Every finding on record at Elderwood of Uihlein at Lake Placid

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labelled and stored in accordance with professional standards of practice. Specifically, (a.) an opened medication bottle had an expired date; (b.) opened medication bottles had no open dates (c.) opened insulin pens were labeled with incorrect expiration dates; (d.) a pre-poured medication cup was noted at a resident's bedside. This was evident for 2 out of 3 medication carts reviewed. This is evidenced by: The facility's Policy and Procedure titled, Medications Administration Methods, date last modified: [DATE] documented under PRODCEDURE #5: Medications may not be pre-poured/pre-punched. #6: Medication expiration dates are checked prior to administration. Refer to manufacturer guidelines for medications with shortened expiration dates (i.e. insulin). GENERAL PRECAUTIONS FOR ADMINISTRATION OF MEDICATIONS #3: A medication must never be left at bedside or be out of sight of the nurse administering the medication. The nurse must watch each resident take the medication, and ensure the medication is swallowed, unless the resident has an order for self-administration of medications. Medications will not be handled with bare hands. Medicine cups are discarded after use in administering a medication to a resident. The facility's Health Direct Pharmacy Services Insulin Expiration Dates Grid documented, All insulins should be stored in the refrigerator until opening and protected from light. Once opened or removed from the refrigerator for storage in the medication cart, the insulin should be dated as it will expire in a specified time per manufacturer. Insulin Glargine U-100 (Lantus, Basaglar, Semglee, Insulin Lispro (Humalog, Admelog, Lyumjev - expiration is 28 days after opening. During an observation and interview on [DATE] at 12:54 PM, Resident # 41 was noted to have approximately 10 empty medication cups stacked on end table, and a medication cup with approximately 4 pills at the bedside. Resident #41 stated nurse often left pills and they take them when they get up. During an observation on [DATE] at 11:34 AM, Unit 100 medication cart contained 1 bottle of saline nasal spray with an expiration date of ,d+[DATE]; 1 bottle of sertraline suspension with no open date, the expiration date was written for ,d+[DATE]; 1 bottle of lactulose suspension with no open date and a manufacturer expiration date of ,d+[DATE]. During an interview at this time, Registered Nurse #3 stated they would discard the expired medication and proceeded to fill in open dates for medications without open dates. During an observation on [DATE] at 12:20 PM, Unit 200, cart A contained 1 Lispro insulin pen with open date of [DATE] and an expiration date of [DATE]; 1 Lantus insulin pen with an open date of [DATE] and an expiration date of [DATE], both greater than manufacturer expiration of 28 days after opening. During an observation and interview on [DATE] at 12:57 PM, Unit 200, cart B contained 1 Humalog insulin pen with open date of [DATE], the expiration date was not legible. Licensed Practical Nurse #4 stated it looked like the expiration date was [DATE]. During an interview on [DATE] at 10:40 AM, Registered Nurse #2 stated they were not aware of any residents who self-medicated. They stated if a resident wished to self-medicate there was a process to follow, although they had never gone through the process. During an interview on [DATE] at 10:39 AM, Social Worker #2 stated, to their knowledge, they had no residents who self-medicate, however, there were steps to take if resident wishes to do so. During an interview on [DATE] at 10:44 AM, Director of Nursing #1 stated they had 1 resident on the 400 unit that self-medicated. Once a resident is evaluated by Occupational Therapy and Medical Doctor, a self-medication form is completed by nurse, and care plan is updated. Resident who self-medicates had a pillbox, and medications were poured into pillbox weekly. During an interview on [DATE] at 10:44 AM, Director of Nursing #1 stated nurses follow the 6 Rights of Medication Administration. They further stated that the nurse is to stay with resident until all medications have been taken, and do not leave medication at the bedside. Nurses could administer medications in the dining room as long as it was not during a meal or an activity. They stated it was the responsibility of the nurse who is assigned to the medication cart to ensure the cart is clean, organized and each medication was labeled appropriately. They stated that when opening medications, nurse should label medication with open and expiration dates; multi dose vial medications would follow the pharmacy grid of shortened expiration dates after opening. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation and interviews during the recertification survey, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for the main kitchen and one of 3 resident unit kitchenettes. Specifically, appliances and surfaces were not clean. This is evidenced by: During observations on 09/24/2024 at 11:04 AM, in the main kitchen, the following appliances or surfaces were soiled with food particles or oily dust: Slicer Cooking line drawers Bulk food bins Cupboard doors 2 exterior windows (windows, windowsills, window screens) 2 exterior window fan grills ABC-rated fire extinguisher During observations on 09/24/2024 at 11:56 AM, in the Unit Four Resident Kitchenette, the following was soiled with food particles: Interior of the microwave oven The undated document titled Cooks Cleaning Check List documented that the slicer is to be cleaned and free of debris and utensil drawers are to be clean inside and out. During an interview on 09/24/2024 at 12:01 PM, Director of Dining Services #1 stated that they would have the items found in the kitchen and the Unit Four Resident Kitchenette cleaned and that the maintenance department would be contacted to have the windows, window fans, and fire extinguisher cleaned. During an interview on 09/25/2024 at 12:40 PM, Administrator #1 stated that they would discuss the cleaning items found with the Director of Dining Services. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14

Based on observation and interviews during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the side doors to the two outdoor garbage dumpsters were not closed, the sides of the dumpsters below the doors were soiled with food drips, and the grounds around dumpsters were littered. This is evidenced by: During observations on 9/30/2024 at 12:02 PM, litter was found in the outdoor employee break area, around the dumpsters, and the loading dock area. During an interview on 9/30/2024 12:27 PM, Administrator #1 stated that they would have the areas outside cleaned, and staff would be in-serviced on keeping the break area and dumpster area pick-up. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, record review, and interviews during the recertification survey, the facility did not provide necessary maintenance services to maintain a clean, sanitary, comfortable, and homelike environment relative to building #1. Specifically, the roof leaked. This is evidenced by: During observations on 09/27/2024 at 10:18 AM, evidence of roof leaks was found in the following areas: Unit One data room had a large tarp hanging from the ceiling. Unit One janitor closet had water-stained ceiling tiles. Activities room had a water-stained ceiling tile. Core area had 2 areas with drain hoses attached to ceiling tiles draining into catch-buckets. During an interview on 09/30/2024 at 2:02 PM, Administrator #1 stated that the facility is looking to secure a contractor and have the roof leaks repaired before winter. 10 New York Codes, Rules, and Regulations 415.5(h)(4)

Based on observation, record review, and interviews during a recertification survey, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for 1 (Resident #73) of 32 residents reviewed. Specifically, Resident #73 was observed with topical pain medications in their room and there was no assessment and/or physician order for the resident to self-administer the medications. This is evidenced by: The Policy and Procedure titled, Self- Administration of Medication, revised 4/10/2018, documented residents who desired to self-administer medication were permitted to do so upon review and approval by the interdisciplinary care planning team members and with an order from the attending physician. Legend or over-the-counter medications would be stored in a locked drawer in the resident's room. The use of self-administered medication would be monitored by licensed nursing staff. Resident # 73 was admitted with diagnoses of chronic obstructive pulmonary disease, polyneuropathy (damage to multiple nerves outside the brain and central nervous system, which causes pain, discomfort, and mobility difficulties), and diabetes. The Minimum Data Set (an assessment tool) dated 6/25/2024, documented the resident was cognitively intact. The Comprehensive Care Plan for Pain Management, revised 8/22/2024, documented the resident had the potential for alteration in comfort related to osteoarthritis (disease of the entire joint). Interventions documented to report non-verbal or verbal signs and symptoms of pain promptly to the nurse; provide medication as ordered; monitor/document effect of treatment plan. The interventions did not include self-administration of any medications. The Comprehensive Care Plan for Behavior/Mood, revised 7/2/2024, documented the resident had reported seeing big animals on the ceiling and they would order things online if they were not provided to them. Interventions documented the resident was to request social service support if assistance was needed with purchasing items. During a tour of Unit 1 on 9/24/2024 at 12:47 PM, four (4) over-the-counter topical pain relief medications were noted in Resident #73's room. One of the medications was generically labeled as lidocaine (pain medication that numbs the skin) cream. Resident #73 stated they purchased the medications themselves, and they (the resident) applied them when they had pain in their joints. Review of the Order Summary Report for active orders as of 8/01/2024, did not document a physician order for the over-the-counter topical pain medications observed in Resident #73's room and there was no order for the resident to self-administer the medications. There was an order dated 4/30/2024, for Aspercreme w/Lidocaine Cream 4% (Lidocaine) that was to be applied to the resident's back topically every 8 hours as needed for pain and another order dated 12/6/2023, for the same medication to be applied to the lower back, knees, shoulders topically every 8 hours as needed for pain. Review of the electronic medical record did not include an assessment by the interdisciplinary team for the resident to safely self-administer the topical pain medications and safely store the medications in their room. During an interview on 10/02/24 09:00 AM, Director of Nursing #1 stated they were not aware Resident #73 had pain medication creams/lotions in their room. They stated the only resident in the facility who was able to self-administer medications resided on the Unit 4. They stated if Resident # 73 was permitted to self-administer medications, they needed to be assessed by the interdisciplinary team to ensure they were able to correctly name the medications used and what they for; was able to follow directions and know when it was time to use the medication; was able to ensure medications were stored safely and securely in their room. They stated the resident also needed to have a physician order to self-administer medications. 10 New York Code of Rules and Regulations 415.3(f)(1)(vi)

Based on interviews and record review conducted during recertification and abbreviated survey, the facility did not ensure that the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental and psychosocial needs for 1 (Resident #42) of 31 residents reviewed for comprehensive care plans. Specifically, for Resident #42 , Certified Nurse Aide did not implement the intervention of geri sleeves prior to care which resulted in skin tear to resident's right forearm. This is evidenced by: Resident #42 was admitted to the facility with diagnoses of unspecified atrial fibrillation (an irregular heartbeat), chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys), and atherosclerotic heart disease (a chronic condition that occurs when plaque builds up in the arteries of the heart, reducing blood flow to the heart). The Minimum Data Set (an assessment tool) dated 8/28/2024, documented the resident had severe cognitive impairment, and rarely or never could be understood or understand others. A review of the residents Minimum Data Set section GG - Functional Abilities and Goals dated 8/28/2024 documents that the resident requires full dependance and one person assistance for upper body dressing. A review of the facility policy titled Activities of Daily Living Assistance and Supervision last revised 1/08/2024 documented that the facility 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. The policy further documented the Nursing Assistant provides Activities of Daily Living assistance/supervision to assigned residents and assists other Nursing Assistants in giving care as needed. A review of the facility policy titled Care Planning last revised 1/22/2019 documented the Kardex (Resident care card followed by Certified Nurse Aides) would be developed, revised, and utilized by the interdisciplinary team as a guide to provide care to the resident. The Kardex would be made available either printed and placed in a designated location in the resident's room or will be available electronically. A review of the resident's skin integrity care plan initiated on 7/05/2024 and revised on 7/18/2024 documented the resident has skin integrity due to frail skin and that the resident is to have Geri sleeves in place on their arms during care. A review of the resident's Kardex (Resident care card followed by Certified Nurse Aides) dated 9/30/2024 documented resident skin/equipment care to have Geri sleeves on arms during care. A review of the incident and accident report dated 7/17/2024 documented that Resident #42 received a skin tear while Certified Nurse Aide #8 was providing care and changing the resident's shirt. During the investigation it was determined that the residents care plan was not followed by the Certified Nurse Aide #8 providing the care for the resident. The Certified Nurse Aide did not apply Resident #42's Geri sleeves causing a skin tear on the resident's arm. During an interview on 10/01/2024 at 11:22 AM, Certified Nurse Aide #8 stated that after placing the resident's shirt on them they noticed a skin tear to the resident's arm. They stated that they did not read the Kardex (Resident care card followed by Certified Nurse Aides) before providing care to the resident and that they needed to place the Geri sleeves on the resident before providing care. They stated that they were disciplined for not following the residents care plan. During an interview on 10/02/2024 at 12:30 PM, Director of Nursing #1 stated that the Certified Nurse Aide did not follow the residents care plan or Kardex when they failed to apply Geri sleeves before providing care to the resident causing an injury to the resident's arm. They stated that the Certified Nurse Aide was disciplined and had to be orientated on the proper use of the Kardex (Resident care card followed by Certified Nurse Aides) and to follow residents care plans. Certified Nurse Aide #8 was placed on additional training days and reeducated on care plan documentation. Director of Nursing #1 stated Certified Nurse Aide #8 was fully trained and educated on residential abuse and neglect. 10 New York Codes, Rules, and Regulations 483.21(b)(1)

Based on record review and interviews during a recertification survey, the facility did not ensure a Significant Change Minimum Data Set assessment was completed for 1 (Resident #128) of 1 resident reviewed. Specifically, a Significant Change Minimum Data Set assessment was not completed for Resident #128, when the resident was diagnosed with a left arm fracture on 4/11/2024, and the resident was no longer able to stand or walk on 4/12/2024. This is evidenced by: Cross-referenced to: F684: Quality of Care Resident #128 was admitted to the facility with diagnoses of rheumatoid arthritis, muscle weakness, and difficulty walking. The Minimum Data Set (an assessment tool) dated 8/7/2024, documented the resident was cognitively intact. The resident was able to make themselves understood and understand others. The document titled, SNF ADL Summary (Interventions) - V2, and dated 4/08/2024, documented focus: ADL (activities of daily living) function/mobility/restorative care: - Sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed documented supervision or touching needed, touching assistant, gait belt, left prosthetic on, shoe on right foot, stand pivot transfer to wheelchair. - Walk 10 feet: once standing, the ability to walk at least 10 feet in a room, corridor, or similar space documented supervision or touching assistance needed, touching assistance, gait belt, left prosthetic on, shoe on right foot. The Hospital Imaging/Cardiology report dated 4/11/2024, documented X-ray of left humerus (upper arm). Impression documented distal humerus fracture (lower part of upper arm). The Hospital Patient Visit Information dated 4/11/2024, documented the resident was seen for a humeral (left upper arm) fracture. It documented the resident's instructions were reviewed and received on 4/11/2024 at 5:04 PM. The document titled, SNF ADL Summary (Interventions) - V3, dated 4/12/2024, focus: ADL (activities of daily living) function/mobility/restorative care: - Sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed documented do no transfer/activity did not occur related to unable to stand, use slide board for transfers, bed to wheelchair. - Walk 10 feet: once standing, the ability to walk at least 10 feet in a room, corridor, or similar space documented resident is not able to walk/activity did not occur. Review of the electronic medical record did not include a Significant Change Minimum Data Set, following diagnoses of a left arm fracture and the resident's inability to stand or walk. During an interview on 10/02/2024 at 10:00 AM, Resident # 128's Representative #1 stated the resident fell and broke their elbow. They stated that on 4/04/2024, they (Representative #1) decided for the resident to do transfers on their own because they needed to be able to prior to discharge. They stated the resident had only been transferring on their own for a whole day and a half when they fell . Resident # 128 was present during the interview and stated they got their wheelchair over to the bathroom door and was going to use the walker. They stated the brake was not on, the wheelchair moved, and they fell . Representative #1 stated the resident broke their elbow in 2 or 3 places. They stated the resident was not able to use their walker for about 2 months following the fracture. During an interview on 10/02/2024 at 11:48 AM, Registered Nurse #5 stated they did not see a Significant Change Minimum Data Set for the resident on 4/11/2024 or after that date. They stated there needed to be two (2) significant changes in the resident's status before a significant change assessment was done. During an interview on 10/02/2024 at 12:11 PM, Director of Nursing #1 stated there should have been a Significant Change Minimum Data Set assessment because the resident fell and sustained a fracture and was no longer able to use their walker. They stated a therapy referral was made. They stated the fracture and the change in ambulation were the 2 changes in the resident's status that would necessitate a Significant Change Minimum Data Set. 10 New York Code of Rules and Regulations 415.11(a)(3)(ii)

