Every finding on record at Elderwood at Waverly

Based on record reviews and interviews during the facility failed to protect residents from sexual abuse for six (6) of six (6) residents (Residents #3, #4, #5, #6, #7, and #8). Specifically, Resident #2 was found in separate sexually inappropriate situations with six (6) residents, all of whom had impaired cognitive function with the exception of Resident #5. The facility's failure to protect residents from sexual abuse placed all 176 residents in the facility at risk of abuse. This resulted in actual harm for Residents #3, #4, #5, #6, #7, and #8 that was Immediate Jeopardy and Substantial Quality of Care for residents' health and safety. Findings include: The facility policy, Abuse Prevention, Identification, Investigation, Protection and Reporting, dated 04/30/2024, documented all staff would be trained on prevention of all forms of abuse. Training would include recognizing forms of abuse. Prevention included on-going assessments, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect including wandering into other's rooms and sexually aggressive behavior such as saying sexually inappropriate things and sexually inappropriate touching and/or grabbing.Resident #2 had diagnoses including Alzheimer's disease. The 07/10/2025 Minimum Data Set (a resident assessment tool) documented the resident had moderate cognitive impairment, used a walker, walked independently, and had no behavioral symptoms. Resident #3 had diagnoses including Alzheimer's disease. The 07/03/2025 Minimum Data Set documented the resident had severe cognitive impairment, walked independently, had no behaviors, and did not wander. Resident #4 had diagnoses including Alzheimer's disease. The 08/13/2025 Minimum Data Set documented the resident had severely impaired cognition, had no behaviors, did not wander, used a wheelchair, and was dependent on staff for all mobility. Resident #5 had diagnoses including epilepsy (seizure disorder) and dementia. The 10/01/2025 Minimum Data Set documented the resident had intact cognition, had no behaviors, did not wander, used a wheelchair, and was dependent on staff for all mobility. Resident #6 had diagnoses including Alzheimer's disease. The 12/10/2025 Minimum Data Set documented the resident had severely impaired cognition, had no behaviors, did not wander, used a wheelchair, and was dependent on staff for all mobility. Resident #7 had diagnoses including Alzheimer's disease. The 11/26/2025 Minimum Data Set documented the resident had severely impaired cognition, had inattention and disorganized thinking, had no behaviors, did not wander, used a wheelchair, and was dependent on staff for all mobility. Resident #8 had diagnoses including Alzheimer's disease. The 05/29/2025 Minimum Data Set documented the resident had severely impaired cognition, had no behaviors, did not wander, used a wheelchair, and was dependent on staff for all mobility. Incident #1:Resident #2's comprehensive care plan initiated 04/03/2025, documented the resident was at risk for alterations in mood/behavior related to Alzheimer's disease without behavioral disturbance. Interventions included: document mood/behavior status changes and report to the physician; redirect, intervene, or provide distraction for periods of agitation; approach from the front in a calm, gentle manner.Resident #8's comprehensive care plan revised 06/05/2025, documented the resident had trauma with anxiety related to traumatic war experience/traumatic event (sexual, accident, death), environment change, preoccupation with the experience as evidenced by fear, transfer trauma, withdrawal from support system. Interventions included identifying and eliminating triggers in the environment and developing a trusting relationship. The 08/11/2025 at 1:30 PM Accident and Incident Report completed by Registered Nurse #5, documented a resident (identified as Resident #2) was found in Resident #8's bed with their hand in a rubbing motion, down Resident #8's brief. Resident #2 was immediately removed from the room and moved to another unit. A stop sign remained in place on Resident #8's doorway. The Accident and Incident report did not include staff statements or documentation related to Resident #2's activities prior to being found in Resident #8's bed, or when the residents were last observed.There was no documented evidence of social work follow up or updated interventions for Resident #8 related to the 08/11/2025 incident or the resident's potential to be a victim of sexual abuse. There was no documented evidence of the intervention of the stop sign across the resident's door. Resident #2's care plan was revised on 08/11/2025 to include the resident was moved to another unit with alert residents, medications were reviewed and adjusted, and behavioral monitoring was initiated. The facility Census List documented Resident #2 was moved from the fourth floor to the second floor on 08/11/2025 and was moved back to the fourth floor on 08/19/2025. There was no documented evidence Resident #2's care plan was updated to reflect the move back to the fourth floor, or any interventions related to their sexually inappropriate behaviors. Incident #2: Resident #3's comprehensive care plan, initiated 04/02/2025, documented the resident was at risk or had been the recipient of verbal or physical altercations from/with other residents and was at risk for elopement and unsafe wandering. Interventions included: assess for inappropriate behavior and unmet needs; engage in diversional activities; monitor for negative effects from an altercation; and monitor whereabouts due to unsafe wandering. The 09/17/2025 at 10:16 PM Registered Nurse Unit Manager #12 progress note documented Resident #3 was found in Resident #2's bed. Resident #3 was wearing a pajama top, and no bottoms and Resident #2 had no clothes on. They were noted to be lying in a spooning position, sleeping. Resident #3 was assessed for injuries, no redness noted (location not documented), and the resident denied pain. The residents were immediately separated.The 09/17/2025 Accident/Incident Report documented Resident #3 was found in Resident #2's bed, wearing a pajama top and no bottoms, Resident #2 was not wearing any clothing. They were lying in a spooning position, with Resident #2 behind Resident #3, asleep. The residents were separated. The 09/17/2025 Witness Accounts of Accident/Incident, completed by Certified Nurse Aide #4 and Support Aide #3 documented they found Residents #2 and #3 sleeping in Resident #2's bed. Resident #2 had no clothing on, and Resident #3 was in a shirt. There appeared to be fluid on the sheet.The 09/22/2025 Witness Account of Accident/Incident completed by Licensed Practical Nurse #32 documented they were made aware a resident (Resident #3) was found undressed in another resident's (Resident #2) room and the residents were in bed together. Licensed Practical Nurse #32 was in the room earlier for a dressing change for Resident #2's roommate, the curtains were pulled (between the bed), and the nurse did not hear anything from Resident #2's side of the room. There was no documented evidence of a care plan update or implemented interventions for Resident #3 related to this incident or their potential to be a victim of sexual abuse. Resident #2's behavior care plan was updated to include a resident was found in their bed on 09/17/2025 and no inappropriate touching was witnessed at the time of the incident. There were no new or revised interventions related to this incident. During an interview on 02/18/2026 at 2:06 PM, Support Aide #3 stated on 09/17/2025, they discovered Resident #3 lying in Resident #2's bed. Resident #2 was completely naked, and Resident #3 was naked from the waist down. Resident #3 was known to wander but not to climb in anyone's bed. Resident #3 was immediately removed from the room and covered. Support Aide #3 stated they were unaware of any safety measures implemented following the incident, and Resident #2 was later transferred to another unit. During an interview on 02/18/2026 at 2:48 PM, Registered Nurse Unit Manager #12 stated Resident #2 liked the female residents and they witnessed Resident #2 kissing and hugging female residents on three (3) to four (4) prior occasions. Resident #2 was redirected and told the behavior was inappropriate. On 09/17/2025, they were told Resident #3 was discovered in Resident #2's bed. The residents were separated, and Resident #2 was transferred to a different unit. Incident #3:Resident #4's comprehensive care plan, initiated 09/19/2025 documented they were at risk or had been the recipient of verbal or physical altercations from/with other residents. Interventions included: diversional activities; intervene immediately if altercations were observed; monitor for negative effects of altercation; move away from other residents who were at high risk to become physically or verbally aggressive. The undated Facility Investigation signed by the Director of Nursing and the Administrator, documented on 09/20/2025 at 8:00 AM, Resident #2 was observed in the dining room, removing their hand from Resident #4's thigh area. Resident #2's hand was on top of Resident #4's pants and the residents were kissing. Resident #2 stated they thought they were kissing their spouse. Resident #2 was recently moved from the fourth floor to the first floor on 09/19/2025 due to a similar incident. The 09/20/2025 Witness Account of Accident/Incident form completed by Certified Nurse Aide #6 documented they entered the dining room, Residents #2 and #3 were kissing, and Resident #2 was removing their hand from Resident #4's thigh area. The 09/20/2025 at 2:23 PM Registered Nurse #26 progress note documented Resident #2 was observed kissing Resident #4 with their hands between Resident #4's legs. Resident #2 was immediately removed from the area. Resident #4 was assessed for injuries and did not recall being kissed or any other inappropriate behavior. No injuries or complaints of discomfort were noted. There was no documented evidence Resident #4's care plan was revised to address the incident on 09/20/2025. Resident #2's behavior care plan interventions were revised on 09/20/2025 to include: medication changes to lower libido; eat in the dining room near the nurses' station; 15-minute paper checks for one (1) day; behavioral monitoring; and 1:1 activities for diversion.During an interview on 02/17/2026 at 11:39 AM Resident #4 stated they were touched a while ago by a gentleman that lived there, they could not recall who it was, and it hasn't happened in a while, thank God. The resident stated the nurses did not do anything about it and they did not recall the details. Incident #4:Resident #5's comprehensive care plan initiated 09/19/2025 documented they were at risk or had been the recipient of verbal or physical altercations from/with other residents. Interventions included: diversional activities; intervene immediately if altercation was observed; monitor for negative effects of altercation; and move away from other residents who were at high risk to become physically or verbally aggressive. The 11/21/2025 at 4:55 PM Incident Report completed by the Director of Nursing documented a certified nurse aide walked by the activity/dining room and observed Resident #2 trying to kiss Resident #5 on the lips and rubbing their breast. Resident #5 was observed turning their head away from Resident #2 and when interviewed, stated it was not OK for Resident #2 to be touching their breast. The residents were immediately separated, and the Registered Nurse Supervisor (unidentified) and Director of Nursing were notified. The interventions implemented included to keep Resident #2 away from Resident #5 and when in the activity room, place them on opposite sides of the table. There were no documented witness statements included with the investigation.Nursing progress notes for Resident #5 on 11/22/2025 at 6:27 AM, 1:39 PM, and 8:46 PM, entered by the Director of Nursing, documented no late injuries were noted from the 11/21/2025 incident. There was no documented evidence of nursing or social services follow up with Resident #5 related to their emotional/psychological status following the 11/21/2025 incident. On 11/21/2025, Resident #2's behavior care plan revision documented when the resident was in the activity room, encourage them to not to sit too close to female residents.There was no documented evidence of care plan revision(s) for Resident #5 following the incident. During an interview on 02/28/2026 at 9:30 AM Resident #5 stated they did not like what happened to them regarding the 11/21/2025 incident with Resident #2. Resident #5 stated they did not recall details about the incident.Incident #5:Resident #6's comprehensive care plan revised 12/23/2025 documented the resident had the potential for alteration in mood/behavior related to Alzheimer's disease. Interventions included: document mood/behavior changes; redirect during episodes of agitation; and seat the resident out of direct contact with other residents walking by. The undated Facility Investigation documented on 02/12/2026 at 6:10 PM, Certified Nurse Aides #6 and #34 entered Resident #6's room and witnessed Resident #2 sitting by Resident #6's bed leaning on the bed. Resident #2 had both their hands under the sheet and did not respond when Certified Nurse Aide #34 told them to stop and to leave the room. The aide repeated their instructions and assisted Resident #2 away from Resident #6 and out of the room. Resident #6's incontinence brief was almost completely unsecured, and the resident stated, it hurts. No open areas to the skin were noted upon assessment, and Resident #6 did not voice any further complaints following the incident. Resident #2 was moved to a room closer to the nurses' station and a stop sign was placed in Resident #6's doorway. Resident #2's behavior care plan was revised on 02/12/2026 and documented the resident's room was moved closer to the nursing station for closer monitoring and to keep them away from Resident #6.Resident #6's care plan was updated on 02/13/2026 to include the resident was at risk or has been the recipient of inappropriate touching by another resident. Interventions included: a stop sign was added to their door; diversional activities; and to keep them away from Resident #2.Incident #6:Resident #7's comprehensive care plan revised 06/18/2025 documented they were at risk or had been the recipient of verbal or physical altercations from/with other residents. Interventions included: intervene immediately if altercations were observed; monitor for negative effects of altercation; and move away from other residents who were at high risk to become physically or verbally aggressive.The 02/17/2026 at 4:31 AM Licensed Practical Nurse #11 progress noted documented Resident #2 was found lying in Resident #7's bed. Resident #7 was yelling help, which they did most of the shift. No contact was noted between the residents. Resident #2 was very combative when trying to get them back to their own bed. The 02/18/2026 at 2:43 AM Licensed Practical Nurse #11 progress note documented Resident #2 was found in Resident #7's room at 10:30 PM, sitting on the bed and holding Resident #7's hand. Resident #7 had no comment. Resident #2 was removed from the room. Resident #2 had been up wandering the unit several times during the night. There were no documented care plan revisions for Resident #7 following the incident. During an interview on 02/18/2026 at 4:00 PM, Licensed Practical Nurse #11 stated Resident #2 wandered and was found in Resident #7's room sitting on their bed. They became agitated when staff attempted to redirect them. Licensed Practical Nurse #11 stated there were no safety measures in place to protect female residents, aside from monitoring Resident #2. They stated it was hard to control Resident #2's wandering at night. During an interview on 02/19/2026 at 8:35 AM, Certified Nurse Aide #13 stated they heard of Resident #2's prior sexual inappropriate touching with one (1) or two (2) female residents but never witnessed any incidents. They stated they used the Kardex (care instructions) or report from the Unit Manager for instructions on resident care. Staff were verbally told to monitor Resident #2 for inappropriate behavior. They were unsure if monitoring was listed on the resident's care instructions. During an interview on 02/19/2026 at 10:23 AM, Social Worker #14 stated they knew of the 02/13/2026 incident involving Resident #2's sexually inappropriate behaviors with Resident #6. They had prior knowledge of incidents involving Resident #2 on the fourth floor. They stated if residents were only holding hands, it was innocent. Staff were told to redirect Resident #2 if they witnessed anything inappropriate. There were no safety measures in place to protect Residents #3, #4, #5, #6 or #7. No follow ups or psychological evaluations were performed, they would just look at the residents and watch their body language. Social Worker #14 stated they did not normally work with Resident #2 and was covering for another social worker. The Director of Social Work was new in their role. They were unaware of how many incidents Resident #2 was involved in. During an interview on 02/19/2026 at 10:46 AM the Director of Social Work stated they were informed by the Administrator Resident #2 had a room change from the fourth floor to the first floor. They were told it was due to sexually inappropriate behaviors with female residents, but they did not have all the details. They thought there was another social worker working on the fourth floor at that time. The Director of Social Work stated they also had knowledge of Resident #2's sexually inappropriate behaviors in September 2025 since moving down to the first floor. They did not have many progress notes related to Resident #2. They stated they did not complete any follow up assessments on the female residents involved and no psychological evaluations were ordered. They thought the residents were followed by the medical providers. Stop signs were placed on the female resident's doors and a psychological evaluation referral was in place for Resident #2. They did not know of any other specific interventions to protect the female residents. They stated it was all staffs' responsibility to make sure the residents' care plans were effective. During an interview on 02/19/2026 at 12:45 PM, the Director of Nursing stated they were aware of Resident #2's sexually inappropriate behaviors since September 2025. They were informed by Registered Nurse Unit Manager #12 that Resident #3 was found in Resident #2's bed (on 09/17/2025) and they had no clothes on. They stated they assessed Resident #3. The interventions to protect residents included a unit and room change for Resident #2. They were aware of the subsequent incidents involving Resident #2 with Residents #4, #5, #6 and #7. Interventions following these incidents were stop signs placed on the doors of the female residents and medication changes for Resident #2. There was no follow-up by social services with the female residents. The facility did not employ psychologists, and social services staff were responsible for following up with victim residents. During an interview on 03/05/2026 at 9:42 AM, the Medical Director stated they were recently made aware of Resident #2's inappropriate sexual behaviors. They were notified in February 2026 interventions were not effective. They stated non-pharmacological interventions included moving the resident closer to the nurses' station and utilizing stop signs in doorways. They stated they did not like to medicate residents without knowing the context; often medication would mask the real issue. Medical intervention could not fix the resident. They stated they worked with staff to utilize the best interventions. The Medical Director stated they expected to be notified of any inappropriate sexual behaviors with residents. ____________________________________________________________________________Immediate Jeopardy was identified and the Director of Nursing was notified on 02/19/2026 at 3:40 PM. Immediate Jeopardy was removed on 02/20/2026 at 2:59 PM prior to survey exit based on the following corrective actions:-Resident #2's care plan was revised to show 1:1 supervision at all times. All residents who resided on the first floor South Unit had their care plans revised to be at risk for a victim of abuse.-On 2/20/2026 at 10:15 AM and 2:01 PM, Resident #2 was observed with 1:1 supervision with no concerns.-All nursing staff working on South Unit were educated on Resident #2's revised care plan. The information was confirmed by signature records. -On 02/20/2026, the Medical Director and Nurse Practitioner #29 assessed Resident #2's medications and made changes. -A referral for a psychiatric evaluation of Resident #2 was made with an appointment date of 02/24/2026. -All staff were re-educated on recognizing and reporting abuse. On 02/20/2026 at 12:30 PM, 91% of staff at the facility were educated. Any staff not available for education due to vacation, illness, etc. will be re-educated prior to their next scheduled shift. -On 02/20/2026, education was verified through staff interviews including licensed practical nurses, certified nurse aides, support aides, activities staff, housekeeping staff, and clerical staff. Education signature sheets were reviewed and verified with a full staffing list. -All residents on the South Unit were interviewed by members of the Interdisciplinary Team on 02/19/2026 and 02/20/2026 to rule out any further instances of unreported abuse. Progress notes from the last 30 days were also reviewed for those residents. No concerns were identified. Documentation was provided by the Administrator detailing the interviews and progress note reviews as noted. - The surveyor reviewed Nursing Progress Notes for Residents #3, #4, #5, #6, #7, and #8 and no additional concerns were identified. -On 2/20/2026, Social Worker #14 followed up with Residents #3, #4, #5, #6, #7, and #8 to ensure no psychosocial/emotional harm was noted. Documentation was provided detailing the social workers' follow-up. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on record review and interviews during the abbreviated survey (iQIES reference #2740895), the facility failed to ensure residents were free from physical abuse for one (1) of seven (7) residents (Resident #1) reviewed. Specifically, Resident #1 was combative during care, struck Support Aide #2, and Support Aide #2 struck the resident back in the left shoulder. The 04/30/2024 facility policy, Abuse Prevention, Identification, Investigation, Protection and Reporting documented all staff would be trained on prevention of all forms of abuse. Training would include recognizing forms of abuse. The facility would ensure supervision of staff on all shifts would occur to identify inappropriate staff behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, and directing residents that need assistance with the bathroom to urinate or defecate in their beds. Prevention included on-going assessments, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as physically aggressive behavior such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures or throwing objects. Resident #1 had diagnoses of Alzheimer's disease. The 01/16/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, used a wheelchair and was dependent on staff for all activities of daily living. The comprehensive care plan revised 01/20/2026 documented alteration in mood/behavior due to Alzheimer's disease, communication deficits and dementia with psychotic disturbance. At times the resident was combative and resistive to care and/or refused all care. The resident could be verbally aggressive towards others. Interventions included: provide verbal cues prior to care routines; administer medications as ordered; report changes in mood/behavior to the physician; redirect/intervene and/or provide distractions during episodes of agitation; and reapproach as appropriate. The 02/10/2026 at 10:50 AM nursing progress note by the Director of Nursing documented Certified Nurse Aide #1 reported to Registered Nurse Unit Manager #7 they witnessed Support Aide #2 (referred to as Nurse Aide Trainee and clarified in interview as Support Aide #2) hit Resident #1 on the left shoulder. Certified Nurse Aide #1 and Support Aide #2 had assisted Resident #1 into their wheelchair and the resident hit Support Aide #2. Support Aide #2 stated the resident was combative during care and they held the resident's hands. When transferred, the resident hit Support Aide #2, and Support Aide #2 struck the resident in the left shoulder. Both Certified Nurse Aide #1 and Support Aide #2 left the room when the transfer into the wheelchair was completed. The 02/10/2026 at 10:55 AM nursing progress note by Registered Nurse Unit Manager #7 documented Certified Nurse Aide #1 reported Resident #1 was hit in the left shoulder. An assessment was completed; no redness, swelling or bruising was observed. Resident #1 could not say what happened due to their cognition. Registered Nurse Unit Manager #7 asked the resident if they were afraid of anyone and the resident did not respond. Resident #1 did not shy away, flinch, or act in any way afraid while Registered Nurse Unit Manager #7 was with them. The family was notified and was appreciative of the call. The 02/10/2026 facility investigation completed by the Director of Nursing documented Certified Nurse Aide #1 assisted Resident #1 with morning care and Support Aide #2 was assisting them. When Resident #1 was transferred into their wheelchair, they hit Support Aide #2 and Support Aide #2 hit the resident back on the left shoulder. Certified Nurse Aide #1 reported the incident to Registered Nurse Unit Manager #7. The Director of Nursing was notified, and upon interview, Support Aide #2 was suspended pending investigation. Resident #1 was assessed and had no injuries. They could not recall what happened. The Medical Director and family were notified. Social services would follow up with the resident. On 02/13/2026, the facility concluded abuse had occurred and Support Aide #2 was terminated. Staff statements in the 02/10/2026 Facility Investigation included: -On 02/10/2026, Support Aide #2 documented they were assisting Resident #1 with care and the resident was combative. Support Aide #2 held the resident's hands so care could be performed and after helping the resident into their chair, the resident swung at them and grabbed their badge. Support Aide #2 reacted and swatted back but did not make contact with the resident. They realized their reaction before they made contact and pulled their hand back. - On 02/10/2026, Certified Nurse Aide #1 documented they and Support Aide #2 were assisting Resident #1 into their wheelchair. Resident #1 struck Support Aide #2, and Support Aide #2 struck the resident back in their left shoulder and then Certified Nurse Aide #1 and Support Aide #2 exited the room. During an interview on 02/18/2026 at 9:45 AM, Registered Nurse Unit Manager #7 stated they were informed about the incident between Resident #1 and Support Aide #2 by Unit Clerk #31. They stated Unit Clerk #31 informed them that Support Aide #2 hit Resident #1. Registered Nurse Unit Manager #7 immediately phoned the Director of Nursing and reported the incident. During an interview on 02/18/2026 at 10:04 AM, Unit Clerk #31 stated on 02/10/2026, Certified Nurse Aide #1 told them Support Aide #2 hit Resident #1 on the shoulder. Resident #1 had been combative with care and hit Support Aide #2. They immediately reported the incident to Registered Nurse Unit Manager #7. During an interview on 02/18/26 at 10:30 AM, Certified Nurse Aide #1 stated Resident #1 could be combative with care. They observed Resident #1 hit Support Aide #2 and Support Aide #2 hit the resident's left shoulder with their right hand and stated, don't hit me. Certified Nurse Aide #1 stated the slap wasn't hard but could be heard. During an interview on 02/17/2026 at 1:42 PM, Support Aide #2 stated Resident #1 was combative with care and the resident hit them. They reacted but thought they hit the string on their badge. They denied making contact with the resident. During an interview on 02/18/2026 at 11:00 AM, the Director of Nursing stated they received a call from Registered Nurse Unit Manager #7 who stated Certified Nurse Aide #1 reported Support Aide #2 hit Resident #1 in the shoulder. Support Aide #2 was brought into the office, interviewed and re-educated immediately on abuse prevention and reporting. The Director of Nursing stated Support Aide #2 was immediately suspended following the re-education and an investigation commenced. They stated following their investigation, they concluded abuse was witnessed and the facility terminated Support Aide #2. All staff were educated on abuse prevention and reporting prior to this incident and were immediately re-educated after the incident. During an interview on 03/05/2026 at 9:42 AM, the Medical Director stated they were notified of the incident between Resident #1 and a staff member. Resident #1 was assessed by Nurse Practitioner #29, and they understood there were no injuries. They would expect to be notified of any incidents related to abuse and expected staff not to be abusive towards any resident in the facility. 10 New York Codes, Rules and Regulations 415.4 (b)(1)(i)____________________________________________________________________________The deficient practice was identified at past non-compliance based on the following corrective actions:-The incident was immediately reported to the Administrator, who reported it to New York State Department of Health as required. -Support Aide #2's personnel file was reviewed. There was documented evidence of education on abuse prevention and reporting prior to the incident.- Verification of social services follow up with Resident #1 to ensure there was no negative psychosocial outcome to the resident. - Verification Resident #1's care plan was reviewed and updated to reflect the 02/10/2026 incident.-Support Aide #2 was suspended on 02/10/2026, immediately following the incident and subsequently terminated. -The facility developed, implemented, and maintained an effective abuse prevention training program.-Facility-wide education was conducted on abuse prevention and reporting and was completed on 02/16/2026. -The onsite investigation included observations and interviews with staff for verification of abuse training and reporting.

