Every finding on record at Elderwood at North Creek

Based on observation and interviews conducted during the recertification survey, the facility did not provide effective housekeeping and maintenance services on 2 of 2 resident units (A and B wings) and the building exterior. Specifically, floors, walls, ceilings, sinks, and building exterior were not clean and/or maintained. This is evidenced by: During observations on 9/16/2024 at 1:50 PM, the following areas on the A-Wing unit were soiled or in disrepair: Door jams casings were chipped. Walls were cracked at the baseboards. The wall was cracked in the corridor below the window air-conditioner. Air vents were dirty and grimy. Ceiling tiles were not in place, and the suspended ceiling metal grid was or discolored or damaged. The corridors floors were dirty, grimy, and sticky. During observations on 9/17/2024 at 2:15 PM, the exterior facia of the building was in disrepair as follows: One 36-inch by 30-inch section of stucco was falling off and one 15-inch by 12-inch section was missing on the exterior of the garage. One 3-foot by 1-foot section of stucco was missing and several areas were peeling on the exterior of the employee dining room. One 3-foot section of stucco was peeling on the exterior of the Rotunda. Six small areas of stucco were chipped off. The stucco exterior was soiled with dirt drip marks. The roof overhang around the A-wing was peeling or heavily soiled with dirt. Paint was peeling under three resident rooms on the exterior of the A-Wing. During observations on 9/20/2024 at 9:21 AM, the following areas on the B-Wing unit were soiled or in disrepair: Sporadically, all resident room walls were soiled with scrape marks or grime. Walls were peeling and/or had gouges behind the beds in room #s 201, 206, 209, 211, 220, and 221. The heater register was soiled with scrape marks in room [ROOM NUMBER]. The bathroom door frame scraped in room [ROOM NUMBER]. Walls were chipped around the closet in room #s 205 and 215. Ceiling tiles were not in place in room #s 201 and 207. Sections of the lower half of the corridor walls throughout the unit were soiled with scrape marks, had peeling wallpaper, and/or were chipped. The corridor floor, library floor, physical therapy room floor, and the floor in room [ROOM NUMBER] were soiled with ground-in dirt. The kitchenette sink was not working (labeled Out of Order). During an interview on 9/20/2024 at 10:02 AM, Administrator #1 stated that the facility would have the walls and floors on the A-Wing and B-Wing and the building exterior cleaned, repaired, and/or repainted; new cleaning and painting schedules for the building interior would be developed; and the kitchenette sink would be repaired. 10 New York Codes, Rules, and Regulations 415.5(h)(4)

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, opened insulin had no open and/or expiration dates written on them. This was evident for 2 of 2 medication carts reviewed on Units A and B in the facility for medication storage. This is evidenced by: The facility's Policy and Procedure, titled Medication Label and Container Requirements, last modified [DATE] did not address labeling multi-use medications with expiration dates. During a medication cart review on Unit A with Licensed Practical Nurse #2 on [DATE] 10:53 AM, the following were observed: Resident #14's Insulin Lispro Solution had a sticker for date opened and date expired with nothing written on it. Resident #14's Lantus SoloStar Pen-injector had a sticker for date opened and date expired with nothing written on it. Resident #21's Lantus SoloStar Pen-injector had a sticker for date opened and date expired with an open date ,d+[DATE] and no expiration date written on it. Resident #32's Lantus SoloStar Pen-injector had a sticker for date opened and date expired with an open date ,d+[DATE] and no expiration date written on it. During a medication cart review on Unit A with Licensed Practical Nurse #1 on [DATE] 9:56 AM, the following were observed: Resident #24's Levemir FlexTouch Pen-injector had a sticker for date opened and date expired with nothing written on it. Resident #24's Humalog Injection Solution Pen had a sticker for date opened and date expired with nothing written on it. Resident #24's Insulin Lispro vial had a sticker for date opened and date expired with a date of expiration not legible. Resident #13's Insulin Lispro had a sticker for date opened and date expired with an open date ,d+[DATE] and no expiration date written on it. During a review of the above medication orders, it was found that the Physician's Orders for Resident #13's Insulin Lispro was discontinued on [DATE] and Resident #24's insulin Lispro was discontinued on [DATE]. During an interview on [DATE] at 11:21 AM, Licensed Practical Nurse #2, stated both the date opened, and date expired, 28 days after opening, should be put on the sticker when a new pen or vial was opened. Licensed Practical Nurse #2 stated the medications that were not dated would have to be discarded as there was no way to know if they had expired. During an interview on [DATE] at 9:56 AM, Licensed Practical Nurse #1 stated all multiuse insulin should be dated when opened. When asked when they would discard the Insulin Lispro for Resident #13 that was documented as opened on ,d+[DATE], Licensed Practical Nurse #1 looked at the manufacturers label and stated it says [DATE]. When asked what the date was that was written on Resident #24's Insulin Lispro they stated, I think it says 2025. During an interview on [DATE] at 12:42 PM, Licensed Practical Nurse #1 stated the night shift nurse was supposed to check the cart and get rid of expired/discontinued medications and signed off on the sheet. Licensed Practical Nurse #1 provided the last documented review sheet dated [DATE]. Licensed Practical Nurse #1 stated they noticed some of the medications that they looked at this morning were discontinued and had removed them from the cart. During an interview on [DATE] at 10:05 AM, Director of Nursing #1 stated the nurses should be writing on the label when the insulin were opened, when asked if the section on the label for expiration should be filled in the Director of Nursing stated, that is not done consistently, but it is standard practice to discard after 28 days and the nurses know that. During a subsequent interview on [DATE] at 12:58 PM, Director of Nursing #1 stated the night shift nurse was supposed to check the cart and sign the sheet daily. They stated they were not aware this had not been done since [DATE] on A Unit or that medications that were discontinued in January and June of 2024 were still in the cart this morning. Director of Nursing #1 stated there was no system in place to ensure this was done, but there would be. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were in accordance with professional standards of practice, for 3 (Resident #'s 28, 34, and 59) of 3 residents reviewed for oxygen administration. Specifically, (a.) for Residents #s 28, 34, and 59, their supplemental oxygen tubing were not dated and labeled to reflect when the tubing were changed. (b.) Resident #28's portable oxygen tank was empty. This is evidenced by: A review of the facility's policy and procedure (P&P) titled Oxygen Therapy, Concentrator, last revised on 3/26/2018, documented that oxygen would be administered by licensed nurses with a physician's order. As part of the procedure nursing staff would label and date the tubing and all tubing would be changed at least weekly (7 days), or more often if soiling with secretions occurs. A review of the facility's policy and procedure (P&P) titled Oxygen Therapy, Oxygen Cylinder, last revised on 6/27/2023, documented that oxygen would be administered via an open oxygen cylinder by licensed nurses with a physician's order. As part of the procedure nursing staff will label and date the tubing and all tubing would be changed at least weekly (7 days), or more often if soiling with secretions occurs. Oxygen flow rates, tubing connections, and the amount of oxygen remaining in the cylinder should be checked every shift and as needed. Resident #28 was admitted to the facility with diagnoses of hypertensive disease with heart failure, chronic diastolic heart failure (an impairment in the heart's ability to fill with and pump blood), and chronic respiratory failure with hypoxia (when there is not enough oxygen in the body's tissues). The Minimum Data Set, dated dated dated [DATE], documented the resident could be understood and understand others with no impaired cognition. During an observation on 9/17/2024 at 3:09 PM, Resident #28 was on oxygen at 3 liters per minute via a nasal cannula. The nasal cannula tubing was not labeled or dated to reflect when it was last changed. During an observation on 9/18/2024 2:47 PM, Resident #28's oxygen tubing had no label on the tubing when it was changed. During an observation on 9/19/2024 at 10:10 AM, Resident #28 was observed in the hallway in their wheelchair. The resident did not have their oxygen nasal cannula tubing in their nose and was wrapped around the oxygen cylinder which also was not labeled or dated when it was changed. An observation of the resident's portable oxygen bottle noted that the amount remaining was less than 500 pounds per square inch, which required changing. The resident stated that they had had shortness of breath the night prior and were still having some shortness of breath that day. A review of Resident #28 Treatment Administration Record for September 2024 had no documentation that the resident's oxygen tubing was to be changed weekly. Resident #34 was admitted to the facility with diagnoses of hypertensive heart and chronic kidney disease with heart failure, acute and chronic heart failure (an impairment in the heart's ability to fill with and pump blood), and type 2 diabetes with chronic kidney. The Minimum Data Set ( an assessment tool) dated 6/22/2024, documented the resident could be understood and understand others with no impaired cognition. During an observation on 9/17/2024 at 11:34 AM, Resident #34 was on oxygen at 2 liters per minute via a nasal cannula. The nasal cannula tubing was not labeled or dated when it was last changed. During an observation on 9/18/2024 at 2:57 PM, Resident #34's oxygen tubing had no label on the tubing when it was last changed. During an observation on 9/19/2024 at 10:04 AM, Resident #34's oxygen tubing had no label on the tubing when it was changed. A review of Resident #34 Treatment Administration Record for September 2024 had no documentation that the resident's oxygen tubing was to be changed weekly. Resident #59 was admitted to the facility with diagnoses of chronic respiratory failure with hypoxia (when there is not enough oxygen in the body's tissues), chronic obstructive pulmonary disease, and dependence on supplemental oxygen. The Minimum Data Set, dated dated dated [DATE], documented the resident could be understood and understand others with no impaired cognition. During an observation on 9/17/2024 at 12:28 PM, Resident #59 was on oxygen at 3 liters per minute via a nasal cannula. The nasal cannula tubing was not labeled or dated when it was last changed. During an observation on 9/18/2024 2:43 PM, Resident #59's oxygen tubing had no label of when it was changed. During an observation on 9/19/2024 10:07 AM, Resident #59's oxygen tubing had no label on the tubing when it was changed. A review of Resident #59's Treatment Administration Record for September 2024 documented that the resident's oxygen tubing was to be changed weekly every Sunday night. The last documented change for the resident's oxygen tubing was on 9/01/2024. During an interview on 9/19/2024 at 11:40 AM, Certified Nurse Aide #4 stated they did nothing with the oxygen tubing or supplies. They stated that the nurses usually handle the oxygen for residents. The nursing staff changed the tubing on the weekend and at night, sets the flow rate for the resident's oxygen, and checked the portable oxygen cylinder reserve amount. They stated that if the resident was on portable oxygen they would either move the resident to the nursing station or have a nurse come to the resident's room to verify that the portable cylinder had enough oxygen and did not require changing. During an interview on 9/19/2024 at 1:00 PM, Licensed Practical Nurse #4 stated the oxygen tubing should be changed weekly and labeled. They stated that the oxygen tubing for residents would be changed on Sundays. They stated the portable oxygen cylinders should be monitored regularly and changed when needed. Licensed Practical Nurse #4 mentioned that it was reported to them that the oxygen tubing for the residents were changed as scheduled during their report on Monday 9/16/2024. They stated that the nursing staff would document in the resident's electronic records that the change was completed. In mentioning Resident #38 oxygen cylinder almost empty and complaint of shortness of breath, Licensed Practical Nurse #4 stated that it was an issue and would address it immediately. They stated that they were the only nurse for the unit that day as the scheduled nurse left early. During an interview on 9/20/2024 at 11:48 AM, Director of Nursing #1 and Assistant Director of Nursing #1 stated the nursing staff administered the oxygen per the order from the physician. They stated that Certified Nurse Aides were not allowed to touch or do anything with the oxygen for residents. They stated that oxygen administration was a medication that was prescribed by the physician and should be monitored regularly by the nursing staff. Portable cylinders should be looked at regularly and changed as needed. They stated that the tanks should be checked for proper levels anytime the resident left their room on portable oxygen. They stated that if the portable cylinder was low it should be changed by the licensed nursing staff. They stated oxygen tubing was changed weekly and scheduled on the overnight shift to be completed by the licensed nursing staff. They stated when the tubing was changed the individual performing the task should label and date when the tubing was changed. Assistant Director of Nursing #1 stated they have created new labels for the staff for this task to standardize labeling for oxygen tubing. 10 New York Code of Rules and Regulations 415.12(k)(6)

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, equipment and floors were not clean, and equipment and walls were not in good repair. This is evidenced by: During observations in the main kitchen on 9/16/2024 at 11:14 AM, the following areas were soiled with food particles or a black build-up: The 3 upright freezers were soiled with food particles. Two drawers in the preparation area were soiled with food particles. The preparation area floor was soiled with a black build-up. The kitchen floor in corners, next to walls, and behind cooking equipment was soiled with food particles and a black build-up. The handwashing sink faucet and 3-bay sink faucet were leaking. The handle on the rightmost upright chest freezer was loose. Three wall tiles under the knife rack were broken. During an interview on 9/18/2024 at 10:43 AM, Administrator #1 stated the maintenance workers would be asked to repair the freezer door handle and the broken wall tiles, and the freezers, drawers, and floor would be cleaned and placed on a cleaning schedule. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14