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure treatment with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality for 3 (Resident #s48, 100 and 113) of 32 residents reviewed for dignity. Specifically, (a.) Resident #48 was administered an insulin shot in the resident common area during lunch; (b.) Resident #100 had their shirt on inside and backwards, and (c.) Resident #113 was seen in their room removing their pants with their room door open and in full view of the resident common area. This is evidenced by: A facility policy titled Dignity date modified 8/01/2019, documented that each resident had the right to be treated with dignity and respect. All activities and interaction with residents by any staff, temporary agency staff or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's, goals, preferences, and choices. When providing care and services, staff must respect each resident's individuality, as well as honor and value their input. Resident #48 was admitted with the diagnoses of type 2 diabetes with hyperglycemia (an endocrine dysfunction causing problems regulating blood sugar levels), dementia without behavioral disturbance (a neurological disease causing memory issues), and hypertension (high blood pressure). The Minimum Data Set, dated dated dated [DATE] assessment documented the resident was able to understand others, be understood, was significantly cognitively impaired and required some assistance with activities of daily living. The Cognitive Skills Care Plan dated 2/19/2024 documented that Resident #48 was moderately impaired with decision making related to financial and healthcare decisions. Goals included maintaining/attaining the highest practicable level of cognitive function. Interventions listed included but were not limited to encouraging the resident to make decisions as able. Facility Policy titled Medication Administration Methods dated 1/25/2024, did not document any rules regarding medication administration in public common areas. During a general observation on 9/25/2024 at 11:02 AM, Registered Nurse #3 was observed administering insulin to Resident #48 in the common area dining room. It was noted that Registered Nurse #3 did not ask the resident if they were comfortable receiving their injection in the common area and lifted the resident's shirt to administer the injection into the resident's abdomen exposing their abdominal area to all the residents in the common area. Two other residents were sitting at the table, and two other residents were at another table, while two more residents were sitting in front of the television. During an interview on 9/26/2024 at 11:34 AM, Registered Nurse #3 was asked if and how they explained to residents what they were doing. Registered Nurse #3 stated that they knew the resident was getting their medications, so no explanation needed. During an interview on 10/01/2024 at 10:44 AM, Director of Nursing #1 stated nursing staff could pass medication in the dining area as long as it was not during a meal time or an activity. During a subsequent interview on 10/02/2024 at 9:59 AM, Director of Nursing #1 stated that giving medications in public areas was allowed unless it was during meals or activities. If the medication was receiving an invasive procedure like an injection, it should be done in private. If the resident needed to have medications at the exact moment when they were doing an activity or during mealtime, the staff should ask the resident if they wanted their medications then and help them to a private area or wait until the activity or meal was finished. The decision was left to resident preference. Resident #100 was admitted with the diagnoses of unspecified dementia with behavioral disturbance (a progressive neurological disease), hypertension (high blood pressure), and abnormalities of gait and mobility (problems with movement and walking). The Minimum Data Set (an assessment tool) dated 8/16/2024 documented the resident could sometimes be understood, sometimes understand others, was significantly cognitively impaired, and required extensive assistance with activities of daily living. The Behavior Care Plan dated 6/03/2023 documented the resident could disrobe in the public areas of the unit. Goals included maintain stable behavior status through positive socialization/interaction with staff/other residents, altercations/confrontations with staff/other residents would be addressed immediately to minimize negative outcomes, and the resident would maintain/attain the highest practicable level of psychosocial well-being as evidenced by the absence of or reduced behaviors. Interventions included, but were not limited to, administering medications as ordered, anticipate the resident's needs, check for loose fit for clothing if noting to be removing clothing in public areas, encourage clothing to be tucked in if noted to be stripping, and if removing clothing, ensure the resident does not need to use the restroom. During an observation on 9/24/2024 at 12:40 PM, Resident #100 walked out of their room topless and was redirected back to their room to find a shirt by housekeeping staff. During an observation on 9/27/2024 at 11:01 AM, Resident #100 was observed walking in and around the sensory room on unit 4 with their shirt on backwards and inside out. During an interview on 10/02/2024 at 9:45 AM, Certified Nurse Aide #2 stated that it was the expectation that if a resident needed to change their clothes or use the bathroom that the staff would assist them to do so and close the door for privacy. If a resident was observed wearing their clothes incorrectly, they would attempt to fix it at the time it was seen if the resident was in a state to be approached about it. During an interview on 10/02/2024 at 9:30 AM, Registered Nurse #1 stated that if a resident was to be seen wearing their clothes incorrectly, they would expect that staff would fix it at the time it was seen, unless there was something else going on that staff were involved in, or the resident was not approachable at the time. During an interview on 10/02/2024 at 9:59 AM, Director of Nursing #1 stated that if a resident was wearing clothing incorrectly, it would be expected that the staff would fix the resident's clothing at the time it was seen, unless the resident was unapproachable, or if the staff were in the middle of something more pressing. Resident #113 was admitted with the diagnoses of Alzheimer's disease (a progressive neurological disease causing confusion and memory loss), dementia with behavioral disturbance (a progressive neurological disease causing memory issues and behavior disturbances), and hypertensive chronic kidney disease (high blood pressure causing kidney damage). The Minimum Data Set, dated dated dated [DATE] documented the resident was usually able to understand others, usually be understood, was significantly cognitively impaired, and required some assistance with activities of daily living. The Behavior Care Plan dated 2/28/2024 and last revised 8/02/2024, documented that the resident could self-transfer and not use their assistive device, refuse to wear glasses, remove shoes and socks stating that they didn't need them, and urinate or spit on the floor. Goals included demonstrating stable behavior status through positive socialization/interaction with staff and other residents. Interventions included but were not limited to anticipating needs, encouraging resident to keep their shoes on, monitor for changes in mood and behavior, provide verbal cues, and redirect, intervene and/or provide distraction during episodes of agitation. Resident #113 was observed on 9/27/2024 at 10:23 AM removing their pants and undergarments in their room with the door open in full view of the common area and people in the common area. During an interview on 10/02/2024 at 9:45 AM, Certified Nurse Aide #2 stated that it is the expectation that if a resident needed to be changed or use the bathroom that the staff would assist to do so and close the door for privacy. During an interview on 10/02/2024 at 9:30 AM, Registered Nurse #1 stated that if staff were to assist someone to the bathroom or to change their clothes, they would expect that they would shut the resident's door and blinds so that their privacy could be ensured. During an interview on 10/02/2024 at 9:59 AM, Director of Nursing #1 stated that it was expected that if a resident needed to be changed or use the bathroom, the staff would shut the doors and blinds for privacy. 10 New York Code Rules Regulations 415.5(a)

Based on record review and interviews during a recertification survey, the facility did not ensure patient centered care plans were reviewed and revised by the interdisciplinary team after each assessment in a timely manner for 2 (Resident #'s 128 and 2) of 32 residents reviewed. Specifically, the facility did not ensure A) Resident #128's care plan was reviewed and revised timely following a fall on 4/6/2024 and fracture diagnosed on [DATE] and B) Resident #2's care plan was reviewed and revised following resident-to-resident altercations on 7/01/2024, 7/08/2024 and 8/03/3024. This is evidenced by: Cross-referenced to: F684: Quality of Care, F637: Comprehensive Assessment After Significant Change The Policy and Procedure titled, Care Planning (IDT), revised 1/22/2019, documented the interdisciplinary team (IDT) would review/revise the care plan after each assessment, including both the comprehensive and quarterly review assessments per the Resident Assessment Instrument manual. It documented that between care plan reviews, each discipline updates/adds/resolves care plan problems, goals, and approaches as needed. Resident #128 Resident #128 was admitted to the facility with diagnoses of rheumatoid arthritis, muscle weakness, and difficulty walking. The Minimum Data Set (an assessment tool) dated 8/7/2024, documented the resident was cognitively intact. The Comprehensive Care Plan for Safety, revised 8/29/2024, documented the resident was at risk for falls related to impaired gait. The Incident Report for Resident #128 dated 4/6/2024 at 4:32 PM, documented the resident had an unwitnessed fall. The resident stated their left arm was tender. The resident was assessed by the Registered Nurse and was able to move their left arm and had normal range of motion. The Nurse's Note dated 4/11/2024 at 12:08 PM by Director of Nursing #1, documented the resident's left arm/hand was noted to be swollen, with bruising to the arm/hand and the resident complained of left arm pain/discomfort. The resident had a recent fall. A new order was received for x-ray of left arm. The Hospital Imaging/Cardiology report dated 4/11/2024, documented X-ray of left humerus (upper arm). Impression documented distal humerus fracture (lower part of upper arm). The Care Plan for Safety was not revised to include the resident's fall on 4/06/2024 and subsequent fracture diagnosed on [DATE]. A care plan for the fracture was not initiated until 5/18/2024. During an interview on 10/2/2024 at 12:11 PM, Director of Nursing #1 Stated they should have developed and implemented a care plan for the fracture when the resident returned from the hospital on 4/11/2024. 48744 Resident #2: Resident #2 was admitted with diagnosis of traumatic brain injury a sudden injury that causes damage to the brain); generalized muscle weakness; and adjustment disorder with depressed mood (excessive reactions to stress that involve negative thoughts, strong emotions, and changes in behavior). The Minimum Data Set (an assessment tool) dated 9/2024, documented a Brief Interview for Mental Status (BIMS) score of 03, suggests resident with severe cognitive impairment. Resident #107 was admitted with diagnosis of adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions, and changes in behavior) major depression (persistent feeling of sadness) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning). The Minimum Data Set (an assessment tool) dated 9/2024, documented a Brief Interview for Mental Status (BIMS) score of 05, suggests resident with severe cognitive impairment. Based on review of Facility Reported Incident dated 8/3/2024, there had been three resident to resident incidents between Resident #2 and Resident #107. Incident #1 (NY00346912) occurred on 7/1/2024, incident #2 (NY00347483) occurred on 7/8/2024, and incident #3 (NY00350225) occurred on 8/3/2024. In all three incidents Resident #107 was documented as the aggressor and had approached Resident #2. Review of Care Plan for Resident #107 documented revisions on: 7/5/2024 - Verbal altercation with another resident with no psychosocial distress noted. AGGRESSOR: potential for aggressive behaviors or actions that can be threatening or harmful and can be physical in nature (hitting) at others when provoked. On 8/03/2024 - Physical Altercation with another resident with no psychosocial distress noted. Intervention: Break tasks down into simple, manageable steps and proceed with one at a time. o Do not have multiple staff approach. o Reduce stimulation in the environment as possible (control noise levels) and promote a calm environment (soft lighting, avoid crowding). o Remove any staff/residents in the immediate area who may be in danger. o Slowly assess for unmet needs (presence of pain, hunger/thirst, hot or cold body, temperature, need to go to the bathroom) and attempt to meet my needs with caution and in a safe manner. o Talk to my provider about my behaviors and medication regimen as needed. Review of Care Plan for Resident #2, revised 10/01/2024 documented, BEHAVIOR/MOOD PART 2/2: I can go to bed following breakfast tray delivery. I can report that I do not recall staff waking me up. I can refer to staff as liars, if they seek clarification with other staff. I can refuse to use sit and stand lift. I can tease or antagonize residents, such as making faces, when I think staff members can't see me. Review of Care Plan for Resident #2, revised 8/13/2024 documented, BEHAVIOR/MOOD PART 2/2: I can go to bed following breakfast tray delivery. I can report that I do not recall staff waking me up. I can refer to staff as liars, if they seek clarification with other staff. I can refuse to use sit and stand lift. Review of Care Plan for Resident #2, revised 7/01/2024 documented, BEHAVIOR/MOOD PART 2/2: I can go to bed following breakfast tray delivery. I can report that I do not recall staff waking me up. I can refer to staff as liars, if they seek clarification with other staff. Review of Care Plans for Resident #2 did not document revisions following resident to resident incidents and interventions for dates 7/1/2024, 7/8/2024 and 8/3/3024. 10 New York Code of Rules and Regulations 415.11(c)(2)(i-iii)