Based on observations, record review, and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 7 of 7 resident beds (beds for Resident #15, #29, #31, #38, #91, #99, and #106) reviewed. Specifically, Resident #15's mattress was not securely placed within the bedframe brackets; Resident #29's mattress did not fit within the bedframe mattress brackets resulting in a gap between the mattress and the assist rail; Resident #99's mattress was not securely placed in the bedframe brackets resulting in an entrapment zone that exceeded the United States Food and Drug Administration's recommended dimensional limits; and Residents #31's, #38's, #91's, and #106's assist rails were not routinely inspected for possible zones of entrapment. The facility policy, Bed Rail use (Side Rails, Assist Rails, Transfer Rails, Bed Enablers), revised 9/27/2018, documented upon installation and routinely the resident was assessed for the use of the assist rail and risk for entrapment. The use of an assist rail required a physician's order that included the number and type of rail(s). The Bed Side/Rail Assessment was completed by the registered nurse/designee in conjunction with the interdisciplinary team initially, quarterly and as needed; and bed assessments were completed by the maintenance department in conjunction with the clinical team per facility policy. The November 2005 High-Low Bed Instruction Manual documented all the mattresses supplied by their company worked together with the siderails to meet the Food and Drug Administration's regulations and guidelines at the time of purchase. If other mattresses were used, it was up to the end user to determine whether their mattress was suitable for minimizing entrapment risks. The undated owner's manual for the alternating pressure mattresses utilized by the facility, including bariatric, documented due to concerns over the possibility of patient entrapment, the use of rails of any length was a matter currently addressed by various regulations from local, national, and international government agencies, and by individual facility protocol. It was the responsibility of the facility to be in compliance with those laws. There was no documented evidence of facility assist rail inspections for 2024 or 2025. 1) Resident #15 had diagnoses including hand contractures (shortening of the muscle), cerebral palsy (a neurological condition), and muscle weakness. The 3/13/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not reject care, required substantial/ maximal assistance with bed mobility, was dependent for transfers, and did not use a bed rail. A 2/26/2024 Side Rail/ Assist Rail Assessment completed by Licensed Practical Nurse Unit Manager #43 documented the resident used bilateral enabler/assist bars. There were documented alternatives that were considered or attempted, entrapment risk and the risks/ benefits of usage were reviewed with the resident, and the resident consented and agreed to the use of the side rail/ assist rails. There were no additional documented Side Rail/ Assist Rail Assessments in the resident's medical record. The 11/14/2024 physician order documented the resident used a right assist rail for bed mobility related to diagnosis of muscle contractures. The Comprehensive Care Plan initiated 7/14/2024 and revised 3/12/2025 documented the resident had an activity of daily living deficit related to muscle weakness and cerebral palsy. Interventions included substantial/ maximal assistance of 2 or more with bed mobility using a bed assist rail on the right side and substantial/ maximum assistance using a mechanical lift with transfers. The 3/11/2025 Physical Therapist #35 progress report documented the resident required moderate/ maximal assistance with bed mobility and used handheld assistance or the bed assist rail. The resident was observed in their bed with 1 right sided assist rail with their mattress unsecure in the bedframe brackets: - on 3/24/2025 at 12:35 PM and 1:00 PM. - on 3/25/2025 at 9:22 AM and 1:45 PM. - on 3/26/2025 at 9:20 AM. - on 3/27/2025 at 9:04 AM and 1:38 PM. During an interview on 3/26/2025 at 11:57 AM, Licensed Practical Nurse #9 stated they were not aware of any issues with mattresses not fitting securely in the bedframe brackets. This would be something they would want to be made aware of especially if a resident had an assist rail as it could pose a safety issue. If they were made aware they would place a work order and notify a supervisor. During an interview and observation on 3/27/2025 at 1:42 PM, Certified Nurse Aide #44 stated the resident typically stayed in bed per their preference. Their mattress was not secure in the bedframe brackets, and they used the right sided enabler bar for bed mobility. During an interview on 3/28/2025 at 1:02 PM, Registered Nurse Unit Manager #6 stated the side rail/ assist rail assessment was completed at least quarterly and as needed by a registered nurse. They were unaware Resident #15 did not have a Side Rail/ Assist Rail Assessment completed since February 2024. They expected nursing to observe mattresses to ensure they fit in the bedframe brackets. If a resident had an assist rail and their mattress was not in the bedframe brackets it could pose a safety risk. 2) Resident #29 had diagnoses including osteoarthritis and a Stage 4 sacral pressure ulcer (full tissue loss with exposed bone, muscle and tendon). The 2/5/2025 Minimum Data Set assessment documented the resident was cognitively intact, required maximum assistance for bed mobility, used a pressure reducing device for their bed, and did not use an assist rail. The Comprehensive Care Plan initiated 10/24/2019 and revised 3/5/2025, documented the resident had an activities of daily living deficit. Interventions included one assist for bed mobility and bed rails. The Comprehensive Care Plan initiated 8/2/2024, documented the resident used assist rails on the right side of their bed to assist with bed mobility. Interventions included the interdisciplinary team reviewed and documented assist rail use quarterly and as needed. There was no documented evidence of a physician order for an assist rail. The 3/21/2025 Physical Therapist #35's discharge summary documented the resident utilized an assist rail on the right side of their bed. During an observation and interview on 3/24/2025 at 12:25 PM, the Resident #29's bed had a 1/4 assist rail on the right side; was pushed up against the wall on the left side; had a perimeter, alternating pressure mattress with contoured foam bolsters around the sides and ends of the mattress; was not securely nestled into the four bed frame brackets; and had a gap the width of approximately 4.25 inches between the mattress and the assist rail when the mattress was pushed up against the wall. The resident stated they once had two assist rails, but the facility removed them which impaired their ability to move. One assist rail was put back on and now they could move better. They were unsure of the timeline of those events. The 5/2/2024 Registered Nurse #27 Side Rail/Assist Rail Assessment documented the resident had assist bars on the right and left side of their bed; had a condition that caused the resident to move in the bed or tried to exit from the bed; and was discussed by the interdisciplinary team and the benefit outweighed the risk. There were no additional documented Side Rail/ Assist Rail assessments in the resident's medical record. During an observation on 3/26/2025 at 9:29 AM, the resident was transferred into bed with the use of a stand aid. The mattress was against the wall and there was a gap between the mattress and the assist rail. During an interview on 3/27/2025 at 1:29 PM, Certified Nurse Aide #16 stated bed frames had curved metal brackets on each corner the mattress should be nestled into, so it would not slide. That was important because the mattress could fall off the frame and the resident could fall. If a mattress did not fit properly on the bed frame it could also cause a gap between it and the assist rail which a resident could get stuck in. Resident #29 had an air mattress; the left side of their bed was against the wall; and there was an assist bar on the right side. Upon looking at the resident's bed and pushing the mattress toward the wall, they stated the mattress was not secured as it jumped right over the bracket on the left upper side of the bed frame causing a big gap and it should not be like that. During an interview on 3/27/2025 at 1:57 PM, Licensed Practical Nurse #2 stated mattresses should fit firmly into the four brackets on the bed frame and if the mattress fit properly, it should not slide. There was a potential for a gap if the mattress was not secured on the bed frame which could result in a resident getting a body part stuck. Resident #29 had an air mattress, one assist rail for bed mobility, and the left side of their bed was up against the wall. After looking at the resident's bed they said that the mattress was not secured within the brackets and slid when pushed creating a gap between the assist rail and the mattress. During an interview on 3/28/2025 at 1:31 PM, the Registered Nurse Clinical Educator #1 stated if a resident was approved to have an assist rail a medical order was obtained; the care plan was updated; the maintenance department was notified to place the assist rail; and an assist rail assessment form was completed by the Unit Manager and was updated quarterly thereafter. Housekeeping kept an inventory of the mattresses and if a specialty mattress was recommended, maintenance would retrieve and apply that mattress. They did not know if the type of mattress was taken into consideration when putting on a particular bed frame. They believed maintenance did monthly checks on all the beds to include frame and mattresses but did not know specifically what their process was. The four brackets on the bed frame kept the mattress on the bed and if a mattress did not fit within those four brackets, it was not the right mattress for that bed and should be switched out or reassessed. If one side of a bed was against the wall and the mattress moved the opposite way it could cause a gap between the wall and the mattress and lead to entrapment or a fall out of bed. During an interview on 3/28/2025 at 2:18 PM, the Director of Nursing stated if an assist rail was recommended and approved, the maintenance department would apply it. Maintenance took care of the beds and mattresses and were supposed to be doing routine checks, but they were unsure how often those checks were done. Checks were important to ensure the mattresses fit properly and to prevent injuries and entrapments. Mattresses should fit within the four brackets on the bed frame, so it did not slide and cause a risk for entrapment. There should be no gaps between the mattress and assist rails; assist rail use should be in the care plan; the assist rail assessments should be done quarterly and be accurate; and assist rails did not require a physician's order. During an interview on 3/28/2025 at 3:48 PM, the Director of Maintenance stated mattresses should not move about on the bed frame or slide away from the assist rails. Mattresses should fit within the four bed frame brackets. Mattresses that did not fit in those bed frame brackets created a potential entrapment zone. Entrapment zone checks were important for the safety of the residents. They stated entrapment zone checks were not completed in 2024. 3) Resident #99 had diagnoses including Alzheimer disease and muscle weakness. The 1/2/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not reject care, used a walker and wheelchair, was independent with bed mobility and transfers, had no falls since admission/ entry or reentry, and did not use a bed rail. The last documented bed inspection was completed on 2/21/2024. The 7/30/2024 physician order documented the resident was to have a right assist rail on their bed for bed mobility related to a diagnosis of weakness/ impaired mobility. The Comprehensive Care Plan initiated 12/10/2020 and revised 7/29/2024 documented the resident used a right assist rail for bed mobility to promote independence. Interventions included a right assist rail, resident/ responsible party was educated regarding the benefits and risks of assist rail use, resident/ responsible party was educated on the use of assist rail device to promote maximum functional ability, physical/ occupational therapy evaluations were completed as needed per physician orders, and the interdisciplinary team reviewed and documented assist rail use quarterly, and as needed. The 2/6/2025 Side Rail/ Assist Rail Assessment completed by Registered Nurse Unit Manager #6 documented the resident used bilateral enabler/ assist bars. There were no documented alternatives considered or attempted, entrapment risk and the risks/ benefits of usage were reviewed with the resident, and the resident consented and agreed to the use of the side rail/ assist rails. The 3/14/2025 Physical Therapist #35 progress report documented bed mobility assessment and training was facilitated with the resident using the right-side assist rail. The undated certified nurse aide care instructions documented the resident had a right assist rail and required supervision/ touching assistance with chair/ bed to chair transfers and bed mobility. The resident's bed was observed to have 1 right sided assist rail, and their mattress was not secure within the bedframe brackets, and slid of the bedframe with gentle knee pressure on: -3/24/2025 at 12:22 PM and 1:53 PM. -3/25/2025 at 9:17 AM and 12:59 PM. -3/26/2025 at 9:26 AM. During an interview on 3/26/20225 at 11:57 AM, Licensed Practical Nurse #9 stated they were not aware of any issues with the resident's mattress not fitting securely in the bedframe brackets. This would be something they would want to be made aware of especially if a resident had an assist rail as it could pose a safety issue. If they were made aware they would put in a work order and notify a supervisor. During an interview and observation on 3/26/2025 at 11:58 AM, Maintenance Assistant #10 stated they looked at beds with assist rails to determine if there were any entrapment zones. They had a Food and Drug Administration approved bed entrapment measurement tool with them. They stated Resident #99 had a standard mattress and standard bedframe. When they initially tested Resident #99's bed to determine if there were any entrapment zones the mattress was not secure in the bedframe brackets causing the mattress to slide away from the assist rail and it did not pass entrapment zone 3 (area between the rail and mattress). Once the mattress was securely placed in the brackets of the bed frame and tested again the bed did not have any entrapment zones identified. They were unsure the last time the resident's bed was inspected for entrapment zones. If they had been made aware of any issues with the bed via a work order the maintenance department would have addressed, it. During an interview on 3/26/2025 at 12:27 PM, Certified Nurse Aide #39 stated they were assigned to Resident #99 and did not notice their mattress was not secure in the bedframe brackets. They made the resident's bed and put new sheets on the bed. They last checked the resident's mattress was secure in the bedframe brackets at 6:30 AM. If they noticed any issues with the mattress not fitting into the bedframe brackets, they would tell the nurse. During an interview on 3/28/2025 at 1:02 PM, Registered Nurse Unit Manager #6 stated side rail/ assist rail assessments were completed at least quarterly and as needed by a registered nurse, the interdisciplinary team determined which residents were candidates for assist rails and would determine alternatives to trial. After a physician order was obtained and a therapy evaluation was completed the Director of Nursing gave final approval to have assist rails installed and the maintenance department installed the rails onto the residents' bedframes. The maintenance department was responsible for inspecting the residents' beds and checking for entrapment zones. If staff observed any issues with a residents' mattress not secured in the bedframe brackets or issues with the assist rails, they should tell a nurse as it posed a possible safety issue. They completed Resident #99's side rail/ assist rail assessment in February 2025. When they completed the assessment, they visualized their bed, spoke with the resident and/ or representative about the risk/ benefits associated with the assist rail usage, and reviewed the resident's medical record. They stated when they reviewed Resident #99's February side rail/ assist rail assessment it was not accurate as the resident only had a right sided assist rail. They did not realize the resident did not have capacity to make medical decisions until they reviewed their record. They stated nursing staff should ensure the mattress fit in the bedframe brackets when they were transferring the resident in and out of bed. They had not been made aware of any issues. During an interview on 3/28/2025 at 2:18 PM, the Director of Nursing stated if an assist rail was recommended and approved, the maintenance department would apply it. Maintenance took care of the beds and mattresses and was supposed to be doing routine checks, but they were unsure how often those checks were done. Checks were important to ensure the mattresses fit properly and to prevent injuries and entrapments. Mattresses should fit within the four brackets on the bed frame, so it did not slide and cause a risk for an entrapment. During an interview on 3/28/2025 at 3:48 PM, the Director of Maintenance stated mattresses should not move about on the bed frame or slide away from the assist rails. Mattresses should fit within the four bed frame brackets. If the mattress was not in the bedframe brackets it could create a potential entrapment zone failure. There were no documented entrapment zone checks completed in 2024, and all resident beds should be inspected annually or per the manufacture's specifications which ever was the higher level of requirements to ensure safety. It was difficult to inspect all the beds as there were some residents who refused to get out of bed. They would report to the nurses that residents refused to get out of bed, but did not notify administration. During a follow up interview on 3/28/2025 at 4:15 PM, the Director of Nursing stated the Side Rail/ Assist Rail assessments were to be done quarterly and as needed and should be accurate. 10NYCRR 415.29(b) 49448 50561