Based on observation and interviews during the recertification survey, the facility did not dispose of garbage and refuse properly for 3 of 3 dumpsters. Specifically, dumpsters were not kept closed, and the dumpster area was not clean. This is evidenced by: During observations on 9/16/2024 at 1:02 PM, the top cover to one garbage dumper was open with refuse inside, the side door to a second dumpster was open with refuse inside, and refuse was on the ground in front of the third dumpster. During an interview on 9/18/2024 at 10:46 AM, Administrator #1 stated the facility staff would be re-educated on keeping the dumpsters closed and to always place the garbage inside. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observations and staff interviews during the recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, the staff did not use appropriate personal protective equipment when entering and exiting the rooms of COVID-19 positive residents and residents on Contact/Droplet Precautions. This was evident for 2 (Unit A and Unit B) of 2 resident units observed. This is evidenced by: The facility policy titled, Preventing the Spread of COVID-19 Through Infection Prevention and Control Measures, last modified on 12/29/2023 documented, Health Care Personnel who enters the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to transmission-based precautions and use a NIOSH-approved fit tested particulate respirator with N95 filters or higher, gown, gloves, and eye protection. The Center for Disease Control's Infection Control Guidance: SARS-CoV-2 dated JUNE 24, 2024, documented, This guidance applies to all United States settings where healthcare was delivered, including nursing homes and home health. The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency. Health Care Personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. During an observation on 9/17/2024 at 10:50 AM, Certified Nurse Aide #3 was observed entering a resident's room [ROOM NUMBER] on Unit A identified by signage on the door as Transmission/Contact/Droplet Precautions without wearing personal protective equipment other than a surgical mask that they had on prior to the observation. Certified Nursing Aide #3 exited the room at 11:05 AM carrying soiled linen bag with a gloved hand. During an interview on 9/17/2024 at 11:07 AM, Certified Nurse Aide #3 stated they should have had precautions on prior to going into the room. When asked what the sign on the door meant they stated that anytime resident was cared for they should have personal protective equipment on. They stated that when they went into the room, they noticed resident was already up and in bathroom and they did not think to come back out and put the personal protective equipment on and they should have. During an observation on 9/19/2024 at 10:45 AM, Certified Nurse Aide #4 exited a resident room on Unit A, removed gloves, and proceeded to enter and exit a locked utility room, pushing the buttons to enter an unlock code, then returning to the resident room. Certified Nursing Aide #4 did not use hand sanitizer or wash their hands during the observation. During an Interview on 9/19/2024 at 10:50 AM, Certified Nurse Aide #4 stated that they were supposed to use hand sanitizer after wearing gloves and coming out of resident rooms. During an interview on 9/19/2024 at 1:00 PM, Licensed Practical Nurse/Unit Manager #3 stated staff put on personal protective equipment outside of door. Staff should use personal protective equipment when providing care to residents regardless of if they were going to be in contact. After care, they should remove all personal protective equipment and place it in the appropriate containers within the resident room. Staff should wear N95 mask to bring resident's meal tray in room if resident was COVID positive. During an observation on 9/19/2024 at 8:40 AM, Certified Nurse Aide #1 was observed entering and exiting resident room [ROOM NUMBER] on Unit B identified by signage on the door as a Red Zone Contact/Droplet Precautions, wearing only a surgical mask for personal protective equipment. During an interview on 9/19/2024 at 8:40 AM, Certified Nurse Aide #1 stated one of the residents in the room was COVID positive, however the staff were told they did not have to wear personal protective equipment other than the surgical mask when entering the COVID positive resident's room to care for roommate. They must remain 6 feet away from COVID resident. During an observation on 9/19/2024 at 12:15 PM, Certified Nurse Aide #2 was observed delivering meal trays to resident rooms on Unit B wearing only a surgical mask for personal protective equipment. Certified Nursing Aide #2 entered and exited room [ROOM NUMBER], identified by signage on the door as a Red Zone Contact/Droplet Precautions, without additional personal protective equipment, using hand sanitizer, or washing hands prior to entering another resident room. During an interview on 9/19/2024 at 12:18 PM, Certified Nurse Aid #2 stated they did not have to put on additional personal protective equipment if they were just delivering trays and not touching the residents. Certified Nursing Aide #2 stated they put the tray on the overbed table in front of the resident but did not touch the resident so did not need to change gloves or wash hands. During an interview on 9/20/2024 at11:42 AM, Assistant Director of Nursing/Infection Control Nurse #1 stated a yellow tag on door means contact precautions. When taking care of resident staff need to wear gloves, gown, and mask. Hands should be washed hands before entering and exiting the room. New York Code of Rules and Regulation 415.19(a)(1-3) 48413

Based on observations, interviews, and record review during a recertification survey on 4/4/2022 through 4/8/2022, the facility did not ensure a resident received respiratory care consistent with professional standards of practice for 1 (Resident #47) of 1 resident reviewed for respiratory care. Specifically, the facility did not ensure Resident #47 received 4 liters of continuous oxygen via nasal cannula as documented in the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: Resident #47: Resident #47 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 3/22/2022, documented the resident was cognitively intact, could understand others and could make themselves understood. The Policy and Procedure (P&P) titled Oxygen Therapy (Concentrator) dated 3/26/2018, documented oxygen therapy through use of an oxygen concentrator (a mechanical device that provides oxygen through the nasal cannula) would be provided as ordered by the physician. Appropriately trained Licensed Nurses/Therapists/Therapy Assistant were to set up and monitor the use of the equipment. The Comprehensive Care Plan for Respiratory Status, last revised 4/1/2022, documented Resident #47 had an alteration in respiratory status related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan interventions included: O2 (oxygen) at 4L (liters) via NC (nasal cannula) continuous to maintain saturation greater than 90%; administer oxygen per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order documented to confirm any finger hypoxemia with ear lobe testing every shift for hypoxemic respiratory failure. During the following observations Resident #47's O2 concentrator was set on: -4/4/2022 at 11:10 AM, between 3L and 3.5L. -4/4/2022 at 12:14 PM, between 3L and 3.5L. -4/5/2022 at 11:11 AM, between 3L and 3.5L. -4/5/2022 at 12:51 PM, between 3L and 3.5L. -4/6/2022 at 10:45 AM, between 3L and 3.5L. -4/7/2022 at 9:57 AM, between 3L and 3.5L. -4/7/2022 at 11:54 AM, between 3L and 3.5L. A review of Resident #47's Oxygen Saturations from 3/29/2022 to 4/4/2022 documented: -3/29/2022 at 12:16 AM, 95% -3/30/2022 at 12:11 AM, 95% and at 9:59 AM, 93% -3/31/2022 at 12:11 AM, 95% -4/1/2022 at 3:13 AM, 95% -4/2/2022 at 12:45 AM, 95% -4/3/2022 at 3:25 AM, 91% and at 1:42 PM, 91% -4/4/2022 at 12:10 AM, 91% The medical record dated 3/29/2022 to 4/4/2022 did not include documentation of oxygen saturations every shift for hypoxemic respiratory failure as documented in the physician order. During an interview on 4/6/2022 at 9:50 AM, Physical Therapist (PT) #1 stated Resident #47 put the oxygen tubing under their chin and did not realize the O2 was not on properly. The PT stated after they put the NC in place on 4/6/2022, the resident's O2 saturation came up from 85% to 91% on 3L of oxygen on the concentrator. The PT stated the concentrator was already set at 3 liters, so they just put the NC in place for the resident. During an interview on 4/6/2022 at 10:40 AM, Licensed Practical Nurse (LPN) #1 reviewed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated the order was that the resident was to be on 4L of O2 via NC continuously and an O2 saturation was to be taken every shift. If the O2 was low, meaning under 90%, the staff should then use the ear lobe to get the O2 saturation. The LPN stated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If the O2 saturation was not documented on the TAR, then it should have been documented under the Vital Sign tab in the EMR. Resident #47 was on 4 liters of O2 according to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated they did not know why the order documented weaning efforts, because that was not something they were doing with the resident. The LPN stated there had been no effort to take the resident off 4 liters of oxygen. During an interview on 4/7/2022 at 10:01 AM, Director of Nursing (DON) reviewed Resident #47's oxygen order in the electronic EMR and stated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the resident had a lot going on right now and did not think weaning efforts would be appropriate. Resident #47's O2 saturations should have been monitored every shift according to the physician order. The DON stated the nurses should have read the order and noticed that the order was missing the place to document the residents O2 saturation every shift. During an interview on 4/7/2022 at 10:58 AM, Registered Nurse (RN) #1 stated O2 was care planned under respiratory status and the RNs utilized the resident's diagnoses, physician orders, and the MDS when developing care plans for residents. The facility had a process in place to review care plans to make sure the care plans were updated and included the same information that was documented in the MDS, physician orders, and diagnoses. The RN stated the nurses on the unit were supposed to follow the care plans. During an interview on 4/7/2022 at 11:54 AM, LPN #2 stated they signed off the resident's oxygen order this morning (4/7/2022) at 4 liters. When documenting in the TAR, the nurses were supposed look at the oxygen liter flow rate on the concentrator. During the interview, LPN #2 and the surveyor observed Resident #47's concentrator, and LPN #2 stated it was set at 3.5 liters. The LPN stated they did not document the resident's O2 saturations because it was not ordered for the resident to have O2 saturations obtained every shift. The LPN stated they followed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated the care plan did not necessarily indicate the oxygen liter flow for residents who received O2 and that they referred to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 10NYCRR415.12(k)(6)

Based on observation, record review and interview during the COVID-19 Focused Infection Control Survey completed on 7/29/2021, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of COVID-19 on 1 (Unit A) of 2 units. Specifically, the facility did not ensure staff on Unit A put on a gown prior to contact with residents on isolation precautions and did not ensure staff performed hand hygiene after removing Personal Protective Equipment (PPE). This is evidenced by: The New York State Department of Health guidance, titled Health Advisory: COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and revised 7/10/20, provides that when there are confirmed COVID-19 positive cases in a nursing home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e., do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The Center for Disease Control (CDC) guidance titled Using Personal Protective Equipment (PPE), updated on 8/19/20, provided: PPE was needed for a patient with confirmed or possible COVID-19 and healthcare personnel should adhere to standard and transmission-based precautions when caring for patients with COVID-19 infection. This guidance further documents that before exiting a patient's room, gloves and gown shall be removed (doffed) and the gown discarded in a trash receptacle, the facemask or respirator removed and discarded, and hand hygiene performed thereafter. Likewise, the CDC diagram guidance regarding PPE Sequencing, How to Safely Remove Personal Protective Equipment (PPE) document ID CS 2-E (undated), provides: discard [gloves, disposable face shield, gown, and mask or respirator] in a waste container before performing hand hygiene. Per CDC guidance, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 3/29/21, HCP should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for [residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection and are placed on quarantine], and if there is a new COVID-19 infection among personnel or residents, HCP should care for residents using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. During an entrance interview on 7/24/2021 at 9:30 AM, the Administrator stated the facility was on isolation precautions and staff were required to wear full PPE (gowns, gloves, N95, and face shield) with resident contact due to the facility-wide isolation precautions. The Administrator stated the COVID-19 positive resident, and the exposed COVID-19 resident were in the Red Zone on Unit B. In the Red Zone, staff were required to change their N95, face shield, gown, and gloves with every resident encounter. The rest of the facility was the Yellow Zone including all of Unit A. In the Yellow Zone, staff did not have to change their N95 and face shield with every encounter but had to change their gowns and gloves with every resident encounter. The facility Policy and Procedure (P&P) Preventing the Spread of COVID-19 dated 7/1/2021, documented staff were to clean their hands, including before and after contact with residents, after contact with contaminated surfaces or equipment, and after removing PPE. The facility P&P COVID-19 Patient Zone Placement, PPE Requirements and Considerations revised 7/15/2021, documented healthcare personnel (HCP) PPE for residents in the Red Zone and Yellow Zone was N95 mask, eye protection, gown, and gloves. The P&P documented gowns were changed after each resident encounter. Finding 1: During an observation on 7/24/2021 at 10:02 AM, Certified Nurse Assistant (CNA) #1 was in a resident room on A Unit and was wearing a face mask, face shield, and gloves and was not wearing a gown. CNA #1 carried a wash basin to the resident who was lying in bed. CNA #1 placed the wash basin on an over bed table next to the resident's bed, then pulled the resident's privacy curtain, but the foot of the bed remained visible to the surveyor from the doorway. The CNA pulled the resident's sheets down to the end of the bed and raised the resident's bed. Registered Nurse (RN) #1 was donning PPE to go into the room to assist CNA #1 with the resident's care and the surveyor made RN #1 aware that CNA #1 was not wearing a gown. RN #1 went into room and CNA #1 came out of the room. During an interview on 7/24/2021 at 10:08 AM, CNA #1 stated they had been in the room providing morning care to the resident but did not have time to put a gown on and had not worn a gown all morning when providing care to residents. CNA #1 stated every room they had gone into, was a mess, and they did not have time to don a gown. CNA #1 gave an example that a resident in another room had feces in the bed. The CNA did not have time to put on a gown, so they cleaned the feces without wearing a gown but did wear gloves and performed hand hygiene. CNA #1 stated they had been educated to put on and take off a gown going in and out of each resident room but had not worn a gown all morning while providing morning care to 8 of 19 residents on CNA #1's assignment. Finding 2: During an observation on 7/24/2021 at 10:17 AM, CNA #2 was wearing a face mask, face shield, and gown when exiting a room on Unit A. CNA #2 removed the gown in the hallway and was holding a water pitcher that was brought out of the room. CNA #2 carried the gown and water pitcher up the hallway to a receptacle to discard the gown. CNA #2 did not perform hand hygiene after removing or disposing of the gown and continued to walk up the hall, holding the water pitcher with both hands, toward the nursing station in the direction of the unit kitchenette. During an interview on 7/24/2021 at 10:20 AM, CNA #2 stated they had just finished providing morning care to the resident and should have removed the gown and discarded it in the room before coming out, but there was no garbage can in the resident's room. CNA #2 also stated they should have performed hand hygiene after disposing the gown in the trash in the hallway. CNA #2 stated they were holding the resident's water pitcher because they were going to refill it for the resident and bring back it to the resident's room. During a subsequent observation on 7/24/2021 at 10:22 AM, a garbage can was visible in the resident's room from which CNA #2 had come. The Infection Preventionist was not available for interview. During an interview on 7/24/2021 at 4:15 PM, the Director of Nursing (DON) stated gowns were supposed to be worn with direct contact and care with the residents. CNA #1 should have had a gown on when providing resident care. The DON also stated hand hygiene was supposed to be performed after removing PPE. CNA #2 should have removed the gown prior to leaving the resident's room and should not have removed the gown in the hallway. The DON also stated CNA #2 should have performed hand hygiene after removing the gown and throwing it away. Additionally, CNA #2 should have gotten a new water pitcher for the resident. 10 NYCRR 415.19(a)(1),(b)(4) 10 NYCRR 400.2