Based on observations, interviews, and record review during the recertification survey, the facility did not ensure a dependent resident was provided with appropriate treatment and services to maintain or improve their language and communication for 1 of 1 resident (Resident #118) reviewed for Activities of Daily Living. Specifically, nursing staff did not provide Resident #118 with adequate, consistent interpreter services in accordance with professional standards of care. This is evidenced by: Resident #118 was admitted with diagnosis of stenosis of small artery (the walls of the small arteries in the heart aren't working properly); cervicalgia (pain in or around your spine beneath your head) and history of falls. The Minimum Data Set (an assessment tool) dated 9/2024, documented a Brief Interview for Mental Status indicated resident was cognitively intact. The facility document titled, Limited English Proficiency Policy, last modified 4/24/2018, documented Language assistance will be provided through use of competent bilingual staff, staff interpreters contracts of formal arrangements with local organizations providing interpretation or translation services, or technology and telephonic interpretation services. All staff will be provided notice of this policy and procedure, and staff that may have direct contact with Limited English Proficiency individuals will be trained in effective communications techniques, including the effective use of an interpreter. The New York State Department of Health Code, Rules and Regulation, Volume C (Title 10) Section 415.3 Effective 2/24/2022, documented each resident shall have the right to: (i) adequate and appropriate medical care, and to be fully informed by a physician in a language or in a form that the resident can understand, using an interpreter when necessary, of his or her total health status including but not limited to, his or her medical condition including diagnosis, prognosis, and treatment plan. Residents shall have the right to ask questions and have them answered. On 9/24/2024 at 11:45 AM, Resident #118 was observed in their room sitting in wheelchair intermittently watching television. Writer knocked on door and asked if they may come in. Resident #118 pleasantly responded in another language. Writer entered and resident continued to speak in another language. During an interview on 9/24/2024 at 12:40 PM, Certified Nurse Aide #4 stated Resident #118 speaks creole, and they did not have any training on communication with Resident #118 or with any other resident with Limited English Proficiency. When caring for Resident #118 they generally made gestures or use their google translator on their personal cell phone. During an interview and observation on 9/24/2024 at 01:13 PM, Registered Nurse #2 stated Resident #118 spoke creole only. Nursing staff utilized tablet translator to communicate with Resident #118. Registered Nurse #2 was asked to demonstrate tablet translator. Registered Nurse #2 tried then conceded they were not familiar with use of the tablet translator. They asked for assistance from Certified Nurse Aide #7. Certified Nurse Aide #7 had limited familiarity and was unsuccessful in communicating with resident using the tablet translator. When approached with the tablet, Resident #118 appeared curious and confused as though they had never used device previously. Registered Nurse #2 stated they also use a language line. However, they had never used the language line and did not know where to obtain telephone number and or instructions. During an observation on 9/24/2024 at 01:20 PM, a laminated card with simple tasks were noted at Resident #118's bedside. There were no posted signs regarding language line or other means of communication in Resident #118's room. During an interview on 09/27/2024 at 10:38 AM, Registered Nurse #5 stated they used an electronic device for communicating with Limited English Proficiency residents, and deferred training of language device to the Registered Nurse #2 and Director of Nursing #1. They stated Social Worker #1 helped provide the electronic device, but 'no one really had been trained in its use.' Registered Nurse #4 and #5 had no knowledge of the language line. On 10/01/2024 at 10:28 AM, Registered Nurse #2, Certified Nurse Aide #6 and Registered Nurse #5 were observed in Resident #118's room reviewing tablet translator. During an interview on 10/01/2024 at 10:32 AM, Social Worker #2 stated facility used the Institute of Buffalo language interpreter line for Residents with Limited English Proficiency, with instructions were in the Social Worker's office, and utilized a website translator on tablets. Social Worker #2 stated instructions on use of language line were posted in resident's room on 9/30/2024. During an interview on 10/01/2024 at 11:00 AM, Director of Nursing #1 stated staff communicated with Resident #118 via language line, and instructions were posted on the wall above phone in their room. They stated training of staff was done as needed with new residents. Director of Nursing #1 further stated that Resident #118's family member could be called to translate, and there was a certified nurse aide who spoke creole. During an interview on 10/02/2024 at 09:45 AM, Licensed Practical Nurse #1 stated prior to this week when the New York State Department of Health was conducting the survey, they had communicated with Resident #118 by asking the certified nurse aide who spoke creole to be their interpreter. Licensed Practical Nurse #1 further stated that when the certified nurse aide who spoke creole was not working, the resident would make gestures when something was wrong. Care Plan dated 6/24/2024 documented for any meetings to utilize the International Institute of Buffalo and documented a phone number but no pin code. Care Plan dated 10/1/2024 documented to utilize the International Institute of Buffalo when needed and included a phone number and pin code. 10 New York Codes, Rules, and Regulations 415.12(a)(2)

Based on record review and interviews during a recertification survey, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 1 (Resident #128) of 1 resident reviewed for hospitalization . Specifically, the facility did not ensure Resident #128 received an assessment by a qualified person when they returned to the facility on [DATE], following diagnosis and treatment of a left upper arm fracture in the Emergency Department. This is evidenced by: Resident #128 was admitted to the facility with diagnoses of rheumatoid arthritis, muscle weakness, and difficulty walking. The Minimum Data Set (an assessment tool) dated 8/7/2024, documented the resident was cognitively intact. The Comprehensive Care Plan for Safety, revised 8/29/2024, documented the resident was at risk for falls related to impaired gait. The Incident Report for Resident #128 dated 4/6/2024 at 4:32 PM, documented the resident had an unwitnessed fall. The resident stated their left arm was tender. The resident was assessed by the Registered Nurse and was able to move their left arm and had normal range of motion. The Nurse's Note dated 4/11/2024 at 12:08 PM by the Director of Nursing #1, documented the resident's left arm/hand was noted to be swollen, with bruising to the arm/hand and the resident complained of left arm pain/discomfort. The resident had a recent fall. A new order was received for x-ray of left arm. The Hospital Imaging/Cardiology report dated 4/11/2024, documented X-ray of left humerus (upper arm). Impression documented distal humerus fracture (lower part of upper arm). The Hospital Patient Visit Information dated 4/11/2024, documented the resident was seen for a humeral (left upper arm) fracture. It documented the resident's instructions were reviewed and received on 4/11/2024 at 5:04 PM. The electronic medical record did not include a documented assessment of the resident's condition upon return to the facility on [DATE]. During an interview on 10/2/2024 at 12:11 PM, Director of Nursing #1 stated the resident should have received an assessment by the Registered Nurse when they returned to the facility. They stated there should have been a Nursing note that the resident returned from the hospital, along with the outcome of the visit. 10 New York Code of Rules and Regulations 415.12

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were consistent with professional standards of practice, for 2 (Resident #'s 29 and 35) of 2 residents reviewed for oxygen administration. Specifically, for Residents #29 and 35, their supplemental oxygen tubing was not dated and labeled to reflect when the tubing was changed. This is evidenced by: A review of the facility's policy and procedure titled Oxygen Therapy, Concentrator, last revised on 3/26/2018, documented that oxygen would be administered by licensed nurses with a physician's order. As part of the procedure nursing staff would label and date the tubing and all tubing would be changed at least weekly (7 days), or more often if soiling with secretions occurs. A review of the facility's policy and procedure titled Oxygen Therapy, Oxygen Cylinder, last revised on 6/27/2023, documented that oxygen would be administered via an open oxygen cylinder by licensed nurses with a physician's order. As part of the procedure nursing staff would label and date the tubing and all tubing would be changed at least weekly (7 days), or more often if soiling with secretions occurs. Oxygen flow rates, tubing connections, and the amount of oxygen remaining in the cylinder should be checked every shift and as needed. Resident #29 was admitted to the facility with diagnoses of hypertensive heart disease with heart failure, chronic congestive heart failure (a syndrome caused by an impairment in the heart's ability to fill with and pump blood), and chronic obstructive pulmonary disease (lung disease characterized by chronic respiratory symptoms and airflow limitation). The Minimum Data Set (an assessment tool) dated 8/21/2024 documented the resident could be understood and understand others with no impaired cognition. During an observation on 9/24/2024 at 11:50 AM, Resident #29 was on oxygen at 2 liters per minute via a nasal cannula. The oxygen tubing was not labeled or dated when it was last changed. During an observation on 9/25/2024 at 9:41AM, Resident #29's oxygen tubing was labeled and dated for 9/24. During an observation on 9/27/2024 at 9:41AM, Resident #29's oxygen tubing was labeled and dated 9/24. During an observation on 10/01/2024 at 10:32 AM, Resident #29 oxygen tubing was labeled and dated for 9/24. A review of Resident's #29 Treatment Administration Record for September 2024 documented Oxygen tubing to be changed tubing and mask/cannula every Saturday night shift. - A review of Treatment Administration Record on 9/27/2024 at 11:50 AM documented that Resident #29's oxygen tubing was changed on 9/22/2024. - A review of Treatment Administration Record on 10/01/2024 at 10:45 AM documented that the resident's oxygen tubing was changed on 9/28/2024. Resident #35 was admitted to the facility with diagnoses of chronic respiratory failure with hypoxia, (when the body does not receive enough oxygen) chronic obstructive pulmonary disease (lung disease characterized by chronic respiratory symptoms and airflow limitation), and hypertensive heart and kidney disease with heart failure. The Minimum Data Set, dated dated dated [DATE], documented the resident could be understood and understand others with no impaired cognition. During an observation on 9/24/2024 at 12:54 AM, Resident #35 was on oxygen at 4 liters per minute via a nasal cannula. The nasal cannula was hanging from the resident's ear and not in their nose and the oxygen tubing was not labeled or dated when it was last changed. During an observation on 9/25/2024 at 11:21 AM, Resident #35's oxygen tubing had no label on the tubing when it was changed. During an observation on 9/27/2024 at 10:44 AM, Resident #35's oxygen tubing was labeled 9/25/2024. The resident nasal cannula was not in the resident's nose and sitting on the floor next to the resident's chair appearing discolored at nostril prongs. A review of Resident #35's Treatment Administration Record for September 2024 documented Oxygen tubing to be changed tubing and mask/cannula every Sunday night shift. - A review on 9/27/2024 at 11:50 AM documented that the resident's oxygen tubing was changed on 9/22/2024. - A review on 10/01/2024 at 10:45 AM documented that the resident's oxygen tubing was changed on 9/28/2024. During an interview on 10/01/2024 at 11:22 AM, Certified Nurse Aide #8 stated that they sometimes change the oxygen tubing for the resident when it appeared damaged or soiled. They stated that they sometimes changed the oxygen tanks that are within the concentrator when it beeps, which were low or portable cylinders when needed. They stated that once the oxygen tubing or tank was changed they would let the nurse know that it was completed. During an interview on 10/01/2024 at 12:32 PM, Certified Nurse Aide #9 stated that they change the oxygen tubing for the resident when it appeared damaged or soiled since they know how to do it. They stated that they sometimes changed the oxygen tanks that are within the concentrator when it beeps that it was low or they look at the gauge and know that it is not flowing. They stated that they would not let the nurse know that they had changed tubing or oxygen cylinders. During an interview on 10/02/2024 at 9:26 AM, Licensed Practical Nurse #2 stated that the resident's oxygen tubing was to be changed every 14 days or when the order documented to be changed. They stated that Certified Nurse Aides were not allowed to change tanks or oxygen tubing and that this was a licensed nursing staff's task. Certified Nurse Aides were not allowed to do anything with resident's oxygen, and they were supposed to notify a nurse if anything needs to be done. During an interview on 10/02/2024 at 12:27 PM, Registered Nurse #1 stated that the resident's oxygen tubing was to be changed every Sunday during the overnight shift. They stated that Certified Nurse Aides were not allowed to touch the resident's oxygen. They stated that the Certified Nurse Aides were to notify a licensed nursing staff member when there was a question or problem with the oxygen of a resident. In mentioning the observations discovered to Registered Nurse #1, they stated that the tubing was not changed for the residents, which they stated was an issue. During an interview on 10/02/2024 at 12:30 PM, Director of Nursing #1 stated that the nursing staff administered the oxygen per the order from the physician. They stated that Certified Nurse Aides were not allowed to touch or do anything with the oxygen for the resident. They stated that oxygen administration was a medication that was prescribed by the physician and should be monitored regularly by the nursing staff. They stated that oxygen tubing was changed weekly and scheduled on the overnight shift to be completed by the licensed nursing staff. They stated that when the tubing was changed the individual performing the task should label and date when the tubing was changed. In mentioning the observations discovered to Director of Nursing #1, they stated that the tubing was not changed for the residents, which they stated was an issue. They stated they would need to have additional education for the staff. 10 New York Codes, Rules, and Regulations 415.12(k)(3)

Based on observation, interview, and record review during the recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infection for all residents and staff on 4 of 4 units (Units #1, 2, 3, and 4) during the recertification survey. This is evidenced by: The facility's policy titled Infection Prevention Control Program dated 7/15/2024, documented that all department heads would ensure that the following procedures would be followed: 1. Staff were responsible for washing their hands frequently, especially after handling soiled or contaminated objects; before and after coming into contact with residents or handling possessions of resident, and handling equipment. 2. Protective gloves or other protective equipment were worn when a staff member had direct contact with body fluids during work duties. Staff member should follow infection prevention policies and procedures and use protective equipment when coming into contact with resident (or their belongings) who were on transmission-based precautions. The facility's policy titled Transmission Based Precaution Levels (Type of Infectious Condition, Techniques and Documentation) Skilled Nursing Facility dated 6/06/2024, documented that: 1. Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a Multi-Drug Resistant Organism as well as those at increased risk of Multi-Drug Resistant Organism acquisition (e.g., residents with wounds or indwelling medical devices). 2. Contact Precautions involve gown and glove use when patient care activities require working within 3 feet of the resident and/or clothing would come in contact with the resident's environment. 3. If a resident was on transmission-based precautions, items needing removal from the precaution room (for disposal, laundering, laboratory tests, reuse in another location) would be double bagged at change of shift. Resident #124 was admitted to the facility with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affect a non-dominant side (a bleed on the brain that caused limited to no use of the side of the body), dysphagia following cerebral infarction (a bleed on the brain causing difficult swallowing), and atrial fibrillation (an irregular heart rate). The Minimum Data Set (an assessment tool) dated 8/06/2024 documented that the resident was able to understand others, be understood by others, had minimal cognitive issues but required significant assistance to complete activities of daily living. During an observation on 10/01/2014 at 10:39 AM, staff were seen cleaning room [ROOM NUMBER] which had a contact precaution sign on the room. The Support Aide #10 was not wearing any personal protective equipment. Bed linen was placed in a bag and a Support Aide #10 was observed coming out of the resident's room carrying the bag to dispose of in the dirty utility room. The Support Aide #10 then proceeded to push Resident #124 in their wheelchair back into their room. They then took the resident's water pitcher to fill. Support Aide #10 did not sanitize their hands between any of these actions. During lunch observations on Unit 3 on 10/01/2024 at 11:45 AM, it was noted that 3 Certified Nurse Aides were distributing lunches to residents. Certified Nurse Aide #11 and Support Aide #10 did not sanitize their hands between residents when handing out the lunch meals for the residents. Certified Nursing Aide #8 sanitized their hands in between distributing residents' meals. During an interview on 9/26/2024 at 1:33 PM, Registered Nurse #4 stated staff should be washing their hands when they come into building, prior to stepping in and providing care. Hand washing should be done (with soap and water) at mealtime, after smoking, eating, coming out bathroom, or if they pick something off the floor. Hand sanitizer should be used before and after coming out of resident rooms depending on what the staff did in the room after removing their gloves. Staff should not be walking out of a room with gloves on. During an interview on 10/01/2024 at 10:48 AM, Support Aide #10 stated they were waiting for the next class to start to become a Certified Nurse Aide. The contact precaution sign on the resident's door meant that they needed to wear extra personal protective equipment for care. Additionally, Support Aide #10 stated they would wear personal protective equipment while performing care, cleaning, and changing linen on the bed. During an interview on 10/01/2024 at 11:15 AM, Certified Nurse Aide #8 stated everyone should wear personal protective equipment when doing anything with the resident. Personal protective equipment should be put on when entering the room. Personal protect equipment was kept on the back of the door. When exiting the room, the personal protective equipment should have been removed before leaving the room and placed in the garbage. After removing, the garbage should be taken out and then hands should be washed. Any resident who had yellow or red contact precaution signs on their doors would require that the personal protective equipment be taken off in the cluster in front of the garbage area. Once they were done in the resident's room they need to wash or sanitize hands. During an interview on 10/01/2024 at 12:30 PM, Certified Nurse Aide #9 stated green contact signs were standard precautions and yellow signs meant resident care required staff to wear extra personal protective equipment on. Residents with additional enhanced barrier signs required dressing up for care, including gowns and gloves. Additionally, the staff needed to wash hands, put gloves on, and gown on to provide care. When the care was completed, the staff should take off the personal protective equipment and throw them in the garbage in the room. It was then expected that the staff member took the garbage out then washed their hands. Certified Nurse Aide #9 also stated staff were supposed to wash their hands in between residential distribution of meals. Certified Nurse Aide #9 stated that they had seen staff not washing hands when distributing the meals to residents in the past. They did not say anything to them at the time, but probably should have. During an interview on 10/02/2024 at 10:20 AM, Registered Nurse #1 stated it was stated that there was one sign for COVID exposure. [NAME] means the resident was OK, yellow meant the resident had been exposed to COVID and red meant the resident had COVID. The other sign noted was for enhanced barrier or contact precautions. Anything involving providing direct care of residents, would require that the staff would need to wear personal protective equipment. Registered Nurse #1 stated they would not wear personal protective equipment if they were not providing care such as answering call bell. Staff should never walk across the cluster to dispose of or remove the personal protective equipment. During an interview on 10/02/2024 at 10:47 AM, Director of Nursing #1 stated that there was one sign for COVID exposure. [NAME] means the resident was OK, yellow meant the resident had been exposed to COVID and red meant the resident had COVID. The other sign noted was for enhanced barrier or contact precautions. Anything involving providing direct care of residents, would require that the staff would need to wear personal protective equipment. Director of Nursing #1 stated they would not wear personal protective equipment if they were not providing care such as answering call bell. Staff should never walk across the cluster to dispose of or doff the personal protective equipment. 10 New York Codes, Rules, and Regulations 415.19(a)(1-3)