Based on observations, record review, and interviews during the recertification and abbreviated (NY00333993) surveys conducted 3/24/2025-3/28/2025, the facility did not ensure residents received adequate supervision to prevent accidents for 2 of 13 residents (Residents #164, and #171) reviewed. Specifically, -Resident #171 had dysphagia (difficulty swallowing), was on aspiration (inhaling food/fluid into the lungs) precautions and the resident was provided ice chips without a physician order or supervision. -Resident #164 was at high risk for elopement (leaving premises/safe area without facility knowledge), the resident frequently wandered in non-residential areas, and there was no documented evidence of a plan to limit the resident's wandering to potentially unsafe areas. Additionally, the resident's wander alert device was not checked for function as planned. Findings include: The facility policy Aspiration Precautions Guidelines, revised 7/24/2018 documented if orally fed, maintain the resident's head of bed at 45 or higher for at least 30 minutes after meals and consumption of food/liquids, unless otherwise ordered by medical. Provide constant supervision/assistance at mealtime. Observe closely for signs/symptoms of aspiration (respiratory distress, coughing, wheezing, cyanosis [bluish discoloration from low oxygen levels], and tachycardia [high heart rate]). The facility policy Care Planning, revised 1/22/2019 documented the interdisciplinary team would develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. The facility policy Electronic Wandering Security System, revised 2/13/2019 documented an electronic security system designed specifically for those residents identified as being at risk for elopement was installed to allow residents to ambulate independently in a controlled, safe environment, while preventing them from leaving the building without staff awareness. The nursing staff applied and maintained the bracelet/anklet, the nurse would verify the placement of the bracelet/anklet every shift, and the nursing department or maintenance department would be designated to check the functionality of the device daily using the designated tester. Functionality would be documented in the resident medical record or maintained in the maintenance department. 1) Resident #171 had diagnoses including dysphagia (difficulty swallowing), dysarthria (slurred speech), and facial weakness following a stroke. The 2/15/2025 Minimum Data Set assessment documented the resident was cognitively intact, complained of difficulty or pain with swallowing, had a feeding tube, and received partial/moderate assistance with most activities of daily living. The 3/18/2025 at 12:23 PM Licensed Practical Nurse #30 progress note documented the resident returned from a barium swallow study. Findings included aspiration of thin and nectar thick barium, penetration of honey and pudding puree barium. Recommendations included baseline diet intake (FOIS level 1, Functional Oral Intake Scale, nothing by mouth) and [NAME] free water protocol (allows patients to drink small sips of water or have ice chips between feedings). The 3/18/2025 at 1:55 PM Speech Language Pathologist #32 progress note documented the resident would remain nothing by mouth at that time and would work towards treatment for safe oral intake of purees and manage chronic pharyngeal residue. The plan did not include provision of ice chips. The 3/20/2025 at 10:35 AM Speech Language Pathologist #32 progress note documented the resident's diet changed to nothing by mouth with oral gratification to allow pureed items. The resident remained dependent on their tube feedings for nutrition and hydration. The resident was to be upright in a chair to consume by mouth and aspiration precautions were in place. The 3/20/2025 physician order documented nothing by mouth with oral gratification diet, pureed consistency, no liquids consistency; aspiration precautions maintain every shift. The Comprehensive Care Plan initiated 2/12/2025 and revised 3/20/2025 documented the resident had a potential for alteration in nutrition related to nothing by mouth status with oral gratification to allow pureed items. Interventions included aspiration precautions, pureed solids/honey thick liquids, must be out of bed and in a chair for meals, and may have 60 milliliters of ice chips upon request when upright in a chair and not in bed outside of mealtimes. The undated care instructions documented the resident was on aspiration precautions, could have 60 milliliters of ice chips with a teaspoon when upright in a chair, not in bed, and outside of mealtimes. There was no documented evidence the resident had a physician order to consume water or ice chips. The 3/24/2025 at 11:16 Physician #47 progress note documented the resident was evaluated for history of dysphagia. The resident continued to aspirate despite therapy, worse with thin liquids than with honey thickened liquids. Resident #171 was observed: - on 3/26/2025 at 10:12 AM, lying in bed with the head of bed elevated at 45 degrees. They had a 20-ounce cup full of ice chips on their bedside table and no staff was present. They stated they ate them in bed when their mouth was dry, or they were thirsty. - on 3/27/2025 at 9:00 AM, lying in bed with the head of their bed elevated at 45 degrees. Certified Nurse Aide #25 brought in a 20-ounce cup full of ice chips and put them on their bedside table and exited the room. At 9:05 AM, lying in bed with the head of their bed elevated at 45 degrees eating ice chips with a spoon. - on 3/28/2025 at 9:30 AM, lying in bed with a 20-ounce cup of ice chips on their bedside table with no staff present. During an interview on 3/27/2025 at 1:20 PM, Certified Nurse Aide #25 stated they cared for Resident #171 that morning and brought them ice chips. They did not follow the care instructions, the resident was in bed and not in a chair, and they brought more than 60 milliliters of ice chips. They stated if they ate the ice chips in bed and not in a chair it put the resident at risk to choke, and it was important to follow the care instructions for Resident #171's safety. During an interview on 3/28/2025 at 9:48 AM, Certified Nurse Aide #29 stated Resident #171's diet recently changed, and they were allowed to have 1 pureed item at mealtime and ice chips upon request. Their care instructions said 60 milliliters of ice chips which was a small amount, and they had given the resident 20-ounces which was much more than that. They let Resident #171 have the ice chips while they were lying in bed because they thought the resident knew to sit up while eating them. They did not think the resident was on aspiration precautions. They should have the resident go to the dining room to be monitored while eating and would not have left the ice chips at their bedside without supervision. During an interview on 3/28/2025 at 10:14 AM, Licensed Practical Nurse #30 stated Resident #171's diet had recently changed, and they were allowed to have ice chips. They did not think there was a restriction on how much they could eat, and they were not aware it said 60 milliliters. The black cup at the resident's bedside was much more than 60 milliliters and the certified nurse aides should follow the care instructions for Resident #171's safety. If they left the ice chips while the resident was lying in bed and not in the chair it put them at risk for aspiration. During an interview on 3/28/2025 at 10:38 AM, Assistant Director of Therapy #31 stated Speech Language Pathologist #33 was working with Resident #171 and upgraded their diet to allow them to have 1 or 2 pureed items at mealtime and 60 milliliters of ice chips in between mealtime but they had to be out of bed and sitting in a chair. They were on aspiration precautions which meant they were supposed to have staff supervision while consuming their food or ice chips. They expected nursing to follow the recommendations they were all educated on and only give the resident 60 milliliters of ice chips at a time and not fill a 20-ounce cup and leave it at Resident #171's bedside. The resident should have a small amount of ice chips at a time with staff supervision and if they consumed them while lying in bed it put them at a higher risk for aspiration. During an interview on 3/28/2025 at 1:51 PM, Registered Nurse #14 stated the care instructions contained all the information the certified nurse aides needed to provide care and they should review them often to see if any changes were made. Resident #171 was on aspiration precautions which meant they required staff supervision while they consumed food or ice chips. The certified nurse aides were educated to know the size of their cups and 60 milliliters which was about 2 ounces of ice chips and would have been one of their medium sized plastic cup. Resident #171 should not have received a 20-ounce cup of ice chips while they were lying in bed and without direct supervision because it put them at a higher risk for aspiration or choking. Speech Language Pathologist #33 declined an interview prior to the survey exit. 2) Resident #164 had diagnoses including early onset Alzheimer's disease and history of falling. The 12/20/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, wandered 4-6 days placing the resident at a significant risk of getting to a potentially dangerous place, had no upper or lower extremity impairments, did not use a mobility device, required supervision/ touching assistance with walking 10 feet, walking 50 feet with two turns, and walking 150 feet, and used a wander/elopement alarm daily. The 12/12/2024 Elopement Assessment completed by Licensed Practical Nurse Unit Manager #5 documented the resident was a low risk for elopement. Nursing progress notes documented: - on 12/12/2024 at 10:16 PM by Licensed Practical Nurse #15 the resident was wandering the unit on several occasions. - on 12/13/2024 at 2:40 PM by Licensed Practical Nurse #9 the resident wandered down towards the lobby and was redirected by staff. - on 12/13/2024 at 2:50 PM by Registered Nurse #14 the resident was noted to have impaired cognition, wandered off the unit to the lobby, and was easily redirected. A new Elopement Assessment was completed, the resident was a high risk for elopement, and a wander alert device was applied to the resident's right ankle. The 12/13/2024 at 2:48 PM Elopement Assessment completed by Registered Nurse #14 documented the resident was high risk for elopement. The 12/13/2024 physician order documented to check for the presence of the electronic security bracelet/ anklet (wander alert device) every shift and check the function every night shift. On 12/13/2024 the Comprehensive Care Plan was updated and documented the resident was at high risk for unsafe wandering/ elopement. The resident ambulated without a device, had dementia, a history of wandering, and impaired cognition and memory. Interventions included a wander alert device on the right ankle, complete wandering/ elopement risk assessment per policy, and place a picture of the resident with the receptionist and other units as appropriate. The 12/2024 Treatment Administration Record documented check electronic security bracelet/ anklet function every night shift. Nursing progress notes by Licensed Practical Nurse #12 documented on 12/13/2024 at 11:02 PM, 12/16/2024 at 11:53 PM, 12/21/2024 at 11:15 PM, 12/22/2024 at 11:13 PM, 12/23/2024 at 10:47 PM, 12/26/2024 at 10:52 PM, and 12/30/2024 at 10:49 PM there was no meter to check the function of the resident's wander alert device. A 12/14/2024 at 5:01 PM, Licensed Practical Nurse #9 progress note documented a certified nurse aide (unidentified) and they were able to redirect the resident out of another resident's rooms. The resident then walked down the hallway towards the education room and the North Unit. The resident was redirected back to their unit and the doors to the education room and North Unit were closed. At 5:22 PM, the resident wandered into the lobby and was easily directed back to the unit. The doors leading to the lobby were closed to prevent the resident from wandering off the unit. Licensed Practical Nurse #9's 12/15/2025 progress notes documented at 12:10 PM, the resident was wandering on and off the unit. The certified nurse aide (unidentified) directed the resident back from the elevators. The resident appeared agitated and was going in and out of other resident's rooms. At 1:49 PM, the resident wandered down to the time clock and was difficult to redirect. At 1:52 PM and 4:40 PM, the resident was wandering at times and was difficult to redirect. Licensed Practical Nurse #9's 12/28/2024 progress notes documented at 10:32 AM the resident was brought back to the unit from the Human Resource office area and the double doors were closed. At 11:44 AM, the resident wandered off the unit into the employee cafeteria through the kitchen entrance. The supervisor was able to redirect the resident to the lobby area and eventually back to the unit. At 5:11 PM, the resident wandered off the unit into the lobby and was brought back to the unit. There was no documented evidence the resident's care plan was revised to include interventions when the resident attempted to wander to potentially unsafe areas of the facility. Nursing progress notes by Licensed Practical Nurse #12 documented on 1/1/2025 at 11:17 PM, 1/3/2025 at 10:51 PM, 1/4/2025 at 10:55 PM, 1/5/25 at 11:59 PM, 1/6/25 at 10:42 PM, and 1/7/25 at 11:45 PM there was no meter to check the function of the resident's wander alert device. A 1/5/2025 at 12:20 PM, Licensed Practical Nurse #17 behavior monitoring note documented the resident was pacing periodically, wandering into inappropriate areas, was exit seeking, and restless. This behavior lasted over 60 minutes and non-pharmacological interventions such as toileting, offering food/ drink, and small group activities did not change their behavior. Licensed Practical Nurse #9 progress notes documented: - on 1/10/2025 at 5:41 PM the resident wandered into the lobby and other resident rooms all day. - on 1/11/2025 at 3:58 PM the resident wandered in and out of rooms. - on 1/16/2025 at 5:09 PM the resident wandered off the unit into the kitchen and was brought back to the unit by staff. A 1/17/2025 at 5:03 AM progress note by Registered Nurse #1 documented the resident wandered all night, was found in other resident's room, and in the lobby by the front door. The resident was easily redirected. A 1/22/2025 at 2:49 PM, Licensed Practical Nurse #20 behavior monitoring note documented the resident was wandering into inappropriate places, wandered off the unit into the lobby, and had increased confusion. Their behavior occurred a few times and non-pharmacological interventions were effective. On 1/30/2025 at 4:25 PM, Licensed Practical Nurse #11 documented the resident was walked to the unit by kitchen staff who stated the resident was standing next to the steam table. The resident was currently seated in a chair by the nurse's station and would continue to be monitored. During an observation on 3/28/2025 at 10:37 AM, the employee time clock was in a hallway behind the main elevator bank near an alcove that went to the employee cafeteria, an entrance to the main kitchen with access to the steam tables, and an area where the meal carts were stored. The employee cafeteria had another entrance that accessed the hallway near the Human Resource office area. The doors to the employee cafeteria and main kitchen were open. The resident was observed on 3/27/2025 at 10:10 AM, walking the long hallway holding a doll. At 10:20 AM, wandering into other resident's rooms in the long hallway, and at 1:26 PM, walking the long hallway. During an interview on 3/28/2025 at 12:18 PM, Licensed Practical Nurse #11 stated the wander alert devices only alarmed if a resident was near the main entrance or near the Human Resource office area as there was an exit near that area to the adult day program. They did not think the system would alarm if a resident went into the main kitchen, employee cafeteria area, or time clock area. Nursing was supposed to check for the presence and function of the wander alert device. If they did not have a scanner/ meter to test the function of the wander alert device a supervisor should have been made aware. The meter was observed in the top drawer of the medication cart. They stated one evening an unknown kitchen staff brought the resident back to the unit. The resident was found by the steam tables in the serving area of the main kitchen. They alerted the Nursing Supervisor and documented the incident. During an interview on 3/28/2025 at 12:35 PM, Licensed Practical Nurse #9 stated Resident #164 used to wander the unit, go to the lobby, was found by the time clock, in the kitchen, employee cafeteria, and Human Resource office area. They alerted the nursing supervisor each time the resident was brought back to the unit from nonresidential areas and documented the incidents in their notes. They would do a visual check and document any observed issues. Nursing staff should observe the placement and test the function of the wander alert device daily, and document in the chart. If staff were unable to find the wander alert device scanner/ meter to check the function of the wander alert device, they should alert a supervisor. They never heard of any issues with the wander alert device meter missing or not working. A telephone interview was attempted with Licensed Practical Nurse #12 on 3/28/2025 at 3:21 PM and a voicemail was left. No return call was received prior to exit. During an interview on 3/282/2025 at 3:24 PM, Licensed Practical Nurse Unit Manger #5 stated wander alert devices should be checked daily for placement and function. If a nurse was unable to locate the wander alert device scanner/ meter to perform the function test they should alert the supervisor. During an interview on 3/28/2025 at 4:35 PM, the Director of Nursing stated each unit had a wander alert device scanner/ meter to check the function of wander alert devices. If they were unable to locate the wander alert device scanner/ meter they should alert the supervisor. They were unaware Resident #164 was found in the main kitchen near the steam tables and stated a supervisor should have been made aware and completed a nursing assessment. 10NYCRR 415.12 (h) 48052 48675

Based on observations, record review, and interviews during the recertification survey conducted 3/24/2025 to 3/28/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 7 residents (Resident #142) reviewed. Specifically, Resident #142 was not provided with supervision and maximum cueing with eating and was not provided meals in the dining room as planned. Findings include: The facility policy [Activities of Daily Living] Assistance and Supervision. approved 1/18/2018, documented the Unit Manager and licensed practical nurse team leaders monitored the activity of daily living and supervision provided to the residents and gave appropriate guidance and assistance to nursing staff. The certified nurse aides provided the activities of daily living assistance and supervision to their assigned residents. The personal care profile and care plan were referenced for the type of activities of daily living and supervision needed by a resident. Resident #142 had diagnoses including Parkinson's disease (a progressive neurological disorder), dysphagia (difficulty swallowing), and dementia. The 2/19/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, had no behavioral symptoms, and required supervision/touching assistance for eating. The Comprehensive Care Plan, initiated 7/24/2023 and revised 3/7/2025, documented the resident had an activities of daily living function and mobility deficits related to muscular weakness. Interventions included the resident required supervision or touching assistance for eating, was to be in the dining room for all meals and needed maximum encouragement for eating. The resident had an eating functional maintenance plan to have the staff set-up the resident's meals, strongly encourage the resident to eat in the dining room for all meals and required supervision to stand by assistance and constant verbal cues to eat and not just drink at meals. Turn off the television when providing care in the resident's room to increase participation as they were easily distracted and had increased difficulty participating in activities of daily living when their attention was divided. The resident's care instructions (Kardex) documented the resident required supervision or touching assistance and maximum encouragement at meals and was to be in the dining room for all meals. The percentage of meal consumption from 03/20/2025 to 3/27/2025 documented: - on 3/20/2025 breakfast was 26-50%, lunch was not documented; and dinner was 0-25%; - on 3/21/2025 breakfast was 0-25%, lunch was 0-25%, and dinner was 0-25%; - on 3/22/2025 breakfast was 0-25%, lunch was 26-50%, and dinner 51-75%; - on 3/23/2025 breakfast was 0-25%, lunch was 0-25%, and dinner was 26-50%; - on 3/24/2025 breakfast was refused, lunch was 0-25%, and dinner was 51-75%; - on 3/25/2025 breakfast was 51-75%, lunch was 0-25%, and dinner 0-25%; - on 3/26/2025 breakfast was 26-50%, lunch was 0-25%, and dinner 0-25%; - on 3/27/2025 breakfast 0-25%, and lunch 0-25%. The following observations of Resident #142 were made: - on 3/24/2025 at 12:02 PM staring straight ahead and not eating their lunch. There was no staff encouragement provided to the resident throughout the meal. - on 3/26/2025 at 11:36 AM, Licensed Practical Nurse #20 asked the resident if they wanted to have lunch in the common area across from the nursing station and the resident agreed. At 12:17 PM, the resident had their meal on an overbed table. There was a partially eaten hot dog in their hand, resting on their leg. At 12:26 PM, the resident continued to hold the hot dog in their hand, resting on their leg. The resident was staring straight ahead. The rest of their meal tray included meat loaf, cheesy potatoes, beets, chocolate milkshake, and pears and was untouched. Staff did not provide encouragement or assist the resident with their meal. - on 3/27/2025 at 8:59 AM in bed with their breakfast tray in front of them on the overbed table. The tray included two juices, chocolate milk, eggs, biscuits and gravy, and a cut up banana. All the items appeared untouched. The resident was watching television. Licensed Practical Nurse #34 administered the resident's morning medications and did not encourage the resident to eat or offer food alternatives. From 11:56 AM to 12:58 PM, the resident was in the dining room and received their lunch tray which included a hotdog with mustard, a small portion of turkey noodle bake, and bacon brussels sprouts. The resident did not eat anything on their tray. At 12:30 PM Certified Nurse Aide #42 passed by the resident without stopping and encouraged them to eat their hotdog. The resident only drank their chocolate milk and was not offered an alternative when they did not eat their lunch. - on 3/28/2025 at 8:58 AM sitting on the side of their bed looking out window. The resident had untouched toast with jam and two pieces of bacon on their breakfast tray. The resident drank all their chocolate milk and some of their juice. At 9:17 AM, the resident had not touched their meal. During an interview on 3/28/2025 at 9:34 AM, Certified Nurse Aide #33 stated a resident's meal assistance level was on the resident care instructions. If a resident required supervision with max cueing that meant staff had to constantly encourage the resident to pick up a utensil and put it to their mouth. Resident #142 required supervision with max cueing for their meals. The resident was provided cueing for lunch but not as much during breakfast. They stated they were not present for lunch on 3/27/2025 so they did not know if the resident was cued. It was important to provide cueing and supervision so the resident could get proper nutrition. During an interview on 3/28/2025 at 9:58 AM, Licensed Practical Nurse #34 stated the resident care instructions documented a resident's assistance level for meals. Resident #142 required supervision for meals. Supervision with max cueing meant the resident had to be reminded to take a bite, take a drink, and have someone always supervising. They expected Resident #142 to be supervised and receive max cueing with meals. If the resident was alone in their room or in the independent dining room with no one cueing them, they were not receiving supervision with max cueing as planned. During an interview on 3/28/2025 at 10:21 AM, Registered Nurse Unit Manager #19 stated resident care instructions documented what the resident's assistance level was for meals. Resident #142 required supervision with max cueing for meals which meant staff went in and out to supervise and offer food to the resident. They expected the resident receive assistance during meals as care planned. If the resident was in the independent dining room they should receive cueing during meals. It was important to provide cueing and supervision, so they received proper nutrition. During an interview on 3/28/2025 at 12:25 PM, the Assistant Director of Therapy/Occupational Therapist #31 stated Resident #142's functional maintenance program was initiated in January 2024 and updated in March of 2024. Resident #142 required supervision with maximum cueing due to the resident having trouble maintaining attention when eating. The resident consumed liquids but did not eat when unattended. This did not mean someone had to sit with Resident #142 constantly during their meal, but they should be giving the resident consistent cues to eat if they were not paying attention. If Resident #142 was in their room during breakfast, the cueing would be more intermittent. If the resident was in the dining room and had not touched their food, staff should provide more frequent cueing. They stated if the resident did not touch their food and was not provided with cueing, that was a problem. If a resident needed cueing and did not receive it, they could have decreased intake and weight loss. 10 NYCRR 415.12(a)(3)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00343302 and NY00370767) surveys conducted 3/24/2025-3/28/2025 the facility did not ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Residents #143) reviewed. Specifically, Resident #143's telepsychiatry recommendations for non-pharmacological interventions for behavioral symptoms were not implemented. Findings include: The facility policy SEASONS Memory Care Program, updated 12/20/2019, documented the program provided the residents a safe environment while enlarging their life with appropriate and purposeful activity that accommodated the individual's strengths, interests, and needs while promoting autonomy and assisting them in maintaining their level of ability. This was to reduce anxiety and boredom driven behaviors. The facility policy Behavior Monitoring, approved 2/10/2020, documented the facility ensured that mood, behaviors, social problems or psychosocial adjustment difficulties of the individual were reported, recorded, monitored, and care plan interventions were developed to address those observed behaviors. Evaluation of the effectiveness of those interventions was monitored on an ongoing basis by the interdisciplinary team. Non-pharmacological Interventions were implemented to help manage behaviors. Resident #143 had diagnoses including dementia with agitation, and depression. The 1/29/2025 Minimum Data Set documented the resident had severe cognitive impairment, continuous inattention, verbal and other behavioral symptoms one to three of seven days, and took antidepressant and antipsychotic medications. A 6/5/2024 physician order documented telepsychiatry appointments as needed for depression. The comprehensive care plan initiated 8/1/2024 and revised 3/20/2025, documented the resident had the potential for alteration in mood and behavior related to Alzheimer's, agitation, and anxiety. The resident was resistive to care; hit, bit, scratched, and pinched staff; and verbally threatened and swore at staff. The resident was depressed and had a history of suicidal ideation; was exit seeking and attempted to kick out windows or punch walls; was socially inappropriate and disruptive; had self-abusive acts of hitting themself in the face; refused medications and meals; and had unpredictable behaviors. Interventions included provider review of medications for intrusive and aggressive behaviors; ensure the resident held their doll or a soda bottle to prevent taking other residents' items; administer medications as ordered; approach the resident from the front in a calm, gentle manner; assure the resident did not attempt to stand on or push a chair; encourage to verbalize feelings; document behaviors; psychiatric consults as needed; monitor pain; remove from stressful situations; bring to the nurses' station if they were up early; offer drinks or snacks; offer busy work like folding clothes; and trazodone (antidepressant often used as a sleep aid) was started for increased insomnia and inappropriate wandering. The 11/14/2024 at 4:22 PM Social Worker #37 progress note documented they discussed the resident's continued aggressive behaviors and telepsychiatry recommendations with the nurse practitioner. The resident's next telepsychiatry appointment was scheduled for 12/16/2024. The 12/16/2024 Telepsychiatry progress note by Telepsychiatry Nurse Practitioner #46 documented they saw the resident via real time audiovisual for a follow-up to the 8/28/2024 visit. There was no improvement with the resident's agitation and combativeness. The resident admitted to getting angry with staff and feeling scared at times but could not explain why. Recommendations included it may be beneficial to meet with Registered Nurse Engagement Specialist #28 to develop a non-pharmacological behavioral care plan. Staff could reschedule a follow-up appointment approximately 4 weeks after institution of recommendations to assess response. The 12/18/2024 Telepsychiatry Nurse Engagement Behavioral Care Plan Interventions by Telepsychiatry Registered Nurse #28 documented they received communication asking for additional nonpharmacological recommendations per the telepsychiatry provider's recommendation. The resident had a history of abuse from their father and ex-husband. Staff at the facility was challenged by the resident's combativeness, yelling and screaming, difficulty redirecting from exit seeking, and not sleeping through the night but on and off throughout the day. Interventions like a baby doll, one-to-one reassurance, snacks and beverages, and redirection were short-lived. The non-pharmacological interventions recommended were: - antecedent behavior consequence (before, behavior, and after charting) to assist with identifying triggers such as when the resident's behavior was best, worst, what happened before the behavior, and the environment. - when the resident was exit seeking: avoid using negatives and no statements when redirecting or distracting, approach from the front and allow the resident space without touching them while smiling and cueing them to follow. - when the resident was combative with care: provide soft music, dimmed lights while displaying positive/favorite pictures, offering a snack prior or something to occupy their hands, and always stop when the resident resisted. - provide trauma-informed care as dementia residents could live in the past; introduce self when entering the resident's room; frequent reassurance they were okay; identify triggers such as where and when the abuse took place such, were they frightened at night and stayed up because of this; or when redirecting the resident from exiting, could their combativeness be related to their history of abuse. - encourage proper sleep by maximizing bright light exposure during the day especially between 9:30 AM to 11:30 AM, shades up early in the morning and down in the evening, limit daytime napping, and provide frequent exercise opportunities. The 12/18/2024 at 12:09 Social Worker #37 progress note documented telepsychiatry recommendations were reviewed with the physician. The physician agreed and the resident's Depakote was increased from 375 milligrams to 500 milligrams at bedtime. They would follow up for effectiveness. There was no documented evidence the non-pharmacological telepsychiatry recommendations were reviewed or implemented. The 2/10/2025 Social Worker #37 Care Plan Meeting progress note did not include documentation of discussion regarding telepsychiatry non-pharmacological recommendations for the resident's behavioral symptoms. The following observations of the resident were made: - on 3/24/2025 at 12:42 PM in another resident's room, clutching their babydoll. When staff attempted redirection, the resident did not want to leave the room. The resident laid down in the other resident's bed. - on 3/27/2025 at 8:47 AM, in a room next to theirs, asleep in a stationary high back winged chair with their meal tray in front of them. At 9:02 AM, the resident was woken by staff and reminded to eat their breakfast. The resident went back to sleep after the staff member left. At 11:51 AM, asleep in a recliner chair directly in front of the nursing station. During an interview on 3/28/2025 at 9:34 AM, Certified Nurse Aide #33 stated Resident #143 wandered while grabbing other people's items and had a cart to push around. The cart was taken away because staff thought the resident might hurt someone. Resident #143 wandered a lot at night and tried to get other residents out of bed. Staff were supposed to walk with the resident. They stated staff should try to get the resident to activities, walk with them, or do distraction activities so they were not sleeping throughout the day. The resident did not have any interventions for their yelling or distress, they just tried talking to the resident. It was not a preference of the resident to have their door shut and sometimes other residents shut the door because of the resident yelling. Resident #124's yelling lessened when they were out in the common area. The resident should not be left in their room alone with the door shut when they were distressed or yelling and often tried to get out of bed when that happened. They were unaware of any television preferences for the resident. During an interview on 3/28/2025 at 9:58 AM, Licensed Practical Nurse #34 stated the Unit Manager was responsible for updating the care plans. They were unsure what interventions Resident #143 had for their behaviors. They tried walking with the resident and gave them soda as they liked that. The resident wandered a lot at night. There were no interventions to keep the resident up at night as they were taught to let the resident do what they wanted with sleep and waking. They tried aroma therapy and tried to talk to Resident #124 to calm them down. The resident should not be left in their room yelling and/or distressed without intervention. If the resident had specific television preferences, they should be utilized. During an interview on 3/28/2025 at 10:21 AM, Registered Nurse Unit Manager #19 stated they had meetings every Friday to discuss the effectiveness of care planned interventions. Resident #143 wandered a lot at night. The resident did not sleep much during the day, just took small naps which were appropriate for them. If the resident was sleeping a lot during the day, it was part of their care to try and get the resident to activities. Resident #124 had a lavender scent patch for comfort, and they had a little laptop they put the resident's shows on. The resident did not know why they were yelling. If a resident was in their room with the door shut yelling the staff should intervene. If the resident preferred children's cartoons for the voices, it should be care planned. It was important to have personalized behavior and wandering interventions for residents to provide comfort for the residents. Their care plan should be centered around their likes and dislikes. During an interview on 3/28/2025 at 11:59 AM, Social Worker #37 stated they were responsible for mood and behaviors, psychotropic medications, and comfort measure care plans. The care plans and the interventions should be personalized because every resident was different and required different interventions to help calm them. They reviewed notes for all residents receiving telepsychiatry and incorporated the recommendations after they were approved by the provider. They documented the review under a social services note. They stated the non-pharmacological telepsychiatry interventions from 12/2024 were not incorporated in the resident's plan of care and they should have been. They stated they were unaware of the recommendation for antecedent, behavior and consequence charting to identify triggers. It should be on the resident's care plan they had a history of abuse, and the resident did not like to be touched. They were aware Resident #124 had yelling and distressing behaviors. The resident was scared and did not understand what was happening and yelled out. The staff should not leave the resident in a room by themself when they yelled. It was important for residents with dementia to be provided with interventions when they were distressed so they were provided with comfort and did not have undo stress. 10 NYCRR 415.12 124