Based on observation, record review and staff and resident interviews for an abbreviated survey (Case #'s NY 469 and NY 348), the facility did not ensure residents had the right to be free from physical abuse for 2 (Resident #s 2 and 3) out of three residents' reviewed, from verbal abuse for one (Resident #3) of one resident reviewed and from psychological harm for one (Resident #2) of one resident reviewed. Specifically, the facility did not ensure that Resident #2 was free from physical abuse and psychological harm when on 12/15/19, Resident #1's altercation with Resident #2 resulted in an injury to Resident #2's right hip and a concern for his/her safety. Additionally, the facility did not ensure Resident #3, was free from verbal and physical abuse when on 7/6/19, a facility employee shouted obscenities at Resident #3 and another employee applied restrictive force to return the resident to his/her room. This is evidenced by: The Policy and Procedure for Abuse Prevention, Identification, Investigation, Protection and Reporting dated 4/17/19, documented all residents had the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, exploitation, and involuntary seclusion. Finding #1 Resident #1 (Aggressor) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment tool) dated 10/31/19, documented the resident had severe cognitive deficit, was usually understood, and could usually understand others. During an observation and interview 1/17/20 at 9:28 AM, Resident #1 was dressed and lying on his/her bed in the second room on the left from the end of the hall. The resident stated he/she was waiting to get the kids on the school bus. A Nursing Documentation note dated 12/15/19 at 7:30 PM, written by Registered Nurse Supervisor (RNS) #1, documented he heard yelling and screaming from the residents' hall and saw Resident #'s 1 and 2 yelling at each other. RNS #1 witnessed Resident #1 grab Resident #2's arm, pulling him/her out of the wheelchair (w/c) onto the floor and the w/c tipped over. The residents were immediately separated. The Comprehensive Care Plan (CCP) for mood/behavior dated 3/20/19 for Resident #1, documented to intervene and redirect resident from situations if becoming agitated and remove from stimuli or elevated situations as needed. It documented his triggers for agitation were the perception of a man hitting a woman, he would hit back if hit, and the death of his brother (7/19/19). The CCP for Aggressor/Victim, dated 8/26/19, documented to move the resident away from others at risk for becoming physically or verbally aggressive and if in an altercation, intervene to keep the resident safe. The Comprehensive Care Plan (CCP) dated as revised on 12/16/19 for Mood/behavior, documented to provide 1:1 visits from staff, as necessary, and as available, to monitor/document/report to Medical Provider of danger to self and others as needed, and to remove resident from stimuli or elevated situations as needed. Resident #2 (Victim) Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was usually understood and could understand others. During an observation on 1/17/20 at 9:32 AM: Resident #2 was alert, oriented and was sitting by the nurse's station in a w/c. He/she had bilateral lower extremity above the knee amputations. He/she was independent with wheelchair (w/c) mobility. His/her room was the last room on the right at the end of the hall. The undated Investigation Summary Report regarding the 12/15/19 incident that occurred at 7:30 PM, documented Resident #2 was in his wheelchair wheeling down the hall toward his room at the end of the hall. As he approached Resident #1's room, Resident #1 became increasingly agitated stating, No, no, don't go in my room. Resident #1 then grabbed Resident #2's left wrist and pulled him from his w/c to the floor. The CCP dated 12/15/19 for Victim (for Resident #2), documented he/she was pulled out of the w/c by another resident. Interventions included intervening immediately to protect him/her if an altercation occurred, monitor for negative effects from an altercation, and move the resident away from others who were at high risk to become physically or verbally aggressive. A Nurse's Note Dated 12/15/19 at 7:30 PM, written by the Registered Nurse Supervisor (RNS), documented he heard yelling coming from the residents' hallway. The two residents were yelling at each other. He/she then witnessed Resident #1 grab Resident #2's left arm and pulled him/her out of his/her w/c. As he/she was being pulled out of his w/c, it tipped over and the resident landed on his/her hip. A full Registered Nurse (RN) assessment found no abnormal findings other than the resident's complaint of hip pain. A Nurse's Note dated 12/16/19 at 1:19 AM, written by an RN, documented the resident told him/her about the previous evening's incident when asked. Resident #2 reported he/she was just trying to get by Resident #1 to go to his own room. Resident #1 told Resident #2 to get out of his house and stay out of his/her house. Resident #2 stated Resident #1 then took him/her by the arm and pulled him out of the w/c. A Nurse's Note dated 12/16/19 at 2:18 PM, written by a RN, documented Resident #1 was complaining of significant right hip pain from the fall out of his w/c the evening of 12/15/19. The Medical Doctor (MD) was notified. A Nurse's Note dated 12/16/19 at 2:31 PM, written by a Licensed Practical Nurse (LPN) documented the MD ordered an x- ray of the resident's right hip. The x-ray results dated 12/17/19 of Resident #2's right hip documented there was no fracture or dislocation of the hip. An MD order dated 12/17/19, documented an order was received for Tylenol 650 MG three times a day before meals for 7 days for right hip pain. The resident received 20 doses from 12/17/19- 12/23/19 for right hip pain. An MD Progress Note dated 12/18/19 at 10:09 AM, documented Resident #2 was examined for the right hip pain that resulted from the 12/15/19 incident. The resident was angry about the incident. The MD documented the resident had right hip pain and a contusion (blood or bleeding under the skin due to trauma). The resident refused a pelvic x-ray but may consider if the pain did not subside. Routine Tylenol was ordered three times a day for 7 days. The resident did not want a stronger pain medication. Interviews During an interview on 1/17/20 at 9:32 AM, Resident #2 stated that last month, Resident #1 grabbed him/her and pulled him/her out of the w/c. He/she was lucky not to have broken a hip. He/she had severe pain for about 3 weeks following the incident. The resident stated he/she was and still is very upset by the incident. He wanted to be transferred to the other unit, or at least to the opposite end of the unit he was on, and preferably to another facility altogether. He/she stated he/she could not take it anymore. Resident #1 continued to try to get into his room. He/she had not felt safe ever since the incident occurred. He/she stayed in his/her room whenever Resident #1 was in the hall. During an interview on 1/17/20 at 9:58 AM, the Director of Social Work (DSW) stated she spoke with Resident #2 who was very angry about the 12/15/19 incident. She stated after the incident he/she asked to be moved. When beds became open on the short hall, he/she was offered a room, but declined stating he/she wanted to move to the long hall. The resident also requested to be moved to a different facility. She thought he/she was all set to go to an adult living facility in a neighboring county, but was notified by the facility that they could not accept him/her. She was exploring every option to honor the resident's request to move to another facility. She stated Resident #2 was still upset over the incident and with the agreement of the resident's roommate, kept the door closed but ajar whenever he/she was in his room. During an interview on 1/17/20 at 1:37 PM, Certified Nursing Assistant (CNA) #1 stated she provided care for Resident #2 on the 7:00 AM- 3:00 PM shift. She stated the day after the incident, Resident #2 told her he/she was going to go after Resident #1. He was very upset. After the incident Resident #2's behavior changed. Prior to the incident, Resident #2 had started coming out of his room and was becoming more conversive with staff. After the incident, he/she became more irritable with the CNAs and became withdrawn, staying in his/her room most of the time. When she asked him what was wrong, he would not answer her. During an interview on 1/17/20 at 1:43 PM, CNA #2 stated Resident #2 told her that jerk pulled me out my chair and he/she wanted to retaliate. The resident also told her he/she had pain in his/her hip. She stated prior to the incident, Resident #2 had started opening up to the CNAs and she had developed a good rapport with him/her. After the incident he/she became more withdrawn and was staying in his/her room. He became more irritable. The resident had just recently, within the past week, started coming out of his/her room into the hallway. During an interview on 1/17/20 at 1:53 PM, LPN #1 stated anytime Resident #2 saw Resident #1 he/she would say, I'm staying away from that guy/girl. During an interview on 1/17/20 at 2:28 PM, the Director of Nursing (DON) stated on 12/15/19, she received a phone call from the RNS to report the incident. Resident #1 thought Resident #2 was going to go into his/her room, when in fact, Resident #2 was going to his/her own room. Following the incident that evening a support aide provided 1 to1 supervision for Resident #1 until he/she went to bed. She stated Resident #1 did not target Resident #2, specifically; he had exhibited aggressive behaviors toward other residents as well. She stated there was physical and psychological harm to the resident because he/she was injured during the incident and was still very upset. Resident #2 had requested a room change and did not except a transfer to a bed that was offered because he/she felt it was still too close to Resident #1. She stated she felt the facility had failed Resident #2 because no rooms had become vacant that the resident felt was far enough away from Resident #1. During an interview on 1/21/20 at 8:32 AM, the RNS who was working on the unit at the time of the incident stated he was just starting toward the residents' hall at 7:30 PM (12/15/19), when he saw 2 residents yelling at each other. He started down the hall to separate them, when he witnessed Resident #1 pulling on Resident #2's left arm and pulled him out of the wheelchair, tipping it over. He assessed the resident who complained of hip pain. There were no assessment findings that indicated a fracture. He offered Resident #2 Tylenol for pain, but he/she declined it. A CNA assisted him in putting Resident #2 into bed. He attempted to redirect Resident #1 to his/her room, but he/she would not comply. During an interview on 1/29/20 at 2:44 PM, Resident #2's MD stated the resident told him he/she was angry about the incident when he examined him/her on 12/18/19 following the incident. He stated Resident #1 was not followed by psychiatric or psychological services because he did not have a mental health diagnoses. His [DIAGNOSES REDACTED]. He would not benefit from counselling because of his level of confusion and lack of recall from visit to visit. He stated Resident #1's behaviors were unpredictable. He saw Resident #2 intermittently and the resident made it clear he/she did not want any intervention from psychiatry/psychology following the incident and wanted no medication for anxiety. During a subsequent interview on 1/29/20 at 3:09 PM, the DON stated that neither resident was followed by mental health providers before or after the 12/15/19 incident. She clarified that Resident #1 had aggressive behaviors toward other residents prior to the incident with Resident #2. He/she had hit another resident because he/she thought a man was hitting a woman. Resident #1 had distant supevision with locomotion on and off the unit, which was added to his/her care plan. The staff redirected the resident away from situations that could contribute to an outburst of aggression. A velcro stop sign was recently placed across Resident #2's door to keep other residents from entering the room. Another room change was offered to Resident #2 who declined it. She stated she did not know if a room change would really matter because Resident #1 wandered (with distant supervision) throughout the facility in his/her wheelchair. Finding #2 Resident #3 (VICTIM) The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could understand others. Incident #1 The undated facility Investigative Summary Report for the 7/6/19 incident, documented that at approximately 3:15 PM, Resident #3 approached the nurses' station yelling an obscenity and stated that he/she owned the place, would do what he/she wanted, and did not want to leave the unit. He/she leaned forward over the nurses' station and LPN #1 stood up face to face with the resident and screamed go to your (obscenity) room and get out of my (obscenity) face. As Resident #3 was leaving, he/she called LPN #1 a (obscenity) whore, to which the LPN yelled back, It takes a whore to know one. The testimonial evidence documented in the facility's Investigation Summary Report documented that during an interview with LPN #2 (on 7/7/19), the resident was using foul language and ordered staff to get out. He/she was asked several times to leave the nurses' station and go back to his/her own unit. The resident stated he/she was going to get the (obscenity) out of the place to which LPN #1 stated she told the resident, So go the (obscenity) back. She stated the resident looked taken aback that something was finally said to him/her. The resident said a few more obscenities and then returned to her unit. She stated she apologized to her staff and began her shift. A Behavior Note dated 7/6/19 at 4:30 PM, written by LPN #2 documented the resident was at the Nurses' station while shift report was being given at 3:00 PM. She began to rant about how staff were not doing their jobs and she was going to call the police. Her behavior escalated and she escorted the resident back to her unit. A Behavior Note dated 7/6/19 at 7:05 PM, written by an LPN on the resident's unit, documented she was agitated, trying to go behind the Nurses' station to call the police, and told staff they needed to throw the resident out who was screaming. At that time, the resident wandered over to the other unit and started yelling at staff over there. LPN #2 brought the resident back to her unit where she sat quietly in a chair for about 30 minutes and then went to her room. A Nurse's Note dated 7/8/19 at 10:25 AM, written by a Registered Nurse (RN) documented a skin check was completed following the 7/6/19 incident. There were no bruises, abrasions, or redness observed on the resident's skin. There was no indication of psychological distress or harm as the resident had no recollections of the events that occurred on 7/6/19 with staff. A Social Services Note dated 7/8/19 at 1:05 PM, written by the Director of Social Services, documented she initiated a conversation with the resident who was telling her of his/her adventures over the weekend with his/her brother and sister-in-law (confabulated). The resident did not seem to have any recollection of any negative interactions or perceived punishment from facility staff over the weekend. Incident #2 The undated facility Investigative Summary report the the second incident involving Resident #3 on 7/6/19, documented that at approximately 3:20 PM, the resident returned to the nurses' station after he/she had been involved in a staff to resident verbal altercation. The resident was standing next to CNAs #1 and #2. LPN #2 came from around the nurses' station, placed the resident in a restraint-like hold, escorted the resident back to his/her unit, and put him/her in a chair. During an interview on 1/21/20 at 11:59 AM, CNA #1 stated she was getting report at the nurses' station when the 7/6/19 incident occurred. The resident was at the nurses' station and was asked to leave by LPN #1. The resident yelled an obscenity at her, and LPN #1 yelled back using profanity to tell him/her to get out of her face. The resident retorted that she was a (two obscenities used) and LPN #1 yelled back it took one to know one. She then witnessed LPN #2 put the resident in a hold that restrained him/her to escort the resident back to his/her unit. The resident was resistant and was dragging his/her feet. Staff were not supposed to put their hands on a resident in that way. She stated nobody interceded to stop the incident. During an interview on 1/21/20 at 1:31 PM, the DON stated staff should remove the person who was being accused of abuse/neglect, and ensure the involved resident was safe. She stated the physical restraint procedure used by LPN #1 was not allowed to be used in nursing homes. Staff knew they were supposed to call the DON when an incident occurred, but did not report the incident until the next day. During an interview on 1/21/20 at 2:04 PM, the resident stated her care was ok. Sometimes staff would call her names. She stated when that occurred, she would go outdoors and vent and feel better when she came back inside. She would swear but did not use real bad words. She said you learn to live with it and not let it bother you. During an interview on 1/23/20 at 2:56 PM, CNA #2 stated she was getting report from LPN #'s 1 and 2 at the nurses' station on 7/6/19 a little after 3:00 PM. The resident was standing next to the nurses' station. The resident leaned over the desk at the nurses' station and swore at LPN #1, who swore back at the resident and told her to get out of her face. Then LPN #2 put the resident in a SCIP hold (a physical restaint method used in group homes for the developmentally disabled population to protect themselves and others), and aggressively removed the resident from the unit. She was forcing the resident to take steps. The resident did not want to go and was dragging her feet. Staff did not intervene to stop the nurses from their actions, but did try to redirect the resident from the area. The resident did not comply and that was when the nurses intervened. Other staff present did not intervene to stop the LPNs from their actions. During an interview on 1/23/20 at 3:07 PM, CNA #3 stated he was working on the resident's unit on 7/6/19 and was at the nurses' station when at 3:15 PM, he witnessed the resident being escorted by an LPN with the LPN's arm around the resident under the resident's arm and she was kneeing the resident to keep her moving. She then roughly assisted the resident to sit in a chair. He stated if he had witnessed that occur to his family member, he would have been very upset. 10 NYCRR 415.4(b)(1)(i)