Based on record review and interviews during an abbreviated survey (Case #s NY00301926, NY00311450), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse for 1 resident (Resident #4) of 6 residents reviewed for abuse. Specifically, the facility did not ensure that an allegation of rape made by Resident #4 on the 9/7/2022 evening shift was reported immediately to the Director of Nursing (DON), Administrator, or designee after Certified Nursing Aide (CNA) #3 reported the allegation to Registered Nurse Supervisor (RNS) #2. RNS #2 reported the allegation to the DON on 9/8/2022 when they reported to work the evening shift. This was evidenced by: The Policy and Procedure titled, Abuse Prevention, Identification, Investigation, Protection and Reporting dated 12/8/2022, documented all facility staff are required to immediately report to the Administrator, DON, or designee when abuse was observed or suspected. The facility Administrator or designee will report all alleged violations to state agencies immediately, but no later than 2 hours after the allegation of abuse and mistreatment. Resident #4 Resident #4 was admitted to the facility with diagnoses of encephalopathy, depression, and altered mental status. The Minimum Data Set (MDS-an assessment tool) dated 8/24/2022, documented the resident had moderate cognitive impairment, could usually be understood, and could understand others. An untimed statement dated 9/7/2022, written by RNS #2, documented CNA #3 reported to them Resident #4 was saying weird things while providing care. The CNA felt uncomfortable, so finished the resident's care and left the room. RNS #2 documented the resident came to the nurses' station and stated that guy ripped off their clothing (the resident's) and threw the resident on the bed. The resident stated CNA #3 planned to strip them and take them to a bar naked and then stated they (CNA #3) raped them too. A Nurse's Note dated 9/7/2022 at 11:42 PM, RNS #2 documented the resident stated they were told that CNA #3 was going to strip them naked and take them to a bar. RNS #2 documented the resident continued suggesting inappropriate things such as, what are you going to do, tie me up to the couch when they saw CNA #3 replacing trash bags on the unit. The RNS documented they spoke to the resident and informed the resident that they were safe and that no one was going to take them anywhere. The resident eventually went to bed and remained quiet. A Nurse's Note dated 9/8/2022 at 3:15 PM, (who documented) documented RNS #2 reported Resident #4 stated some guy came and took their clothes off and put them to bed. The resident stated the guy told them they were going to take them to a bar naked. The resident had no signs of redness/bruising or bleeding on any areas of their body. During an interview on 3/9/2023 at 11:44 AM, CNA #3 stated they were getting Resident #4 ready for bed. The resident had soiled themselves. The CNA stated they gave the resident their bedtime care, changed their pajamas, and put them to bed. CNA #3 stated as they carried the bags of soiled clothing and leaving the room, the resident must have transferred themselves out of bed to their wheelchair because they came up behind them and asked if they were going to tie them up with the bags and put them on the couch and also stated that they (CNA #3) had raped them. CNA #3 stated RNS #2 overheard the resident and went to their room to talk to the resident. During an interview on 3/9/2023 at 12:31 PM, RNS #2 stated to best of their memory, CNA #3 had gone in to get the resident ready for bed. They stated the CNA came out of the room and told them the resident was saying crazy things, such as they were going to take them to the bar naked. The resident told them the same thing. The next day, the DON requested they assess Resident #4. The resident did not report they had been raped at the time of the assessment. They stated they learned they should have reported the allegations to the DON when they learned about it the prior evening because there was only a 2-hour window for reporting abuse. During an interview on 3/9/2023 at 2:34 PM, the DON stated they did not know about the 9/7/2022 incident until the next day. The RNS told them on 9/8/2022 when they arrived for their shift about the comments the resident had made to CNA #3. The DON stated when Resident #4 made the statements of abuse the prior evening to CNA #3 and RNS #2, the RNS should have reported the incident to them or the Administrator immediately because abuse must be reported within 2 hours. 10 NYCRR 415.4(b)

Based on record review and interviews during an abbreviated survey (Case #s NY00301926, NY00311450), the facility did not ensure in response to allegations of abuse, the facility must prevent further potential abuse while the investigation is in progress for 1 resident (Resident #4) of 6 residents reviewed for abuse. Specifically, the facility did not ensure that Certified Nursing Aide (CNA) #3 was sent home by Registered Nurse Supervisor (RNS) #2 following an allegation of rape made by Resident #4 against CNA #3 on 9/7/2022 during the evening shift. RNS #1 sent CNA #3 to finish their shift on a different unit. This was evidenced by: The Policy and Procedure titled, Abuse Prevention, Identification, Investigation, Protection and Reporting dated 12/8/2022, documented the facility would ensure that all residents are protected from physical and psychosocial harm during and after the investigation. Staff responsible for investigating will immediately take actions to protect the alleged victim that may include temporary suspension. Resident #4 Resident #4 was admitted to the facility with diagnoses of encephalopathy, depression, and altered mental status. The Minimum Data Set (MDS-an assessment tool) dated 8/24/2022, documented the resident had moderate cognitive impairment, could usually be understood, and could understand others. An untimed statement dated 9/7/2022, written by RNS #2, documented CNA #3 reported to them Resident #4 was saying weird things while providing care. The CNA felt uncomfortable, so finished the resident's care and left the room. RNS #2 documented the resident came to the nurses' station and stated that guy ripped off their clothing (the resident's) and threw the resident on the bed. The resident stated CNA #3 planned to strip them and take them to a bar naked and then stated they (CNA #3) raped them too. During an interview on 3/9/2023 at 11:44 AM, CNA #3 stated they were getting Resident #4 ready for bed. CNA #3 stated as they were carrying the bags of soiled clothing and leaving the room, the resident must have transferred themselves out of bed to their wheelchair because they came up behind them and stated that they (CNA #3) had raped them. They stated RNS #2 had them finish their shift on a different unit. During an interview on 3/9/2023 at 12:31 PM, RNS #2 stated following the resident's allegation of abuse, they sent CNA #3 to a different unit to work. They learned (were they educated on this and did they know to send the CNA home) they should have sent the CNA home. was this RN not oriented to abuse? During an interview on 3/9/2023 at 2:34 PM, the DON stated CNA #3 should have been suspended immediately pending the outcome of an investigation for the 9/7/2022 allegation of abuse. 10 NYCRR 415.4(b)(3)

Based on record review and interviews during an abbreviated survey (Case #'s NY00311450 and NY00301926), the facility did not ensure the right to refuse treatment for 1 (Resident #1) of 6 residents reviewed for Do Not Resuscitate (DNR) status. Specifically, the facility did not ensure the facilities Basic Life Support policy and procedure was followed when facility staff did not confirm the resident's DNR status with their paper medical record prior to initiating CPR when the resident was found unresponsive and without a pulse on the evening of [DATE]. This was evidenced by: The Policy and Procedure (P&P) titled, Basic Life Support dated [DATE], documented if resident is unresponsive, immediately confirm DNR status. The electronic medical record will be utilized as the initial method of immediate identification. Send another staff member to obtain the medical record. The paper medical record will be the confirmation method of verifying code status in all instances. The medical record will be brought to the area where basic life support is being provided or considered. Resident #1 Resident #1 was admitted to the facility with diagnoses of chronic respiratory failure, chronic obstructive pulmonary disease, and emphysema. The Minimum Data Set (MDS-an assessment tool) dated [DATE], documented the resident was cognitively intact, could be understood, and could understand others. The Facility Incident Report submitted to DOH on [DATE] at 9:20 AM, documented on [DATE] at 8:46 PM, Resident #1 was observed on the floor next to their bed. When LPN #2 approached the resident, they observed the resident's lips were blue and they were unresponsive. LPN #2 checked for a pulse and none was felt and began chest compressions on the resident while calling out Code Blue 3 times. Code Blue was announced over the intercom, 911 was called, and staff responded to the room. The Comprehensive Care Plan (CCP) for Advance Directives revised on [DATE], documented the resident's wishes would be honored throughout their facility stay, to ensure compliance with requirements of state law regarding advance directives, and to maintain documentation in the record for the directive to be considered current and binding. Medical Doctor (MD) orders dated [DATE] for the MOLST documented the resident was a DNR. Resident #1's MOLST dated [DATE], documented the resident was a DNR. The February 2023 electronic medication administration record (eMAR), documented under Advance Directive, the resident was a DNR. The Prehospital Care Report NY (PCR) from the ambulance service documented they received the notification of cardiac arrest/death on [DATE] at 8:50 PM. It documented the ambulance was enroute at 8:52 PM, arrived at the scene at 8:54 PM, and EMS providers were at the resident's side at 8:56 PM. Upon arrival, Registered Nurse Supervisor (RNS) #1 was asked by Emergency Medical Services (EMS) providers it the resident was a full code or if they had a valid DNR. Another nurse helping with care stated the resident was a full code. EMS asked the RNS to provide any paperwork or MOLST form that the facility had on file. An intraosseous line (a line put in a bone for medication infusion into the bone marrow) was placed in upper tibia (the largest of the 2 bones in the lower leg) of the left leg. At 9:00 PM Epinephrine was injected and an Intravenous (IV) was started. EMS's automated external defibrillator (AED) advised a shock to the resident's heart. It was delivered at 9:00 PM. CPR providers were switched every 5 cycles of CPR. A final dose of Epinephrine was administered at 9:06 PM. RNS #1 came to the room with a valid DNR order in hand and CPR was stopped. Medical control was notified, and the resident's time of death was called at 9:10 PM. It documented the facility had provided CPR for approximately 10 minutes prior to EMS arriving. It documented Patient dead at scene-resuscitation attempted (without transport). During an interview on [DATE] at 9:05 AM regarding the [DATE] incident, LPN #2 stated Certified Nurse Aide (CNA) #1 was in the cluster where Resident #1 resided. When they (LPN #2) entered the cluster at approximately 9:00 PM and heard a beeping noise, they asked CNA #1 what the sound was. The CNA stated they thought it was a resident's TV. They both started going around the cluster clockwise looking into everybody's rooms and when they got to Resident #1's room, they saw the resident lying on their right side on the floor next to the bed. LPN #2 stated they went to the resident to check them. They yelled the resident's name, and the resident did not respond. When the resident did not answer back, they called RNS #1 from their phone and also told CNA #1 to get the RNS as they were dialing the number. LPN #2 stated when they rolled the resident over, and did not find a pulse, they screamed call code blue 3 times and started CPR. They stated they did not ask anyone to bring the MOLST so they could check the resident's code status. CNA #s 1 and 2 brought the crash cart and then other support staff (RNS #1 and LPN #s 3, 4, and 5) arrived, entered the resident's room, and began assisting with CPR. When EMS arrived, they left the room, got the MOLST and saw the resident was a DNR. They gave the MOLST to RNS #1 and told them the resident was a DNR. When RNS #1 told EMS personnel the resident was a DNR, they immediately took their hands off the resident and stepped away. During an interview on [DATE] at 12:30 PM, RNS # 1 stated the first notification they received of the [DATE] incident regarding Resident #1 was a phone call from LPN #2 who stated the resident had no pulse. RNS #1 stated they headed immediately for the unit, and halfway to the unit, code blue was announced 3 times on the overhead paging system. They ran to the unit, arrived at the resident's room, saw the resident on the floor, another nurse (RNS #1 did not know their name) and LPN #2 were doing CPR. 911 was called, and they ran to get the AED (automatic external defibrillator). When returning to the resident's room, 2 CNAs were just ahead of them with the crash cart. The RNS stated they yelled out to no one in particular for someone to get the chart. RNS #1 stated when they got back to the room with the AED, they applied it to the resident and listened to the prompts that directed no shock was advised, and to continue CPR. RNS #1 stated as the RNS, they were running the code and they were under the impression Resident #1 was a full code because of hearing the code blue announced. RNS #1 stated EMS arrived between 8:55- 9:00 PM: likely closer to 9:00 PM. They stated EMS personnel applied their own AED and took over CPR. Prior to the resident's MOLST being brought to the room, EMS had inserted an intraosseous access line and administered Epinephrine to the resident. At this time, LPN #2 arrived at the room with the resident's MOLST, showed it to them and it documented the resident was a DNR. They stated they told EMS personnel the resident was a DNR. CPR was stopped, and EMS personnel called the code off at 9:10 PM. RNS #1 stated the facility started CPR at 8:46 PM and CPR was continued for about 10 minutes by EMS. It was panic, trying help the resident, and the chart being obtained too late that caused the incident. When EMS arrived and took over, staff had time to check the chart for the resident's code status. During an interview on [DATE] at 2:27 PM, the Director of Nursing (DON) stated LPN #2 heard a beeping noise ([DATE]), went to see what it was, found the resident on the floor, turned them over, saw their lips were blue, started CPR and called a code blue. Someone else overhead paged code blue, someone got the crash cart, someone called 911, and staff arrived from the other units and CPR was continued. The DON stated when EMS arrived, they asked the resident's code status. LPN #3 grabbed the MOLST form and took it to LPN #2 who saw the resident was a DNR. LPN #2 walked into the room and announced to staff still in the room and EMS that the resident was a DNR and CPR was stopped. They stated they did not know what the delay was in getting the MOLST after EMS requested it. The DON stated it should have been LPN #2's responsibility to yell out instructions on what needed to be done since they had found the resident and called the code. They would have been the lead at that time. They should have told someone to call 911, someone to grab the crash cart, check the eMAR for the resident's code status and then confirmed it with the MOLST form. A code blue was only called after the resident's code status was confirmed. The first thing they should have done was to check the code status. Had staff done that, nothing else would have been needed because the resident was DNR. The DON stated RNS #1 reported to them CPR was done on the resident and they were a DNR. They notified the Administrator, started the investigation immediately and interviewed all of the nurses involved. The outcome of the investigation determined LPN #2 reacted to an unresponsive individual and needed to save their life. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: -A blank Code Verification Audit Form was provided that included columns for resident name, date of death , resident code status, code status performed, and correct code status. -Coaching Performance Records for LPN #s 2, 3, 4, 5, and RNS #1 documented each participant in the code blue was coached individually by the DON about code status identifiers (MOLST and eMAR) and location of them and the policy and procedure for responding to a code blue. -A document titled Emergency CPR Code Blue Drill dated [DATE] was conducted. LPN #2 was a participant. P&P was followed. -An Inservice titled, Verifying Code Status dated [DATE], documented 85 licensed (RN, LPN, OT, PT, PTA) and Certified Nurse Aides (CNAs) were in-serviced on [DATE] regarding verification of code status. -An Inservice titled, Unresponsive Resident dated [DATE], documented ancillary staff (human services, business office, environmental services, social work, kitchen, activities, nutrition, maintenance, laundry, and administration) were taught if a staff member entered the room of an unresponsive resident, the nurse needed to be notified immediately. Review of the location of the MOLST, crash cart, and AED was provided. 41 ancillary staff employees were in-serviced. -On [DATE], the facility provided an Inservice to licensed staff for use of the Code Blue Flow sheet and the location of the form. There were 22 participants. This education was also provided to staff at the [DATE] Inservice for verifying code status which had 85 attendees. -LPN #'s 2, 3, 4, 5, and RNS #1's CPR certifications were current. 10 NYCRR 415.3(e)(1)(ii)