Based on observations and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 of 5 medication rooms (Unit 1 North and Unit 3) reviewed. Specifically, lorazepam (a controlled substance) was stored in unlocked refrigerators (not double locked) that were not permantly affixed in Unit 1 North's and Unit 3's medication rooms. The facility policy Medication Rooms on Nursing Units, revised 7/30/2024, documented a double locked box in the refrigerator would be used for the storage of controlled substances that required refrigeration. The facility policy Medications Administration Methods, revised 1/25/2024, documented controlled substances should be stored in a double-locked cabinet until immediately before administration. During an observation on 3/25/2025 at 9:22 AM, the medication refrigerator in the Unit 1 North medication room had an exterior lock on the main door that was not engaged and a locked interior drawer containing a bottle of liquid lorazepam. During an observation and interview on 3/25/2025 at 9:26 AM, the Unit 3 medication room had a table top sized refrigerator with two locks on the main exterior door that were not engaged and a locked drawer inside containing two bottles of liquid lorazepam. Licensed Practical Nurse #2 stated they counted with the other nurse that morning and it was their responsibility to lock the refrigerator after they counted. They did not lock the door after they counted, it should have been locked because lorazepam was a controlled substance and required a double lock. Locking the refrigerator was important because someone could access it, and a narcotic error or discrepancy could occur. During an interview on 3/28/2025 at 1:23 PM, Registered Nurse Clinical Educator #1 stated controlled substances were double locked behind the locked door to the medication room. The medication refrigerator had a lock on the exterior door and a locked box inside it for controlled substances. If there was lorazepam in the refrigerator drawer, both the drawer and the main refrigerator door should be locked at all times to maintain the safety of that controlled substance. If those locks were not in place then someone could gain access to those medications and a diversion could occur. 10 NYCRR 415.18 (d)

Based on observations and interviews during the recertification and abbreviated (NY00333993) surveys conducted 3/24/2025-3/28/2025, the facility did not ensure the provision of food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 lunch meals tested (3/24/2025 and 3/28/2025 lunch meals). Specifically, the 3/24/2025 lunch meal entree was difficult to cut; and the 3/28/2025 lunch meal was not served at palatable and safe temperatures. Findings include: The facility policy Food Temperature Requirements and Holding Time, revised 6/28/2019, documented the Director of Dining Services or designee was responsible for assuring the proper temperatures and holding times of foods were maintained during the preparation and service of meals. The 3/24/2025 posted lunch menu documented cube steak with brown gravy, garlic mashed potatoes, peas and onions, and pineapple chunks. The following observations and interviews were made during the 3/24/2025 lunch meal: - at 12:41 PM Resident #383 stated sometimes the food was served cold and tasted bland. - at 12:50 PM Resident #19 stated the cube steak was hard, and staff called for a replacement meal for them. - at 12:50 PM Resident # 58 stated the cube steak was tough, and staff called for a replacement meal for them. - at 12:54 PM Residents #80's spouse stated the meat was very tough. Their spouse did not have teeth, and they could not cut the cube steak with their knife. They complained for months about the meat being too tough. - at 1:18 PM Resident #10 stated their cube steak was too tough, and staff called for a meal replacement. - at 1:23 PM Resident #49's meal ticket documented the resident required food that was easy to chew. The cube steak was attempted to be cut, and force was used to move the knife back and forth. Staff called for a meal replacement. During an observation on 3/27/2025 at 11:58 AM with Licensed Practical Nurse #20, Resident #383's lunch meal was tested for taste, temperature, and palatability. The resident was provided with a replacement tray. The applesauce measured at 65.1 degrees Fahrenheit; the turkey bake was 134.6 degrees Fahrenheit; Brussels sprouts were 123.9 degrees Fahrenheit; coffee was 129.2 degrees Fahrenheit; and milk was 55.7 degrees Fahrenheit. During an interview on 3/27/2025 at 12:08 PM, Licensed Practical Nurse # 20 stated they were unsure what the proper food temperatures should be, but hot food should be served hot and cold food should be served cold. During an interview on 3/28/2025 at 10:56 AM, the Food Service Director stated cold food should be served below 40 degrees Fahrenheit and hot food should be served between 140 and 150 degrees Fahrenheit. The food was tasted prior to being sent to the units and the cube steak served on 3/24/2025 was tested by Assistant Food Service Director #26 who described the cube steak as a little tough. Cube steak was a tough product, cuts of meat varied, and they were limited in the types of cube steak they could order due to budget constraints. They were aware of the significant number of meal replacements requested during the 3/24/2025 lunch meal due to reports from residents that the steak was either difficult to chew or unappealing. If a meal ticket documented easy to chew then food items should be tender enough to cut with a fork. They stated food held within a danger zone could have impacted both taste and palatability. They had not received complaints about the temperature or the quality of the food. 10NYCRR415.14(d)(1)(2) 48675

Based on observations, record review, and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in the main kitchen. Specifically, the main kitchen had food items past their expiration dates, undated food items, the walk-in freezer had ice buildup on an open box of food, and food was stored on the floor. Findings include: The facility policy Dietary Food and Supply Orders-Storage, revised 10/26/2018, documented food and non-food supplies were stored in a food storeroom and in refrigeration or freezer areas of the kitchen, in conformance with applicable sections of the New York State Health Code, rules and regulations. Containers of food were stored at a minimum of six inches above the floor to protect the food from splash and other contamination. Food was protected from contamination by dust, insects, rodents, unclean equipment and utensils, unnecessary handling, drainage and overhead leakage at all times during storage. Food removed from original containers or packages was protected from contamination by storage in clean, covered, labeled and sanitized containers. Food not readily identifiable was stored in properly labeled original product containers or in containers labeled to identify the food by common name. The following observations were made in the main kitchen with the Food Service Director on 3/24/2025 at 10:29 AM: - the walk-in cooler contained one 1-quart plastic container of diced beets dated 3/20/2025, one 4-inch metal pan of sliced carrots dated 3/20/2025, and one 20.8-inch by 12.8-inch x 2.5-inch pan of minestrone soup dated 3/3/2024. - the walk-in freezer contained 1 box of vegetarian chicken wings that was not securely closed. The box had ice buildup on the outside and the inside. One box of pulled white turkey was stored on the floor, and one 20.8-inch by 12.8-inch x 2.5-inch pan of vegetable lasagna had 2 inches of ice buildup and was dated 12/6/2024. - the cooks cooler contained 2 pounds of undated sliced American cheese wrapped in plastic and 1 pound of sliced provolone cheese wrapped in plastic dated 3/13/2025. - the salad cooler contained a 1-gallon plastic container with 2 cups of thousand island salad dressing with a best used by date of 12/4/2024. During an interview on 3/24/2025 at 11:02 AM, the Food Service Director stated all food items should be labeled and dated and used within 3 days when removed from their original package. Food items in their original containers with a best used by date or expiration date should be discarded after the date on the container. This ensured the best product and food safety. Food should not be stored on the floor or have ice buildup on the box or inside the box because it could possibly cause contamination of the food. 10NYCRR 415.14(h)

Based on interview and record review during the recertification survey conducted 3/24/2025 through 3/28/2025, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the facility did not provide the facility matrix for all residents and access to all resident electronic health records requested by the New York State Department of Health (NYS DOH) surveillance team in a timely manner. Findings include: The Centers for Medicare and Medicaid Services survey form Entrance Conference Worksheet provided to the Administrator/designee upon survey entrance documented the following items were required during the recertification survey: - the complete matrix for all residents within 4 hours of entrance. - access to all resident electronic health records and specific information on how surveyors could access the electronic health record outside of the conference room by the end of the first day of survey. The New York State Department of Health surveillance team entered the facility on 3/24/2025 at 10:02 AM. The Team Coordinator met with the facility's Director of Nursing at 10:40 AM to review the documents required for survey as outlined on the entrance conference worksheet. The Director of Nursing was provided with a hard copy of the entrance conference worksheet. The worksheet included the time frame for providing the complete matrix for all residents and facility computers with access to all resident electronic health records. On 3/24/2025 at 3:16 PM, the Director of Nursing stated facility computers with access to resident electronic health records were on the evening shipment and would not be available until after dinner time. On 3/25/2025 at 8:26 AM, the Team Coordinator sent an email to the Director of Nursing requesting the complete matrix for all residents that should be provided within 4 hours of entrance and attached a blank matrix with instructions for completion. On 3/25/2025 at 8:35 AM, Administrative Assistant #41 stated the Director of Nursing was in a meeting and the facility computers never arrived at the facility. The Team Coordinator sent an email to the Director of Nursing as a reminder that access to resident electronic health records was to be provided to the survey team by the end of the first day and asked if they had a time frame for the arrival of the computers. On 3/25/2025 at 9:20 AM, the Director of Nursing delivered three facility computers to the conference room with access to electronic health records. They stated they were aware all six surveyors needed access, and they would be able to deliver three more computers when they arrived on the truck that afternoon. On 3/25/2025 at 10:06 AM, the Director of Nursing sent the completed matrix for all residents. On 3/25/2025 at 11:00 AM, the Director of Nursing stated the facility computers did not arrive on the truck, and they were unsure when they would arrive. On 3/25/2025 at 11:08 AM, the Director of Nursing delivered three computers with access to electronic health records to the conference room. They stated they were able to borrow the computers from the therapy department and would switch them out when the others arrived. 10 NYCRR 483.70(i)

Based on record review and interviews during the abbreviated survey (NY00369096), the facility failed to establish mechanisms for documenting and communicating the resident's choice regarding Advance Directives to the staff responsible for the resident's care for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 updated their Medical Orders for Life-Sustaining Treatment to reflect a change in their wishes from cardiopulmonary resuscitation (attempt to restart the heart) to do not resuscitate (allow natural death). The paper medical record (Medical Order for Life Sustaining Treatment form) and electronic medical record code status orders did not match to reflect the resident's Advance Directives wishes to allow natural death (do not resuscitate). Subsequently, when the resident was found without signs of life, nursing staff verified their status with the prior Medical Orders for Life-Sustaining Treatment form and initiated cardiopulmonary resuscitation. When nursing staff noted in the electronic record there was an order for do not resuscitate, lifesaving efforts were discontinued, and the resident was pronounced deceased . This resulted in no actual harm with likelihood of serious harm, serious injury, or serious impairment, that is Immediate Jeopardy past non-compliance, for all residents in the facility who had advance directives in place. Finding includes: The facility policy, Basic Life Support, revised [DATE], documented: - Basic life support included cardiopulmonary resuscitation, rescue breathing, and defibrillation, and would be initiated on all appropriate residents unless advance directives documenting exclusion of these procedures were on file in the medical record. - When a resident was found unresponsive, staff should immediately confirm Do Not Resuscitate status. The electronic record would be utilized as the initial method of immediate identification. Another staff should obtain the paper medical record, and this will be the confirmation method of verifying code status in all instances. - If Do Not Resuscitate status is not present and immediate response was critical. Call 911, announce Code Blue, position resident on back board, check pulse and breathing, and begin cardiopulmonary resuscitation once Code status was confirmed. Resident #1 had diagnoses including acute posthemorrhagic anemia (condition that occurs when a significant amount of blood is lost), pancytopenia (blood disorder that occurs when the bone marrow has issues forming all three types of blood cells), and chronic kidney disease. The [DATE] Brief Interview for Mental Status assessment documented the resident's cognition was intact. The [DATE] Comprehensive Care Plan documented the resident's Advance Directive was full code (initiate lifesaving interventions). Interventions included the advance directive documentation should be reviewed quarterly and as needed. The [DATE] physician order documented Full Code. The Medical Orders for Life Sustaining Treatment form, signed by the resident on [DATE] at 1:30 PM, documented the resident wished for a cardiopulmonary resuscitation order in the event their heart stopped. The [DATE] at 3:46 PM Registered Nurse Unit Manager #2 progress note documented the resident arrived back to facility (from the hospital) and was able to make their needs known. The Medical Orders for Life Sustaining Treatment form was reviewed with the resident and a family member/ healthcare proxy and was signed and updated. The Medical Orders for Life Sustaining Treatment form, signed by the resident's healthcare proxy on [DATE] at 3:00 PM, documented the resident wished for a do not resuscitate order. The form was witnessed by Registered Nurse Unit Manager #2 and Licensed Practical Nurse #4. The form was signed by Nurse Practitioner #5 on [DATE]. The [DATE] electronic medical record order, entered by Registered Nurse Unit Manager #2 documented Do Not Resuscitate. There was no documented evidence the [DATE] Medical Orders for Life Sustaining Treatment was voided when a new Medical Orders for Life Sustaining Treatment was completed. The [DATE] Physician #9 progress note documented the resident was cognitively intact, had been readmitted to the facility on [DATE] after a hospitalization and based on diagnosis of myelodysplastic syndrome (a blood disorder) and declination of bone marrow biopsy, the resident opted for comfort care measures. The facility investigation dated [DATE], documented: - the resident returned from the hospital on [DATE] and Registered Nurse Unit Manager #2 met with the resident and family. They completed a new Medical Orders for Life Sustaining Treatment form and changed the code status from full code to Do Not Resuscitate. The new form was signed and placed on the medical provider's clipboard for review. The Do Not Resuscitate order was placed in the electronic record. - The prior Medical Orders for Life Sustaining Treatment form was not voided and remained in the file on the unit. - On [DATE] at 4:22 AM, the resident was found unresponsive and not breathing in their room by Certified Nurse Aides #10 and #11. The aides called for assistance; Licensed Practical Nurse #12 and Registered Nurse Supervisor #3 immediately responded, and a Code Blue was paged. - On [DATE] at 4:23 AM, the Medical Orders for Life Sustaining Treatment form was pulled from the file (hard copy on the unit) and the resident was determined to be full code status. Registered Nurse Supervisor #3 started chest compressions. - On [DATE] at 4:34 AM, Emergency Medical Services arrived and took over compressions. - On [DATE] at 4:44 AM, Registered Nurse Supervisor #3 left the room to call the family and notified the on-call Administrator and Assistant Director of Nursing. They were not able to reach the family. - On [DATE] at 4:48 AM, while speaking with the resident's relative, Registered Nurse Supervisor #3 noted in the electronic record the resident had an order for Do Not Resuscitate. The resident's relative/ healthcare proxy confirmed the resident's wishes were Do Not Resuscitate. - On [DATE] at 4:51 AM, Registered Nurse Supervisor #3 notified Licensed Practical Nurse #12 that the family stated the resident was a Do Not Resuscitate. The Director of Nursing was made aware of the situation and Licensed Practical Nurse #12 was looking for the Medical Orders for Life Sustaining Treatment form that was completed on [DATE] - On [DATE] at 4:54 AM, Licensed Practical Nurse #12 found the new form on the provider clipboard and notified Registered Nurse Supervisor #3. - On [DATE] at 4:55 AM, Registered Nurse Supervisor #3 brought the new Medical Orders for Life Sustaining Treatment form dated [DATE] to the room and notified Emergency Medical Services the resident's wishes were Do Not Resuscitate. - On [DATE] at 4:56 AM, all life support efforts were stopped. During an interview on [DATE] at 1:56 PM, Registered Nurse Supervisor #3 stated they were the supervisor on call on [DATE] when the staff notified them Resident #1 was unresponsive. They assessed the resident, who had no pulse. They told the staff to get the crash cart and pull the Medical Orders for Life Sustaining Treatment form. One of the certified nurse aides told Registered Nurse Supervisor #3 Resident #1 was a full code. They reviewed the Medical Order for Life Sustaining Treatment dated [DATE]. During the code, Registered Nurse Supervisor #3 left the room to call the family, and an aide stated the resident had a do not resuscitate order in the electronic record. When the Registered Nurse Supervisor was on the phone with the family member, the family member confirmed the resident had a new order for Do Not Resuscitate. Registered Nurse Supervisor #3 stated they were taught to pull the Medical Orders for Life Sustaining Treatment form from the file, but the updated Medical Orders for Life Sustaining Treatment form was on the provider desk. During an interview on [DATE] at 9:34 AM, the Director of Nursing/Administrator on Record stated after the incident on [DATE], it was determined their system broke down when the new Medical Orders for Life Sustaining Treatment form for Resident #1 was completed on [DATE]. The form was placed on a hanging clipboard for the providers to review and not in the file. When a resident was unresponsive, they should first confirm their code status/order by looking in the electronic medical record. This information would show on the top of the screen under the special instructions for the resident. They stated it was important to have an accurate order and Medical Orders for Life Sustaining Treatment form to ensure the healthcare staff know what the resident wishes were if they were unable to speak in an emergency. During an interview on [DATE] at 9:57 AM, Registered Nurse Unit Manager #2 stated Resident #1 had returned from the hospital and stated they wanted to change their code status and update their Medical Orders for Life Sustaining Treatment form to a Do Not Resuscitate status from full code. The form was completed and put on the provider clipboard and the new order was put in the electronic medical record. They were not sure where to put the new form and did not know they should have placed it in the file with the old form. They put it on the provider clipboard so the provider could sign the new form. During an additional interview at 3:47 PM, they stated they reviewed the hospital discharge summary on [DATE] that stated the resident wanted to be placed on comfort measures. They had to call the on-call provider, Physician #9, to notify them of the changes and then put the verbal order in the electronic record. The resident had capacity to make their own decisions, and the form was changed after discussion with Resident #1 and their family member present. During a telephone interview on [DATE] at 10:45 AM, Nurse Practitioner #5 stated they were unable to recall when they signed Resident #1's updated Medical Orders for Life Sustaining Treatment form. Each unit had a file system and when a Medical Order for Life Sustaining Treatment form needed to be updated, the staff would write a note on the provider clipboard and place the form vertical in the file to prompt the providers to review and sign. It was important to have these forms updated so the healthcare team and family knew what medical measure to take for the resident in case of an emergency or tragic event. During a telephone interview on [DATE] at 1:08 PM, the Medical Director stated the purpose of an accurately completed Medical Orders for Life Sustaining Treatment form was to outline the goal of care for the resident, and to make clear their wishes in certain medical situations. When a resident updated their Medical Orders for Life Sustaining Treatment, the order should be updated in the electronic record, and a Registered Nurse can take the order and put the code status in the record. They stated they have had some recent staffing changes, and the staff should not have placed updated or new Medical Orders for Life Sustaining Treatment form on the provider clipboard; it should have been placed in the file for Medical Orders for Life Sustaining Treatment forms. 10NYCRR 400.21(c) ______________________________________________________________________________ Immediate Jeopardy past non-compliance was identified, and the Administrator on Record was notified on [DATE] at 5:57 PM. The facility provided verification the following corrective actions were completed: - On [DATE], the system for filing the forms was revised. The Medical Orders for Life Sustaining Treatment forms were to be completed upon admission and readmission to ensure accurate code status. Once the new Medical Orders for Life Sustaining Treatment form was completed, it was to be placed in the file and the old form would be marked on the last page. form changed, new form completed. The reviewer would enter the date and time, then sign. Once completed, the voided form would be filed in medical record. The new Medical Orders for Life Sustaining Treatment form was to remain in the file on the unit (not the medical provider clipboard). - On [DATE], all licensed nursing staff were educated on the process for completing a new Medical Orders for Life Sustaining Treatment form, and identification and verification of advance directives. The electronic record would be verified initially and then the paper medical record would be used to confirm the status; this record would be brought to the room where basic life support was being considered. - On [DATE], a full house audit was completed to verify all Medical Orders for Life Sustaining Treatment forms were signed and executed, and that orders were entered correctly into the electronic medical record. - On [DATE], the facility initiated five audits per week for three months to ensure staff could verbalize the appropriate measures and how to verify code status when they found an unresponsive resident. - On [DATE], all staff responsible for performing cardiopulmonary resuscitation or verifying Medical Orders for Life Sustaining Treatment forms were re-educated by the Director of Nursing and Educator on the facility policy for Basic Life Support and the new process for filing the Medical Orders for Life Sustaining Treatment forms. - The facility will complete audits for six months (ending [DATE]) for any resident who expired at the facility to ensure that the policy for Basic Life Support and Medical Orders for Life Sustaining Treatment orders were honored. Any deficiency will be reported to the Director of Nursing immediately. - The facility planned to conduct one code drill per shift for one month, and then quarterly thereafter, to monitor compliance. - Medical Orders for Life Sustaining Treatment audits would be completed by the social workers weekly, for eight weeks and then monthly for three months. All results of the audits were to be reported to the Quality Assurance Team.