Based on record review and staff interviews during an abbreviated survey (Case #NY 348) the facility did not ensure that all violations involving abuse or mistreatment were reported no later than two hours after the allegation is made for 1 resident (Resident #3) of 3 residents reviewed. Specifically, on 7/6/19, Licensed Practical Nurse (LPN) #1 was witnessed by 2 Certified Nursing Assistants (CNA) yelling and shouting obscenities at the resident. Additionally, 3 CNAs witnessed LPN #2 using physical force to restrain a resident while walking the resident back to the resident's unit against the resident's will. The witnesses did not stop the abuse from occurring and did not immediately report the abuse. This is evidenced by: Resident #3 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 6/19/19, documented the resident had severe cognitive impairment, could be understood, and could understand others. The Policy and Procedure dated 4/17/19, documented that all staff were obligated to report to the Administrator and the State Department of Health all incidents or suspicion of physical abuse, mistreatment or neglect of residents. All incidences of alleged or substantiated abuse were to be reported to the Administrator immediately. The New York State Department of Health (DOH) complaint Intake Form documented the incident occurred on 7/6/19 and was reported to the DOH on 7/8/19 after facility administration first learned of the incident on 7/7/19. Interviews: During an interview on 1/21/20 at 11:59 AM, CNA #1 stated she was at the nurses' station getting report when the 7/6/19 incident occurred that involved Resident #3. She did not report the incident until the next morning. She did not feel it was her place to say anything because she was just a CNA and was afraid she would lose her job. During an interview on 1/21/20 at 1:31 PM, the Director of Nursing (DON) stated staff knew they were supposed to call the DON when an incident occurred. She stated the 7/6/19 incident was reported to her on 7/7/19 and both nurses were taken off the schedule at that time. Both accused staff members finished their shifts on 7/6/19. The response time to start investigation and remove the 2 accused staff members would have been much quicker if she had been notified of the incident at the time it occurred. During an interview on 1/23/20 at 2:56 PM, CNA #2 stated she was getting report at the nurses' station when the incident on 7/6/19 occurred. She did not report the incident until the next day. She stated she should have reported the incident when it occurred. 10 NYCRR 415.4(b)(1)(i)

Based on observations, record review and interviews during an abbreviated survey (Case # NY 454), the facility did not ensure a resident's right to be free from abuse for 1 (Resident #1) of 6 residents reviewed for abuse. Specifically, the facility did not ensure Resident #1, who had severe cognitive impairment, was free from sexual abuse when he/she was assaulted by Resident #2 who had no cognitive impairment. Due to the resident's severe cognitive impairment and ability to express their feelings, it was determined that no actual harm occurred as a result of the assault, using the reasonable person concept referenced in Appendix Q of the State Operations Manual. This is evidenced by: The Policy and Procedure (P&P) titled Abuse Prevention, Identification, Investigation, Protection and Reporting dated 1/09/2018 and modified on 4/17/19 documented that each resident would be free from abuse. Abuse could include verbal, mental, sexual or physical abuse. The P&P documented sexual abuse was defined as non-consensual sexual contact of any type with a resident. Resident #1: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 10/30/19, documented the resident was able to make themselves understood and was understood by others, and cognitive skills for daily decision making were severely impaired. The Comprehensive Care Plan (CCP) for Impaired Cognitive Function, last reviewed on 10/15/19, documented Resident #1 had impaired thought processes related to dementia. Appropriate Goals and interventions for care needs well documented. The CCP for Victim of Inappropriate Touch implemented on 7/9/19, last revised on 8/21/19, documented to monitor Resident #1's reaction to female/male residents and observe for any indication of fear of Resident #2 or other female/male residents. A resident account of the incident report dated 7/9/19, documented Resident #1 was in a wheelchair in the hall and another resident stopped beside me and reached out and touched my breast, and then asked me Now that feels good doesn't it? I said no. The resident said she/he didn't feel scared of her/him. No, I'll pop her/him right in the eye if she/he does it again. An Incident Report dated 7/9/19 at 9:45 AM, documented the Registered Nurse Supervisor was informed by the Certified Nursing Assistant #1 (CNA) of a complaint made by Resident #1. After interviewing Resident #1 who reported the big woman/man in a wheelchair touched her/his breast. The Licensed Practical Nurse #1(LPN) had assessed her/his body for injury and none was noted. Resident #1 was calm and did not change the account of the incident after being asked to repeat it twice. I then spoke to Resident #2 who admitted immediately to touching the other residents' breast. Resident #2 stated she/he was just raising hell, I didn't mean anything by it. A Nursing Progress Note dated 7/9/19 at 2:02 PM, by the Registered Nurse Manager (RNM #1), documented she was informed by direct care staff that Resident #1 reported that a female/male resident had touched her/him inappropriately on the breast. Incident was discussed with the Director of Social Services and the Health Care Proxy (HCP) was notified. A CCP for both residents was implemented and a room change was offered and declined by the Resident #1. No negative impact noted, and no psychological harm noted. Facility will continue to monitor status. A Nursing Progress Note dated 7/10/19 at 10:56 AM, by the RNM #2 documented Resident #1 was seen by the SW #1 to determine any harm from the previous days incident where the resident was touched inappropriately by Resident #2. No harm presents. HCP aware, resident refuses room change, care plan updated, and facility will continue to monitor status for additional interventions to prevent similar incident. The Facility Interval Case Review dated 7/10/19 for date of event 7/9/19, documented inappropriate resident-to-resident contact. As CNA #1 was providing care to another resident he overheard Resident #1 who was in the hallway outside the door say that was inappropriate, I didn't like it, as the CNA stepped back to observe what was going on, he saw Resident #2 leaning over Resident #1, he directed Resident #2 to go to her/his room and then Resident #1 reported inappropriate touching of her/his breast by Resident #2. The investigation determined that the CNA #1 reported this to the LPN #1 immediately. The RN Supervisor #2 interviewed Resident #1, who stated she/he had been touched on the breast by another resident. Resident #2 later stated in interview that she/he touched the breast of Resident #1. Immediately upon seeing CNA #1, Resident #2 removed her/his hand and went to her/his room without saying anything as CNA #1 intervened. Resident #1 reported she/he was uninjured and unafraid. Resident #1's HCP was notified, and a room change was offered and declined. Resident #2 stated loneliness prompted the incident but knew it should not have happened and that she/he was just raising hell. Resident #2: Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was understood and could understand others with a BIMS score assessed to be 14/15, and was cognitively intact for daily decision making. The MDS further documented the resident received antidepressant medication for the last 7 days. The CCP for Behavior and Mood implemented on 07/09/19 and updated on 10/26/19, documented Resident #2 may displayed inappropriate sexual behaviors towards female/male residents related to inadequate opportunities for sexual expression due to being a widow/widower. Interventions as follows: Psychiatric consults order as indicated. Resident educated that any sexual inappropriateness towards residents or staff will be reported to the local police department. Provide resident with private time/area for self-gratification. The Social Services Note dated 7/9/19, by Social Worker (SW) #1, documented an interview had been conducted with Resident #2 concerning an incident that occurred earlier on 7/9/19 with Resident #1. Resident #2 voluntarily admitted to touching Resident #1's breast. Resident #2 said they were raising hell. The resident's daughter was contacted and stated there was no history of this behavior to her knowledge. Resident #2 stated later during a follow up I'm kind of sorry this happened. A Nursing Progress Note dated 7/10/19 at 10:51 AM, by the Registered Nurse Manager (RNM) #2, documented Resident #2 was placed on 15 minutes checks on 7/9/19 after inappropriate touching a resident. Staff today indicates no further inappropriate behavior. Care plan was reviewed and revised, and the facility will continue to monitor behavior. A door alarm will be placed today to alert staff when the residents exits the room. The Provider Progress Note dated 7/12/19 at 10:37 AM, documented the resident was seen for discussion of an incident on 7/9/19. When asked about the incident, the resident informed me that it was an isolated event and will not happen again, ordered continued monitoring for further unusual behavior to prevent this from happening again. If it does, law enforcement will be contacted and Resident #2 is aware. The resident has [MEDICAL CONDITION] with spouse dying several years ago. Resident presents with weight gain, little motivation but symptoms seem to be relatively stable. Continue [MEDICATION NAME] and [MEDICATION NAME] as ordered. Resident is apologetic for the incident and states it will never happen again. Resident is mostly independent although there is an alarm on the door for the staff to be aware of resident coming and going from room. Nursing progress notes from 7/12/19 to 7/15/19, documented behavior monitoring continues every shift for sexual inappropriateness. No behaviors documented. An administrative progress note dated 7/15/19 at 3:15 PM, the Administrator documented a follow up visit with Resident #2. It was done to reassess the effectiveness of current interventions placed after the sexual incident with Resident #1 and to ensure the resident understood the actions were not appropriate. The resident stated, don't worry that won't happen again. The resident verbalized displeasure with the door alarm but understood why we made the decision to utilize the alarm. She/he understands our concerns for the safety of all our other residents. We discussed the residents needs and we will continue to follow up with the team and the resident on healthy outlets. During an interview on 11/13/19 at 12:30 PM, the Director of Nursing (DON) stated she was told of the incident at the time by the RN supervisor. It happened on a weekend and quick action was taken to ensure the wellbeing of the resident. Resident #2 admitted to inappropriately touching Resident #1 and understood it was wrong. The resident was placed on 15-minute checks until a door monitor was put in place and checked every 30 minutes after that. Staff is continuing monitoring and doing a general 15-minute hall check on all units. The door alarm is still in place and the residents' room has been changed. No further incidents with any other residents have occurred. During an interview on 11/14/19 at 10:30 AM, Resident #1's representative (RESREP) stated that if Resident #1 was still able to think clearly, the incident wouldn't have happened, however police intervention was offered and declined. It was the decision of her father, who was the residents' brother, that no harm had occurred, and they were both satisfied the facility was doing all they could to monitor the situation. They were very happy with the care Resident #1 was receiving. It was further stated they visit the resident often and no other situations had taken place. It was the family's opinion the resident had suffered no harm and would not want to press charges against Resident #2. The resident didn't speak about it any longer and they all preferred it that way. An administrative progress note dated 7/15/19 at 3:15 PM, the Administrator documented a follow up visit with Resident #2. It was done to reassess the effectiveness of current interventions placed after the sexual incident with Resident #1 and to ensure the resident understood the actions were not appropriate. The resident stated, don't worry that won't happen again. The resident verbalized displeasure with the door alarm but understood why we made the decision to utilize the alarm. She/he understands our concerns for the safety of all our other residents. We discussed the residents needs and we will continue to follow up with the team and the resident on healthy outlets. During an interview on 11/13/19 at 1:35 PM, CNA #2 stated she provided care to Resident #2 on a regular basis. The resident stays in their room a lot and when resident is out on the unit, we keep an eye on them. There have not been any further behaviors of this type that I know of. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this regulatory requirement at the time of the abbreviated survey conducted on 11/13/19 and 11/14/19: -Immediately following the incident on 7/9/19, Resident #2 was placed on 15-minute checks to monitor her/his location and behaviors until door monitoring was placed and then changed to 30-minute checks until 7/12/19 and re-evaluated. - A door monitor was placed on Residents #2 room to alert staff when she/he has exited her/his room and to monitor her/his behavior. - Resident #2 was placed on the provider list for medication review, since the resident was receiving antidepressant medication. - Resident #2 was placed on an outside Psychologist list to talk about her/his psychological needs and the Psychiatrist list for review of [MEDICAL CONDITION] medication changes. - The activities department was to further investigate how Resident #2 filled the day and ensure many alternatives were in place for the resident to address her/his self-reported feelings of loneliness and provide other methods of distraction. - As an extra precautionary measure, recognizing that Resident #2 resided on an advanced dementia unit, the staff was educated not to leave any at risk residents alone in the hall area without monitoring when Resident #2 was out of their room. - Care planning to provide Resident #2 with private time related to self-gratification was implemented. Also, 1 on 1 visits from the SW were implemented to encourage the resident to verbalize loneliness and care plan appropriate outlets. - To provide further distance between Resident #1 and Resident #2, Resident #2 was moved down the hall on 7/19/19 - Care plans were reviewed and revised accordingly for both residents. - The Facility has implemented an all department in-servicing on Abuse, Neglect and Maltreatment education that began on 7/9/19 and was completed on 9/19 /19. 10 NYCRR 415.4(b)(1)(i)