Based on record review and interviews during the recertification survey, the facility did not ensure the resident's environment remained as free of accident hazards as possible for 1 (Resident #37) of 1 resident reviewed for falls. Specifically, for Resident #37, who had 19 falls from 9/21/2021 - 11/10/2021 resulting in 2 fractures (collarbone and hip), the facility did not ensure the resident's fall risk was consistently re-assessed and did not conduct a root cause analysis after the resident fell , did not consistently identify, implement, or revise resident specific interventions in a timely manner to reduce the resident's risk to fall and did not consistently monitor care planned interventions for effectiveness. This is evidenced by: The Policy and Procedure (P&P) titled Accidents/Incident Reporting and Review (Staff/Visitors/Residents) dated 6/14/2021, documented the Administrator and Director of Nursing Services would review all accidents/incidents involving residents to ensure that appropriate actions were taken, and to identify any trends that may affect resident safety. Resident #37: Resident #37 was admitted to the facility with the diagnoses of Alzheimer's disease, anxiety disorder and fracture of left femur fracture. The Minimum Data Set (MDS - an assessment tool) dated 10/11/2021 documented the resident had severely impaired cognition, could understand others and could make self understood. The Comprehensive Care Plan (CCP) for Elimination last revised 11/12/2021, documented the resident was occasionally incontinent, was to receive incontinence care every 1-2 hours and PRN (as needed) initiated 10/7/2021 and revised 11/12/2021 and was to be provided with prompt incontinent care, initiated 10/7/2021. The CCP for Safety last revised 11/18/2021, documented the resident had several falls with injury. Interventions included a green busy box to provide to resident during breakfast hour and after dinner for distraction, initiated 9/24/2021 and revised 11/1/2021; encourage the resident to wear hip protectors initiated 11/3/2021 and revised 11/5/2021; offer resident to go to bed after dinner, initiated 11/18/2021; offer snack in the afternoon, initiated 11/18/2021; complete fall risk assessment per policy; assess for risk factors related to falls/safety, initiated 10/7/2021; Monitor for signs of dizziness, [CONDITION(S)], and unsteadiness, initiated 7/7/2020; and provide a safe environment, initiated 6/1/2020. During observations on: -11/16/2021 at 9:52 AM, Resident #37 was in their wheelchair with their walker in front of them trying to stand. A housekeeper reminded the resident not to stand and then went into a resident room. There were no other staff supervising the common area. The resident was not offered a busy box after breakfast. -11/17/2021 at 8:20 AM - 11:20 AM (3 hours), Resident #37 was not provided incontinence care every 1-2 hours and PRN in accordance with the CCP. At 10:10 AM, the resident was standing alone in their bathroom, at the sink running water. There were no staff in the common area. At 10:15am, the resident was walking toward the Surveyor. A staff member directed the resident to sit in a chair. The resident was not offered to be toileted or provided with a busy box as care planned. -11/18/2021 at 9:25 AM - 12:05 PM (2 hours, 40 minutes) the resident was not toileted per the CCP, was not provided with a busy box per the CCP and was redirected by staff after standing from the wheelchair and walking to a table unassisted. -11/19/21 at 7:54 AM - 9:05 AM, the resident was at the breakfast table. The resident was looking around, leaning back in their chair. A busy box was not offered. A review of facility Incident and Accident (I&A's) reports documented the resident had 19 falls from 9/21/2021 to 11/10/2021 resulting in 2 fractures: a clavicle (collarbone) fracture on 9/21/2021 and a hip fracture on 10/2/2021. A review of 10 of 19 Fall I&A's dated 9/21/2021, 9/24/2021, 9/25/2021, 10/2/2021, 10/15/2021, 10/23/2021, 10/27/2021, 10/28/2021, 10/31/2021, and 1/10/2021 and corresponding progress notes documented: -9/21/21 at 9:20 AM: The I&A documented the resident fell in their room and was observed sitting on their buttocks on the floor next to the bed. A hematoma (collection of blood outside of blood vessels) was noted to the resident's left head with bleeding. The immediate action taken was to apply an ice pack to the forehead and to send the resident to the emergency room (ER) for further evaluation. The I&A documented on 9/22/2021 that the Interdisciplinary Team (IDT) reviewed the incident, and the interventions after the fall were to have a Physical Therapy (PT) evaluation and a provider evaluation. A progress note dated 9/21/2021, documented the resident returned from the ER with a report that indicated a fracture to the distal clavicle (located between your sternum (rib cage) and scapula (shoulder blade)). The note documented the resident's Activities of Daily Living (ADLs) were updated to reflect a 1 assist for all transfers and ambulation with a gait belt until the PT evaluation. There was no documentation of a root cause analysis for the fall or a re-assessment of the resident's fall risk. -9/24/2021 at 8:45AM: The I&A documented the resident was observed on floor against wall in the cluster (common area on the unit). The resident's right shoe was noted not to be on properly and the heel of the foot was pressing down on the heel of the shoe. The resident was self-transferring without assistance. The I&A documented on 9/27/2021, the IDT reviewed the incident, and the interventions were to have a provider visit and to provide an activity box specifically for this resident. The activity box was added to the care plan on 9/24/2021. There was no documentation of a root cause analysis for the fall or a re-assessment of the resident's fall risk. A provider note dated 9/24/2021 at 9:48 AM, documented resident with multiple falls and a CT scan (Computed tomography (CT) scan is a useful diagnostic tool for detecting diseases and injuries) was done at the time with no acute findings. The note documented there were reports of urinary incontinence starting 2 weeks ago with increased malodor and it was difficult to obtain frequency/urgency changes due to the resident's confusion. The note documented to obtain Urinalysis (UA) at this time with blood work and continue fall precautions. -9/25/2021 at 7:15AM: The I&A documented the resident was sitting on floor in room with their pants down in front of their bathroom door and urine was on the floor. The I&A documented on 10/7/2021 the IDT reviewed the incident, and the intervention was to attempt to toilet the resident every 2-3 hours. This intervention was added to care plan on 10/7/2021 (13 days after the fall and after the resident fell on [DATE] sustaining a hip fracture). There was no documentation of a root cause analysis for the fall, a re-assessment of the resident's fall risk or a resident specific intervention implemented at the time of the fall to reduce the resident's risk of falling in the future. A provider note dated 9/27/2021 at 11:06 AM, documented the resident had a fall on Saturday (9/25/2021) with left rib pain. The note documented to continue neurological checks per protocol, staff to assist with ambulation and transfers as needed to prevent falls, fall precautions, encourage resident to use a wheelchair for mobility, continue PT/OT (occupational therapy), and a UA (urinalysis) with Culture and Sensitivity (C&S). The note documented staff had been unable to obtain the UA since the last fall. A progress note dated 9/27/2021 at 7:53 PM, documented several attempts to obtain urine were unsuccessful. The resident continued to ambulate independently and refused to allow staff to assist with ambulation and transfers. A progress note dated 9/29/2021 at 6:03 PM, the facility provider was updated that the resident was having increased difficulty with ambulation, increased confusion, UA was negative for a urinary tract infection ([CONDITION(S)]) and the family did not wish to have a further neurological work up to rule out TIA ([CONDITION(S)]- mini stroke). A provider note dated 9/30/2021 at 3:51 PM, documented hematoma still with fluid collection on left temple and there was concern for continued drainage or rupture of hematoma. The note documented the resident was weaker, continued as a 1 assist with ambulation and family declined workup for TIA/[CONDITION(S)] ([CONDITION(S)] accident- stroke). The note also documented staff had concerns for falls but were monitoring closely. -10/2/2021 at 3:21 PM: The I&A documented after dinner the resident was witnessed walking toward another resident's room when they lost their balance, fell , and hit their head. The I&A documented on 10/4/2021 the intervention was to transfer the resident to the ER and was admitted with a hip fracture and to re-assess the resident when they returned from hospital. There was no documentation of a root cause analysis for the fall. The intervention implemented on 10/7/2021 was for incontinence care every 2-3 hours and PRN. A Fall Risk assessment dated [DATE] documented the resident was at high risk for falling. A progress note dated 10/7/2021, documented the resident was readmitted to the facility status post a left hip fracture repair. -10/15/2021 at 5:20 PM: The I&A documented the resident was walking with their wheelchair, lost their balance and fell . The resident was wearing nonskid socks. The I&A documented on 10/18/2021, the intervention was to trial a fidget apron. There was no documentation of a root cause analysis for the fall, a re-assessment of the resident's fall risk or evidence a fidget apron was attempted to reduce the resident's risk to fall in the future. -10/23/2021 at 3:53 PM: The I&A documented the resident was observed on the side of their bed with their back up against the metal bed frame. The resident was observed to be incontinent of urine. The I&A documented on 10/25/2021, the intervention was to wear hip protectors to prevent further injury. This intervention was added to the care plan on 11/3/2021 (11 days after the fall occurred). There was no documentation of a root cause analysis for the fall, a re-assessment of the resident's fall risk or a resident specific intervention implemented at the time of the fall to reduce the resident's risk of falling in the future. -10/27/2021 at 8:02 PM: The I&A documented the resident was attempting to transfer self from wheelchair to bed. The nurse got behind the resident and held them and lowered the resident down the nurse's leg to floor without causing injury. The I&A documented on 11/1/2021, the intervention was to offer to go to bed after dinner. The intervention was added to care plan on 11/18/2021 (22 days after the fall). There was no documentation of a root cause analysis for the fall, a re-assessment of the resident's fall risk or a resident specific intervention implemented at the time of the fall to reduce the resident's risk of falling in the future. -10/28/2021 at 2:05 PM: The I&A documented the resident had an unwitnessed fall and was sitting on buttocks next to their wheelchair on the floor in the cluster. The I&A documented on 11/1/2021, the intervention was to offer the resident a snack in the afternoon. The intervention was added to care plan on 11/18/2021 (21 days after the fall). There was no documentation of a root cause analysis for the fall, a re-assessment of the resident's fall risk or a resident specific intervention implemented at the time of the fall to reduce the resident's risk of falling in the future. -10/31/2021 at 7:40 PM: The I&A documented the resident was on the floor and complained of pain to left shoulder and elbow. The resident was sent out for an x-ray. The I&A documented on 11/1/2021 the intervention was to offer a green busy box to resident during breakfast and after dinner for distraction. An activity box specifically for this resident was added to the care plan on 9/24/2021. There was no documentation of a root cause analysis for the fall or a re-assessment of the resident's fall risk. -11/10/2021 at 11:15 PM: The I&A documented the resident had an unwitnessed fall. Upon entering the room, the nurse found the resident without clothing or footwear on floor with their feet near bed and the resident's head near the nightstand. The I&A documented on 11/12/2021 the intervention was to change the resident's toileting schedule to every 1-2 hours and PRN. The intervention was added to the care plan on 11/12/2021. There was no documentation of a root cause analysis for the fall or a re-assessment of the resident's fall risk. A progress note dated 11/10/2021 at 11:15 PM, documented the resident was found sitting on the floor with no clothing on and was incontinent of stool. A progress note dated 11/10/2021 at 11:47 PM, documented the resident was last known to be toileted at 8:00 PM. During an interview on 11/18/2021 at 9:41 AM, Certified Nursing Assistant (CNA) #1 stated the CNAs were constantly toileting residents. CNA #1 stated Resident #37 was incontinent and was toileted often, but it was difficult to toilet residents, including Resident #37, according to the toileting schedules on the care plan. Resident #37 is all over the place and the resident did not necessarily fall because they needed to go to the bathroom, the resident just wanted to be up walking so the staff would walk with the resident. CNA #1 stated there was not enough staff to do 1:1 supervision with a resident. During an interview on 11/18/2021 at 2:44 PM, CNA #2 stated toileting was provided to the residents, but it may not be right on time with the resident's toileting schedule. CNA #2 stated the CNAs toileted the residents when the CNAs were able to do it and it could be difficult to toilet according the resident's toileting schedule. CNA #2 stated the CNAs tried to get a routine down to get the care done for the residents. The CNA stated they heard of changes or new interventions on a resident's care plan in shift-to-shift report or verbally by administration, and they would also read the resident's care card. During an interview on 11/18/2021 at 3:27 PM, CNA #4 stated everyone assisted with supervision on the unit and it was everyone's responsibility. CNA #4 stated the staff communicated with each other to let each other know where they were so that staff could watch over the common area if they were in a room providing care. CNA #4 stated the staff found out about changes to the care plan in shift-to-shift report before each shift and the changes would be on the care card. CNA #4 stated they checked the care cards room by room, so they knew what the care was that needed to be provided to each resident. During an interview on 11/18/2021 at 3:35 PM, Licensed Practical Nurse (LPN) #3 stated supervision on the unit was everyone's responsibility. LPN #3 stated the reason Resident #37 fell was because the resident would get up from the chair, get dizzy and lose their balance. LPN #3 stated if they had time they would walk around with the resident. LPN #3 stated the resident was supposed to be toileted every 2 hours and was not aware that the resident was not being toileted every 2 hours. LPN #3 stated the resident was incontinent all the time. During an interview on 11/19/2021 at 8:28 AM, Director of Nursing (DON) stated when a resident fell , the RN (Registered Nurse) was notified and assessed the resident for injury. If the RN felt there was an injury, they would call the provider for direction. The DON stated neurological checks and vital signs were initiated for unwitnessed falls, an incident/accident report was initiated, and new interventions should be put in place at the time of the fall. The DON stated if the nurse did know what intervention to put into place at the time of the fall, they should call the DON or Administrator to come up with an intervention. The interventions should typically be put on the care plan at that time, or when the I&A was reviewed during morning meeting. The DON stated there were a few interventions for Resident #37's falls that were missed and were not put on the care plan timely. The DON stated those interventions should have been on the care plan at the time of the fall. The DON stated the staff would know there was a change in the care plan by looking at the care card, but if the interventions were not on care plan, then the staff would not know to implement those interventions. The DON stated the busy box was at the nurses' station and the staff knew it was there. The DON stated the staff should be aware of all the interventions on the fall care plan. The DON stated the facility did not know why Resident #37 is falling. There had been conversations with the facility providers and family, but they have not been able to figure it out why the resident was falling. The DON stated the family did not want a full work up. The DON stated to maintain a safe environment meant making sure there was no clutter in the resident's way and making sure she had the equipment care planned. The DON stated the resident should be toileted every 1-2 hours and that toileting that frequently would also count as doing frequent checks for supervision. The DON stated Resident #37 should be toileted according to their care plan, every 1-2 hours. The DON stated it was a collaboration of everyone to ensure care plans were being followed and stated they would not know this was not being done unless staff reported it to them. The DON stated a new fall risk assessment was not completed every time a resident fell but an assessment was done for injury with each fall. The DON stated they tried to come up with a root cause at the time of the fall and during the IDT meeting. After a fall when a new intervention was initiated it was then communicated with the staff to be implemented. Staff were made aware of what the new intervention was or what change had been made. During an interview on 11/19/2021 at 9:03 AM, CNA #3 stated Resident #37 might have a busy box in the nurse's room, but CNA #3 had never used it. During an interview on 11/19/2021 at 9:06 AM, CNA #2 stated a busy box for the resident was initiated months ago but the resident did not use it and it was not effective. The CNA stated it was packed away and the staff did not use it. The CNA stated they tried to follow the resident's care plan but a 1-2 hour toileting schedule could be difficult. During an interview on 11/19/2021 at 10:27 AM, the Administrator stated the interventions implemented were part of the team discussion and there should be feedback about the effectiveness of the interventions. The Administrator stated it was their understanding that the resident liked the busy box. The Administrator stated the IDT was responsible for ensuring interventions were implemented, for example the toileting schedule and the activity box. The Administrator stated the staff were made aware of new interventions that needed to be implemented from the Nurse Manager, the DON or during shift-to-shift report. The Administrator stated the interventions discussed by the IDT should be put on the care plan and could be put on the care plan by anyone on the IDT. The Administrator stated the process was that the I&A's were reviewed at morning report and anyone could put the new intervention on the resident's care plan at that time. During an interview on 11/19/21 at 11:02 AM, CNA #5 stated the staff tried everything to maintain the resident's safety but because of the resident's dementia, the resident could not understand. CNA #5 stated the resident was never put on 1:1 supervision, but there was a time when the resident was on 15-minute safety checks. The resident was no longer on 15 minutes checks. CNA #5 stated Resident #37 did not have a fidget box and stated maybe a fidget box could work for Resident #37. CNA #5 stated the nurses would communicate any changes to the care plan that would then be on the care card for the CNAs to follow. During an interview on 11/19/2021 at 11:15 AM, LPN #4 stated the staff tried activities with Resident #37 including books, socialization, moving or walking around with the resident, offering snacks. LPN #4 stated they were aware an activity box was in the medication room. The LPN stated everyone looked out for Resident #37, but the staff cannot be everywhere. LPN #4 stated for Resident #37 it was more about the staff's approach with the resident and continuing to re-approach the resident to maintain the resident's safety. 10NYCRR 415.12(h)(1)