Based on observations, record review, and interviews during the abbreviated survey (NY00369577), the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2 did not receive assistance at meals as care planned. Findings include: The facility policy, Activities of Daily Living Assistance and Supervision, revised 1/4/2018 documented the Unit Manager/designee would ensure that a plan of care for receiving activities of daily living assistance and/or supervision was incorporated into the daily nursing care of each resident. Resident #2 had diagnoses including Alzheimer disease and self-feeding difficulties. The 11/28/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject care, required partial/moderate assistance with eating, and received a mechanically altered diet. The Comprehensive Care Plan updated on 12/5/2024 documented the resident had an activity of daily living self-care performance deficit and impaired physical mobility related to muscle weakness. Interventions included to provide partial or moderate assistance, one-person physical assistance with eating. The 8/27/2024 physician orders documented comfort measures only, no weights, no tube feeding, and no intravenous fluids. The Comprehensive Care Plan and care instructions updated on 12/5/2024 documented the resident had a potential for alteration in nutrition related to Alzheimer's disease and dementia. Interventions included to provide adaptive equipment at meals, monitor and record intake of solids and fluids, monitor for signs of dehydration/malnutrition, provide half portions of regular puree solids and thin liquids, meals in the dining room, offer 120-240 milliliters of fluids between meals three times daily, and provide 120 milliliters Mighty Shake (oral nutrition supplement) at meals. The resident's food was to be in bowls, staff was to place 1 drink in front of the resident at a time to encourage intake of food items, load utensil, tap the resident's right hand to initiate feeding, and check oral cavity at the end of the meal for possible pocketing of food. The following observations of the resident were made: - on 1/29/2025 at 9:05 AM seated in the dining room at a table for breakfast. Their meal included 4-ounce nutrition shake, 8 ounces whole milk, pureed potatoes in a bowl, pureed toast in a bowl, and pureed egg and ham in a bowl. Their food items were all in front of the resident. There were 2 nosey cups (adaptive cup) and 1 large maroon spoon. Their meal ticket documented partial to moderate assistance. The resident was drinking from their nosey cup independently. At 9:18 AM, the resident was independently eating their pureed toast. At 9:20 AM, Certified Nurse Aide #2 asked the resident if they wanted any condiments on their pureed eggs and told the resident what food items were in front of them. The resident continued to eat slowly and did not receive staff assistance or encouragement. At 9:32 AM, certified nurse aide asked the resident if they were done with their meal and removed the meal tray. The resident had consumed 100% of their milk and Mighty Shake (oral nutrition supplement), 75-100% of their pureed toast, 0-25% of their pureed egg and ham, and 0-25% of their pureed potatoes. - on 1/29/2025 at 12:18 PM, in the dining room seated at a table for lunch. All their meal items and drinks were in front of them. The resident had 4 ounces of nutritional shake, an 8 ounce unopened container of whole milk, 1 bowl of pureed beets with the lid on it, 1 bowl of puree potatoes, 1 bowl of pureed meatloaf, and 1 bowl of applesauce. The resident was drinking their nutrition supplement independently. At 12:25 PM, the resident was observed using their large maroon spoon to take spoonfuls of mashed potatoes by themself. At 12:27 PM, Certified Nurse Aide #2 walked over to the resident and spoke to them and left. The aide continued to circulate in the dining room without assisting the resident. From 12:45 PM -12:58 PM, the resident continued to eat slowly and was not assisted or encouraged by staff. At 1:02 PM, Certified Nurse Aide #1 asked the resident if they were done and removed their meal tray. The resident had consumed 100% of their oral nutrition supplement, 0-25% of applesauce, 25-50% pureed mashed potatoes, and 0-25% of their pureed meatloaf. Their 8 ounces of whole milk remained unopened, and the lid remained on the bowl of beets. During an interview on 1/29/2025 at 1:08 AM, Certified Nurse Aide #1 stated staff knew what level of assistance to provide residents by looking at their care plans and it was also listed on the meal ticket. They stated they were assigned to help in the dining room during the lunch meal. Resident #2 did not eat well and drank better at meals. Their intakes were usually 25-50% at meals. They did not know what level of assistance the resident required at meals and checked their care plan. They stated the resident's care plan indicated they were to receive partial to moderate assistance of 1 at meals and the resident did not receive their care planned assistance at the lunch meal. They stated staff that were assigned to the dining room should be checking the resident's meal tickets and care plans to ensure they received the assistance required. If a resident did not receive the level of assistance as care planned it could impact their nutritional status. During an interview on 1/29/2025 at 1:36 PM, Certified Nurse Aide #2 stated they were assigned to the dining room at breakfast that day. They stated staff knew what level of assistance to provide residents by looking at their care plans and it was also listed on the meal ticket. They stated partial/ moderate assistance meant the resident required verbal and sometimes physical cues. If a resident did not receive their care planned level of assistance at meals it could impact the resident's intakes and possibly weights. They stated Resident #2 drank better than they ate. Their intakes were usually 25-50% at meals and very seldom completed all their meals. They were unsure of the resident's level of assistance required at meals. During an interview on 1/29/2025 at 2:24 PM the Director of Therapy stated Occupational Therapy determined the level of assistance a resident needed at meals. Partial to moderate assistance with eating meant staff should provide physical and verbal cues to encourage mealtime intakes. Resident #2 required partial moderate assistance of 1 with meals. During an interview on 1/29/2025 at 3:02 PM Registered Nurse Unit Manager #3 stated they expected staff to open all food items for the residents at meals and assist as care planned. If they had any questions, they should check the resident's care plan or ask the nurse. If a resident did not receive their care planned level of assistance at meals it could impact their nutritional status. 10NYCRR 415.12(a)(3)

Based on record review and interview conducted during the abbreviated survey (NY00327113 and NY00327592), the facility did not ensure adequate supervision was provided to prevent accidents for 8 of 14 residents (Residents #3, #5, #6, #7, #8, #9, #10, and #11) reviewed. Specifically, Residents #7, #8, and #9 had histories of behaviors towards other residents and adequate supervision was not implemented to prevent further resident to resident incidents towards Residents #3, #5, #6, #8, #10, and #11. Findings include: The 1/8/2020 Enhanced Supervision Policy documented enhanced supervision was an integral part of a therapeutic plan and ensured the safe sensitive monitoring of a residents' physical and psychosocial well-being. The three levels of Supervision included: Level 1 (routine checks); Level 2 (designated staff assigned to monitor the resident's whereabouts at specific time intervals), and Level 3 (one to one supervision). The designated staff were to document on the supervision flowsheet and scan the form into the resident's medical record upon completion. All residents on intermittent supervision will be assessed and updated at a minimum daily and a re-assessment completed upon a resident's change. Nursing would use the supervision progress note for documentation along with a 24-hour report. A resident requiring one to one supervision was determined by a registered nurse/Charge Nurse. Documentation for the behavioral reason included a description of the resident's behaviors and the steps taken ensure safety, the interventions that failed, and any supportive measures taken. 1) Resident #3 had diagnoses including dementia. The 8/7/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, exhibited behaviors not directed towards others 1 to 3 of 7 days, did not wander, required limited assistance with most activities of daily living, and used a walker for ambulation. Resident #7 had diagnoses including dementia. The 8/23/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, exhibited physical and verbal behaviors 1 to 3 of 7 days, and did not wander. Resident #8 had diagnoses including dementia. The 8/18/2023 Minimum Data Set assessment documented the resident had moderate cognitive impairment, did not exhibit behaviors, and did not wander. Incident #1 (Residents #7 and 8) Resident #7's comprehensive care plan, initiated 11/21/2022, documented the resident had behaviors directed towards other residents including kissing them on the cheek or lips, asking if they could sit on their lap, and offering to rub their private areas. Interventions included to educate the resident on boundaries, document mood/behavior changes, monitor environmental stimuli, document, and report to the medical provider if the resident was a danger to themself or others. The care plan was revised on 2/27/2023 and documented the resident should not be seated next to residents of the opposite sex in the dining room or at activities. Resident #8's comprehensive care plan, initiated 6/12/2023, documented the resident had moderate cognitive impairment, was independent with ambulation, was at high risk for unsafe wandering, and staff were to monitor the resident's whereabouts. Resident #7's nursing progress notes documented: - on 9/21/2023 at 8:35 PM and 9/22/2023 at 4:30 PM, licensed practical nurse #17 and registered nurse #18 noted the resident tried to sit on the lap of a resident of the opposite sex. - On 9/28/2023 at 8:47 PM, licensed practical nurse #17 noted the resident tried to sit on the lap of a resident of the opposite sex and tried to climb into bed with the other resident. The behavior continued most of the evening. - On 10/4/2023 at 8:02 PM, licensed practical nurse #17 noted medication changes were made to address the resident's sexually inappropriate behavior and included paroxetine (anti-depressant) every other day in the evening for 14 days. - On 10/16/2023 at 1:53 PM, registered nurse #7 noted paroxetine was to be discontinued on 10/19/2023 as it was not recommended for older adults. Resident #7 was still very sexually inappropriate with peers of the opposite sex and attempted to sit on another resident's lap and offered to rub their private areas. Staff redirected the resident, however they continued to be inappropriate. - On 10/18/2023 at 11:01 AM, licensed practical nurse #17 noted Prozac (anti-depressant) was initiated every other day to address behaviors. - On 10/22/2023 at 1:47 PM, licensed practical nurse #17 noted the resident wandered in and out of other residents' rooms all shift and tried to get into other residents' beds. The resident was redirected. Resident #8's nursing progress notes documented: - on 9/12/2023 at 9:12 PM, licensed practical nurse #17 noted Resident #8 made attempts to get into other residents' beds (residents of the same and opposite sexes). - On 10/29/2023 at 2:25 AM, registered nurse #18 noted the resident wandered into other residents' rooms. The 10/30/2023 at 2:40 PM, facility Incident/Accident Form completed by registered nurse #7 documented activity aide #3 saw Resident #7 with their hands in Resident #8's pants. This occurred in the hallway and the residents were separated. No injuries were identified and both residents were placed on 30-minute checks. Resident #7's comprehensive care plan, revised on 10/30/2023, documented 30-minute checks were started. Resident #8's comprehensive care plan, revised on 10/30/2023, documented the resident was a victim of physical aggression. There was no documentation of an intervention of 30-minute checks. The 10/30/2023, 30-minute check form for Residents #7 and #8 documented they were last observed in the hallway at 6:00 PM. There was no documentation that 30-minute checks were done after 6:00 PM. Incident #2 (Residents #7 and 8) The 10/30/2023 at 9:40 PM, facility Incident/Accident Form completed by registered nurse #7 documented certified nurse aide #4 witnessed Resident #8 with their genitals exposed and Resident #7 had their hands on Resident #8's genitals. This occurred at the nurse's station, the residents were separated, and no injuries were noted. Resident #7 was placed on 1:1 monitoring until they went to bed and Resident #8 continued to roam the halls with no further incidents. Resident #7 had a recent medication change and had been involved in a few incidents. The interdisciplinary team met the following day (10/31/2023) and discussed the recent events. Resident #7's medications were being reviewed and a more structured evening activities program was initiated to reduce downtime. There was no documentation Resident #7 received 1:1 supervision on 10/30/2023 until they went to bed as noted on the Incidents/Accident Form and no documentation the comprehensive care plan was updated to include 1:1 supervision as an intervention. Incident #3 (Residents #3 and 7) Residents #3's nursing progress notes from 9/1/2023 through 10/20/2023 did not document the resident had inappropriate sexual behaviors towards other residents. The resident was noted with increased confusion and on 10/12/2023 and displayed inappropriate verbal behavior towards a staff member. The facility Incident/Accident Form dated 11/15/2023 at 4:50 PM completed by registered nurse #9, documented Resident #7 was walking down the hallway behind Resident #3 when Resident #7 grabbed Resident #3's genitalia. Licensed practical nurse #19 separated the residents. Resident #7 was immediately redirected and walked to their room, and an activity person was sent to their room. Registered nurse Supervisor #11 assessed both residents without injuries and neither resident could recall the incident. Resident #7 was placed on 1:1 supervision while awake, the medical provider was to review the resident, and an alarm was placed on Resident #7's door to alert staff of wandering. The Form documented: medication changes were made on 11/16/2023 to address Resident #7's sexual behaviors, Resident #3's care plan was updated to reflect the incident, and interventions were to attempt to keep Residents #3 and 7 separated. Resident #3's comprehensive care plan, revised 11/15/2023, documented to redirect, intervene, and provide distractions during periods of agitation. There was no documentation of the incident between Residents #7 and 3 on this day. Resident #7's comprehensive care plan, revised 11/15/2023, documented 1:1 supervision during waking hours. A 11/16/2023 statement included with the in the facility investigation and completed by certified nurse aide #20 documented, the previous night (11/15/2023) they provided 1:1 supervision for Resident #7 from 6:00 PM to 1:00 AM on 11/16/2023. The resident was ok at first and at around 9:00 PM, the resident went to their room for a good 30 minutes. At one time, the resident came out of the room not wearing clothes, went up to Resident #1 and another resident who was at the desk, and asked the residents to touch them and give them a kiss. At around midnight, Resident #7 came out of their room again, sat next to them and began pulling up their shirt and showing other residents. The behavior continued. 2) Resident #5 had diagnoses including Alzheimer's disease. The 9/8/2023 Minimum Data Set assessment documented the resident had moderate cognitive impairment and did not exhibit behaviors. Resident #6 had diagnoses including Alzheimer's disease. The 9/26/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment and did not exhibit behaviors. Resident #8 had diagnoses including dementia. The 8/18/2023 Minimum Data Set assessment documented the resident had moderate cognitive impairment, did not exhibit behaviors, and did not wander. Incident #1 (Residents #6 and 8) The 11/5/2023 Incident/Accident Form completed by registered nurse Supervisor #9 documented at 4:31 PM, dietary staff #25 witnessed Resident #8 reach out and grab Resident #6's peri area. Registered nurse #25 assessed both residents without injury. Residents #6 and #8 did not recall the incident. After the incident, Resident #8 wandered the unit with 1:1 supervision and redirection and Resident #6 did not display discomfort, emotional distress, or trauma and was at the nurse's station pleasantly interacting with peers. The facility was working to add fidget boards to the unit to stimulate the mind and keep hands busy. A statement by certified nurse aide #24 documented on 11/5/2023, they provided 1:1 for Resident #8 from 6:00 AM to 2:00 PM continuously. Resident #8 presented with inappropriate behaviors of touching themself and attempted to walk towards female residents during the 1:1 supervision. There was no documentation why Resident #8's 1:1 supervision ended at 2:00 PM or whether supervision was provided between 2:00 PM and 4:31 PM, when the incident with Resident #6 occurred. A 11/5/2023 supervisory check form by registered nurse #21 documented 15-minute checks were completed for Resident #8 from 7:00 AM to 5:45 PM Resident #6's comprehensive care plan was reviewed on 11/9/2023 and documented they initiated a sexual behavior. No new interventions were documented on the care plan. Incident #2 (Residents #5 and 8) The facility Incident/Accident Form dated 11/6/2023 at 9:10 PM completed by registered nurse #35, documented certified nurse aide #5 found Resident #8 in Resident # 5's room. Resident #8 was reported to have touched Resident #5's breasts and kissed them per Residents #5 and #8. Resident #8 was removed from the room and placed on 1 :1 supervision while awake and 15-minute checks while asleep. Resident #5 had no ill effects or injuries. Neither resident had recollection of the events. The interdisciplinary team was to discuss Resident #8 with the medical provider. A stop sign was added to Resident #5's door to prevent/discourage others from entering. A 11/6/2023 statement by certified nurse aide #35 documented they provided 1:1 supervision for Resident #8 from 6:00 AM to 2:00 PM. There was no documentation of 1:1 after 2:00 PM on 11/6/2023. It was unclear why the resident's 1:1 supervision was stopped at 2:00 PM and no documentation related to supervision provided between 2:00 PM and 9:10 PM when the incident occurred with Resident #5. The 11/6/2023, 15-minute check form documented Resident #8 was monitored every 15 minutes from 6:00 AM to 5:45 AM by various staff members. The 11/7/2023 and 11/8/2023 15-minute checks form documented Resident #8 was monitored every 15 minutes. Resident #8's comprehensive care plan, revised on 11/7/2023, documented they required 1:1 supervision while awake and 15-minute checks while asleep. Resident #5's comprehensive care plan, revised on 11/7/2023, documented they were a victim of physical aggression, and a stop sign was placed on their door. Interviews: During a telephone interview with certified nurse aide #4 on 12/5/2023 at 12:00 PM, they stated: - if supervisory checks were needed, documentation was on a paper form at the nurse's station and the staff were told verbally if a resident needed checks. - If 30-minute checks were started, then someone had to document when they did the checks every 30 minutes. If there was no documentation, that meant the resident was not monitored or staff were not completing the documentation. - Residents #7 and 8 had dementia; Resident #7 had prior sexual behaviors, and they did not know Resident #8's history. - They were on the unit on 10/30/2023 when the incident between Residents #7 and 8 occurred at 2:40 PM. Activities staff #3 saw the incident and told them about it. They reported to the nurse and did not recall who the nurse was. After the incident at 2:40 PM, they were told to keep the residents separated and within sight. No one person was assigned to watch the residents after the incident at 2:40 PM it was a team effort. They were not told the residents required 30-minute checks. - On 10/30/2023 at 9:40 PM, they found Residents #7 and 8 engaged in a sexual act and they intervened. The residents were at a table by the nurse's station and Resident #7 had their hands down Resident #8's pants. A nurse and a certified nurse aide (they did not recall who) were completing documentation at the nurse's station but they were not positioned somewhere that they could see the incident when it occurred. They did not believe anyone was watching the residents at the time the incident occurred. - At times, when checks were needed, they were not aware of it until the next day. - After the second incident, they kept Resident #7 with them until their shift ended at 10:00 PM, Resident #8 stayed at the table, and they told the oncoming nurse about the incident when they came in. During a telephone interview with registered nurse Unit Manager #7 on 12/5/2023 at 12:27 PM, they stated: - they were responsible to complete facility investigations and comprehensive care plans, including updates. - If they were not in the facility when an incident occurred, the Supervisor initiated the Incident/Accident Form and put interventions in place on the resident's care plans. When they returned to the facility, they would review the reports and care plans. - Resident #8 did not have prior inappropriate behaviors when they came to the facility. Resident #7 had multiple sexual behaviors. - Interventions for Resident #7 included medications, activities, and staff were to try to keep the resident away from residents of the opposite sex. They stated the staff needed to work as a team to monitor the resident. - On 10/30/2023, Residents #7 and #8 had a sexual incident at 2:40 PM. Both residents were placed on 30-minute checks and the comprehensive care plans were updated with the 30-minute checks at that time. When 30-minute checks were initiated, they expected staff to complete the checks and document on the form. If staff did not document they monitored the resident every 30 minutes, they did not follow the care plan and that would be documented in the facility investigation. - When completing an investigation, they reviewed the monitoring sheet for that time frame and if there was no documentation, there would be a care plan violation. They did not remember seeing a block of time when Resident #8 was not monitored. - A second interaction happened on 10/30/2023 between Residents #7 and #8 and after the second incident, Resident # 7 was put on 1:1 until bedtime and Resident #8 would have continued on 30-minute checks. - They thought the second incident may have been prevented if the staff were monitoring the residents as they were supposed to be. During an interview on 12/13/2023 at 12:00 PM with certified nurse aide #5, they stated: - supervision meant having a resident in sight at all times. - They found the resident's care needs in the electronic record and they checked that daily. If a resident was assigned supervision or checks, they received verbal report from the nurse or outgoing certified nurse aides. A supervision form was located behind the nurse's station and that form was completed when a resident was on supervision checks. The person assigned to the resident was ultimately responsible to ensure the check form was completed. - Residents #5 and 8 both had dementia. Resident #5 did not have prior sexual behaviors and Resident #8 had prior issues. - Resident #8 had interventions in place including monitoring before the incident with Resident #5. They did not know when the monitoring stopped, did not recall if there was monitoring in place at the time of the incident on 11/6/2023. - They thought there were 2 incidents in the evening on 11/6/2023 with Residents #5 and 8. They observed Resident #8 leaning over Resident #5 between 7:00 PM and 8:00 PM in Resident #5's room. The room was dark, and Resident #8 had their hands towards the bed while Resident #5 was in the bed. They asked Resident #8 what they were doing, and the resident stated nothing and left the room. Resident #5 stated Resident #8 touched their breast. - Resident #5 had a stop sign on the door to keep other residents out of their room. Resident #8 went under the stop sign and into the room. They stated they thought Resident #5 seemed shaken at that moment. They reported the incident to the nurse on the unit and did not recall who the nurse was that night. - The second incident with Residents #5 and 8 occurred within 20 minutes of the first one. While walking with another resident, they observed Resident #8 going into Resident #5's room again and Resident #8 was leaning over Resident #5. Resident #8 denied anything occurred and Resident #5 stated Resident #8 put their tongue in Resident #5's mouth The told the nurse again what occurred. - They did not recall what monitoring was put in place after the first incident and did not recall what intervention was put in place after the second incident. They worked the following day and was not sure if there was monitoring in place at that time or after that. Now they keep a pretty close eye on (Resident #8). During a phone interview on 12/13/2023 at 12:31 PM with attending physician/Medical Director #12 they stated they were aware of Residents' #3, 7, and 8's behaviors and had discussions about them. They were aware Resident #7 had multiple incidents of sexual behavior and some strategies had been discussed including education of staff and consistency on the unit. They expected the resident with behaviors to be monitored and was not aware 30-minute checks were not documented as completed for Residents #7 and 8. They were not sure if that was a documentation issue or if they were not done. They were not sure if the incidents could have been preventable with supervision however, the likelihood of the incidents may have been reduced. They felt staff education, observations and consistent staffing would reduce the likelihood of the incidents. During a phone interview on 12/29/2023 at 10:00 AM the Director of Nursing stated: - supervision was defined as intermittent observations and further clarified by 1:1, 15-minute, and 30-minute checks. - When supervision was added to a resident's care plan, it was communicated through verbal communication and shift to shift report. - The staff documented the checks on a paper form and the licensed practical nurse oversaw the checks were completed. - If a resident was assigned 1:1 supervision, that would remain for no more than 8 hours depending on the resident. Other interventions were to be put in place during the 8 hours and monitored for the effectiveness of the new interventions. - The unit manager was responsible to review the investigation, review the check forms and the care plan. They would expect when the check forms were reviewed during the investigation, if they found them not completed the staff would be interviewed to determine why the checks were not completed and that would be addressed in the facility investigation. - Residents #7 and 8 had cognitive impairment. On 10/30/2023 at 2:40 PM, Residents 7 and 8 had a sexual encounter. They completed the Incident/Accident Form and ruled out abuse neglect and mistreatment by interviewing the staff and monitoring for lasting effects. Following the incident, Residents #7 and 8 were placed on 30-minute checks and 30-minute checks would remain in place until a new intervention was in place and effective. They expected the assigned checks to be completed and documented and added to the care plan. They did not know the 30-minute checks were not completed and expected them to be done. During the investigation they did not identify the checks were not documented from 6:00 PM to 10:00 PM and did not identify the care plan violation. They stated it was difficult to know if the incident would have been avoidable had the monitoring been completed. - On 11/5/2023, Resident #8 had an incident with Resident #6 and was placed on 1:1 supervision until the end of the evening shift. Fifteen-minute checks were initiated following the 1:1 supervision until the next morning. They could not provide documentation of supervision after 5:45 PM on 11/5/2023. 3) Resident #9 had diagnosis including dementia. The 8/21/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not wander, and did not exhibit behaviors. The resident was independent with ambulation and required supervision or oversight with locomotion on the unit. Resident #10 had diagnosis including non-Alzheimer's dementia The 9/19/2023 Minimum Data Set assessment documented the resident had moderate cognitive impairment. The resident did not exhibit behaviors, needed extensive assistance with most activities of daily living, and was independent with locomotion on the unit. Resident #11 had diagnoses including non-Alzheimer's dementia. The 9/6/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment and rejected care. No other behaviors were documented. Resident #9's comprehensive care plan, initiated 6/27/2022, documented the resident liked to stay busy and engaged in meaningful activities. Staff were to keep them engaged in activities and routines during the day. Mood and behaviors included wandering, verbally threatening, and was physically aggressive with staff during care including hitting kicking scratching biting and pinching. Resident #9's medical record documented the resident had prior incidents with other residents including: - on 9/20/2023, Resident #9 hit Resident #12 in the face, arms, and chest. No injuries were noted, and Resident #9 was to be on hourly checks and kept away from Resident #12. - On 10/9/2023, Resident #9 walked by Resident #5 who yelled they hated them. Resident #9, with an open hand, slapped Resident #5 on the right arm. There were no injuries, and the residents were separated. - On 10/30/2023 at 8:50 PM, Resident #5 was heard yelling ouch and a staff member observed Resident #9 standing over Resident #5 who was holding their shoulder. No injuries were noted, Resident #9 was placed on 1:1 supervision, and the medical provider was asked to review the resident's medications. Resident #9's attending physician #12's progress note dated 10/18/2023 at 2:32 PM documented the resident received anti-psychotic medications for aggressive behaviors. The resident had episodes of grabbing residents and pulling them out of their beds and this was likely due to their past employment as a prison guard. The facility Incident/Accident Form dated 11/5/2023 completed by registered nurse #7 documented certified nurse aide #4 responded to yelling and saw Resident #9 hitting Resident #10 and pulling Resident #11's hair. The residents were separated and assessed by registered nurse Supervisor #11. Resident #10 had a bruise on the right forearm and dried blood in the corner of their mouth. They were offered Tylenol and/or ice and denied pain/discomfort. Resident #11 had their hair pulled with no redness to the scalp and no loss of hair noted. Resident #9 was placed on 1:1. Resident #10's comprehensive care plan, dated 11/5/2023, documented the resident was a victim of aggression on 11/5/2023. Interventions included a bookcase sticker was attached to the outside of the resident's door to prevent residents from wandering in the room and staff were to keep the resident separate from Resident #9. Resident #11's comprehensive care plan, revised 11/5/2023, documented the resident was a victim of physical aggression Interventions included a bookcase sticker was attached to the outside of the resident's door to prevent residents from wandering in the room and staff were to attempt to keep the resident separate from Resident #9 There was no documentation the level of supervision provided to Resident #9 was reviewed or addressed to prevent further incidents. During a phone interview on 12/4/2023 at 9:00 AM, registered nurse unit Manager #7 stated: - Supervision meant monitoring residents intermittently as they could not watch residents at all times. - When a resident had an altercation and 15-minute checks were initiated, that would remain in effect for 24 hours. The resident would then be placed on 30-minute checks for 24 hours. If no more incidents occurred, then the supervision would stop. - Residents #10 and 11 were roommates, Resident #10 was alert and able to state what happened and Resident #11 had severe cognitive impairment. - Resident #9 had severe cognitive impairment with a history of resident-to-resident abuse. - The residents involved in the prior incidents with Resident #9 did not have serious injuries. - Resident #9 had prior interventions including medication changes, 15-minute checks, and staff were to attempt to keep Resident #9 away from the other residents. - Resident #9 had been a former corrections officer and they thought the residents on the unit were inmates. - After the incidents, the care plans were updated with details of the incident and new interventions would be updated by the Director of Nursing or themselves. - Whenever supervision was initiated, the care plan would be revised to include those interventions and the checks were documented on a check form completed by the staff who did the monitoring. - Following the incident with Residents #9, 10 and 11 on 11/5/2023. Resident #9 had 1:1 initiated, medication changes, then 15-minute checks, and then 30-minute checks. Residents #10 and 11 had a bookcase sticker applied to their door to prevent residents from entering that room. - After supervisory checks were completed, the staff watched the residents the best they could. - Resident #9 had another incident after the 11/6/2023 and on 11/21/2023, was placed on 1:1. During a phone interview with certified nurse aide #4 on 12/5/2023 at 12:00 PM, they stated supervision was keeping an eye on residents and ensuring they were in their sight line. They worked with Resident #9 prior to 11/5/2023, the resident had dementia with a lot of behaviors, and was aggressive towards other residents on multiple occasions. Resident #9 was previously assigned to Residents #10 and 11's room and often went in that room thinking it was their room. Residents #10 and 11 had dementia, no aggressive behaviors and were normally a target by (Resident #9) due to where their room was located. During the incident on 11/5/2023, they were on the unit and did not recall if they were assigned to Residents #9, 10 or 11. The staff on the unit were alerted by a family member of the incident and another certified nurse aide told them what happened, and they were unable to recall who that certified nurse aide was. They tried to keep Resident #9 in their line of site for the rest of the night after the incident and they did not know of any other interventions with supervision after that night. If a resident was to be on supervisory checks including 15-minute or 30-minute checks the paperwork would be at the nursing station. During a phone interview on 12/13/2023 at 12:31 PM with attending physician/Medical Director #12 they stated they were aware of Resident #9's abusive behaviors. They were sporadic and unpredictable, and it was hard to tell what would set (the resident) off. Medication changes were made and that had to be done slowly and carefully. 1:1 supervision was not something that could be done at the facility however they did expect standard monitoring with care, nutrition, meals, and activities. They felt medications and consistency would be the best way to protect residents on the unit. During a phone interview on 12/29/2023 at 10:00 AM the Director of Nursing stated they were aware of the incident on 11/5/2023 between Residents #9, 10, and 11. After the incident, they added activities 2 times a week on the memory care unit to increase supervision. 10 NYCRR 483.25(d)