Based on record review and staff interview during a recertification survey the facility did not ensure the physician was notified in a timely manner when there was a significant change in condition for one (Resident #62) of four residents reviewed. Specifically, for Resident #62, the facility did not ensure the physician was notified of the resident's low blood pressure and oxyygen saturation rate on 9/28/19. This is evidenced by: Resident #62: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] and was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment tool) dated 10/15/19, documented the resident had mild cognitive impairment and was able to make his needs known. A policy titled Notification of Resident Changes dated 5/31/2018, documented the facility will immediately consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status. A progress note dated 9/28/19 at 2:21 PM, documented at approximately 9:21 AM, that the resident's blood pressure was 70/38, and oxygen saturation was 78% on 4 Liters (L) via nasal cannula (NC). The resident's name was placed in Medical Doctor's book for low blood pressure (BP). During an interview on 10/31/19 at 12:19 PM, Registered Nurse Unit Manager (RNUM) #1 stated that she assessed the resident, but she did not document the assessment in the progress notes. Additionally, RNM #1 stated that she did not feel that a blood pressure of 70/38 warranted a call to the physician. During an interview on 11/01/19 at 8:34 AM, the Director of Nursing (DON) stated that the Nursing Supervisor should have documented an assessment and the physician should have been notified at the time of the change in the resident's condition. During an interview on 11/01/19 at 9:05 AM, the Medical Director stated that based on the information documented in the progress note dated 9/28/19 at 2:21 PM, the physician should have been notified and the resident probably would have been sent to the hospital sooner. 10NYCRR415.3(e)(2)(ii)(b)

Based on observations, interviews and record reviews during a recertification survey the facility did not ensure written notice was provided to the residents and residents representative of the bed hold and return policy at the time of transfer for three (Resident #'s 36, 62 and 175) of three residents reviewed for hospitalization . Specifically, for Residents #'s 36, 62, and #175, the facility did not provide written notice of bed hold and return policy which specifies the duration of the bed hold, how reserve bed payments will be made, and the conditions upon which the resident would return to the facility. This is evidenced by: A policy title hospitalization (Bed Reservations, Readmission, Notifications) dated 7/11/2018, documented the Director of Social Services or designee is responsible for coordinating the bed reservation process, for knowing the bed reservation status of a resident at all times, and for informing the resident or legally designated representative and/or responsible party of the facility bed reservation policies upon discharge and readmission. Resident #36: The resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 8/23/19, documented the resident was cognitively intact, could make himself understood and could understand others. During record review on 10/31/19, staff were unable to provide bed hold notices for the resident's 6/11, 6/21, and 6/29/19 admissions. XXX During an interview on 10/31/19 at 1:40 PM, the Administrative Assistant stated that bed hold notifications were not provided to the resident for any of the resident's (MONTH) 2019 discharges to the hospital (6/11, 6/21, and 6/29/19). She stated the Social worker had left. She and two other staff members were trying to take care of the discharge notices, but didn't know the procedure that included notification of the bed hold policy. Resident #62: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was discharged to the hospital on [DATE] and re-admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The MDS dated [DATE] documented he had mild cognitive impairment and was able to make his needs known. On 10/31/19, the medical record did not include documentation that a written notification of bed hold and return policy was provided to the resident or the residents representative on 9/30/19. During an interview on 10/31/19 at 11:09 AM, the Nursing Administrative Assistant stated notification of the bed hold policy was not provided at the time of transfer. During an interview on 10/31/19 at 11:18 AM, the Director of Nursing (DON) stated there is not currently a process in place to notify residents and their representatives of the bed hold and return policy at the time of transfer. Notifications have not been provided consistently and they should have been. Resident #175: The resident was admitted to the nursing home on 9/27/19, with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident understood and was understood by others. A Progress Note dated 10/2/19, documented that a call was received from the hospital regarding critical laboratory findings. The Medical Doctor was notified, and the resident was transferred to the hospital. During an interview on 10/30/19 at 08:42 AM, the Administrator stated a bed hold was not given for this resident and that that they recognized that the bed holds were being sent out sporadically. The new Social Worker (SW) had some training recently, but there was still a gap that they are working on. 10NYCRR415.3(h)(4(i)(a))

Based on record review and staff interviews, the facility did not ensure Preadmission Screening (SCREEN) was complete for 1 (Resident #s 25) of 19 residents reviewed. Specifically, for Resident #25, the facility did not ensure the SCREEN form DOH-695 dated 4/5/19 included an answer to the question regarding serious mental illness when the Patient Review Instument (PRI) dated 4/5/19, documented the resident had a [MEDICAL CONDITION]. This is evidenced by: The Policy and Procedure dated 7/10/18 for Admission Screening and Approval Process Long Term Care (New York State), documented for admission to the facility from a hospital of other health facility a PRI must be completed by a qualified Registered Professional Nurse assessor, and the SCREEN must be completed and signed by a qualified assessor. Resident #25: The resident was admitted to the nursing home on 4/5/19, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 8/17/19, assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A Patient Review Instrument (PRI) dated 4/5/19, documented the resident's primary medical problem was [MEDICAL CONDITION]. A SCREEN form DOH-695 dated 4/5/19, was blank for question 23; does the resident have a serious mental illness? During an interview on 10/29/19 at 03:53 PM, the Administrator stated they had screeners that worked for the company that would do the SCREEN and review the clinical documentation to make sure everything was in order. The Screener should have looked at the screen and recognized that question 23 was blank. The [DIAGNOSES REDACTED]. 10NYCRR415.11(e)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure an ongoing program to support residents in their choice of activities for 2 (Resident #'s 13 and 71) of 2 residents reviewed for activities. Specifically, the facility did not ensure residents were provided, an ongoing program to support them in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, based on the comprehensive assessment, care plan and preferences of the resident. This is evidenced by: Resident #71: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 10/2/19, documented the resident had severe cognitive impairment. The annual MDS dated [DATE]. noted that based on resident response, it was very important to the resident to listen to music, be around animals, do things with groups of people, and participate in religious services. Itdocumented the resident required extensive assistance of staff to move about the facility. The Comprehensive Care Plan for Activities - Leisure documented the resident preferred the following activities; cognitive games including Bingo, exercise or sports involving sensory wake-up, balloon volleyball, music, talking with others about my memories/family, sensory programs, comfort animals, sensory bins, therapeutic dolls, and fidget items. An Activities Evaluation completed 10/9/19 documented the resident requires invitation and verbal cues for initiation of attending programs of choice and continued support from staff for continued participation in group programs. The Activities Calendar for (MONTH) 2019 documented 6-7 activities were offered each day from 10/28/19 through 10/31/19, including exercise, wake-up, sensory, social, music, religious, and reminiscing activities. The morning exercise group was scheduled for each morning at 10:00 AM except for 10/31/19, when a Halloween costume judging was scheduled. The Program Resident Detail, which documents all activities offered, the residents that attended, and the length of time they participated for the time period 10/28/19 through 10/31/19 documented this resident participated in one activity, exercise-stretching for 30 minutes on 10/31/2019. The resident specific activity attendance record printed on 10/30/19, documented the last activity attended by this resident was on 10/27/19. It further documented the resident had not attended Bingo scheduled every Sunday in October, the music entertainment scheduled on 10/15/19 and 10/23/19, the music Bingo scheduled on 10/14/19 and 10/26/19, or in any religious activities scheduled for the month of October. During observations on: 10/30/19 from 9:49 AM to 11:38 AM - the resident was seated in a wheeled chair placed against the wall under the television near the nurse's station. 10/30/19 from 11:38 AM to 1:45 PM - the resident was in the dining room. 10/30/19 from 1:45 PM to 2:12 PM - the resident was in her chair, in the hallway outside her room. 10/30/19 from 2:12 PM to 3:40 PM - the resident was seated in a chair in her room looking out the door calling out to staff as they passed by. During an interview on 10/30/19 at 2:12 PM, the resident, when asked by a surveyor if she would enjoy attending a music program, replied I love music. During an interview on 10/31/19 at 9:01 AM, the Regional Memory Care Consultant stated, all residents should be invited to any activity, and activity staff should go around and offer assistance to all residents to go to activities and nursing staff should be reminding residents of the day's activities. During an interview on 11/1/19 at 9:00 AM, Activities Staff member #2 and #3 reported this resident attends activities regularly, she goes to morning exercise most days. When asked why this resident has not attended any activities this week, the activities staff both reported she had attended several activities, however they were unable to provide documentation of participation. When asked why this resident was not invited to attend the music entertainment on 10/30/19 at 1:45 PM, Activity Staff member #2 reported the resident might have been sleeping. Resident #13: The resident was admitted to the nursing home on 5/10/19, with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The admission MDS dated [DATE], documented the resident's preferences as music, pets, doing things in groups, doing favorite activities, outside in good weather, and religious services. A Cognitive Assessment tool (CAT) (a tool used by activities to help identify a person's cognitive status and develop an appropriate activity plan based on their abilities) dated 5/12/19, documented the resident was a level 6 meaning normal cognition. The person could learn something new without demonstration and could independently anticipate potential problems and hazards. An Activity assessment dated [DATE], documented the resident had a cognitive level of 6 and would not participate in the seasons program. She preferred card games, art programs, entertainment, and movies, and the goal was to attend activities up to 4 times a week. The Comprehensive Care Plan (CCP) for Activities, dated 5/12/19, documented to offer choices, invite the resident to activities, and to supply an activity calendar. The resident preferred art programs, cognitive games - trivia, bingo, Pokeno, and brainstorms; exercise, music happy hour, outdoor activities, socials, TV- comedy, drama, action/adventure. During an interview on 10/28/19 10:51 AM, the resident stated that there were not enough activities for the younger residents. Activities were geared more toward geriatric residents and she was only [AGE] years old. She had addressed this with activity staff and was told that most of their population were geriatric with dementia. An Activity Log dated from 9/1/19 - 10/27/19, documented that the resident attended activities on 11 out of 30 days in (MONTH) and 13 days out of 27 days in (MONTH) for a total of 33 activities. During an interview on 10/29/19 at 01:03 PM, the Acting Activity Director (AAD) stated she made up the Activity calendar, hired entertainment and helped run the activities as there was only herself and another activity person. She could tell when the resident was in an activity that she thought was not appropriate for her, because she would roll her eyes. They do have more younger people that like trivia and crafts. The facility was mainly dementia residents so there was not a lot of activities geared to the younger residents. She would like to do more with the younger residents, but had to follow the directives from corporate which was to focus on the dementia activities. If she had a mailing (shopper service) to do, she would have the younger residents stuff the envelopes. During an interview on 10/30/19 at 08:46 AM, the Administrator stated she could see that there was a push in the facility for the Seasons Memory Care Program (dementia focused programs). The facility had a large group of young residents. They need more activities for the younger residents, and she had spoken to the corporate consultant about coming up with a formalized program for their growing younger population. They recently got a donation for more age appropriate movies. 10NYCRR 415.5(f)(1)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly Medication Regimen Review (MRR) that included time frames for the different steps in the process. Specifically, the facility did not ensure a time frame was established when the physician documented an identified irregularity and what action had been taken. This is evidenced by: Medication Regime Review by Pharmacy Consultant Policy revised 08/12/19 documented: The attending physician will document in the medical record (or directly on the written recommendation from the consultant pharmacist) that the identified irregularity has been reviewed and what, if any action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the medical record. During an interview on 10/3/19 at 02:02 PM, the Administrator and the Regional Director of Operations were unaware that a time frame had not been provided in the MRR. They both agreed the policy did not address when the physician would document medication changes. 10NYCRR415.18 (c)(2)

Based on observation, staff interview, and record review during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that food temperature thermometers shall be calibrated, a chemical test kit (test papers) is to be provided for checking chemical sanitizer levels used for manual pot washing, and automatic dishwashing machines (dish machine) are to be maintained in accordance with the manufacturer specifications. Specifically, thermometers were not calibrated, correct test papers were not in use, and the dish machine was not operating in accordance with the manufacturer specifications. This is evidenced as follows. The main kitchen was inspected on 05/22/2018 at 10:37 am. Two of 3 metal stem food temperature thermometers read 28 degrees Fahrenheit (F) and 29F when tested for calibration in an ice bath. The test papers used to check the chemical sanitizer concentration for manual pot washing did not include a 150 parts per million (ppm) graduation and a greater than 400 ppm graduation. And the dish machine was rinsing at 195F and 27 pounds per square inch (psi). The directions for use of the chemical sanitizer concentration and dish machine data plate were reviewed on 05/22/2018. The chemical sanitizer concentration is to be between 150 ppm and 400 ppm. The dish machine final rinse is to be 20 psi ± 5 psi. Supervisor #1 stated in an interview conducted on 05/22/2018 at 9:37 am, that she will correct the thermometer calibration. The Director of Dining Services stated in an interview conducted on 05/22/2018 at 9:37 am that the test papers in use were provided by the new chemical supplier and that it seems that the dish machine final rinse was running high for the last few days. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.85, 14-1.112(c), 14-1.113

Based on interview and record review conducted during the recertification survey, the facility did not ensure one (1) (Resident #46) of one (1) resident reviewed for hospitalization , received written notice of discharge. Specifically, the resident and their representative did not receive written notice of the discharge and the facility did not send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. This evidenced by: Resident #46: This resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was moderately impaired for cognition, was able to understand others and was able to be understood. The resident was a hospice patient with an admission date of [DATE]. A Health Provider note dated 3/07/18 at 9:54 pm, documented the resident was being sent to the hospital for decreased urine output for two days due to a clogged foley catheter. The resident had hematuria (blood in urine) and was shivering and shaking. The resident was in severe pain and requested to go to the hospital. A progress note dated 3/08/18 at 5:47 am, documented the resident was admitted to the hospital with [REDACTED]. During an interview on 5/24/18 at 10:06 am, Social Worker #5 stated she was not aware of the new regulation requiring the facility to notify the resident, resident representative and ombudsman in writing of a resident's discharge from the nursing home. 10NYCRR415.3(h)(1)(iii)(a-c)

