior to their employment. - The Human Resources Coordinator was only conducting New York State Nurse Aide Registry checks on Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Aides (CNAs). - The Human Resources Coordinator was not aware that New York State Nurse Aide Registry checks had to be conducted on employees other than RNs, LPNs, and CNAs. Review of employee files and time sheets provided for facility employees that were hired in the last four months on 3/29/18, revealed the facility did not have documentation that showed a New York State Nurse Aide Registry check had been conducted on the following employees, prior to their employment at the facility. - Employee #1, Business Office Coordinator, worked at the facility for nine days between 3/19/18and 3/29/18. Interview with the Administrator and the Human Resources Coordinator on 3/29/18 at approximately 2:29 PM revealed Employee #1 worked on three of the facility's three units between 3/19/18and 3/29/18. - Employee #2, Supervisor of Housekeeping and Laundry, worked at the facility for six days between 3/20/18 and 3/29/18. Interview with the Administrator and the Human Resources Coordinator on 3/29/18 at approximately 2:29 PM revealed Employee #2 worked on three of the facility's three units between 3/20/18 and 3/29/18. - Employee #3, Unit Clerk, worked at facility for 18 days between 3/5/18 and 3/29/18. Interview with the Administrator and the Human Resources Coordinator on 3/29/18 at approximately 2:29 PM revealed Employee #3 worked on three of the facility's three units between 3/5/18 and 3/29/18, but usually stayed on one unit. - Employee #4, Activity Leader, worked at the facility for 13 days between 3/6/18 and 3/29/18. Interview with the Administrator and the Human Resources Coordinator on 3/29/18 at approximately 2:29 PM revealed Employee #4 worked on three of the facility's three units between 3/6/18 and 3/29/18. - Employee #6, Activity Leader, worked at facility for 38 days between 2/5/18 and 3/29/18. Interview with the Administrator and the Human Resources Coordinator on 3/29/18 at approximately 2:29 PM revealed Employee #6 worked on three of the facility's three units between 2/5/18 and 3/29/18. Review of Nurse Aide Registry Checks dated 3/29/18 for all seven facility employees revealed no findings for all seven of the facility employees. Review of the Records and Process for Hiring a Staff Member Policy and Procedure dated 9/2017 on 3/30/18 revealed the following: Preparation of Personnel Files and Records - The following files or records are prepared for new staff: Basic Hiring Work Sheet: This form is stapled to the inside of personnel folder and completed as indicated. Review of the Basic Hiring Worksheet - Human Resources Use dated 10/2016 on 3/30/18 revealed the following under the heading General: Nurse Aide Registry check (all). Interview with the Administrator on 3/30/18 at approximately 11:18 AM revealed the following: - The Basic Hiring Worksheet was to be completed by Human Resources for all new staff members. - The Nurse Aide Registry check was listed on the worksheet under the General heading and it was to be completed for all new staff members before they were hired. 415.4(b)

Based on observation, interview, and record review conducted during a Standard survey completed on 4/4/18, it was determined that the facility did not ensure that each resident has the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. One (Resident #46) of 36 residents reviewed for Advance Directives had issues with a resident's identification band color was incorrect for the resident's code status and the code status was missing from the band. The finding is: A review of a facility policy and procedure entitled DNR Orders (Completion and Revocation) dated (MONTH) (YEAR) revealed that upon the issuance or revocation (removal) of a Do Not Resuscitate order, the following steps will be followed to ensure resident resuscitative status is known throughout the facility. Wrist band identification - once the wishes have been established or if they change (DNR (do not resuscitate) or Full Code (the resident is to be resuscitated if their heart stops) the appropriate wrist band will be applied. The name, room number, and code status will be listed. Wrist Band Content & Presence verification - the licensed nurse is responsible for verification of the presence and accuracy of the wrist band every shift. The verification will be documented on the Medication Administration Record (MAR). 1. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 2/15/18 documented the resident has severe cognitive impairment, understands, and is usually understood. During an observation of the resident during lunch on 3/28/18 at 12:30 PM, the resident had a white identification (ID) bracelet on her wheelchair. The Comprehensive Care Plan (CCP) with an initiation date of 1/9/17 documented under the Focus section Advance Directives, The resident has no Advance Directives and Full Code. Further review of the CCP under the Interventions and Tasks section, it is documented the resident had a DNR Code Status with an initiation date of 6/21/17. Interventions dated 6/21/17 included to apply wrist band, monitor for accuracy and status of usage. During an observation on 3/30/18 at 3:00 PM, the resident's wheelchair did not have the ID bracelet on it. Further observation revealed that the resident had a blue ID bracelet (wrist band) on their left wrist with only their name handwritten on it. Review of the Medication Reconciliation/ Physician order [REDACTED]. Review of the Medical Orders for Life Sustaining Treatment (MOLST) dated 6/21/17 revealed the resident had a DNR status. Another MOLST form dated 3/15/18 documented the resident had a DNR status. Review of an Order Listing Report for active orders with a date range of 3/1/18 through 3/31/18 revealed the resident had orders for a DNR/DNI, MOLST with comfort measures only. Review of a Progress Note dated 3/15/18 revealed a Psychosocial Note documenting the responsible family member was contacted concerning the resident's DNR status and the resident was a DNR/ DNI (do not intubate) and was to receive comfort measures only. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR revealed the ID bracelet was to be checked for presence and accuracy every shift starting on 1/6/17. On 3/29/18 and 3/30/18 the record was marked that the ID bracelet was checked on each shift. Interview with the Director of Social Work on 3/30/18 at 3:40 PM revealed that every resident on the unit was a DNR. She did not know how long the resident had the blue bracelet. Interview with the Regional Registered Nurse (RN) Consultant on 3/30/18 at 4:08 PM revealed that she would expect the nurses to check the band to make sure that the DNR orders match the ID bracelet and if they didn't match, to change the bracelets. The facility was in the process from changing ID bracelet colors to having the resident's code status on the bracelet. She stated, I don't know what happened. We will do an investigation to find out what happened. Review of the in-house investigation dated 3/30/18 revealed the resident's ID bracelet was noted in the resident's night stand drawer and not on the resident's wheelchair. Further review of the investigation revealed a nurse changed the band within the last two or three weeks because the ID bracelet did not have the resident's room number on it. Interviews with Licensed Practical Nurse (LPN) #5 and LPN #4 on 4/3/18 at 8:30 AM revealed that the resident should have a white bracelet on as the resident was a DNR. LPN #4 further stated that she recalled the resident having a white DNR bracelet on her wheelchair and she believed that it was there on her afternoon shift on Thursday, 3/29/18. She did not recall staff coming up to her about a lost ID bracelet that shift. Interview with the Director of Nursing on 4/3/18 at 9:00 AM revealed she expected her staff to verify the code status of the resident and replace the ID bracelet if it is missing or incorrect. 415.3(e)(1)(ii)

Based on observation, interview, and record review conducted during the Standard survey completed on 4/4/18, the facility did not ensure that a resident who is unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good oral hygiene. One (Resident #57) of five residents observed for ADLs had an issue with staff not providing good oral hygiene. The finding is: The facility's undated policy and procedure identified as current entitled Oral Hygiene documented oral care will be provided to all residents in the morning and evening and as needed to cleanse the mouth and teeth, lessen the occurrences of mouth infection, and to provide comfort. The procedure describes using a toothbrush and toothpaste, and mouthwash for cleansing. 1. Resident #57 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 2/15/18 revealed the resident is cognitively intact, understands and is understood. The resident required total staff assistance for personal hygiene. Review of the resident's Kardex (guide used by staff to provide care) dated 4/1/18 revealed the resident has her own upper and lower teeth. Oral care assistance is required every morning and night. Review of the Hospice CNA (Certified Nurse Aide) Care Plan (guide used by staff to provide care) entered by the hospice Registered Nurse (RN) revealed the resident required oral care every shift and mouth care (swab/ mouth) as tolerated. Observation on 3/30/18 at 7:28 AM revealed the hospice CNA entered the resident's room to provide morning care. The resident was sleeping in semi-fowler's (head of the bed elevated) on her back. When the resident spoke her upper and lower teeth had a copious amount of whitish yellow residue adhering to her teeth and saliva. The CNA swabbed the resident's mouth and teeth with swabs. When the task was finished, a copious amount of whitish yellow residue remained on the resident's teeth. Continued observation on 3/30/18 at 8:00 AM revealed the CNA gave report to the floor LPN, however the CNA did not relay any information regarding the condition of the resident's mouth and stated her care was done and left. During an interview on 3/30/18 at 7:50 AM, the hospice CNA stated we're not brushing her teeth anymore we use swabs to clean the resident's mouth. During an interview on 3/30/18 at 8:37 AM, the Licensed Practical Nurse (LPN #3) Team Leader stated the resident has a hospice CNA Monday to Friday. During an interview on 3/30/18 at 9:07 AM, the hospice Registered Nurse (RN) stated she determined the resident's care plan needs based on her assessment, and care planned the resident for oral care using swabs because the resident has declined and cannot brush her own teeth anymore. The hospice RN showed the surveyor the hospice CNA template which has a specific entry for brushing teeth, which she did not choose. The hospice RN did not know if the resident was unable to tolerate tooth brushing assistance. Additional observation on 4/2/18 at 7:14 AM revealed when the resident spoke the upper and lower teeth had a copious amount of whitish yellow residue adhering to her upper and lower teeth and saliva. During an interview on 4/2/18 at 7:32 AM, the hospice CNA stated she finished doing the resident's care and had finished her oral care with swabs, which were sitting on the bedside table. When the resident spoke, the upper and lower teeth still had a copious amount of whitish yellow residue adhering to her teeth. During an interview on 4/4/18 at 9:00 AM, the resident stated when she became too weak to brush her own teeth, staff just started to swab her mouth. They never offered to brush her teeth for her. The resident stated she would probably prefer her teeth brushed than swabbed. During an observation on 4/4/18 with the Director of Nursing (DON) at 10:00 AM, the resident's teeth were inspected and had a copious amount of whitish yellow residue adhering to her teeth. The DON stated that it is facility policy to brush the resident's teeth and they should not be in that condition. 415.12(a)(3)