Based on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety for 1 of 1 kitchen (main kitchen) reviewed. Specifically, the main kitchen's tray service line cooler was propped open and not maintaining proper temperature, floors were in disrepair, the ceiling was damaged, and cooking and storage equipment was unclean. Findings include: The facility policy Dietary Food and Supply Orders-Storage dated 10/26/2018, documented refrigerator storage was to be 41 F (Fahrenheit) or below. The facility policy Kitchen, Dining and Dietary Equipment Routine Cleaning dated 9/7/2018 documented daily staff assignments included areas of equipment to be cleaned or kept in order after each meal service including the general cooking area, and general kitchen area. Cooking surface of the grill was to be cleaned at least once daily and kept free of encrusted grease and other soil. The monthly cleaning schedule included all counters and shelves, and pots and pans area racks. The undated Weekly Cleaning List documented: - properly clean grill and stovetop; and - properly clean friers (AS NEEDED). 1. Tray Line Cooler During an observation on 4/20/23 at 12:05 PM two refrigerators were propped open on the tray service line during lunch assembly. The left cooler had cottage cheese that was measured at 48 F. The right cooler had hardboiled eggs measured at 54 F and American cheese at 53 F. The door seal was tattered along the bottom edge of the left unit. During an interview on 4/20/23 at 12:09 PM, the Food Service Director stated the cooks checked the final cooking temperatures, and the hot items on the line, but they did not check the cold holding temperatures during meal service. The cold holding equipment was checked once a day, typically in the morning. The Food Service Director stated the coolers were propped open at the start of each meal service and the coolers were stressed to the max. During an interview on 4/20/23 at 12:47 PM, dietary aide #20 stated the cottage cheese was discarded at the end of the shift, the lettuce salads were re-wrapped and moved to another refrigerator in the kitchen, the shelf stable drinks were moved to another cooler, and the items on the bottom shelf (American cheese and hard boiled eggs) remained in the coolers. During an observation on 4/20/23 at 12:50 PM the two coolers from the tray line were closed and pushed against the wall. Dietary aide #20 began removing some of the contents to move to other units. They did not measure the temperature of the contents. During an observation on 4/20/23 at 1:25 PM, the hardboiled eggs were measured at 58 F and the American cheese was measured at 58 F. Both items were in the left side of tray line cooler. A bowl containing individual packets of sour cream was on the bottom shelf of the cooler. The right side of the cooler was empty. During an observation on 4/20/23 at 2:16 PM, the American cheese was measured at 56 F and hard boiled eggs were measured at 55 F. These temperatures were confirmed with the Food Service Director who measured them with the facility and included hardboiled eggs at 55 F, American cheese at 55 F, and the approximately 30 (1) ounce sour cream packets were measured at 53 F. During an interview on 4/20/23 at 2:16 PM, the Food Service Director stated they did not check the temperatures of the tray line coolers after meal service, but they knew they should be shut to come back to temperature. They stated the doors to the coolers had been closed since the end of the lunch service and they were usually locked at that time. The hardboiled eggs, American cheese, and sour cream would have been in that cooler all day. The Food Service Director stated food was allowed to be out of an acceptable temperature range for up to two hours. They stated they were not aware these items had been out of temperature for more than two hours. It was potentially dangerous to leave food out of temperature for more than two hours. 2. General Kitchen Cleanliness On 4/19/23, between 10:30 AM and 11:15 AM, observations of the main kitchen included: - two metal storage racks in the clean area were rusty and not cleanable. The racks contained miscellaneous baking measuring containers, baking sheets, and catering supplies. - the floor near the dish machine area had a 2 foot x 2 foot section of plywood. This material could absorb water, was a potential mold risk, and was not cleanable. - the floor in the dish machine area was missing grout and there was standing water between the tiles. The spaces between the tiles were not cleanable and created a potential for pests in the kitchen. - the metal surfaces of the deep fryer were sticky and not clean. The metal side wall of the steamer, next to the deep fryer, was also sticky and not clean. - the metal side of the stove top, next to the flat top unit was sticky and not clean. - there were two frying pans on a hanging rack near the cook's area that were soiled and caked with black debris. - the solid ceiling over the cook's area was soiled with unknown debris. There was a damaged 2 foot x 6 inch section of solid ceiling. - multiple sections of the tray line area had sections of peeling floor material that was not cleanable and was a tripping hazard. During an interview on 4/19/23 between 10:54 AM and 11:15 AM, the Food Service Director stated the deep fryer was last used for the dinner meal on 4/18/23, was supposed to be cleaned after each use, and should be wiped down and cleaned weekly as per the weekly cleaning list. They stated it appeared that the oil on the deep fryer surfaces had been there for more than one week, and there was no documentation of who was responsible for the last weekly cleaning. The Food Service Director stated the two frying pans hanging in the cook's area were not being used and should have been removed from the kitchen. During an observation on 4/20/23 at 1:05 PM, the main kitchen cooks area had a floor to ceiling sheetrock pillar and the sheetrock was loose and in disrepair. During an interview on 4/26/23 at 1:54 PM, the Maintenance Director stated they were aware of flooring concerns in the dish machine area and there was no official documentation that the facility was in the process of repairing the floor. They stated that the maintenance department had attempted to repair the section of floor under the 2 foot x 2 foot section of plywood, and this area had not yet been fully repaired. The Maintenance Director was not aware of the loose pillar and the damaged solid ceiling in the cook's area. They stated that it was important for the main kitchen to be maintained so that staff could work in a safe environment. During an interview on 4/26/23 at 2:13 PM, the Food Service Director stated they were not aware of the loose pillar in the cook's area and could not find any work orders for the pillar. They stated they thought the metal storage racks were just dirty and was not aware they were rusted. They stated they had checked that the items on the racks were clean but not the condition of the rack itself. The Food Service Director stated it was important for the main kitchen to be maintained so that staff could work in a safe environment. 10NYCRR 415.14(h) 43754

Based on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 4 occupied resident floors (First, Third, and Fourth floors) reviewed. Specifically, - the fourth floor had stained ceiling tiles and the elevator alcove had a loose handrail. - the third floor had a damaged bathroom sink, the soiled utility room did not have a paper towel dispenser, and the dining room window was cracked. - the first floor had damaged walls and ceilings, unsealed penetrations, an open junction box in the education classroom closet, and the library had two sliding windows that opened more than 6 inches. Findings include: The undated facility Window Policy documented the Environment: Common Areas/Nursing Units/Service Hall/Lobby Audit form would be reviewed at the monthly risk management meetings. The following observations were made on the Fourth Floor: - on 4/19/23 at 11:46 AM, the elevator alcove had a loose, 1 foot section of handrail. - on 4/19/23 at 11:50 AM, the hall outside of resident room [ROOM NUMBER] had three dried stained ceiling tiles. - on 4/24/23 at 11:56 AM, the hall outside of resident room [ROOM NUMBER] had three stained ceiling tiles, two of the tiles were wet. Work orders dated from 11/20/2020 to 4/4/2023 documented requests for maintenance for the fourth floor stained ceiling tiles, in the hall near resident room [ROOM NUMBER] (in same vicinity as resident room [ROOM NUMBER]). Monthly safety inspection reports dated 2/1/23, 2/27/23, and 4/3/23 documented the fourth floor hall had stained ceiling tiles. The following observations were made on the Third Floor: - on 4/19/23 at 12:15 PM, the bathroom near the nursing station had a damaged sink where the faucet had been installed in the sink. The sink was loosely attached to the wall. - on 4/19/23 at 12:22 PM, the soiled utility room lacked a paper towel dispenser and paper towels. - on 4/24/23 at 2:11 PM, the dining room window had a 3 foot x 2 foot crack and there was clear tape over approximately 18 inches long on the bottom portion. During an interview on 4/24/23 at 2:11 PM activity leader #24 stated the third floor dining room window had been cracked for about a month. They stated the crack had started at the bottom of the window and had worked up to the top of the window. During interviews on 4/24/23 at 2:13 PM and 4/26/23 at 2:25 PM, the Maintenance Director stated that in the fall of 2022 a resident threw something at the third floor dining room window causing the crack. The window was secured while waiting for better weather. The cracked window created a potential hazard. They stated they were not aware the crack in the window was not fully taped and would expect staff to report if the crack was spreading. The Maintenance Director stated that there were no work orders for the broken window. They stated the vendor that was usually used by the facility had recently converted into a window parts supplier and not a window installing company. They stated they had called the vendor and the voicemail was full. The facility had not started the process to get another vendor to replace the window. The following observations were made on the First Floor: - on 4/19/23 at 10:48 AM, resident room [ROOM NUMBER] had a damaged section of wall behind the B side resident bed. - on 4/19/23 at 2:15 PM, resident room [ROOM NUMBER] had a damaged section of wall behind the B side resident bed, and the area around the bathroom door was scratched. - on 4/19/23 at 2:55 PM, the north dining room area, near the handwash sink, had a damaged section of lower soffit sheetrock shelf. The soffit height was approximately 3 feet off the ground. - on 4/19/23 at 2:59 PM, the dementia unit soiled utility room solid ceiling had an unsealed 3/4 inch conduit penetration and an unsealed 4 inch x 4 inch hole with data wires passing through into the space between the solid ceiling and the flat ceiling above. - on 4/20/23 at 9:06 AM, the dementia unit tub room had a 1/2 inch x 10 inch damaged section of solid ceiling. - on 4/20/23 at 9:30 AM, the first floor education classroom closet had dead low voltage wires coming out of an old call bell system junction box. - on 4/20/23 at 9:47 AM, resident room [ROOM NUMBER] had a 3 foot x 3 foot section of damaged wall, the wall radiator metal cover was loose, and the bathroom had a damaged towel bar with only the end posts present. - on 4/20/23 at 9:57 AM, the library had two sliding windows that opened approximately three feet wide. The window locks that prevented the windows from opening more than 6 inches were broken. During an interview on 4/20/23 at 9:57 AM, the Assistant Administrator stated the library windows were used for COVID-19 window visits. During an interview on 4/25/23 at 10:39 AM, the Housekeeping Director stated if housekeeping staff observed damaged walls, they should tell the nursing unit clerks or Unit Managers who would complete work orders. The Housekeeping Director stated different staff was assigned to do a general survey of environmental issues such as clear hallways and ensuring rooms were in good working order. They stated that besides the stained ceiling tiles on the fourth floor, they were not aware of any of the other items identified during the tour of the facility. The Housekeeping Director stated housekeeping staff were in resident rooms everyday cleaning and disinfecting and were trained to identify issues. They stated they toured the resident floors daily and entered resident rooms as needed. Twice a week 2 to 3 rooms on each floor were randomly cleaned and all resident rooms were deep cleaned monthly. The Housekeeping Director stated work orders were completed in order from critical to medium. During an interview on 4/26/23 at 2:25 PM, the Maintenance Director stated work orders could only be found for the fourth floor stained ceiling tiles. They stated there were no documented inspections of resident rooms, and the entire facility was checked monthly by the risk management team which included Administration, Unit Managers, Housekeeping Director, and the Food Service Director. The Maintenance Director stated the first floor library window guards were damaged during one of the COVID-19 window visits in 2020 and 2021. They stated that the facility was the residents' home, and it should look nice and provide a safe environment. During an interview on 4/26/23 at 2:30 PM, the Assistant Administrator stated the cracked window, and the other items observed during the tour of the facility were not homelike. 10 NYCRR 415.29(j)(1)

Based on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 4 of 10 medication carts (medication carts 1 and 2 on Unit 100 South and medication carts 1 and 2 on Unit 3) inspected. Specifically, there were 4 insulin pens and 1 eye drop bottle observed without pharmaceutical labels including resident information, medication name, medication dosage, and administration instructions. Findings include: The facility policy, Medication Label and Container Requirements revised 5/20/2018 documented medications accepted from a Pharmacy Services Provider or administered to residents of the facility must be packaged in compliance with all applicable state and federal laws; labels must clearly indicate specific information legibly and completely. Medications will not be accepted at this facility if the general label requirements and package-type specific label requirements are not met including full name of resident, address of resident, name and strength of the medication, directions for administration of the medication, name of prescriber ordering the medication and the prescription number. During an observation on 4/24/23 at 9:21AM, medication cart 1 on Unit 100 South was inspected with licensed practical nurse (LPN) # 6. The medication cart contained an opened bottle of brimonidine tartrate 0.2% eye drop solution (used to treat glaucoma) with a torn pharmaceutical label. There was no identification including resident information, medication name, medication dose, the date the bottle was opened, and Resident #110's name was handwritten on the bottle with a black marker. Additionally, medication cart 1 contained a gray colored insulin pen with no pharmaceutical label including the type of insulin, or an opened date. Resident #156's name was handwritten on the side of the pen with a black marker. During an observation on 4/24/23 at 9:38 AM, medication cart 2 on Unit 100 South was inspected with licensed practical nurse (LPN) #6. The medication cart contained a gray colored insulin pen. The pen had a yellow sticker with Resident # 11's name written with a black marker and there was no pharmaceutical label attached to the pen. Medication cart 2 also contained an aqua colored glargine (long-acting insulin) insulin pen with a piece of white medical tape affixed to it with Resident #37's name written in black marker. There was no pharmaceutical label or opened date on the pen. During an interview on 4/24/23 at 9:45 AM, LPN #6 stated that all nurses were responsible for checking the medication carts for expired medications or medications that did not contain labels. Insulin pens should be labelled when they are opened. During a follow-up interview on 4/24/23 at 2:08PM, LPN #6 stated that eye drops should be in the original box, be labelled with the resident's name, medication name, medication dose, and instructions for use. Insulin pens should be labelled with the resident's name, type of insulin, medication dose, and instructions for use. LPN #6 stated they knew Resident #11's pen was not labelled, and they gave the resident 5 units of insulin from the pen on this date. They stated if a medication was not labelled it could result in the wrong medication or dose being given to the resident. Another nurse may not know what resident the medication belonged to. During an interview on 4/24/23 at 2:17 PM, LPN Unit Manager # 11 stated the medication carts were audited once per month and they were responsible for the audits. LPN # 11 stated that insulin pens and eye drops should be labeled and if they were not, they should be removed from the cart and re-ordered to reduce the risk of a resident receiving the wrong medication. They stated they expected staff to check the medication carts once per shift for expired medications and unlabeled medications. They should pull any unlabeled medications from the carts. During observations on 4/25/23 at 11:45 AM, medication carts 1 and 2 for Unit 3 were inspected with LPN #10. Medication cart 1 contained an insulin pen with no pharmaceutical label or opened date on it. Resident # 142's name was written on the pen in black marker. Medication cart 2 contained an insulin pen with no pharmaceutical label or opened date on it. Resident #180's name was written on the pen in black marker. During an interview on 4/25/23 at 11:45 AM, LPN # 10 stated they were unsure about a medication labelling policy. If medications were unlabeled, nurses should write the resident's name on the pen with a black marker and put a yellow sticker on them with the date and time the pens were opened. LPN #10 stated the resident's insulin pens were stored in individual drawer sections with the resident's name in the cart. The risk of an unlabeled insulin pen could be that it could slide into another resident's drawer area resulting in a resident receiving the wrong medication. During an interview on 4/26/23 at 11:36 AM the Director of Nursing (DON) stated insulin pens were sent to the facility as house stock and would not be labeled. The LPNs, Nurse Managers, and pharmacy staff were all responsible for checking the medication carts. The DON stated they did not feel it was a risk if an insulin pen was unlabeled because the staff referred to the electronic medication administration records (EMARS). During an interview on 4/26/23 at 3:02 PM registered pharmacist (RPH) #14 stated eye drops, and insulin pens were individually dispensed, resident specific, and had pharmaceutical labels including the resident's name, medication name, and medication dose. Insulin pens came with tamper tape and a blank sticker with to write the date opened and date expired on them. RPH #14 stated only one type of insulin that came in a vial was used as house stock. It was not acceptable for a resident's name to be written on an insulin pen with a sharpie marker. If a label fell off, the facility should call the pharmacy and they would re-dispense another insulin pen. RPH# 14 stated the risk of medications not being labeled could be an unclear resident name or medication dose and the potential for a medication error. 10 NYCRR 415.18(d)