Based on interview and record review conducted during the recertification survey, the facility did not ensure written notice was provided to the resident's representative of the bed hold and return policy for one (1) (Resident #46) of one (1) resident reviewed for hospitalization . Specifically, there was no documented evidence the resident and the resident's representative received written notice of the bed hold policy when the resident was admitted to the hospital. This evidenced by: Resident #46: This resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was moderately impaired for cognition, was able to understand others and was able to be understood. The resident is a hospice patient with an admission date of [DATE]. A Health Provider note dated 3/07/18 at 9:54 pm, documented the resident was being sent to the hospital for decreased urine output for two days due to a clogged foley catheter. The Resident had hematuria (blood in urine) and was shivering and shaking. The resident was in severe pain and requested to go to the hospital. A progress note dated 3/08/18 at 5:47 am, documented the resident was admitted to the hospital with [REDACTED]. During an interview on 5/24/18 at 10:06 am, Social Worker #5 stated she had talked to the family about the bed hold policy on admission. She stated she was not aware of the new regulation requiring the bed hold policy to be submitted in writing to the resident's representative when the resident is discharged to a hospital. 10NYCRR415.3(h)(4)(i)(a)

Based on observations, record review and interview, during a recertification survey the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident to meet the resident's medical, nursing, mental and psychosocial needs for 2 (Residents #'s 46 and 50) of 18 residents reviewed. Specifically: For Resident #50, the facility did not develop a comprehensive care plan (CCP) to address bruising of the resident's hands and forearms; For Resident #46, the facility did not ensure the CCP for Urinary Tract Infections/Chronic [MEDICAL CONDITION] was implemented. This is evidenced by: Resident #46: This resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was moderately impaired for cognition, was able to understand others and was able to be understood. The resident is a hospice patient with an admission date of [DATE]. The Comprehensive Care Plan (CCP) for history of Urinary Tract Infections, Chronic [MEDICAL CONDITION], date initiated 1/23/18, documented a goal of the resident's urinary tract infections will resolve with treatment as they occur without complications. An intervention listed was to monitor intake and output. A Documentation Survey Report for (MONTH) (YEAR) revealed foley outputs were not documented 3/01 on 7-3 shift, 3/02 on 3-11 shift, 3/03 on 11-7 shift, 3/04 on 3-11 and 11-7 shifts, 3/05 on 7-3 shift, 3/06 on 3-11 shift and 3/07 on 7-3 and 3-11 shifts. During an interview on 05/24/18 at 09:00 AM, MDS Coordinator #4 stated blank spaces on the input and output log mean foley output was not documented. During an interview on 05/25/18 at 08:05 AM, Registered Nurse Manager (RNM) #2 stated the resident did not drink a lot. Certified Nursing Assistants (CNAs) left drinks at the bedside, but were not documenting amounts consumed. The resident was recently sent to the hospital with a clogged foley catheter. RN #2 stated she did not know why the CNAs were not documenting the resident's foley output prior to the resident being sent to the hospital. The CNAs work 12 hour shifts and were documenting at end of their shift only. They had previously been told they needed to document for all 3 shifts. The only time urine output was monitored was during routine physician visits. CNAs monitor urine output daily and report if there is no output. RN #2 stated she did not know if agency personnel report output declines to nursing. She is not aware if urine outputs are being monitored by nursing. There is no policy for nursing to be monitoring output. Hydration policy is now in effect which monitors intake only with meetings being held every two weeks. Internal audits started the first week in April. The resident's foley outputs should have been monitored per careplan. During an interview on 05/25/18 at 08:30 AM, Licensed Practical Nurse (LPN) #1 stated the resident had issues with his foley not being patent. The resident did not consume an adequate amount of fluid each day and his urine often contained sediment. There was no policy to monitor urine output from the foley and nurses were not inserviced to do so. CNAs should report if the resident had less than 100 cc's output from the foley. She stated if she is not working output may not be reported. Monitoring foley output can be added as a task for nurses to do. Irrigation of foley catheter started one month ago because the resident does not drink well. All nurses should have been monitoring urine output. The CNAs were not emptying the foley bag and were not charting at the end of their shift. She had addressed this with the nurse manager. Changes were made to ensure the foley was emptied every shift and the foley was to be flushed every day. During an interview on 05/25/18 at 08:48 AM, the Director of Nursing (DON) stated the facililty has initiated a new procedure/task for nurses to document output. The CNAs will no longer be responsible for this task. Resident #50: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident could understand, be understood and had severe cognitive impairment. During an observation on 05/23/18 at 7:44 AM, multiple areas on the resident's bilateral hands and forearms had varying degrees of purple/blue discoloration. A review of Provider Notes, Progress Notes and Comprehensive Care Plans (CCP) did not include documentation regarding the resident's hands and forearms. During an interview on 05/25/18 at 9:36 AM, Nurse Manager (NM) #2 was unable to find documentation. The resident has had the discoloration for at least 2 months. The NM stated she believed it was discoloration of the skin and not bruising, although the resident is often combative and bruising of the hands and forearms is not unlikely. This should have been assessed by the provider and care planned accordingly. During an interview on 05/25/18 at 9:45 AM, the Physician's Assistant reported he has not seen the resident lately and was not aware of the issue, nor does he recall being told about the resident's hands. He will look into it today. During an interview on 05/25/18 at 9:50 AM, Licensed Practical Nurse (LPN) #1 reported she thought the discoloration was bruising from hitting into things while self-propelling the wheelchair and the resident is often combative, swinging at people so some of it could be self-inflicted. She did not know of a CCP or any specific interventions in place to prevent injury. During an interview on 05/25/18 at 10:39 AM, the Director of Nursing reported she believed the discoloration was bruising, because she has observed the resident hitting hands on doorways and furniture while self-propelling the wheelchair. This should have been addressed in a CCP and it was not. 10NYCRR415.11(c)(1)

Based on observation, record review, and interview of staff it was determined during the recertification survey and an abbreviated survey (Case#NY 834) that the facility did not ensure that a resident who was admitted without a pressure sore does not develop a pressure sore in three (3) (#13,#32 and #83) of six (6) resident's reviewed for pressure sores. Specifically: Resident #13 developed a pressure sore after being admitted to the facility without a pressure sore and Resident #32 was found to have a developed a discolored area of skin on her left heel which was not monitored for condition of the wound. This resulted in actual harm for Resident #13 and the potential for more than minimal harm that is not immediate jeopardy for Resident #32. Also, during an abbreviated survey (Case#NY 834) the facility did not provide the necessary treatment and services to promote healing of a pressure ulcer for one (1) (Resident #83) of four(4) resident's reviewed. Specifically, Resident #83 was identified as having acquired stage II pressure ulcers to her coccyx and right and left ischium while in the facility. Weekly wound assessments were not completed in a timely manner, and did not always include an adequate description of the wound. The wounds were not always properly staged by the facility. In addition, the dressings documented as being applied to the wounds varied, and were not always consistent with physician's orders. This resulted in no actual harm, but with the potential for more than minimal harm that is not immediate jeopardy. This was evidenced by: 1.) Resident #13 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident with severe cognitive impairment, Brief Inventory for Mental Status (BIMS) score 4, and full ability to understand and be understood. The MDS also assessed the resident to be at risk for development of pressure sores. The Nursing Admission Checklist dated 9/3/14 documented, under the skin section, no areas of skin breakdown to either the left or right heels. The Braden Scale dated 9/6/14 documented the resident to be assessed for a total score of 14, which placed the resident at moderate risk for development of pressure ulcers. The Weekly Wound Observation dated 10/26/14 documented a pressure ulcer acquired on 10/25/14, as unstageable, with necrotic tissue present, dry in appearance, and measuring 2.5 cm (centimeter) in length and 2.5 cm in width. The current treatment as of 10/25/14 was to apply skin prep every day. The special equipment/preventative measures noted a bootie was applied when the pressure ulcer was discovered. The comment section documented that the pressure area was brought to the attention of the Registered Nurse Manager (RNM) late 10/25/14 at which time the area was noted as a hardened scab with peeling around the edges. There were no signs/symptoms of infection and the area will continue to be monitored. The Nursing Progress Note dated 10/28/14 documented the writer of the note was notified by the Licensed Practical Nurse (LPN) that the scab on the left heel had come off. The note further documented that there is a "Y" shaped red open area noted, appearing as granulation tissue with measurements of 1.5 cm in width by 1 cm in width and 0.1 millimeter in depth. The surrounding skin was dry with no [DIAGNOSES REDACTED] noted. Below the wound is a small area of dry lifting skin and to the right of this area is some yellowing/slightly purplish ecchymosis. The nurses note documented that a foam dressing was applied . The Weekly Wound Observation assessment dated [DATE] documented the location of a pressure sore to the left heel, date acquired 10/25/14, and the pressure sore stage to be unstageable. The comments section documented the wound as three separate areas; #1 is scabbed, hardened (area) 2.0 cm by 0.5 cm ; #2 just below is a 2.0 cm by 0.5 cm freshly opened top superficial section of skin that is peeled back with scant bloody drainage; and #3 to side of heel area 2 cm by 2 cm sealed but tenuous for opening. The treatment section for changes to the treatment plan in the last week documented a current treatment of [REDACTED]. The evaluation and wound progress section documented a previous large scab had come off and believed to be caused by the resident rubbing her foot (left heel) up and down on the bed. The physician progress notes [REDACTED]. The resident has two parallel ulcers each 1 cm long and minimal surrounding redness and no [MEDICAL CONDITION]. The physician progress notes [REDACTED]. The Comprehensive Care Plan (CCP) dated 9/12/14 and revised on 10/29/14 documented under interventions to include pressure relief cushion in wheelchair and pressure relief mattress. The interventions section also documented a bootie on left foot when in bed (staff explained the bootie on the left foot was not used until 10/25/14). The Visual/Bedside Kardex Report dated 10/29/14 documented under resident care pressure relief cushion in wheelchair and bootie on left foot when in bed. During an observation of the left heel wound on 10/30/14 at 9:10am the wound was noted to have an area of eschar in the middle of the wound and surrounded by yellowish, brown tissue surrounding the area of eschar . The surrounding area contained some redness of the skin. During interview on 10/30/14 at 8:00 am the RNM stated there was no other off- loading devices utilized on the left and right heel until the foam bootie was added to the left heel on 10/25/14. The RNM stated the resident was at increased risk for pressure sore development because the injury to the resident's left hip places an increased risk of pressure sore development if off-loading devices are not used. The RNM stated that pressure relieving devices such off- loading booties are not utilized on all residents with hip injuries. The RNM stated there was no way to determine when the eschar developed to the resident's left heel. The RNM further stated she was not aware that the resident was rubbing her left heel on the bed prior to development of the pressure ulcer. The RNM stated that rubbing any bony prominence, without proper protection, can result in formation of a pressure ulcer. During interview on 10/31/14 at 9:30am the Director of Nursing (DON) stated there is sometimes a lack of communication between the CNA's and the licensed nursing staff and it is something that needs addressing. The DON stated she was not aware that the resident was rubbing her heels against the bed sheets. The DON stated the type of bootie used when the pressure ulcer was discovered on 10/25/14 was not the the optimal device for pressure relief. During interview on 10/30/14 at 2:30pm CNA #2 stated she had noticed that the resident rubbed her heels on the bed since admission and had reported this to the RNM. During interview on 10/30/14 at 3:00pm the Licebsed Practical Nurse (LPN) stated she was not aware of the resident rubbing her heels on the bed and was not aware of any scabs to the resident's left heel prior to 10/25/14. During interview on 10/30/14 at 3:15pm Certified Nursing Assistant (CNA) #1 stated the resident rubs her lower legs on the bed sheets and has done so since admission. CNA #1 stated he was told to watch for this behavior and report to the nurses when it occurs. The Policy and Procedure for prevention of pressure ulcers dated 2001 and revised 10/2010 documented for resident's at risk for shear and friction need to protect bony prominences as needed. The definitions and description sections documented an unstageable pressure ulcer as a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. 2.) Resident #83 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated 8/13/14 assessed the resident as having severely impaired cognition. The Weekly Wound Observation dated 6/23/14 at 12:01 pm documented that the resident had acquired the following wounds: coccyx area with a 1 X 1 stage II open area-appears like a broken blister-red wound bed. Right ischial area with a broken blister 0.5 X 0.5cm/ some shearing. Wound bed red. It further documented treatments of Duoderm (a [MEDICATION NAME] dressing) to the coccyx, and [MEDICATION NAME] (a transparent dressing) to posterior thigh open area. In the Administration Note (progress note) dated 6/23/14 at 1:53 pm the LPN documented zinc oxide to coccyx and right posterior thigh every shift for broken blister, excoriation. The Physician's Orders dated 6/24/14 documented [MEDICATION NAME] to coccyx area every shift for open area on coccyx. Check every shift, and change every 3-5 days as needed. There was no documented evidence in the medical record of a physician's order for the [MEDICATION NAME] dressing. In the Administration Note dated 6/26/14 the LPN documented "[MEDICATION NAME] Miscellaneous" apply to right posterior leg every shift to open area. Check every shift, reapply only if loose or falling off. In the Skin/Wound Note dated 6/29/14 the LPN documented resident with 3 red areas on buttocks and back of thigh, [MEDICATION NAME] applied. In the Skin/Wound note dated 7/2/14 the Registered Nurse (RN) documented coccyx with a [MEDICATION NAME] Absorbant dressing (an acrylic dressing) which is intact-skin underneath appears red approximately 5 X 5cm. Right ischium with [MEDICATION NAME] Absorbant-skin underneath appears red with some small yellow areas where there is a break in the skin. Left ischium with a clear dressing-skin underneath pink. See new orders-we will change dressings only when falling off. The Physician's Orders dated 7/2/14 documented [MEDICATION NAME] to any pressure areas on coccyx, posterior thighs, buttocks, or ischial-change as needed when loose or falling off. (Of note, this is the first documented physician's order for treatment to the wounds located in the ischial areas. Also, may it be noted that the resident had [MEDICATION NAME] Absorbant dressings applied as noted above. [MEDICATION NAME] Absorbant is not a [MEDICATION NAME]). The Weekly Wound Observation dated 7/16/14 (14 days after the last documented RN assessment) documented the following: coccyx area-two stage II open areas noted-3cm X 2cm and 1.5cm X 1cm-red wound bed, areas with pink [DIAGNOSES REDACTED] around them. Right ischial area-entire area 7cm X 6cm. Within this area is a dark area of tissue measuring 2cm X 1cm and 2cm X 2cm area of yellow slough. Left ischial area with a 2cm X 2cm dark maroon dry spot within surrounding [DIAGNOSES REDACTED]. It further documented the wounds were worsening, initially stage II and were now "X," or unstageable with slough and necrotic tissue. The Weekly Wound Observation dated 7/27/14 eleven (11) days after the last documented RN assessment) documented the following: coccyx stage II area shows signs of healing is present. The area covered with Thin Duoderm for protection. Right and left ischial areas unchanged. Continue to cover with Thin Duoderm for protection. It further documented the areas remain stage II pressure ulcers, however slough tissue was present. (Of note, eleven (11) days prior they were identified as "unstageable"). There were no documented measurements of the wounds. The Weekly Wound Observation dated 7/28/14 documented the following: coccyx-all areas now present as healed scar tissue-covered with Thin [MEDICATION NAME] dressing. Left ischial-1cm X 1cm wound with 100% slough-surrounding skin with dark pink scar tissue-Exuderm (a [MEDICATION NAME]) applied. Right ischial-3.5cm X 1cm-top of wound with slough-lower wound is red. Surrounding skin with pink scar tissue-Exuderm applied. It further documented the wounds were improving, but unstageable. (Of note, the day before they were identified as stage II). The Skin/Wound Note dated 8/10/14 (thirteen (13) days after the last documented RN assessment) documented the following: coccyx remains healed. Duoderm application for skin protection. Stage II pressure areas on ischial areas unchanged in size. Covered with Duoderm for protection. There was no further description of the wounds. The Weekly Wound Observation dated 8/27/14 (seventeen (17) days after the last documented RN assessment) documented the following: coccyx-all intact scar tissue. Left ischial-0.5cm X 1.4cm-wound bed 100% slough. Right ischial-1cm X 2cm-wound bed 70% slough, 30% granulation tissue. Above wound is a 0.3cm round open area with 100% yellow slough in wound bed. It further documented the wounds were improving, but unstageable. (Of note, seventeen (17) days prior the wounds were identified as stage II). In the Skin/Wound Note dated 8/29/14, the RN documented she observed two stage II pressure ulcers on bilateral buttocks and one stage I on coccyx. The areas were cleansed and Duoderm applied to all 3 sites. There were no further descriptions of the wounds. The Weekly Wound Observation dated 9/5/14 documented the following: coccyx healed in appearance-"zinc" applied. Right ischial-total area is 5cm X 5cm-within this measurement are 3 open areas. 2cm X 1cm with 100% yellow slough. The other two are approximately 0.2cm X 0.2cm. Left ischial 2cm X 1.5cm-wound bed with dark dry eschar surrounded by [DIAGNOSES REDACTED]. It further documented the wounds were worsening and were unstageable. During an interview on 9/11/14 at 2:35 pm the RNM stated that pressure ulcers were assessed weekly by the Infection Control nurse, but at times she would fill in and complete wound assessments as needed. During an interview on 9/11/14 at 3:05 pm the Infection Control Nurse stated that she worked in the facility 3-4 days/week. She stated she completed weekly wound rounds, however if she was unable, the RNM would fill in for her. She stated all wounds were cleansed with the facility's "wound cleanser" that did not require a physician's order and was available in the treatment carts. While reviewing Resident #83's wound documentation she could not explain why weekly assessments were missing. She could not explain why some nurses documented applying dressings there were no physician orders for, stating she would like for the treatments to stay the same, but sometimes, depending on the nurse, they get changed. She stated there should be physician orders for the dressings being applied. She further stated she did not know why they have not changed the treatment order for Resident #83's wounds as they were worsening. She further stated she was going to have an affiliate with the facility, who specialized in wound care come see and provide suggestions regarding Resident #83's wounds early next week. During an interview on 9/11/14 at 4:00 pm the Director of Nursing (DON) stated that there should be weekly assessments of Resident #83's wounds. While reviewing Resident #83's wound documentation she stated there was a problem with the staging of Resident #83's wounds, it was not in accordance with guidelines established in their Policy and Procedure. She stated that dressings should be applied per physician's order. She further stated an affiliate with the facility was going to come in and assist with suggestions regarding the wound care of Resident #83. 3.) Resident #32 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident with intact cognition, BIMS score of 14, and full ability to understand and be understood. Progress notes dated 9/12/14 documented a skin/wound note skin check of both heels done with interventions in place, skin prep every shift, and air booties at all times, and remove for care; see skin integrity assessment. The Wound Description and Treatment sheet dated 9/12/14 documented a skin issue noted/observed on 9/12/14 that the right heel was tender to touch , color was within normal limits, no noted [DIAGNOSES REDACTED], and the heel was a bit soft to touch. The left heel had a 0.8 cm in length by 0.5 cm wide dark purple colored spot on this heel. The Charge Nurse documented a deep tissue injury due to the presence of purple discoloration on her left heel and to apply skin prep every shift and air booties at all times/remove for care. No further documentation was available for tracking of the wound to the left heel. The CCP for pressure sore development dated 7/22/14 and revised on 10/28/14 documented an intervention with date initiated 9/9/14 apply booties when in bed to bilateral feet, to keep heels elevated off the bed. The CCP documented the resident has a history of dark purple spots which resolved and the resident continues to wear inflatable booties while in bed. The Braden Scale for Predicting Pressure Sore Risk dated 7/20/14 documented a score of 12 placing the resident in the high risk category for development of pressure sores. The Nursing Admission Checklist dated 7/18/14 documented no areas of redness or breakdown to the resident's left heel. During observation of the left heel on 10/30/14 at 7:45am the left heel was found to have fully intact skin. During an interview on 10/30/14 at 7:45am the RNM stated no wound tracking of the dark purplish area to the resident's left heel was available after 9/12/14 and could not determine the condition of the wound after that time. The RNM stated she could not recall any off loading devices in place other than a pillow prior to 9/9/14. The RNM stated that inflatable booties were not utilized until after 9/9/14. 10NYCRR 415.12(c)(2)