Based on observation, interview and record review during the recertification survey and an abbreviated survey (Case #NY 258), the facility did not 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 (Resident #'s 37 and 40) of 3 residents reviewed for ADL's. Specifically, for Resident #'s 37 and 40, who were dependent on staff for ADL care, the facility did not ensure incontinence care was provided in accordance with the resident's care plan. This is evidenced by: The Policy and Procedure (P&P) titled ADL Assistance and Supervision dated 1/8/2018, documented the Unit Manager/designee would ensure that a plan of care for receiving ADL assistance and/or supervision was incorporated into the daily nursing care of each residents, if needed. The P&P titled Bladder and Bowel, Incontinence Management dated 4/10/2018, documented residents who were incontinent, or unable to express their needs should have a bladder incontinence management program and should be placed on the toilet or bedpan every 2 to 4 hours, before and after meals, before going to bed and after high level of fluid intake. Resident #37: Resident #37 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 10/11/2021 documented the resident had severely impaired cognition, could understand others and could make self understood. The Comprehensive Care Plan (CCP) for Elimination last revised 11/12/2021, documented the resident was occasionally incontinent, was to receive incontinent care every 1-2 hours and PRN (as needed), and was to be provided with prompt incontinent care. The CCP for ADLs last revised 11/17/2021, documented the resident was an extensive assist of one person for toileting transfers and toileting hygiene. During an observation on 11/17/2021 at 8:20 AM - 11:20 AM (3 hours), Resident #37 was not provided incontinence care every 1-2 hours and PRN in accordance with the CCP. -8:20 AM, Resident #37 was lying in bed and there was a very strong smell of urine in the resident's room at bedside. -10:10 AM, staff did not enter the resident's room since 8:20 AM. The incontinence pad on the resident's bed was saturated with what appeared to be urine and smelled like urine. The resident was standing alone in the bathroom at the sink with the water running. -10:15 AM, Resident #37 came out of their room walking toward the surveyor and smelled like urine. A staff member directed the resident to sit in a chair in the common area. -11:18 AM, Resident #37 stood up from the chair in the common area and a staff member intervened, commenting the resident smelled like urine. -11:20 AM, 2 staff came to assist the resident to the resident's room and one of the staff carried incontinence care supplies into the room with them. There was a large wet circle on the seat of chair when the resident stood up from it. -11:26 AM, CNA #2 stated the chair was wet from Resident #37 and removed the chair from the area. During an observation on 11/18/2021 from 9:25 AM - 12:05 PM (2 hours, 40 minutes), Resident #37 was not provided incontinence care every 1-2 hours and PRN in accordance with the CCP. -9:25 AM - 9:50 AM, Resident #37 was walking around with a staff member. The resident was not toileted during that time or before sitting in the common area. -10:50 AM, Staff intervened to re-direct resident back to their wheelchair after the resident stood up to un-assisted walk to a table. -11:36 AM, Resident #37 was getting their lunch tray and was not toileted or offered to be toileted before lunch. -12:05 PM, when the observation ended, Resident #37 was finishing lunch at the table and had not been toileted since the observation began at 9:25 AM. During an interview on 11/18/2021 at 9:41 AM, Certified Nursing Assistant (CNA) #1 stated the CNAs were constantly toileting residents. CNA #1 stated Resident #37 was incontinent and was toileted often, but it was difficult to toilet residents, including Resident #37, according to the toileting schedules on the care plan. During an interview on 11/18/2021 at 2:44 PM, CNA #2 stated toileting was provided to the residents, but it may not be right on time with the resident's toileting schedule. CNA #2 stated the CNAs toileted the residents when the CNAs were able to do it and it could be difficult to toilet according the resident's toileting schedule. CNA #2 stated the CNAs tried to get a routine down to get the care done for the residents. During an interview on 11/18/2021 at 3:35 PM, Licensed Practical Nurse (LPN) #3 stated Resident #37 was incontinent all the time and was supposed to be toileted every 2 hours. LPN #3 stated they were not aware the resident was not being toileted every 2 hours. During an interview on 11/19/2021 at 8:28 AM, the Director of Nursing (DON) stated they were not aware residents were not being toileted according the toileting schedule on the CCP. The DON stated Resident #37 should be toileted according to their care plan, every 1-2 hours. The DON stated it was a collaboration of everyone to ensure care plans were being followed and stated they would not know this was not being done unless staff reported it to them. During a subsequent interview on 11/19/21 at 9:06 AM, CNA #2 stated they tried to follow the care plan for toileting, but it could be difficult with 2 CNAs on the unit, especially with every 1-2 hour toileting schedules. CNA #2 stated they worked hard to get things done in a timely manner. The CNA stated toileting schedules were tough and this was a tough unit (the facility's Memory Care unit). CNA #2 stated they did rounds to try to get all the resident's toileted and cleaned. During an interview on 11/19/2021 at 10:27 AM, the Administrator stated the Interdisciplinary Team (IDT) was responsible for ensuring interventions were implemented, including toileting schedules. The Administrator stated if the care plan documented a toileting schedule then that was the care that should be provided. The Administrator stated as far as they knew care was being provided according to the care plans and stated they were made aware if there were issues or concerns related to care not being provided. Resident #40: Resident #40 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 10/13/2021 documented the resident had severely impaired cognition, could rarely/never understand others and could rarely/never make self understood. The Comprehensive Care Plan (CCP) for Elimination last revised 11/12/2021, documented the resident always incontinent, received Incontinent care every 2-3 hours and PRN (as needed) and was on a toileting schedule every 2-3 hours and PRN to bedside commode. The CCP for ADLs last revised 11/12/2021, documented the resident required a mechanical lift with an assistance of 2 staff for toileting transfers and was total dependence of 2 staff for toileting hygiene. During an observation on 11/17/2021 at 8:18 AM - 12:30 PM (4 hours 12 minutes), Resident #40 was not provided incontinence care every 2-3 hours and PRN in accordance with the CCP. -8:18 AM, Resident #40 was sitting in Broda chair (tilt and space wheelchair) in the common area. -11:00 AM, Resident #40 was sitting in common since observation began and had not been offered by staff to be changed or toileted. -12:10 PM, Staff were feeding the resident. Resident #40 appeared to be restless, fidgety in the chair. The staff stated to the resident You're ok. It's ok and continued to feed the resident. -12:30 PM, when the observation ended, the resident was fidgeting in their chair, making low groaning sounds and had not been changed or toileted since the observation began at 8:18 AM. A progress note dated 11/12/2021, documented the resident's transfers status changed to stand lift with x2 staff to chair/bed and to commode every 2-3 hours and PRN for toileting. During an interview on 11/17/2021 at 11:30 AM, Certified Nursing Assistant (CNA) #2 stated Resident #40 was assisted out of bed and changed around 7:30 AM. CNA #2 stated that was the last time Resident #40 was changed. CNA #2 stated they documented the morning care they provided at 7:30 AM to Resident #40 at 10:55 AM. CNA #2 stated they documented the care provided after it was done but not at the time care provided. During an interview on 11/18/2021 at 9:41 AM, CNA #1 stated Resident #40 was incontinent and was toileted or changed every couple of hours. CNA #1 stated it could be difficult to toilet according to the toileting schedules on the care plan and the CNAs were constantly toileting residents. During a subsequent interview on 11/18/2021 at 2:44 PM, CNA #2 stated toileting was done for the residents but may not be right on time with the resident's toileting schedule. CNA #2 stated the CNAs toileted the residents when the CNAs were able to do it and it could be difficult to toilet according the resident's toileting schedule. During an interview on 11/19/2021 at 8:29 AM, the Director of Nursing stated (DON) stated Resident #40 was incontinent and was supposed to be toileted every 2-3 hours. The DON stated they were not aware residents were not being toileted according the toileting schedule on the CCP. The DON stated Resident #40 should be toileted according to their care plan, every 2-3 hours and it was a collaboration of everyone to ensure care plans were being followed. The DON stated they would not know this was not being done unless staff reported it to them. During an interview on 11/19/2021 at 10:36 AM, Administrator stated there was no question Resident #40 should have been toileted within 2-3 hours. The Administrator stated the care documented on the care plan should have been provided. The Administrator stated the Interdisciplinary Team (IDT) was responsible for ensuring interventions were implemented, including toileting schedules. 10NYCRR415.12(a)(3)

Based on record reviews and interviews during a recertification survey, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standard of quality care for 3 (Resident #'s 2, 32, and #57) of 11 residents reviewed for baseline care plans. Specifically, for Resident #'s, 32 and #57, the facility did not ensure a baseline care plan was developed or completed within 48 hours of the residents' admission. This is evidenced by: The facility Policy and Procedure titled Care Plan - BASELINE last revised 2/15/2018, documented that the interdisciplinary team will develop a baseline care plan within 48 hours of admission which provides instructions for the provision of effective and person-centered care to each resident. Resident #2: Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS - an assessment tool) dated 8/6/2021, documented the resident was understood, was able to make self understood and was cognitively intact. During a record review on 11/18/2021 at 12:40 PM, the medical record did not include documentation of a baseline care plan for Resident #2. During an interview on 11/18/2021 at 1:14 PM the Director of Nursing (DON) stated baseline care plans should be completed within 48 hours of admission. DON stated this was an issue they were looking into. Resident #32: Resident #32 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS-an assessment tool) dated 10/1/2021, assessed the resident had adequate hearing, clear speech, was understood, understood others and had a moderate cognitive impairment. During a record review on 11/19/2021 at 12:42 PM, the medical record did not include documentation of a baseline care plan for Resident #32. During an interview on 11/19/2021 at 11:45 AM, the Director of Nursing (DON) stated an awareness that there were baseline care plans absent from residents' charts and that the facility was in the process of improving this process. Resident #57: Resident #57 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS-an assessment tool) dated 10/20/2021, assessed the resident had adequate hearing, adequate vision, clear speech, was understood, and understood others. The resident also had severely impaired cognitive skills. During a record review on 11/19/2021, the medical record did not include documentation that Resident #57's baseline care plan was completed within 48 hours of admission. During an interview on 11/19/2021 at 11:45 AM, the Director of Nursing (DON) stated that baseline care plans were expected to be completed within 48 hours of admission. The baseline care plan should have been completed sooner for this resident. 10 NYCRR 415.11

Based on observation, record review and interviews during the recertification survey and an abbreviated survey (Case #NY 271), the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice for 1 (Resident #8) of 3 residents reviewed for pressure ulcers. Specifically, for Resident #8, the facility did not ensure an open area on the resident's coccyx was assessed upon discovery and did not ensure that a timely treatment plan was initiated. This is evidenced by: The facility Policy & Procedure titled Skin Care Program, last modified on 5/8/2018 documented: If a skin breakdown occurs, the Team Leader informs the Unit Manager/Designee and completes a skin assessment and documents in the medical record, notifies the Attending Physician, Dietician, and other members of the inter-disciplinary care team as necessary. The Unit Manager/designee and/or Skin Care Assessment Team will determine ongoing monitoring after assessment of the wound. Resident #8: Resident #8 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 8/4/2021, documented the resident had mild cognitive impairment. A Progress Note dated 7/24/2021 at 9:13 AM, Licensed Practical Nurse (LPN) #1 documented a new pressure area discovered on right buttock near coccyx. Supervisor and on call provider notified. A Progress Note dated 7/26/2021 at 12:00 PM, written by the Director of Nursing (DON) documented, writer notified this morning, resident noted to have an open area to coccyx, wound assessed to be stage 2 pressure ulcer. Resident also noted to have a stage 2 pressure ulcer to left ischial tuberosity. Wounds cleansed, hydrogel applied, and covered with foam border dressing, orders and care plan updated. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Treatment Administration Record (TAR) for July 2021 documented the treatments ordered on 7/26/2021 were administered starting on 7/27/2021. During an interview on 11/17/2021 at 1:58 PM, LPN #1 reported having observed the area on the coccyx on 7/24/2021 and reporting to the Supervisor. The Supervisor should have assessed the area and reported to the physician to obtain treatment orders immediately. LPN #1 stated I did not notify the provider, I believed the Supervisor had done it. During an interview on 11/18/2021 at 11:56 AM, the DON reported the Supervisor should have done an assessment and gotten orders from the provider during the shift the wound was discovered. The DON stated, it appears the treatment was unnecessarily delayed and that should not have happened. The facility Administrator, present during the interview, agreed with the DON. 10NYCRR415.12(c)(2)