48052 Based on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for 2 of 4 residents (Residents #66 and #93) reviewed. Specifically, Resident #93 was not wearing their bilateral palm devices (helps prevent hand contractures) as care planned during multiple observations; and Resident #66 did not have their neck brace applied appropriately and was not wearing positioning and palm devices as care planned for multiple observations. The facility policy Splint, Brace Care updated 5/23/2018 documented that appropriately trained nursing staff would provide assistance as needed through a scheduled program of applying and removing a splint or brace, monitor the resident's skin and circulation under the device, and reposition the limb as needed. The program for use of splints and/or braces was documented by therapy on the interdisciplinary care plan and the nursing assistant documented the splint/brace program in the electronic medical record (EMR) along with any refusals which must also be verbally reported to the Unit Manager. 1) Resident #66 was admitted to the facility with diagnoses including dementia and contractures (tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) of the right and left hand. The 2/13/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, did not reject care, required extensive assistance of one for bed mobility, dressing, toileting, was totally dependent on one for hygiene, totally dependent on two for transfers, and had limited range of motion (ROM) in bilateral (both sides) arms and legs. The comprehensive care plan (CCP), revised 06/15/2021, documented that resident was at risk for limited ROM due to muscle weakness and contractures. Interventions included a neck support brace during meals only, to be applied while supine (lying flat on the back) in bed or reclined in the wheelchair while in a supine position prior to meals. If the resident refused the neck brace, they were to be assisted by the nurse for the meal. The resident was to have a carrot hand contracture device placed in their right hand and a rolled washcloth was to be place in their left hand during AM care. If the resident refused the carrot hand contracture device, a rolled washcloth was to be used in place of the carrot. Ensure hips were aligned while in their wheelchair with the head rest applied, foot buddy, wedge on left side with arm on top of wedge, like an arm rest, and bean pillow under right elbow and brought up between forearm and bicep, so their elbow was slightly extended. The 2/8/23 occupational therapist (OT) evaluation documented the resident had bilateral upper extremity contractures. Resident #66 was totally dependent for all meals, attempted to initiate self feeding, and required their neck support device on for all meals. The resident was on a nursing rehabilitation program for splint assistance that included a blue neck support applied prior to all meals. Instructions for application included to apply neck support while the resident was supine in bed or reclined while in their wheelchair to achieve a supine position. Staff were to remove the pillow and allow the resident's head to relax back onto the bed or wheelchair, align the resident's head and neck to midline, and apply the neck support with the small side slightly below the [NAME]. The neck support strap was to be loosely applied behind the neck, the strap was marked on the back to indicate application location, and red stitches indicated where the stopping location was. If the resident refused to wear the neck brace they were be assisted with eating by a nurse. A second nursing rehabilitation program for splint assistance included a carrot in the resident's right hand and a rolled washcloth in the resident's left hand after AM care. Instructions included to utilize a rolled washcloth in the resident's right hand if the carrot was refused. A third nursing rehabilitation program instructed to ensure the resident's hips were aligned while in their wheelchair with an applied head rest, foot buddy on wheelchair legs, wedge on left side with their arm on top of the wedge, like an arm rest, and a bean pillow under the right elbow and brought up between the forearm and bicep so the elbow was slightly extended. The 3/22/23 nurse practitioner (NP) progress note documented the resident had contractures to bilateral upper extremities with very limited range of motion (ROM) in both the upper and lower extremities and bilateral hand splints were in place. The care instructions (Kardex) documented that a rehab carrot was to be placed in the resident's right hand and a rolled washcloth in their left hand after AM care. If the resident declined the carrot, staff were to use a rolled washcloth. The Kardex also included instructions for the application of the neck support for meals and placement of body positioning devices. Resident #66 was observed without a right or left hand contracture device in place: - on 4/19/23 at 1:40 PM while sitting in their wheelchair in the dining room. - on 4/21/23 at 10:27 AM while sitting in their wheelchair in their room, and at 12:06 PM while sitting in their wheelchair in the dining room. - on 4/24/23 at 9:01 AM while sitting in their wheelchair in the dining room, at 9:24 AM while lying in bed, at 12:23 PM while sitting up in their wheelchair in the dining room, and at 2:17 PM while lying in bed. The 4/2023 activities of daily living (ADL) record, completed by certified nursing assistants (CNAs), documented following for the right and left hand contracture devices: - on 4/19/23 applied on the day and evening shift. - on 4/21/23 not applicable on the day shift and not applied on the evening shift. - on 4/24/23 applied on the day shift and not applied on the evening shift. Resident #66 was observed: - on 4/21/23 at 1:03 PM in the dining room being assisted with their meal by an LPN. The resident's neck was tilted down against their chest, and they did not have on the neck brace on while eating. - on 4/24/23 at 12:54 PM registered nurse (RN) Clinical Educator #42 applied the neck brace while the resident was sitting up in their wheelchair. The resident's neck was tilted down and slightly to the right. The neck brace was not applied according to the care planned directions. - on 4/25/23 at 12:52 PM CNA #43 tilted the resident's head back by the top of the resident's head/forehead while the resident was in an upright seated position and slid on the neck brace. The neck brace was not applied according to the care planned directions. The 4/2023 ADL record, completed by CNAs, documented the functional maintenance plan that included the application of the resident's neck support device for swallowing per plan of care was: - followed for all three meals on 4/21/23. - followed for all three meals on 4/24/23. - followed for breakfast and lunch on 4/25/23. Resident #66 was observed without positioning devices implemented per their CCP: - on 4/21/23 at 10:27 AM and at 12:06 PM sitting in their wheelchair without a supportive pillow device for their right arm/wrist. - on 4/24/23 at 12:23 PM with no black wedge for their left arm shelf support. The 4/2023 activities of daily living (ADL) record, completed by certified nurse aides (CNAs), documented the functional maintenance plan that included the application of positioning devices in the wheelchair per plan of care were: - followed for both day and evening shifts on 4/21/23. - followed for day and evening shifts on 4/24/23. During an interview on 4/26/23 at 11:11 AM CNA #48 stated staff followed resident specific care instructions on the Kardex or the care plan. They stated Resident #66 required a pink wedge when they laid down and it had to be on for two hours and off for two hours. The resident also required a neck brace while eating along with a carrot for one hand and wash cloth for other. They stated Resident #66 also had a black wedge on their left side and a bean pillow on their right side for positioning while in their wheelchair. They stated nursing staff had been trained by therapy on how to apply the neck brace. They stated they were trained to put the neck brace on in bed if possible. They should remove the resident's pillow and allow the resident's neck to stretch back. If the resident was up in their wheelchair, they should recline the chair to allow the resident's neck to stretch. They stated that they are supposed to monitor the resident's swallow as well as skin integrity while the neck brace was in use. If the resident refused the neck brace, the resident should be assisted with eating by a nurse. CNA #48 stated it was important for the neck brace to be applied appropriately to prevent injury and to straighten the resident's neck for swallowing support and to have a washcloth or carrot in the resident's hands as their hands were very contracted. The devices kept nails from digging into their palm, promoted skin integrity, and kept the contractures from worsening. During an interview on 4/26/23 at 11:36 AM CNA #43 stated they referred to the Kardex to care for a resident. Resident #66 wore a neck brace while eating. They stated that it was easier to put the brace on the resident while they were in bed, but if the resident was in their wheelchair, they lifted the resident's head up and back to put the brace on. They stated that they usually held the resident's head there for a few seconds to stretch their neck and the resident would tell them when it was enough. They had been trained by therapy on how to put the neck brace on but was unaware that the resident's wheelchair needed to be tilted back when the brace was applied while in their wheelchair. It was important to apply the brace so that the resident did not choke while eating. If the resident refused the brace, a nurse needed to assist the resident with eating. The resident had not refused the brace for them. They stated the resident required a carrot for their right hand and a rolled-up washcloth for their left hand for contracture management. The resident also had a side support/wedge pillow on their left side under their arm, like an arm rest. The CNA stated it was important to apply the contracture devices to stop the progression of the contracture and to open the resident's hands to avoid pressure areas. During an interview on 4/26/23 at 12:12 PM LPN #47 stated they expect CNAs to utilize the iPads and hand-held devices to view to Kardex for resident specific care instructions. They stated the positioning and contracture management devices as well as specific application instructions were included on the Kardex. LPN #47 stated that Resident #66 used a neck brace for all meals unless they refused and then they were to be assisted with eating by a nurse. They stated that they were not trained how to apply the brace but that the CNAs on the unit were. LPN #47 stated that they did not usually work on the resident's unit, and they had the CNAs apply the brace prior to meals. LPN #47 stated it was important for the neck brace to be applied correctly to ensure the proper neck position for swallowing to avoid aspiration. They stated the resident had a bean bag device for their arm, a black wedge, and other positioning devices to keep them straight while in their wheelchair; and a carrot for one hand and a washcloth for the other hand for their hand contractures. They stated that the hand contracture devices were important for the resident to use to avoid worsening of the contractures and to prevent their nails from embedding into their skin. During an interview on 4/26/23 at 12:32 PM LPN Unit Manager #49 stated that nursing staff should look at the Kardex for resident specific care instructions. They expected all positioning and contracture management devices in place per the plan of care and Kardex instructions. They stated the devices assisted in preventing further contraction, helped with pain management, provided pressure relief, and promoted skin integrity. They stated that they would expect to be notified of any refusals and they were not notified the resident had refused any ordered devices. The resident should have their neck brace on for all meals and staff were trained to apply and remove the brace. They stated the neck should be extended when the brace was applied and preferably while the resident was lying down. If the resident was in their wheelchair, the wheelchair should be tilted backwards to achieve a lying position for neck extension prior to the brace being applied. They stated it was important for the resident's neck brace to be applied properly to ensure their neck was in the correct position to swallow and avoid aspiration. During an interview on 4/26/23 at 2:54 PM occupational therapist (OT) #53 stated if a resident had contractures nursing would request a referral and OT would assess the resident and determine if any interventions were needed. They trialed several different options for hand contracture management for Resident #66 and concluded that the carrot in the right hand and a rolled washcloth in the left hand was best tolerated by the resident. They stated they expected staff would follow the recommendation to wash the resident's palms in the AM and at minimum place the rolled washcloths in their hands. They stated that it was important to have the hand contracture management devices in place to prevent the contractures from worsening. OT #53 stated the resident also had a bean pillow, black wedge, and neck travel pillow for positioning in their wheelchair. The bean pillow was placed under the right elbow and up around the arm to help keep the arm from being contracted against their body, and the wedge on the left side provided support to the arm. They stated the resident was seen originally for the neck brace because they could not hold their head up during meals making it difficult to swallow. Staff had been educated on how to apply the brace properly and should recline the resident's wheelchair to open their neck position. They stated it was easiest to put the brace on when the resident was already in a supine position in bed. It was not appropriate for staff to apply the neck brace while the resident's neck was tilted forward or by tilting the resident's head up manually while the resident was in a seated position. The resident had tight muscles in their neck staff, and this would not allow the right clearance for the resident's throat for adequate swallowing. 2) Resident #93 was admitted to the facility with diagnoses including Alzheimer's disease and contractures of the left and right hand. The 3/31/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, did not reject care, required extensive assistance of 2 for dressing, and had impairment in range of motion (ROM) to both upper extremities. The 7/13/21 physician orders documented a right upper extremity blue carrot (contracture prevention device) and a left upper extremity resting splint (to help reduce swelling and pain). The blue carrot was to only be removed for care and the blue resting splint was to be applied in AM and removed at bedtime. The revised 5/23/22 comprehensive care pan (CCP) documented the resident had limitations in ROM related to decreased functional activity with contractures. Interventions included the resident must have carrots or wash cloths at minimum in their hands during the day and if unable to apply carrots, place rolled wash clothes in their hands. The undated care instructions (Kardex) documented the resident was to have carrots or rolled wash cloths at a minimum in their hands during the day and were to be off at night. The April 2023 treatment administration record (TAR) documented to ensure the right upper extremity blue carrot and left upper extremity resting splint were put in place on the 6:00 AM - 2:00 PM shift and the 2:00 PM to 10:00 PM shift. The blue carrots were to be removed for care only and the blue resting splint was to be applied in the AM and removed at bedtime. The 4/2023 activities of daily living (ADL) record task form documented the resident was to have carrots or wash cloths in their hands at a minimum during the day. On 4/19/23 at 12:14 PM, the resident was observed seated in their high back recliner chair at a table in the dining room. Both resident's hands were contracted, and they did not have any contracture management devices in their hands. At 1:21 PM, the resident was observed lying in bed, both hands remained contracted without a contracture management device in place, and there was a blue carrot on their bed side table. On 4/19/23 registered nurse (RN) #44 signed the TAR indicating to ensure the right upper extremity blue carrot and left upper extremity resting splint were put in place on the 6:00 AM - 2:00 PM was completed on the 6:00 AM- 2:00 PM shift. On 4/19/23 at 1:30 PM certified nursing assistant (CNA) #50 documented on the CNA ADL task form not applicable (N/A) for placement of the right upper extremity blue carrot and left upper extremity resting splint. On 4/20/23 at 9:50 AM, the resident was observed lying in their bed, their hands were contracted, and they did not have a contracture management device in place. The blue carrot was on their bed side table. On 4/20/23 registered nurse (RN) #44 signed the TAR indicating to ensure the right upper extremity blue carrot and left upper extremity resting splint were put in place on the 6:00 AM - 2:00 PM was completed on the 6:00 AM- 2:00 PM shift. On 4/20/23 at 11:56 AM CNA #51 documented on the CNA ADL task form the placement of the right upper extremity blue carrot and left upper extremity resting splint was completed. On 4/21/23 at 9:24 AM, the resident was observed seated in their high back recliner chair in the dining room, the resident's hands were contracted, and they did not have a contracture management device in place. At 11:15 AM, the resident was observed in their low bed sleeping, their hands were contracted, they did not have a contracture management device in place, and a blue carrot was on their bed side table. At 12:02 PM, the resident was observed in their high back recliner chair in the dining room, their hands were contracted, and they did not have a contracted management device in place. On 4/21/23 licensed practical nurse (LPN) #34 signed the TAR indicating to ensure the right upper extremity blue carrot and left upper extremity resting splint were put in place on the 6:00 AM - 2:00 PM was completed on the 6:00 AM- 2:00 PM shift. On 4/21/23 at 1:59 PM CNA #50 documented on the CNA ADL task form not applicable (N/A) for placement of the right upper extremity blue carrot and left upper extremity resting splint. On 4/24/23 at 9:23 AM and 10:23 AM, the resident was observed in their high back recliner chair in the dining room, their hands were contracted, and they did not have a contracture management device in place. At 12:59 PM, the resident was observed seated in their high back recliner chair in the hallway, both of their hands were contracted, and they did not have a contracture management device in place. On 4/24/23 RN #45 signed the TAR indicating to ensure the right upper extremity blue carrot and left upper extremity resting splint were put in place on the 6:00 AM - 2:00 PM was completed on the 6:00 AM- 2:00 PM shift. On 4/24/23 at 1:59 PM CNA #52 documented on the CNA ADL task form the placement of the right upper extremity blue carrot and left upper extremity resting splint was completed. On 4/25/23 at 8:43 AM, the resident was observed in their high back recliner chair in the dining room, their hands were contracted, and they did not have a contracture management device in place. At 11:01 AM, the resident was observed in the hallway seated in their high back recliner chair, both hands were contracted, and they did not have a contracture management device in place. At 11:38 AM, the resident remained in the hallway with no contracture management devices in their hands. During an interview on 4/25/23 at 12:50 AM CNA #35 stated they were floated to the unit on this day, and they were supposed to check the CNA care instructions prior to assisting residents so they knew what level of care to provide and if the resident needed any special devices in place. They stated Resident #93 was on their assignment, they did not check the CNA care instructions before providing care, and they were verbally told what level of assistance each resident needed by another staff member. They stated when they provided care to Resident #93, the resident's hands were contracted, they struggled to wash the resident's hands, and they were unaware the resident needed contracture management devices in their hand. They stated if the resident required any special devices it was listed on the care instructions. It was important to ensure the contracture management devices were in place to ensure the contractures did not worsen. If they were aware of the devices, they would have tried to apply them or use a rolled up wash cloth. They did not tell anyone the resident's hands were hard to open and they should have. During an interview on 4/25/23 at 2:01 PM LPN #34 stated they were floated to the unit on 4/21/23. The TAR indicated what devices the resident needed, and the nurse should only sign if the treatment was completed. They were familiar with Resident #93, their hands were contracted, and they had contracture management devices or rolled wash cloth ordered for their hands. The resident must have had something in their hands on 4/21/23 otherwise they would not have documented it was in place on the TAR. They stated it was important for the resident to have their contracture management devices in place to prevent skin breakdown and to prevent their contractures from worsening. During an interview on 4/26/23 at 11:34 AM LPN #10 stated if a resident required any special devices for contractures it was listed on the TAR and If they signed the device was in place that meant they either observed the device in place or they had applied it themselves. The CNAs should let the nurse know if they could not apply the device, the CNA should document the resident refused, and the nurse should write a note regarding the refusal as well. Resident #93 had contractures, was supposed to have contracture management devices in place or a rolled washcloth. If the resident's contracture management devices were not applied the resident's contractures could worsen. During an interview on 4/26/23 at 11:43 AM, RN unit manager #22 stated Resident #93 had contractures and was supposed to have contracture management devices or rolled wash cloths in their hands to prevent the contractures from worsening and prevent skin breakdown. If the nurse signed the TAR that the device was in place, that meant they either observed the device in place or applied it themselves. The CNAs should not document N/A and should document either the resident refused, or they applied the device. Staff should be checking the resident's care instructions before care to ensure the correct level of assistance and proper care were provided. During a telephone interview on 4/26/23 at 1:19 PM RN #44 stated if a resident had an order for a device for contractures it was listed on the TAR. If they signed the TAR that the device was in place, they either observed the device in place or they applied it themselves. If the resident refused any care or application of contracture management devices the CNA should let the nurse know and they both would document the refusal. They could not recall if they were notified if the resident refused their contracture management devices. During an interview on 4/26/23 at 3:15 PM occupational therapist (OT) #46 stated if a resident had an order for contracture management devices, it was in place for preventative measures to help prevent skin breakdown, and further worsening of their contractures. They stated Resident #93 had bilateral hand contractures and one of their hands was worse than the other. It was very important for the resident to either have blue carrots or rolled wash cloths in their hands daily. The unit staff had been recently educated on this topic in March or early April 2023. The resident's care plan and care instructions documented the need for the blue carrots or rolled wash cloths and listed the instructions on how to apply the devices. If the resident refused, staff should let the nurse know so they could document the refusal. If staff was having a hard time opening the resident's hands, they should let the nurse know so therapy could be made aware and could reassess the resident. They expected staff to follow the resident's care plan to prevent further worsening of their contractures. 10NYCRR 415.12(e)(2)

Based on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 10 residents (Residents #108 and 109) reviewed. Specifically, Resident #108 was not assisted with shaving, nail care, or eating; and Resident #109 was not assisted with eating. Findings include: The facility policy, ADL Assistance and Supervision revised 1/8/18 documented the nursing assistant would provide assistance with daily activity (ADL) assistance/supervision to assigned residents and assist other nursing assistants in providing (ADL) care as needed. The Team Leader would monitor the (ADL) assistance/supervision provided for residents throughout the shift and give appropriate guidance to the nursing assistants. The Unit Manager would record the ADL assistance on the EMR (electronic medical record), monitor assistance/supervision provided for residents, and provide appropriate guidance to the nursing staff. The facility policy, Shaving a Male Resident revised 5/8/18 documented a nursing assistant would shave the face of a male resident if the resident was unable to do the procedure safely by themself. This procedure would be carried out daily, or as needed. The facility policy, Hygiene/Grooming revised 7/24/18 documented designated nursing staff would ensure that residents were clean and appropriately groomed at all times. The individual preferences of residents for personal care and grooming would be established and documented. Residents would be provided with care to maintain or improve abilities to perform hygiene and grooming tasks, as needed. AM care included oral hygiene; a partial bath; perineal care (as necessary/ordered) and any specific hygiene care (such as catheter or colostomy care) on days when no shower/bath was scheduled. Hygiene care was repeated before and after meals and throughout the day as needed. 1) Resident #108 was admitted to the facility with diagnoses including Alzheimer's disease and hypertension. The 2/23/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, had no behaviors, required limited assistance of 1 for eating, and extensive assistance of 2 for bathing, dressing and personal hygiene. The comprehensive care plan (CCP) initiated 10/2/22 and revised 1/2/23 documented Resident #108 required limited assistance of 1 for eating and was a messy eater, and extensive assistance of 2 for bathing and personal hygiene. Interventions included to provide finger foods if the resident wandered, set up their meal without the tray, provide cues to help facilitate bringing food and drinks up to their mouth to minimize mess, approach in a calm, gentle manner, and re-approach if the resident refused care. The 4/26/23 resident care instructions documented the resident could safely be assisted with meals from a feeding assistant, required limited assistance of 1 for eating, required cues for eating, could not understand what was required of them, required guidance from staff, and required extensive assistance of one for personal hygiene and bathing. The following observations of Resident #108 were made: - on 4/19/23 at 12:34 PM sitting in the dining room approximately 3-4 feet away from the table feeding themself lunch and spilling food on themself and the floor. The resident had 1/4 inch- 1/2 inch long facial hair. The resident was not assisted with eating or positioning. At 12:43 PM, licensed practical nurse (LPN) # 34 called for a staff member to get them a towel and cleaned up the spilled food under the resident's chair. The LPN did not position the resident closer to the table or assist them with eating. - on 4/20/23 at 12:43 PM, sitting at a dining room table with facial hair approximately 1/2 inch long. - on 4/21/23 at 11:21 AM, sitting in the dining room approximately 1-1/2 feet away from the table while waiting for lunch. The resident had facial hair on their [NAME] and face approximately 1/2 inch long. At 11:34 AM the resident was eating lunch and spilling their food. Certified nursing assistant (CNA) # 36 walked by the resident and did not offer to push the resident closer to the table or assist them with eating. At 11:40 AM, the resident continued to attempt to feed themself and was spilling food on their lap. The resident was sitting approximately 1-1/2 feet away from the table and was sitting at an angle. Several staff members walked by the resident and did not assist them with positioning or eating. At 11:46 AM support aide # 37 asked the resident how they were doing and did not help with eating or positioning. At 11:53 AM the resident dropped their peaches on the floor and bent over to pick them up. Their chair remained at an angle away from the table. The resident continued to spill food on their pants and was not helped by staff. At 12:15 PM the resident completed their meal and there was food on their pants, on the floor, and on the table in front of their plate. CNA # 36 handed the resident chocolate milk, and the resident spilled the milk on their pants and on the floor and CNA #36 did not attempt to assist the resident. - on 4/24/23 at 12:39 PM, sitting at the dining room table eating lunch and spilling food on the table and their lap. Staff did not cue or assist the resident with eating. At 12:40 PM, LPN #34 removed the resident's plate while they were still eating and placed their dessert in front of them. LPN #34 did not ask the resident if they were finished eating their meal. - on 4/25/23 at 9:43 AM, walking down the hall with facial hair approximately a 1/2 inch long with a brown substance under their fingernails. - on 4/26/23 at 10:03 AM, sitting in the dining room with food particles and stains on their pants, long facial hair, and a brown substance under their fingernails. During an interview on 4/26/23 at 10:05 AM, CNA # 36 stated Resident #108 should sit at a 90-degree angle for eating. Resident #108 required limited assistance of one for eating, extensive assistance of 2 for ADL care, and the CNAs were responsible for ADL care. The resident should have been cued and assisted with eating. The CNA stated Resident #108 had not been shaved in 3 weeks. They stated they should re-approach the resident with care if they became agitated and did not know why the resident had not been shaved. During an interview on 4/26/23 at 10:30 AM, LPN # 34 stated Resident #108 required set up with limited assistance for eating. They stated they asked for towels and cleaned up food under the resident's chair and did not assist the resident with eating. They stated Resident #108 required extensive assistance of 1-2 for their ADLs and did not refuse care. LPN #34 stated they would assist the CNAs with shaving and nail care but had not assisted with Resident #108's shaving or nail care. During an interview on 4/26/23 at 10:45 AM RN #35 stated Resident #108 required extensive assistance of 1-2 for ADL care and should be reapproached if agitated. They stated shaving and nail care was completed by CNAs and should be done with morning care. Resident #108 required limited assistance of 1 for eating and should be pushed up to the table for positioning. 2) Resident #109 was admitted to the facility with diagnoses including vascular dementia and unspecified occlusion (blockage) of the coronary artery. The Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, had no behaviors, and required supervision with assistance of 1 for eating. The comprehensive care plan (CCP) initiated 8/17/20 and revised 1/5/23 documented the resident had ADL deficits related to muscular weakness. Interventions included limited assistance of 1 for eating, divided plate, and assist with appropriate use of silverware, cut all items into bite-sized pieces to be easily scooped with spoon or stabbed with a fork, and place any items from bowls onto divided plate. The resident may require intermittent verbal and/or tactile cues for appropriate use of silverware, assistance to be fed with non-finger food items (varied daily based on mood and behaviors), and one item at a time was recommended. The 4/26/23 resident care instructions documented Resident #109 was on aspiration (inhaling food/fluid into lungs) precautions, could be safely assisted with meals by a feeding assistant, and required limited assistance of 1-person physical assistance for eating and intermittent cueing to use their silverware. The following observations were made of Resident #109: - on 4/19/23 at 12:25 PM, sitting in the dining room eating lunch with their drinks and dessert on a tray on the windowsill behind them. The resident was not eating the main meal. At 12:49 PM LPN #34 handed the resident a glass of orange juice and did not cue or assist the resident with eating. At 12:57 PM LPN #34 handed the resident their strawberries after the main meal was completed and all other residents were removed from the dining room. The resident remained in the dining room unattended and was not assisted or cued with eating. - on 4/21/23 at 11:38 PM, registered nurse (RN) #35 handed the resident their lunch on a divided plate and told the resident to use their spoon. The resident picked the spoon up and smashed their food around the plate, did not eat, and set their spoon down. No cueing or assistance with eating was provided by staff. At 12:04 PM, the resident finished a cup of coffee while the rest of their drinks and dessert were on a tray behind them. At 12:12 PM the resident was trying to drink out of an empty coffee cup while their drinks were behind them. No staff assistance with drinks was offered. At 12:16 PM, the resident had a plate of baked ziti and continued to attempt to eat. CNA # 26 handed the resident their milk and did not offer to feed or assist the resident during the meal. At 12:25 PM, the resident had consumed less than 25% of their meal, drank 240 milliliters (ml) of coffee, and 60 ml of their milk. At 12:27 PM, CNA #36 handed the resident their orange, took away the resident's untouched main meal and did not offer an alternative meal, cueing, or assistance. - on 4/24/23 at 12:27 PM, sitting in a recliner chair across from nursing station with milk and only a dessert in front of them. Their plate of food remained in the dining room untouched. The resident was not helped or cued by staff. During an interview on 4/26/23 at 10:13 AM CNA #36 stated Resident #109 required assistance of 1 for eating. The resident often mixed drinks in their food. Staff were supposed to offer alternative items such as sandwiches to the resident, but they often just took their plate away. Resident #109 often expressed hunger. CNA #36 stated they did not know why staff did not think about giving additional alternatives to the resident if they did not eat. During an interview on 4/26/23 at 10:45 AM LPN #34 stated Resident #109 required supervision, cueing, and set up with their meals but would require feeding assistance at times. The resident would mix their drinks in their food. They stated staff should offer the resident a sandwich if they did not eat. During an interview on 4/26/23 at 10:55 AM RN #35 stated Resident #109 had declining vision, required limited assistance of 1 for eating, would often require cues to remind them of food still on their plate, and would require a staff member to pull up a chair and assist them with eating when they were not eating well. They stated staff needed to be re-educated if Resident #109 did not eat and staff did not offer any alternative meal items. 10NYCRR 415.12 (a)(3)