Based on observation, record review and staff interview, during the partial extended abbreviated survey (Case #NY 905), it was determined that for 13 (#s 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 16, 17, and 18) of 40 residents reviewed, the facility failed to ensure that the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to have a system to ensure that residents were appropriately assessed and protected from accidents, including entrapment, related to the use of bed rails. The facility lacked policies and procedures related to the use of bed rails, failed to assess/reassess residents for the safe use of bed rails, failed to develop care plans for the bed rails, and failed evaluate the risks and/or benefits for use of the devices. Subsequently Resident #6 was found "hanging " from the bed rail, gasping for breath and choking. This resulted in no actual harm with the potential for serious harm that was Immediate Jeopardy and Substandard Quality of Care to residents' health and safety. This was evidenced by: 1. Resident #6 Bed rails were in use with this resident and there was no evidence of assessment/reassessment for the appropriateness of bed rail use, no care planning for bed rails, and no documentation of resident education of the risks and benefits of bed rail use. The resident was found entrapped between the bed rail and the mattress. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed as requiring the extensive assistance of two staff members for bed mobility. Bed rail use was not documented on this MDS. The Fall Risk assessment dated [DATE] documented that the resident had a history of [REDACTED]. The resident was also assessed to be on prolonged bed rest and at times to be disoriented to person, place or time. The resident was assessed to be at high risk for falls. It was also documented on this assessment that the resident rolled out of bed on 4/12/10. The Comprehensive Care Plan (CCP) for Falls, dated 4/10/06 documented that the resident was assessed to be at risk for falls related to a history of multiple falls, and that she was at risk to roll out of bed. One approach listed on this CCP was for safety devices "per NACP", (Nurse Aide Care Plan, which the Certified Nurses Aides (CNA) used to know what care each resident required). There was no documentation of measurable objectives and timetables in the CCP for the use of bed rails. The undated NACP, which was located in the resident's room, documented that the left side bed rail was to be up. The 24 Hour Nursing Report dated 9/14/10 documented in the day shift column that at 11:30 am this resident had slid out of bed to the floor and redness was noted under her chin. An Incident/Deviation/Unusual Occurrence Report (I&A) dated 9/14/10, documented that at 11:30 am, this resident had fallen from her bed and that the bed rails were in the up position. Licensed Practical Nurse (LPN) #1 documented that the resident rolled out of bed to the floor mat. The underside of the resident's chin was reddened. The I&A was signed by the Director of Nursing (DON) and the Administrator. A nurse's note dated 9/14/10 at 12:00 pm, documented that at 11:30 am, the resident was found sitting on the floor with her chin resting on the side rail and that redness was noted on the underside of the chin. The nurse's note was signed by LPN #1. A nurse's note dated 9/14/10 at 12:30 pm, documented that Registered Nurse (RN) #1 assessed the resident after the fall at 11:30 am. The underside of the resident's neck was red and tender to touch. The medical record revealed that there was no bed rail assessment of this resident. There was also no documentation noted of when the bed rails were initiated or when they were discontinued. The User-Service Manual for the bed in use for this resident on 9/14/10 listed several warnings under the title Important Precautions. One of the warnings documented that an assessment should be conducted on each resident by a qualified clinician to ensure maximum safety of the resident. The manual also documented that the assessment should be conducted in compliance with a guideline titled, Clinical Guidance for the Assessment and Implementation of Side Rails. The Clinical Guidance for the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities and Home Care Settings, dated 4/03, and developed by the Hospital Bed Safety Workgroup of the United States Food and Drug Administration (FDA) covered areas such as Guiding Principles, Policy Considerations, Process/Procedure Considerations and Risk Intervention. It was documented on page three of the Guideline that the automatic use of bed rails may pose unwarranted hazards to patient safety. "The potential for serious injury is more likely to be related to a fall from a bed with raised bed rails when the patient attempts to climb over, around, between, or through side rails." Evaluation was required to assess the risk of using or not using bed rails, and strangling, suffocation, bodily injury or death could occur when patients or parts of their body are caught between rails or between bed rails and mattresses. The decision to utilize bed rails should occur within the framework of an individual patient assessment. The care plan should include educating the patient about possible bed rail danger and address options for reducing the risks of bed rail use. During an interview with the Director of Maintenance on 10/6/10 at 10:27 am, he set up an empty bed with the same equipment in place that was in use with this resident on 9/14/10. The DON was also present during this interview and demonstration and stated that this was the bed setup that was in use for this resident on 9/14/10. The upper portion of the bed, which was able to be raised and lowered, measured 33.5 inches in length. The bed rail attached to the upper portion of the bed measured 28.5 inches. These bed rails were considered 1/4 size bed rails. During an interview with CNA #1 on 10/4/10 at 1:00 pm, she stated that on 9/14/10 at 11:30 am, she heard this resident's bed alarm sounding. She went to the room and the resident had fallen out of bed. Her knees were on the floor mat and her head was trapped between the bed rail and the bed. The resident's chin was on the inside of the bed rail and her neck was pressing against the end of the bed rail. She stated that the resident was "hanging " from the bed rail, gasping for breath and choking. As soon as CNA #1 saw the resident, she began calling for help. She immediately lifted the residents neck off the bed rail and held the resident until help arrived a few seconds later. CNA #1 stated that the resident was too weak to have rescued herself from that position. CNA #2 and LPN #1 arrived to assist with returning the resident to bed. CNA #1 stated that she described the incident to CNA #2 and LPN #1 when they came into the room, telling them that the resident had been hanging from the bed rail and choking. CNA #1 also stated that a few minutes later RN #1 came into the room and was told the circumstances of the fall. RN #1 stated to her that the resident did not need the bed rails and that they should be removed. During an interview on 10/4/10 at 2:28 pm, with RN #1, who was the Staff Development Coordinator, she stated that as part of her job she also acted as a supervisor and filled in for Registered Nurse Managers (RNM) when they were not working. She stated that on 9/14/10 she was notified that this resident had fallen from her bed. When she entered the room, the resident had been returned to her bed and when she assessed the resident she noted a reddened area under the resident's chin. She stated that the resident could no longer use the bed rails and did not need them. She also stated that this resident moved around a lot in bed but did not use the bed rails for assistance. During an interview with CNA #2 on 10/5/10 at 10:17 am, she stated that on 9/14/10 she was working on this resident's unit. At approximately 11:30 she heard CNA #1 yelling for help, it sounded like an emergency so she ran to this resident's room. When she entered the room the resident was on the floor and CNA #1 was supporting the resident's head and neck area. LPN #1 came into the room almost immediately after she arrived and just a minute or two later RN #1 came into the room. CNA #1 told her, LPN #1 and RN #1 that she found the resident with her neck stuck in the bed rail and was choking. During an interview with LPN #1 on 10/5/10 at 11:49 am, she stated that this resident was known to move around a lot in bed. The resident did not turn herself in bed, but would inch herself around and had to be frequently repositioned. She stated that the bed rails had been in place for this resident ever since she started working here about a year ago or more. She stated that on 9/14/10 she heard CNA #1 yelling for help. It sounded like an emergency so she ran to the room where she found CNA #1 on the floor holding the resident. The resident was lifted back to bed and was assessed to have a reddened area under her chin. She stated that CNA #1 told her what happened, but that all she could remember was that the resident's chin had gotten stuck in the bed rail. She and RN #1 discussed the bed rails and both nurses determined that they were unsafe for this resident so the bed rails were removed. During an interview with the DON on 10/5/10 at 10:31 am, she stated that the bed rails were considered to be enabler bars, which would help the residents to be more mobile in bed. She stated that there was no Policy and Procedure that addressed bed rails or enabler bars and that there was no formal process for assessing a resident for the appropriateness and safety of using bed rails unless they were being used as a restraint. During an interview on 10/5/10 at 2:10 pm, with the Rehabilitation Program Director, who was a Physical Therapist, she stated that she was the director of both physical and occupational therapy. She stated that she was not aware of any system used by the facility to assess and evaluate residents for the use of bed rails. She stated that she had been at this facility for approximately a year-and-a-half and that there had never been a request to have any resident's assessed or evaluated for the use of bed rails. During an interview with RNM #1 on 10/6/10 at 9:38 am, she stated that after this resident fell on [DATE], RN #1 had the bed rails removed from this resident's bed. She stated that she did not know why or for how long this resident had her side rails. She stated that there was no policy for and no formal assessment tool for determining which residents received bed rails or if it was safe for a resident to have them. She stated when a resident was admitted to the facility, she determined on a case-by-case basis who she thought might benefit from the use of bed rails as an assistive device, but there was no assessment form and no notification to the resident or the resident's representative of the risks and benefits of bed rail use. RNM#1 also stated that there was no formal evaluation or re-evaluation of this resident's bed rails, and because the bed rails were not documented in the CCP, they were not discussed in the quarterly care plan meetings. During an interview with the Administrator on 10/6/10 at 11:34 am, he stated that he was not aware that there was no formal process in place for assessing residents for the use of bed rails. He also stated that he was not aware that the nursing staff were making random decisions about which residents did or did not receive the bed rails. The Administrator stated that the facility only assessed residents for the use of bed rails, if they were ? or full bed rails. He stated that if the bed rail did not restrain the resident, it was not necessary to track them for reassessment and reevaluation. There was no assessment or evaluation process in place for 1/4 and 1/2 bed rails. On 10/5/10 at 11:20 am review of the undated NACP, which was located in the resident's room, documented that the left side bed rail was to be up. On 10/5/10 at 11:20 am, the resident was observed to be lying in bed. No side rails were in place. On 10/6/10 at 11:15 am review of the undated NACP, which was located in the resident's room, documented that the left side bed rail was to be up. On 10/6/10 at 11:15 am, the resident was observed to be lying in bed. No side rails were in place. 2. Resident #9 Bed rails were in use with this resident and there was no evidence of assessment/reassessment for the appropriateness of bed rail use, no care planning for bed rails, and no documentation of resident//resident representative education of the risks and benefits of bed rail use. The resident had a history of [REDACTED]. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident to have had short and long term memory impairment, modified independence in cognitive decision making skills, and as requiring the extensive assistance of two staff for bed mobility. Bed rail use was not documented on this MDS. The Fall Risk assessment dated [DATE] documented that the resident had fallen in the past 90 days, had balance and joint problems, and was on prolonged bed rest. She was also disoriented to person, place or time. The resident was assessed to be at high risk for falls. It was also documented on this assessment that the resident fractured a hip on 7/1/10 and rolled out of bed on 7/4/10 (resident in hospital on [DATE]; records document resident fell on [DATE]). The CCP dated 7/19/10 documented that the resident was assessed to be at risk for falls, needed assistance with ADL's, had a history of [REDACTED]. One approach listed on this CCP was for safety devices "per NACP," which the CNAs used to know what care each resident required. It was also documented that the resident had a history of [REDACTED]. There was no documentation of measurable objectives and timetables in the CCP for the use of bed rails. The undated NACP, which was located in the resident's room, documented that the left side bed rail was to be up. Review of the medical record revealed that there was no bed rail assessment of this resident. A nurses note dated 7/1/10 at 5:15 am. Documented that the resident was found on the floor in her room. The resident was assessed and transferred to the hospital for evaluation after complaining of right hip pain. The resident was transferred to the hospital. A nurses note dated 7/6/10 at 3:30 pm, documented that the resident returned to the facility with 15 staples to the right hip with a small amount of bloody drainage. Another fall was documented in a nurses note dated 7/6/10 at 6:45 pm documented that the resident had rolled out of bed onto the floor with no apparent injury. An I&A dated 7/6/10, documented that at 6:45 pm, this resident had fallen with no apparent injury. A CNA had found the resident "hanging" out of bed with her legs still on the bed. The resident was lying on her stomach, supporting herself with her forearms. The portion of the I&A that asked if the bed rails were up or down was not completed. The I&A was signed by the DON and the Administrator. A nurse's note dated 7/16/10 at 10:45 pm documented that the resident had fallen out of bed to the floor with no apparent injury. An I&A dated 7/16/10, documented that at 10:45 pm, this resident was found on the floor at the bedside. The bed rails were in the up position. The resident was not injured. It was also documented that the resident had stated that she did not know how she fell . The I&A was signed by the DON and the Administrator. On 10/5/10 at 9:00 am, the resident was observed lying in bed in his room. The 1/4 size, left bed rail was in the up position. During an interview with CNA #3 on 10/6/10 at 9:40 am, she stated that she did not know why this resident had bed rails in place. She stated that the bed rail was always on the bed and in the up position when the resident was in bed. During an interview with RNM #1 on 10/6/10 at 9:38 am, she stated that she did not know how long this resident had her side rails. She stated that there was no policy for and no formal assessment tool for determining which residents received bed rails or if it was safe for a resident to have them. She stated when a resident was admitted to the facility, she determined on a case-by-case basis who she thought might benefit from the use of bed rails as an assistive device, but there was no assessment form and no notification to the resident or the resident ' s representative of the risks and benefits of bed rail use. RNM#1 also stated that there was no formal evaluation or re-evaluation of this resident's bed rails, and because the bed rails were not documented in the CCP, they were not discussed in the quarterly care plan meetings. During an interview with the DON on 10/5/10 at 10:31 am, she stated that the bed rails were considered to be enabler bars, which would help the residents to be more mobile in bed. She stated that there was no Policy and Procedure that addressed bed rails or enabler bars and that there was no formal process for assessing a resident for the appropriateness and safety of using bed rails unless they were being used as a restraint. During an interview 10/5/10 at 2:10 pm, with the Rehabilitation Program Director, who was a Physical Therapist, she stated that she was not aware of any system used by the facility to assess and evaluate residents for the use of bed rails. She stated that she had been at this facility for approximately a year-and-a-half and that there had never been a request to have any resident's assessed or evaluated for the use of bed rails. During an interview with the Administrator on 10/6/10 at 11:34 am, he stated that he was not aware that there was no formal process in place for assessing residents for the use of bed rails. He also stated that he was not aware that the nursing staff were making random decisions about which residents did or did not receive the bed rails. The Administrator said that the facility only assessed residents for the use of bed rails if they were ? or full bed rails. He stated that if the bed rail did not restrain the resident, it was not necessary to track them for reassessment and reevaluation. If the bed rails were less than ? size, there was no assessment or evaluation process. 3. Resident #2 Bed rails were in use with this resident and there was no evidence of assessment/reassessment for the appropriateness of bed rail use, no care planning for bed rails, and no documentation of resident/resident representative education of the risks and benefits of bed rail use. The resident had a history of [REDACTED]. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident to have had short and long-term memory impairment, moderately impaired cognitive decision-making skills, and as requiring the extensive assistance of two staff for bed mobility. It was also documented on this MDS that the resident used two side rails daily. The Fall Risk assessment dated [DATE] documented that the resident had a history of [REDACTED]. The resident also received psychotropic medications. The resident was assessed to be at high risk for falls. The CCP for Falls dated 12/31/08 with a Goals Target Date of 2/4/10, documented that the resident was at risk for falls due to a potential for wandering, history of dizziness, unsteady gait, balance problems, joint difficulty, disorientation to place and time and the use of psychotropic medications. One approach listed on this CCP was for safety devices "per NACP," which the CNAs used to know what care each resident required There was no documentation of measurable objectives and timetables in the CCP for the use of bed rails. The undated NACP, which was located in the resident s room, documented that the resident was not able to walk, required mechanical assistance in transfers and the right side bed rail was to be up. Review of the medical record revealed that there was no bed rail assessment of this resident. A nurse's note dated 9/10/10 at 8:23 pm documented that the resident was found on the floor in his room. The resident had stated that he was trying to get up to go to the bathroom. An I&A dated 9/10/10, documented that at 8:23 pm, this resident had fallen with no apparent injury. The resident's head was under his bed and he had stated that he was trying to get up to go to the bathroom. The I&A was signed by the DON and the Administrator. A nurse's note dated 9/11/10 documented that at 4:35 am, the resident had fallen out of bed to the floor with no apparent injury. An I&A dated 9/11/10, documented that at 4:35 am, this resident was found on the floor in his room. The bed rails were in the up position. The resident was not injured. The RN who wrote the I&A documented that it looked like the resident was trying to get out of bed and slid off the edge of the bed. The I&A was signed by the DON and the Administrator. A nurse's note dated 9/11/10 documented that at 10:45 pm, the resident had fallen out of bed to the floor with no apparent injury. The resident had stated that he slid out of bed. An I&A dated 9/11/10, documented that at 10:45 pm, this resident was found on the floor in his room. The position of the bed rails was not documented. The resident was not injured. The resident had stated that he slid out of bed. The I&A was signed by the DON and the Administrator. A nurse's note dated 9/18/10 documented that at 12:00 am, the resident slid out of bed to the floor mat. There was no apparent injury. An I&A dated 9/18/10, documented that at 12:00 am, this resident was found on the floor in his room. The bed rails were in the up position. The resident was not injured. The resident had reported that he was trying to get out of bed and walk to the bathroom when he fell . The I&A was signed by the DON and the Administrator. A nurse's note dated 9/25/10 documented that at 6:15 am, the resident slid out of bed to the floor with no apparent injury. An I&A dated 9/25/10, documented that at 6:15 am, this resident was found on the floor in his room. The bed rails were in the up position. The resident was not injured. The resident was assessed and returned to bed. The I&A was signed by the DON and the Administrator. On 10/5/10 at 9:00 am, the resident was observed lying in bed in his room. The The 1/4 size, right bed rail was in the up position. During an interview with RNM #1 on 10/6/10 at 9:38 am, she stated that she did not know how long this resident had bed rails in place. She stated that the resident had several falls but did not reassess the appropriateness of side rail use for the resident. She stated that there was no policy for and no formal assessment/reassessment tool for determining which residents received bed rails or if it was safe for a resident to have them. She stated when a resident was admitted to the facility, she determined on a case-by-case basis who she thought might benefit from the use of bed rails as an assistive device, but there was no assessment form and no notification to the resident or the resident's representative of the risks and benefits of bed rail use. RNM#1 also stated that there was no formal evaluation or re-evaluation of this resident's bed rails, and because the bed rails were not documented in the CCP, they were not discussed in the quarterly care plan meetings. During an interview with the DON on 10/5/10 at 10:31 am, she stated that the bed rails were considered to be enabler bars, which would help the residents to be more mobile in bed. She stated that there was no Policy and Procedure that addressed bed rails or enabler bars and that there was no formal process for assessing/reassessing a resident for the appropriateness and safety of using bed rails unless they were being used as a restraint. During an interview 10/5/10 at 2:10 pm, with the Rehabilitation Program Director, who was a Physical Therapist, she stated that she was not aware of any system used by the facility to assess and evaluate residents for the use of bed rails. She stated that she had been at this facility for approximately a year-and-a-half and that there had never been a request to have any resident's assessed/reassessed for the use of bed rails. During an interview with the Administrator on 10/6/10 at 11:34 am, he stated that he was not aware that there was no formal process in place for assessing residents for the use of bed rails. He also stated that he was not aware that the nursing staff were making random decisions about which residents did or did not receive the bed rails. The Administrator said that the facility only assessed residents for the use of bed rails if they were ? or full bed rails. He stated that if the bed rail did not restrain the resident, it was not necessary to track them for reassessment and reevaluation. If the bed rails were less than ? size, there was no assessment or evaluation process. 10NYCRR 415.12(h)(1)