Based on observation, record review, and interviews during an abbreviated survey (Case #NY 606), completed on 5/27/2021, the facility failed to protect residents' rights to be free from sexual abuse for 2 (Resident #s 1 and 2) of 4 residents reviewed for abuse. Specifically, after Resident #s 1 and 2, both of whom had severe cognitive impairment, were discovered in a sexual encounter, the facility failed to ensure the residents' safety and did not implement a plan to prevent further occurrence. Subsequently, on 5/19/2021, the residents were again found in a sexual encounter and Resident #1 told staff she did not want to have that kind of relationship with Resident #2, but was afraid to say no, and did not want to be alone with Resident #2. This resulted in Immediate Jeopardy and Substandard Quality of Care for Resident #1 and Resident #2. This was evidenced by: The Policy and Procedure (P&P) titled Abuse Prevention, Identification, Investigation, Protection and Reporting dated 4/17/2019, documented all residents have the right to be free from sexual abuse. The Administrator or designee was responsible for the identification, investigation of allegations of abuse, and the protection of residents during investigative procedures. Residents with needs and behaviors that might lead to conflict were to be monitored and assessed daily, and appropriately care planned as needed to prevent occurrences of abuse. The facility's Investigation Summary Report dated 5/11/2021 documented that on 5/10/2021 at 10:30 PM, the Director of Nursing (DON) was notified that Resident #1 and Resident #2 were found in Resident #1's room. Resident #1 was lying on top of the bed with a shirt on and no pants, Resident #2 was standing on the other side of the room with a t-shirt and no pants. The residents were assessed for injury and a Registered Nurse (RN) assessment found no evidence of injury or trauma. Resident #2 was assisted back to Resident #2's room and the residents were monitored for the night. The Social Worker (SW) visited both residents on 5/11/2021 and neither resident could recall any incidents and did not appear upset by anything. The Documentary Evidence section of the investigation form documented the residents were interviewed and initially Resident #1 appeared embarrassed and could not recall what had happened, but was tearful because Resident #1, didn't want to get in trouble. When approached a few minutes later Resident #1 could not recall what happened and was walking up to Resident #2 and rubbing Resident #2's arm. The Facility Response/Plan to Prevent Recurrence documented Resident #2 was being reviewed for medication management and behavior monitoring. After speaking with family and the Ombudsman, it was determined that, if the two residents were interested in a relationship they would be provided with privacy and support to do so. The facility would maintain resident's rights for the two residents, and staff would be educated on how to support resident's rights regarding relationships of mutual acceptance between residents. Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 4/8/2021, documented the resident had severe cognitive impairment, could be understood, and could understand others. The Contacts section the Resident #1's Admission Record documented Health Care Proxy (HCP) #1 as Emergency Contact #1 and the resident's Health Care Proxy. A Comprehensive Care Plan (CCP) for Romantic Relationship dated 5/19/2021, documented Resident #1 was confused as to whether they wanted to have a sexual relationship with Resident #2. Resident #1 had been observed initiating sexual contact with Resident #2, and afterward, Resident #1 expressed feelings of regret, shame, and guilt in doing so. It was also documented that if Resident #1 refused to remove themself from a resident they were attempting to engage in physical/sexual contact with, staff were to attempt to move the other resident to a different location. If Resident #1 was observed initiating physical contact with Resident #2, staff were to separate Resident #1 from the other resident by offering distraction, engagement in another activity, conversation, food, and drinks. The CNA Kardex (used by the CNAs to know what care the resident needed) dated 5/25/2021, documented that if Resident #1 refused to remove themself from a resident they were attempting to engage in physical/sexual contact with, staff were to attempt to move the other resident to a different location. If Resident #1 was observed initiating physical contact with Resident #2, staff were to separate Resident #1 from the other resident by offering distraction, engagement in another activity, conversation, food, and drinks. During an observation on 5/25/2021 at 10:52 AM, Resident #1 was sitting on Resident #2's lap, stroking their arm and whispering to them. Resident #2 was calm and did not show any response to Resident #1. Certified Nurse Aide (CNA) #2 and one other staff member were present and did not redirect either resident. A Nurse's Note dated 5/11/2021 at 12:55 AM, written by RN #1 documented that on the 5/10/2021 evening shift, Resident #1 had an altercation with another resident on the unit. No injuries noted upon assessment. Resident #1 denied pain but appeared somewhat in distress. A Telemed/Emergent Care Note dated 5/11/2021 at 10:40 AM, written by the Physician's Assistant (PA) documented that, following verbal consent from Resident #1's Health Care Proxy (HCP), the resident was seen in response to staff reports that Resident #1 was found in bed with Resident #2, both nude from the waist down. Both residents lacked capacity and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Nurse's Note dated 5/19/2021 at 3:52 PM, written by RN #2, documented Resident #1 was found in their room with Resident #2. When Resident #2 left Resident #1's room, Resident #1 complained of pain in the vaginal area. The RN assessed the area and there were no signs of injury. Resident #1 stated they were upset and sorry over the situation happening. A Social Services Note dated 5/19/2021 at 3:40 PM, written by SW #2 documented they went to Resident #1's unit to speak with the resident. Upon arrival on the unit, Resident #1 was in the hallway speaking with Resident #2, who was involved in an incident with Resident #1 earlier in the afternoon. The SW took Resident #1 to their room to discuss the incident, and when asked how they were feeling, Resident #1 stated I was not willing to do it and I was not a willing participant. The resident was clearly distressed, anxious, and confused during the interview. The resident also stated Resident #2 would not stop when Resident #1 wanted them to, and that Resident #1 stated they told Resident #2 no. Resident #1 cried at one point and stated they had trusted Resident #2 and did not think Resident #2 would do something like that. Resident #1 stated they did not feel safe. A Nurses' Note dated 5/19/2021 at 4:00 PM, written by the DON, documented staff reported a sexual interaction between Resident #1 and Resident #2. When staff walked into the room the residents were undressed. Resident #1 stated Resident #1 knew they did something wrong and appeared upset. Resident #1 had approached Resident #2 all that afternoon. At times Resident #1 appeared upset or confused at what was going on. Staff had reported that Resident #1 was the aggressor, as the resident approached Resident #2, kissing their cheek, rubbing their arm, and whispering in their ear. Then, Resident #1 would be remorseful and did not appear to want to continue with the relationship. A Behavior Note dated 5/19/2021 at 4:03 PM, written by RN #2 documented Resident #1 was crying and tearful. A Social Services Note dated 5/19/2021 at 5:26 PM, written by SW #1, documented they met with Resident #1 after the resident reported negative feelings about having sex with Resident #2. Resident #1 stated they felt bad for Resident #2, because Resident #1 did not want that kind of relationship with Resident #2, but felt afraid to say no. Resident #1 also stated they did not want to be alone with Resident #2. A Social Services Note dated 5/20/2021 at 9:33 AM, written by SW #1, documented Resident #1 remained conflicted about their feelings of having a sexual relationship with Resident #2. The SW advised Resident #1 that if they remained emotionally torn, they should avoid sexual contact with the resident until they could resolve their feelings on the matter. After the visit with Resident #1, Resident #1 was observed approaching Resident #2, kissing them, touching their back, and told Resident #2, that they could not do that anymore, that Resident #1 loved Resident #2 too much to do that again. Resident #2 nodded yes and seemed to have gone back to napping in their chair. A Nurse Practitioner note dated 5/24/2021 at 2:04 PM, written by Psychiatric Nurse Practitioner (PNP) #1, documented that, starting two weeks ago, Resident #1 had been engaging in a romantic and sexual relationship with another resident. There were multiple conflicting accounts on how Resident #1 felt about the relationship. Sometimes Resident #1 was happy with the relationship, and other times the resident reported feeling shame and regret, and other times would not acknowledge the relationship beyond a friendship. Staff had noted that since this began, and sexual intercourse had occurred, the resident had been incontinent of urine, and had bleeding/blood on the resident's pants. Resident #1 referred to Resident #2 as their companion, but denied a sexual relationship, that it was just pretend. The resident reported the year as 1976, did not know the month, and stated they were at another skilled nursing facility in the area. The PNP documented Resident #1's judgment, insight, and impulse control were all impaired. The PNP documented collaborating with the Psychiatrist who recommended when Resident #1 acknowledged the relationship, to attempt to verify the resident's capacity to make decisions about the relationship, the consequences, what the resident hoped to gain from the relationship, desires, intention, and if it was the resident's will that the relationship continue - at what level. During an interview on 5/25/2021 at 10:55 AM, CNA #2 stated Resident #s 1 and 2 were together a lot and had been in bed together a few times. They had been behaving affectionately toward each other for a couple weeks. The CNA stated staff were to separate the residents (Resident #1 was sitting on Resident #2's lap at the time of this interview), however, was reluctant to do so because the family was ok with it, and Resident #1 would get upset if Resident #2 was with someone else. During an interview on 5/25/2021 at 11:00 AM, CNA #3 stated that, after the 5/19/2021 incident, Resident #1 said Resident #2 hurt them and kept telling staff Resident #1 felt like they had done something wrong. CNA #3 reported this to the DON but was told not to intervene. During an interview on 5/25/2021 at 11:15 AM, CNA #4 stated that on 5/19/2021 they had looked into Resident #1's room and both Resident #1 and Resident #2 were in the room. Resident #1 was sitting on the edge of the bed saying that Resident #1 was doing bad things. CNA #4 called for assistance and, together with CNA #3, removed Resident #1, because they were having difficulty removing Resident #2 from the room. CNA #4 reported this to the DON and was told not to keep Resident #1 and #2 apart, and that staff were not to intervene. During an interview on 5/25/2021 at 11:30 AM, Occupational Therapist (OT) #1 stated that on 5/19/2021 they knocked on Resident #1's door, and when they opened it, saw Resident #s 1 and 2 both naked from the waist down. The OT told the DON they had heard Resident #1 say Resident #2 had hurt them. The DON told OT #1 to leave them be. During an interview on 5/25/2021 at 1:00 PM, the DON stated that a few weeks ago, Resident #1 had been seen kissing Resident #2 and rubbing Resident #2's arm, and that facility Administration was unsure if that type of relationship was appropriate or not. Resident #1 was more the aggressor and sought out Resident #2 most of the time and Resident #2 did not seem opposed to the affection. The DON stated that, on 5/10/2021, the two residents were observed with their pants off, and there was no visible injury to Resident #1. The family members of both residents were contacted and both families were supportive of the relationship between Resident #1 and Resident #2. The DON stated there was no written consent from the family members consenting for Resident #1 and Resident #2 to have a sexual relationship, and that the consent was obtained verbally, and notes were written in the medical record. The DON stated if Resident #1 decided they no longer wanted the relationship, then a plan would be put in place to keep Resident #1 safe, such as a possible move to another unit. The DON stated they did not know if the residents were able to consent, but that there might be something in the telepsych notes. The DON stated that, when Resident #1 was sitting in Resident #2's lap on 5/25/2021, staff should have redirected Resident #1. The 5/19/2021 incident between Resident #1 and Resident #2 was not reported to the State because the facility considered it a consensual relationship between the two residents. During an interview on 5/25/2021 at 2:49 PM, Resident #1's HCP stated that on 5/24/2021, the HCP visited Resident #1 who introduced Resident #2 as their companion. The HCP stated that recently they had been informed by the facility that the two residents were found lying together with no bottoms on and that the facility had never dealt with a situation like that before. The HCP stated they really wanted Resident #1 to be happy but the HCP and the rest of Resident #1's family was uncomfortable with a sexual relationship. During an interview on 5/25/2021 at 3:42 PM, the Physician's Assistant (PA) stated they examined Resident #1 on 5/11/2021 following a report from staff that on 5/10/2021 Resident #s 1 and 2 were found lying together and were not wearing bottoms. The PA stated that in their professional opinion, they did not believe Resident #1's judgement and insight were intact. The PA stated they believed Resident #1 could express their wants and needs effectively, but their judgement was impaired for sure. The PA also stated that, at the time of the assessment, Resident #1 seemed weary of the relationship. During an interview on 5/26/2021 at 3:20 PM, Social Worker (SW) #1 stated they had assessed Resident #1 on 5/19/2021 and again on 5/20/2021. SW #1 stated Resident #1 was emotionally torn whether or not to have a sexual relationship with Resident #2 and SW #1 recommended they refrain from a sexual relationship. On 5/20/2021, when SW #1 again saw Resident #1, they were still torn and asked what they could do about their feelings. After that conversation, SW #1 stated they heard Resident #1 tell Resident #2 they loved them too much to do that again, then gave Resident #2 a hug and a kiss. During an interview on 5/27/2021 at 10:31 AM, the Psychiatric Nurse Practitioner (PNP) stated they were very conflicted about the relationship between Resident #1 and Resident #2. In the PNP's opinion, both residents had dementia, so how could they give consent? The PNP stated Resident #1 told them they had a companion but could not remember the companion's correct name, and Resident #1 did not provide any details about the relationship. The PNP stated that according to staff, Resident #1 was the aggressor in the relationship. The PNP stated they consulted with the Psychiatrist who advised them if the resident spoke about a sexual relationship, then ask questions to determine capacity to consent. The PNP started there had been no assessment of either resident to determine if they were able to consent to a sexual relationship. The PNP had been told both families consented to the relationship, but did not know to what extent, if it was for just hand holding, or consent to a sexual relationship between the two residents. Resident #2: Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could understand others. The Contacts section the Resident #2's Admission Record documented Health Care Proxy (HCP) #2 as Emergency Contact #1 and the resident's Health Care Proxy. The CCP for Cognitive Skills revised on 4/29/2021, documented Resident #2's was severely impaired with decision making related to dementia. The CCP for Sexually Inappropriate Behavior, last revised on 5/3/2021, documented Resident #2 had inappropriate sexual behavior toward staff and other residents. Staff were to redirect the resident if the behavior was inappropriate and to monitor the resident's movements on the units when others were sleeping. The CNA Kardex documented to redirect Resident #2 if the resident's behavior was inappropriate, and to monitor the resident's movements on the units when others were sleeping. A Nurse Practitioner Progress Note dated 5/17/2021 at 3:17 PM, written by the PNP, documented Resident #2 had been spending time with, and was very affectionate with Resident #1, but both families/HCP had consented for the relationship to continue, so staff were monitoring closely at that time. The note documented the resident had severe cognitive impairment. Review of Nurses Notes and Behavior Notes from 5/10/2021 to 5/25/2021 revealed no documentation regarding the 5/10/2021 or 5/19/2021 incidents involving Resident #1 and Resident #2. Additionally, there was no documentation of family/HCP notification, or that the family/HCP provided consent for the relationship between Resident #s 1 and 2. There were no SW notes for Resident #2 in the medical record for the 5/10/2021 or 5/19/2021 incidents. During an interview on 5/25/2021 at 1:00 PM, the DON stated Resident #2's family consented to the resident's relationship with Resident #1. During an interview on 5/25/2021 at 3:21 PM, HCP #2 stated the facility had notified the HCP that Resident #2 and Resident #1 had been found in a room with their shirts off and that Resident #1 kept stroking Resident #2's arm. The facility told HCP #2 that they would keep a closer eye on the two residents. HCP #2 stated the facility had not asked about consent for Resident #2's relationship with Resident #1. The HCP stated Resident #2 had late stage dementia and asked, so how could they give consent? HCP #2 stated the relationship was not appropriate and did not understand how Resident #2 and Resident #1 could have that kind of relationship when neither one could consent. Additional Interviews: During an interview on 5/26/2021 at 2:33 PM, the Registered Nurse Unit Manager (RNUM) #1 stated Resident #1 and Resident #2 had taken a liking to one another. Resident #1 would lean on Resident #2's shoulder, hold hands when walking, and whisper into Resident #2's ear. Resident #1 had expressed feelings of guilt about their interactions with Resident #2. After the 5/10/2021 incident, RNUM #1 stated the DON instructed the RNUM, who then instructed the staff that they were not to intervene since both residents shared the same cognitive status and the families were okay with the relationship. Additionally, RNUM #1 stated staff had been educated to allow the residents to persist in whatever manner they chose with their relationship despite their own personal moral objections and not to make either resident feel bad about the relationship. No formal staff education had been provided to staff on how to manage the situation, just verbal conversations. RNUM #1 stated the staff were having a difficult time dealing with those conversation. During an interview on 5/27/2021 at 10:03 AM, SW #2 stated that, on 5/19/2021, the DON requested SW #2 see Resident #1 because Resident #1 and Resident #2 had been found in bed together. SW #2 went to the residents' unit and saw Resident #1 and Resident #2 standing close together talking. SW #2 and Resident #1 went to Resident #1's room, and, when asked how they were, Resident #1 said they were not a willing participant with Resident #2, then said maybe Resident #1 did want it to happen. SW #2 stated that, by the look on Resident #1's face, the resident was in distress. Eventually the resident told SW #2 that Resident #1 and Resident #2, had sex. Resident #2 would not stop when Resident #1 wanted them to and that Resident #1 had said no to Resident #2. SW #2 stated that later in the conversation, Resident #1 said they did not expect Resident #2 to do that, and that Resident #1 had trusted Resident #2. SW #2 stated SW #2 had no conversation with Resident #1's family. SW #2 reported their findings from the visit with Resident #1 to the DON and asked the DON if they were going to report the incident (that occurred on 5/19/2021) to the State. The DON said something to the effect that they had talked to the State about those sorts of things in the past. The DON told SW #2 that their focus was to educate the staff about these kinds of incidents because the staff were having strong reactions and their reaction to the situation in front of Resident #1 could make them feel worse about the incident. During an untimed interview on 5/26/2021, while providing documentation requested by the state agency, the Administrator stated there were no documented consents for Resident #1 or Resident #2 related to the residents' relationship. During an interview on 5/26/2021 at 4:05 PM, the Administrator stated that since the 5/10/2021 incident, staff had described the relationship between Resident #s 1 and 2 as a companionship. The Administrator stated facility staff had not notified the Administrator of the 5/19/2021 incident until their return from vacation on 5/24/2021. When the State's abbreviated survey became lengthy on 5/25/2021, the Administrator started reviewing Resident #1's records, and became aware of the 5/19/2021 incident between Resident #1 and Resident #2. During an interview on 5/25/2021 at 3:58 PM, the Medical Director, who was also Resident #1's Primary Care Physician, stated Resident #1 initiated the relationship with Resident #2. The DON, Nurse Manager and SW had reported to the Medical Director that both families were aware of the extent of the relationship. The primary concern was to be sure both residents were protected and were not feeling ashamed of themselves. 10 NYCRR 415.4(b)(1)(i)