Based on record review and interview during the recertification survey conducted 4/19/23-4/27/23 the facility failed to provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #438) reviewed. Specifically, Residents #438 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 (Centers for Medicare and Medicaid Services) for Medicare Part A as required. Findings include: The CMS form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 (expiration date 1/31/26) documents that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 must be issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service - FFS) beneficiaries in situations where Medicare payment is expected to be denied. The SNF ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice prior to services ending. Resident #438 was admitted to the facility with diagnoses including Alzheimer's Disease, hypothyroidism, and chronic kidney disease. The 10/14/22 Minimum Data Set (MDS) assessment documented it was a SNF PPS (Prospective Payment System) Part A discharge (end of stay) assessment. The SNF Beneficiary Protection Notification Review documented the resident's Medicare Part A skilled services start date was 9/19/22 and the last covered day of Part A service was 10/14/22. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. An SNF ABN form CMS-10055 was not provided to the resident. The explanation why the form was not provided was checked as other: Private Pay. During an interview on 4/27/23 at 8:48 AM the MDS Coordinator stated they issued SNF ABN CMS-10055 frequently at the same time they issued the Notice of Medicare Non-Coverage (NOMNC) CMS-10123. They stated that the only time they would not issue a SNF ABN CMS-10055 was if a resident was discharged to the community the day after their covered Medicare Part A services ended. The MDS Coordinator stated if a resident remained in the facility past their covered Medicare Part A services, issuing a SNF ABN CMS-10055 was required. They stated MDS registered nurse (RN) #33 issued the NOMNC CMS-10123 to the resident. The resident went to long-term care in the facility and should have been issued a SNF ABN CMS-10055. During an interview on 4/27/23 at 9:11 AM MDS RN #33 stated they issued SNF ABN CMS-10055 when they were instructed to by the MDS Coordinator. They stated that the SNF ABN CMS-1005 was supposed to be issued in almost all circumstances unless the resident was discharging home the day after Medicare Part A services were done. They stated they did not know why the SNF ABN CMS-10055 was not issued for Resident #438. Any resident staying in the facility for long term care after being discharged from Medicare Part A services should have been issued a SNF ABN CMS-10055. 10 NYCRR 415.3(g)(2)(iii)

Based on observation, record review, and interview during the recertification survey conducted 4/19/23 -4/27/23 the facility failed to determine if medication self-administration was clinically appropriate for 1 of 1 resident (Resident #98) reviewed. Specifically, Resident #98 was observed on 5 days with Odomzo (generic name sonidegib, a chemotherapeutic medication) in a cup at their bedside and there was no assessment to determine the resident's ability to safely self-administer medications or a physician order for self-administration of medications. The facility policy Self Administration of Medication dated 5/2018 documented residents who desired to self-administer medications required review and approval of the interdisciplinary care planning team members and an order from the attending physician. The medications would be stored in a locked drawer in the resident's room, and the self-administered medications would be monitored by licensed nursing staff. Resident #98 was admitted to the facility with diagnoses including basal cell carcinoma of the skin. The 2/17/23 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and was independent with activities of daily living (ADL). The 10/16/18 comprehensive care plan (CCP) documented the resident had deficits in ADL function. Interventions included the resident was independent with most ADLs. The resident had basal cell carcinoma and interventions included administer medications per medical orders. The 6/30/22 physician orders documented Odomzo capsule 200 milligrams (mg) once every 24 hours for basal cell carcinoma. There was no order for the resident to self-administer medications. A 3/17/23 progress note by physician #40 documented the resident was seen for a mandated 30/60 day visit. The resident had basal cell cancer, was stable, and was followed by oncology. The resident had two cancerous lesions removed and they had healed, and the resident continued to receive Odomzo. There was no documentation of the resident's ability to safely self-administer medications. During an observation and interview on 4/19/23 at 10:33 AM the resident stated they took a pill for their cancer. The resident entered their room and returned to the hallway with a reddish colored pill and swallowed it. They stated they took the pill approximately 2 hours after eating their breakfast every day. The resident showed the pamphlet titled sonidegib (Odomzo) that came with the medication. The April 2023 medication administration record (MAR) documented Odomzo 200 mg capsule was administered on 4/19/23 at 7:11 AM by licensed practical nurse (LPN) #10. On 4/20/23 at 10:39 AM, Resident #98 was observed in their room. The resident stated they were getting ready to take their Odomzo. The resident walked to their over the bed tray table and retrieved a reddish colored pill from a clear plastic medication cup and swallowed the pill. They stated one day they had forgotten to take the medication until 3:00 PM. The resident stated they did not set any alarms to remind them to take their pill, and they were usually pretty sharp. The April 2023 MAR documented Odomzo 200 mg capsule was administered on 4/20/23 at 8:32 AM by LPN #10. On 4/21/23 at 9:30 AM, the resident was observed seated in a straight back chair in the hallway, the resident gave permission to the surveyor to enter their room, and a reddish colored capsule with sonidegib 200 mg printed on the capsule was observed in a plastic medication cup on the resident's over the bed tray table. The April 2023 MAR documented Odomzo 200 mg capsule was administered on 4/21/23 at 6:53 AM by LPN #10. On 4/24/23 at 9:23 AM, the resident was not in their room and a reddish colored capsule with sonidegib 200 mg printed on the capsule was observed in a plastic medication cup on their over the bed tray table. The April 2023 MAR documented Odomzo 200 mg capsule was administered on 4/24/23 at 8:09 AM by registered nurse (RN) Unit Manager #22. On 4/25/23 at 9:38 AM, Resident #98 was observed in the dining room conversing with another resident and at 10:05 AM, a reddish colored capsule with sonidegib 200 mg printed on the capsule was observed in a plastic medication cup on the resident's over the bed tray table in their room. The April 2023 MAR documented Odomzo 200 mg capsule was administered on 4/25/23 at 7:00 AM by LPN #10. There was no documented evidence that Resident #98 had been assessed for the ability to safely self-administer medications or had a physician's order to self-administer medications. During an interview on 4/25/23 at 11:02 AM LPN #10 stated if a resident was able to self-administer their own medications it would be listed on the MAR and the resident would need a physician order to do so. They stated when they administered the medication to a resident, they were supposed to ensure the resident took the medication prior to leaving the resident and the time stamp on the MAR was when the medication was given to the resident. They stated they did not watch Resident #98 take their medication, as the resident usually came to them and asked for their medication in the morning. They were unaware the resident was keeping medication in their room to take later. They stated they should have watched the resident take their medication for safety reasons and to ensure they were taking their ordered medications. If they were aware the resident wanted to take their medications at a different time or wanted to keep their medications in their room, they would have notified the Nurse Manager or a medical provider. During an interview on 4/25/23 at 11:16 AM RN Unit Manager #22 stated a resident needed a self-medication administration assessment completed before they were able to take their own medications or to keep medications in their room. The resident would also need a physician order and it would be listed on the MAR. The nurse who administered medications should ensure that the resident had taken all their medications per physician orders. Resident #98 did not have a self-medication administration assessment, did not have a physician order to administer their own medication, and they were unaware the resident was keeping medication in their room to take later. Resident #98 never mentioned they kept medication in their room to take later or they wanted to self-administer their own medications. If they were aware the resident wanted to take their medications at a different time, they would have notified the physician to get an order for the resident's preferred time. If the resident wanted to self-administer their own medications, they would have assessed the resident's ability, discussed the resident's wish with the interdisciplinary team, and obtained a physician order. The RN stated they had provided Resident #98 with their medications on 4/24/23 and thought the resident had taken all their medications at that time. They stated it was important for residents to take their medications as ordered and if a resident was keeping medication in their room, it was a potential safety concern. During an interview on 4/26/23 at 4:33 PM nurse practitioner (NP) #39 stated a resident needed a medical order to self-administer their medications. They stated Resident #98 received a chemotherapy medication for their active basal cell cancer. It was important for the nurse to ensure the resident was taking their prescribed medications as ordered. If they were aware the resident wanted to take their medication at a different time, they would have changed the order time. During an interview on 4/26/23 at 4:33 PM the Director of Nursing (DON) stated residents needed an order to administer their own medications and they should have a self-medication administration assessment completed annually and as needed. The nurse who gave the resident their medication should ensure that the resident took all their medications per physician orders. If they did not it was a potential accident hazard. 10 NYCRR 415.3(e)(1)(vi)

Based on interviews and record review conducted during an abbreviated and partial extended survey (NY 476), the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to an unresponsive resident who had Full Code status with Advance Directives and physician orders [REDACTED].#1). Specifically, on [DATE] at approximately 2:50 AM, Resident #1 was observed unresponsive. The staff failed to identify the resident's code status, failed to respond with emergency equipment in a timely manner, failed to initiate a Code Blue (emergency response) to summon additional help, failed to activate the 911 system, and failed to provide cardio-pulmonary resuscitation efforts for a resident who was a full code. This resulted in actual harm and the potential for serious harm to the health and safety of all residents in the facility that is Immediate Jeopardy and Substandard Quality of Care. Findings include: The facility Basic Life Support Policy dated [DATE] documented Basic life support procedures including CPR, rescue breathing, and defibrillation would be initiated on all appropriate residents unless advance directives documenting the exclusion of the procedure were on file in the medical record. Staff were to initiate CPR when a [MEDICAL CONDITION] occurred. Resident #1 was admitted to the facility on [DATE]. Significant [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired. Resident #1's face sheet documented the resident was a full code and wanted cardio [MEDICAL CONDITION] resuscitation (CPR). The physician orders [REDACTED].#1 was a full code (provide CPR). The Remember Blue You Do (a list of residents who were full codes) list dated [DATE] documented the resident was a full code. The list was located on the crash cart (a wheeled container carrying equipment for use in emergency resuscitations) at the nursing station and was reviewed every shift by the nurse assigned to that unit to identify residents who required CPR. The comprehensive care plan (CCP) dated [DATE] and the certified nurse aide (CNA) care guide dated [DATE] documented Resident #1 wished to have CPR and his wishes were to be honored. Interventions included the resident was a full code status, staff were to initiate emergency care, CPR, defibrillation (automated external defibrillator, AED) and to call emergency medical services. The facility was to ensure compliance with requirements of state law regarding advanced directives. The RN Supervisor (RNS) #3 progress note dated [DATE] at 2:50 AM, documented she was contacted by a CNA that Resident #1 was found unresponsive and the CNA reported the resident was dead. She arrived on the unit at 2:50 AM to assess the resident. Upon entrance to the resident's room his face was blue and his ears were purple in color. When auscultating (listening with a stethoscope) chest sounds for 60 seconds he was cold to touch and no chest sounds or lung sounds were heard. Within 5 minutes of arrival to the floor the charge nurse looked at the code list located on the crash cart and saw the resident was a full code. Immediately the AED was placed on the resident. The AED did not advise to shock, and chest compressions were not initiated. The NP (nurse practitioner) was contacted that the resident was a full code, assessed and connected to the AED. CPR was not initiated; no pulse or chest sounds were heard. The DON (Director of Nursing) was notified, and the same information was relayed. The family was notified and arrived within 15 minutes. The resident's body was released to the funeral home at 5:12 AM. The licensed practical nurse (LPN) #1 progress note dated [DATE] at 3:18 AM, documented a CNA came to her and said the resident was not breathing. LPN #1 went to the room and the resident was not breathing and had no pulse. The note did not document if a code was called or if CPR was initiated. The resident's death certificate dated [DATE] at 2:50 AM documented Resident #1's cause of death was cardio-pulmonary arrest. The facility investigation dated [DATE] at 2:50 AM documented the following time line per video review of the incident: -At 1:35 AM CNA #4 last observed Resident #1 in room [ROOM NUMBER] on the south unit. He was sitting on the edge of his bed and was assisted back to bed and checked for incontinence. -At 2:45 AM LPN #1 was sitting at the nursing station on the south unit and reviewed and placed the clip board that contained a list of residents requiring CPR back on the crash cart. -At 2:50 AM CNA #2 went down the hall to Resident #1's room and returned at 2:50.48 to alert LPN #1 the resident was deceased . -At 2:51 AM CNA #2 contacted RNS #3 via phone and alerted her of the resident's status and he was deceased . -At 2:51.33 AM LPN #1 grabbed her stethoscope and went to Resident #1's room. At 2:52 she returned to the nursing station. -At 2:56 AM RNS #3 entered the unit and went to Resident #1's room. -At 2:58 AM RNS #3 was observed seated at the nursing station. -At 3:02.59 AM LPN #1 returned to the unit after administering medication to another resident on a different unit. -At 3:03 AM RNS #3 left the unit and returned to the south unit at 3:06.26 with funeral home documentation in hand. -From 3:07 AM - 3:17.52 RNS #3, LPN #1 and CNAs #2 and 4 performed various tasks on the unit. -At 3:20.11 LPN #1 walked to the crash cart located at the nursing station, picked up the code blue list and gave the list to RNS #3. -At 3:22 AM LPN #1 obtained the AED and both RNS #3 and LPN #1 went to Residents #1's room. -At 3:23.36 RNS #3 and LPN #1 returned to the nursing unit. From 2:50 AM - 3:22 AM RNS #3, LPN #1 and CNA #2 did not call a code blue, did not initiate CPR, did not apply the AED, and did not notify 911 of the resident's condition. INTERVIEWS: When interviewed on [DATE] at 8:58 AM, the Director of Nursing (DON) stated the facility's system for code blue was to identify the resident's code status by checking the resident's wrist band for a blue dot. If there was a blue dot present that meant blue you do (provide CPR). Other areas to check were on the facility computerized system on the nursing carts and at the nursing desk and on the portable hand held I pod staff carried with them. The residents chart under the advance directives section also documented the code status. She stated the facility was currently updating that policy and protocol to exclude the wrist bands. Resident#1 did have a wrist band at the time of the incident that indicated the resident was a full code. She stated when a code blue was called all staff available were to respond. The facility conducted code drills monthly to ensure staff were aware of how to respond to a code. She stated on [DATE] CNA #2, LPN #1 and RNS #3 did not call a code, did not initiate CPR, did not apply the AED timely and did not notify emergency services per facility policy when the resident was found unresponsive. RNS #3 and LPN #1 were currently on suspension from the facility and an investigation was initiated once she was notified of the incident. When interviewed on [DATE] at 10:42 AM, the Administrator stated the remember list attached to the facility investigation was a list of residents on unit 1 who required CPR and was located on the crash cart for staff to review prior to performing CPR. The list was last updated [DATE]. Resident #1 was identified on the list as requiring CPR. When interviewed on [DATE] at 10:50 AM. LPN #1 reviewed her statement with the surveyor included in the facility investigation and she documented its accuracy with her signature and date. She stated she was CPR certified at the time of the incident. The facility policy on CPR was if you find a full code, you begin CPR and announce an overhead page code blue 3 times with the room number. Areas to check for code status were in the chart under advance directives and in the computer. At 2:55 AM on [DATE] at the time of the incident, CNA #2 approached her and stated Resident #1 was dead. LPN #1 entered Resident #1's room and listened for breath sounds, none were present and there was no pulse. The resident's chest was still warm and his face was purple in color. CNA #2 notified RNS #3. Approximately 5 minutes later she returned to the nursing desk and began to document her note. She remained at the desk for ,[DATE] minutes when RNS #3 responded. RNS #3 asked her to deliver medication to another resident on another unit. She stated that took about ,[DATE] minutes. When she returned RNS #3 was still at the desk. RNS #3 told her RNS #3 had pronounced Resident #1 deceased . She sat at the desk again for about ,[DATE] minutes and realized that she did not check the crash cart list to see what Resident #1's code status was. She then checked and saw he was a full code. She told the supervisor at that time and about ,[DATE] minutes later they took the AED in and placed it on the resident. The AED stated no shock was advised and to follow facility protocol. The RNS #3 stated they did not need to complete compressions. They removed the AED and returned to the nursing desk. RNS #3 called the physician and the DON and alerted them to what had occurred. She had received training on abuse, neglect and mistreatment within the past year. She was currently out on suspension pending the outcome of the investigation. She did not check any other areas for the resident's code status. When interviewed on [DATE] at 11:53 AM, RNS #3 reviewed 3 statements provided in the facility investigation. She identified the 2 facility statements were copies of the same statement and the New York State Department of Health form was the most accurate statement. She identified a time discrepancy and notification issues and documented new information on her NYSDOH statement and documented her signature indicating its accuracy. She stated she was CPR certified and held a current certification. The residents code status was in the resident's chart under the MOLST, on the crash cart, the resident's bracelet and the computer. The facility CPR policy was, if a resident was a full code and required CPR she was to call 911, page overhead code blue and start chest compressions. She stated she had never been through a code blue drill. She began her employment at the end of (MONTH) (YEAR). She received training and education on CPR, code status and abuse neglect and mistreatment during orientation. After the incident she did have to refresh that information after the resident had expired. On [DATE] at 2:50 AM she was notified by CNA #2 that Resident #1 was dead. Prior to the call she was addressing another issue with a resident who was aggressive towards staff. She arrived on unit south within a couple of minutes and observed CNA #2 and LPN #1 at the nursing station. She requested LPN #1 obtain and deliver medication needed for another resident on another unit. Both CNA #2 and she entered Resident #1's room. The light was on, his shirt was above his belly, she identified his stomach and face were pale, his ears were purplish in color and he appeared to be deceased . She listened to his apical (heart beat) sounds for 60 seconds and his lungs and did not hear anything. The residents skin was cool to the touch. She went back to the nursing station and sat at the desk. She notified the family first and assumed he was a DNR. LPN #1 returned to the unit and grabbed the code list off the crash cart and determined Resident #1 was a full code. The time frame was no more than 30 minutes between the time she was notified of the resident's condition and the time the AED was applied. The AED was applied and stated no shock advised and to follow facility protocol. CNA #2 and 4 went into reposition the resident and wait for the family to arrive. She called the NP and the DON. She informed the NP that the resident had passed away, he was a full code and she had applied the AED. She was unable to recall if she mentioned the resident did not receive chest compressions to the NP. She contacted the DON and informed her of the resident's code status and no one had performed CPR and did not follow facility policy. Based on her assessment she felt the resident had been deceased for a while. She was unable to provide a specific time frame. She did not check the residents code status and assumed LPN #1 checked it prior to her arrival. She stated she was responsible to check the code status. When interviewed on [DATE] at 6: 43 AM, CNA #2 stated via phone the facility code blue policy was to check the resident's bracelet, tell the nurse and call a code blue overhead. The code status was in the resident's chart, on the bracelet, a dot on the chart and in the computerized system. On [DATE] between 2:45 AM - 2:50 AM she went to check on the resident as he usually started to wake at that time and she was going to start her rounds. She opened Resident #1's door and observed his face to be grayish blue. She knew something was not right and did not touch him at that time. She was shocked, did not check the resident's bracelet and ran to tell the nurse who was located near the bathroom within 10 seconds after finding the resident. She then went to the phone and notified RNS #3 that the resident was dead. She did not call a code as she thought the LPN would do that and she was still in shock. She did not recall if she went back into the room with LPN #1. About 5 minutes later the RNS #3 arrived on the unit and both of them went into the resident's room. RNS #3 placed her stethoscope on the resident's chest for a few seconds and listened for a heartbeat. She did not recall if RNS #3 assessed or listened to any other areas. She did not think she touched the resident at that time. She then left the residents room and called CNA #4 to come and assist her with post mortem care. She stated LPN #1 may have helped her begin the resident's care prior to CNA #4 arriving on the unit and was unable to state how long before CNA #4 arrived on the unit. Post mortem care consisted of removing the residents clothing and changing his brief. CNA #2 and 4 placed the resident in a gown. While providing post mortem care Resident #1's left ear and head had a bluish/purplish color and the top of his head had lines from front to back. His skin was warm to touch everywhere including his back and arms. She did not touch his face at that time. She did not call a code because she did not check the residents ID bracelet, she was shocked and thought the nurse would have done that when she was notified of his condition. She did receive training prior to this incident that the facility policy and protocol was to call a code blue overhead. When interviewed on [DATE] at 8:11 AM, CNA #4 stated the facility policy when finding a resident unresponsive would be to call a code blue and tell the nurse on the unit about the resident's status. On [DATE] at 1:35 she observed Resident #1 sitting on the side of his bed, she provided assistance, checked for incontinence, repositioned him and turned the light off. At 3:03 AM CNA #2 called her and told her to come to the unit as Resident #1 passed away. She immediately went to the unit observed RNS #3 sitting at the computer at the nursing station and proceeded to Resident #1's room. Upon arrival LPN #1 and CNA #2 were in Resident #1's room providing post mortem care. She helped CNA #2 put the resident in a gown. His skin was warm to touch and his arm was still warm at that time. When interviewed on [DATE] at 9:16 AM, The Nurse Practitioner (NP) # 6 stated via phone she was on call on [DATE]. RNS #3 notified her at about 3:20 AM - 3:40 AM that Resident #1 had expired. RNS #3 stated Resident #1 was a full code and the AED was applied with no shock advised and he was deceased . She was not informed the resident was still warm or chest compressions were not initiated. She expected staff to initiate CPR when the resident was found unresponsive. Chest compressions should be initiated and a code to be called. The 3 indicators for not providing CPR were, the resident being cold to touch, rigor mortis or mottling of the lower extremities. She stated there would have been a better chance of a positive outcome if CPR was initiated at the time the resident was found unresponsive. When interviewed on [DATE] at 12:49 PM The medical director stated he was the physician assigned to Resident #1 at the time of the incident. He was aware the resident was a full code. When Resident #1 was found unresponsive and without breath sounds the LPN was responsible to check the resident's code status, call a code blue, initiate CPR and call 911 emergency services. There was a lot of breakdown during this incident. He stated you would not initiate CPR if the resident had rigor mortis and stiffness, the body was completely cold or mottling of the extremities or bruising in the dependent areas of the body were present. In this case the body was still warm, without mottling or stiffness and CPR should have been initiated. That decision would be made by the RN Supervisor. The pooling of blood would occur within 2 hours and the stiffing or rigor mortis would occur within 4 hours. The LPN and the RN did not follow facility policy when the resident was found unresponsive. It would be difficult to determine if the resident would have responded to CPR however the protocol was not followed and should have been. On [DATE] CNA #2, LPN #1 and RNS #3 did not call a code blue, did not initiate CPR, did not apply the AED and did not notify emergency services when Resident #1 was found unresponsive in his room. Immediate Jeopardy was removed on [DATE], prior to exit based on the following corrective actions taken by the facility and past non-compliance: - Completed a full house audit verifying accuracy of advance directives. - Completed a full house audit verifying code status identification - QAPI meeting to review incident and facility practices - Updated CPR procedure for code status identification - Reviewed all CPR certifications for staff - Provided re-education to all facility staff on CPR Code Response - Consulted with the Medical Director - Reviewed in-house deaths for the last year to ensure resident wishes were honored. - Conducted Code Blue drills and report to QAPI based on determine schedule - RN/LPN orientation adjusted to include Code Blue drill for all licensed staff. 415.3(e)(2)(iii)