Based on record reviews and staff interview during an partial extended abbreviated survey (Case #NY 905), it was determined that the facility Administrator failed to ensure for 13 (#'s 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 16, 17, and 18) of 40 residents that the facility was operated in a manner that ensured the resident environment remained as free of accident hazards as possible. Specifically, the Administrator failed to develop a system to ensure that residents were appropriately assessed and protected from accidents, including entrapment, related to the use of bed rails. This resulted in no actual harm with the potential for serious harm that was Immediate Jeopardy and Substandard Quality of Care to residents' health and safety. This was evidenced by the following information (see F 323 IJ/SQC): During an interview with the Administrator on 10/6/10 at 11:34 am, he stated that he was not aware that there was no formal process in place for assessing residents for the use of bed rails. Approximately one year ago the facility received new resident beds and he believed that the side rails were no longer in use. He also stated that he was not aware that the nursing staff were making random decisions about which residents did or did not receive the bed rails. The Administrator said that the facility only assessed residents for the use of bed rails if they were ? or full bed rails. He stated that if the bed rail did not restrain the resident, it was not necessary to track them for reassessment and reevaluation. If the bed rails were less than ? size, there was no assessment or evaluation process. 10NYCRR 415.26

Based on record reviews and staff interviews during an partial extened abbreviated survey (Case # NY 905), it was determined that the facility failed to ensure that the quality assessment and assurance program identified issues and activities necessary to develop a system to ensure that residents were appropriately assessed/reassessed and protected from accidents, including entrapment, related to the use of bed rails. This resulted in no actual harm with the potential for serious harm that was Immediate Jeopardy and Substandard Quality of Care to residents' health and safety. This was evidenced by the following information (see F 323 IJ/SQC): During an interview on 8/11/10 at 1:00 pm, with the Director of Nursing (DON) who was the Quality Assurance Coordinator she stated that the Quality Assurance (QA) Committee last reviewed the use of bed rails when the facility obtained new beds approximately one to one-and-a-half years ago. She stated that QA had not reviewed a bed rail assessment or care planning system and that QA was not involved in bed rail use in the facility. 10NYCRR 415.27(a-c)