Based on medical record review and staff interviews during an extended abbreviated survey (Case #NY 272), for two ( #s-1 and 2) of three residents reviewed, the facility failed to ensure that adequate supervision and interventions were in place to prevent incidents of choking. For Resident #1 the facility failed to adequately assessed and supervise, after eating a hot dog, where the resident was unable to breath and turned blue/gray in color (indicating lack of oxygen). The facility failed to notify the physician and failed to ensure that the resident was assessed for swallowing ability and the ability to eat hot dogs. The resident subsequently choked on a hot dog, requiring the Heimlich maneuver and Cardio-Pulmonary Resuscitation. The facility did not ensure that Resident #2, who requires special interventions while eating and who choked during a meal, had the interventions in place to prevent further incidents of choking. The Speech Therapist's recommendations were not carried over onto the resident's Comprehensive care Plan (CCP), they were not communicated to personal care staff, and they were not identified on the care card which the personal care staff (aide) utilized to provide care. For Resident #1 this resulted in actual harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. For Resident #2 this resulted in an isolated deficient practice that is not actual harm but has the potential for more than minimal harm that is not immediate jeopardy . This is evidenced by the following : Resident #1: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have moderately impaired cognition. An x-ray report dated 8/13/13 documented a right mid lung density and recommended a follow up. A facility form titled "Progress Note" dated 8/22/13 (untimed), documented that the resident had become more lethargic with difficulty swallowing. A swallowing evaluation was performed which found that the resident was having difficulty swallowing, and the resident was placed on a pureed diet and a Barium swallow had been ordered. A "Progress Note" dated 9/30/13 (untimed) documented that the resident's barium swallow found her to be improved and the resident was placed on a regular diet. An x-ray report documented a small focal density in the right mid lung and possibly an infiltrate. Nurse's notes dated 8/13/13 at 3:57 pm documented the resident was noted to have poor appetite with increased shortness of breath and audible wheeze. New orders were received for a chest x-ray, laboratory tests and encourage fluids. Nurse's notes dated 8/21/13 at 2:04 pm documented a new order was received for a barium swallow to determine the safest least restrictive diet. An additional nurse's note on 8/27/13 at 2:20 pm documented that the resident had the barium swallow and can return to a regular diet and regular liquids. An x-ray report dated 10/2/13 documented an abnormal mass-infiltrate in the right perihilar-infrahilar (area where the mediastinum and the pleural cavities meet) region which measures approximately 6 by 5 centimeters (cm.), which is more prominent compared to the study completed on 8/13/13. A Computerized Axial Tomography (CAT) scan was recommended due to suspicion of a neoplasm. The Comprehensive Care Plan dated 11/13/2013 documented the resident had nutritional problems and required a therapeutic diet .Interventions included: the resident received a Regular consistency for solids and liquids and monitor/document/report to physician any signs and symptoms of dysphagia such as choking/coughing/appears concerned during meals. A "Progress Note" dated 10/31/13 documented the resident was complaining of shortness of breath, with noted rales (abnormal respiratory sound)and bilateral expiratory wheeze. The physician ordered Lasix (diuretic). An physician order [REDACTED]. A "Progress Note" dated 11/22/13 (untimed) documented increased shortness of breath with decreased breath sounds, rales and wheezes. CAT scan diagnosed a lung mass. Nurse's notes dated 11/20/13 at 3:17 pm documented a new order for a CAT scan and antibiotics. Nurse's note dated 11/23/13 at 10:39 pm by the Registered Nurse (RN) #1 documented that she was called to assess the resident who was having difficulty with dinner along with some difficulty breathing. RN#1 documented that the initial oxygen saturation was 78% (normal 90-100%) and oxygen two liters via nasal cannula was applied and within two to three minutes the oxygen was back up to 92%. Lungs with rhonchi bilaterally. There was no documentation that the physician was notified regarding the low oxygen saturation or difficulty swallowing with dinner. Nurse's note dated 11/23/13 at 11:26 pm written by the Licensed Practical Nurse #1 (LPN #1) documented that the resident had difficulty with dinner and shortness of breath, oxygen saturation 78%, checked oxygen tubing for kinking, retook saturation on two liters of oxygen, 92%. There was no documentation that the physician was notifie .regarding the low oxygen saturation or difficulty swallowing with dinner. Nurse's note dated 12/1/13 at 10:50 pm documented that the resident had her dinner tray set up, and eats a hot dog every night; the consistency on the tray matched her meal ticket. The resident was coughing, took a bite of her hot dog and was having difficulty clearing. The coughing got weaker and a finger sweep was done and a small piece of hot dog and roll was retrieved. The resident continued with a weak cough. The resident was suctioned, the Heimlich was done five times. 911 was called, Cardio-Pulmonary Resuscitation was started, a code was called, and the AED (automated external defibrillator) was applied. The resident was breathing on her own and had a pulse, prior to leaving the building. The resident was transferred to the emergency room (ER). During an interview on 12/3/13 at 2:15 pm RN #1 stated that during the evening shift on 11/23/13 she was called by LPN #1 to assess the resident because of difficulty breathing. RN #1 stated LPN #1 "thought the resident was choking on a hot dog." She stated she did not notify the physician. During an interview on 12/3/13 at 3:10 pm LPN #1, who worked on 11/23/13 and witnessed the incident, stated the resident had difficulty and couldn't speak, which seemed like a problem with the hot dog. He called RN #1 to assess the resident, and brought the resident to her room. During an interview on 12/3/13 at 4:00 pm Certified Nursing Assistant #1 (CNA#1) stated she was working on 11/23/13 during the evening shift. CNA #1 stated the resident was congested and coughing and she usually eats her meals fast. She noticed the resident was in trouble and needed help, because the resident had turned blue/gray in color. The resident's hot dog was cut in half but she had problems with it. It was the night after her CAT scan, and I don't know if she needed more evaluation or assistance. Afterwards, we talked about it, and decided to cut her hot dogs the long (vertical) way in the future because it would be easier to swallow. During an interview on 12/3/13 at 4:30 pm the Registered Dietician stated she was newly employed at the facility and was not aware of any issues with the resident's swallowing or choking. During an interview on 12/4/13 at 8:45 am the Director of Nurses (DON) stated that she was wondering about the event on 11/23/13, after talking with RN#2. The DON stated she read the incident from the twenty-four hour report on 11/25/13 during the morning Interdisciplinary Team (IDT) Meeting. She remembered reading the nurse's notes and there was no mention of "choking". The DON stated "difficulty with dinner", meant the time of day. The DON stated that RN#2 told her the resident had no other events with choking. During an interview 12/4/13 at 9:30 am RN #3 stated she worked on 11/23/13 and was asked to go with RN #1 to assess the resident but doesn't remember what was said exactly related to symptoms. When she arrived on the unit the resident was in her room with oxygen on. If aware that resident had choked, she would have called the physician or sent the resident out to the hospital. The staff did have a discussion about cutting the hot dog lengthwise. During an interview on 12/4/13 at 11:30 am the Diet Technician (DT) stated she did not remember hearing about an incident or problem with the resident's dinner on 11/25/13 IDT meeting. She stated many times all of the information is not read during morning meeting, but summarized. When read the note that LPN#1 wrote on 11/23/13, DT stated she would need more information as to what the problem with dinner meant. The resident was known to eat very fast and coughs a lot. During an interview on 12/4/13 at 12:20pm the Administrator stated that he was not in the building on the morning of 11/25/13, and got an update from the DON when he arrived, regarding morning report. He stated he was not aware of the concerns related to the resident on the evening of 11/23/13. He stated he spoke today (12/4/13) with all three staff members that were in the resident's room on 11/23/13, and all stated no Heimlich was performed and no choking was evident. The Administrator thought the statement from the twenty-four hour report "trouble with dinner" would need clarification. If the resident was not able to breath or if there was a question about swallowing, he would have the physician order [REDACTED]. He stated that only Sunday's report was being read from the weekends. During an interview on 12/4/13 at 1:00 pm the Nurse Practitioner (NP) stated she was unaware of any previous incidents with the resident having problems swallowing. During an interview on 12/4/13 at 1:15 pm the night RN supervisor, RN #4, who worked 7:00 pm on 11/23/13 to 7:00 am 11/24/13, stated she always writes down report from the off going shift. RN #4 retrieved her notebook where she documented reports, but the report from 11/23/13 was missing. RN #4 stated she thought the resident had a problem with dinner, possibly related to coughing and secretions. During an interview on 12/4/13 at 1:50 pm RN #2 stated she reviewed the nurse's notes after I left last night, and understood the nurse's note "problem with dinner" written on 11/23/13 to mean related to secretions. In retrospect, she would call the nurse who wrote the note to get clarification. During an interview on 12/4/13 at 2:00 pm the physician stated he was not aware of the issue on 11/23/13, and would have expect to be notified, if it was something different than before. He stated that the mass in her lung and adenopathy probably contributed to her problems with swallowing and choking. Resident #2 The resident was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident to have severe cognitive impairment. The facility form titled "Quality Improvement Incident Report" dated 10/7/13 at 6:20 pm documented that the resident was eating supper and began gasping for air. The private duty aide began patting her back, and called for the nurse. The nurse arrived and instructed the resident to cough and the resident was able to cough/vomit the french fry up. Under the section titled "Interventions to prevent reoccurrence" it was documented on food item at a time, pre-cut food as needed, and speech evaluation. Review of the twenty-four hour supervisors report dated 10/7/13 did not contain any documentation related to the incident of the resident choking on a french fry. Nurse's notes written by a LPN, dated 10/7/13 at 7:00 pm documented that it was witnessed by the private duty aide and a LPN that the resident choked on a french fry during the dinner meal, the resident quickly coughed it back up. There was no documentation of an RN assessment after the choking incident. Nurse's notes dated 10/8/13 at 2:07 pm documented by a RN documented that the writer was notified by the private duty aide that the resident had an incident yesterday at supper that the resident was gasping for air and appeared to have food stuck in her throat. The resident was ambulating at the time, and the private duty aid began patting the resident on the back and notified the nurse on the unit. The LPN arrived and instructed the resident to cough it up. The resident coughed/vomited up a french fry that she had been eating. Private duty aide stated the resident said "my throat hurt". Resident was offered a drink and no other injury was noted. RN assessment was completed 10/8/13 and no signs or symptoms of injury noted. Resident up ambulating around and does not appear to remember the incident. Denies throat pain and no swallowing difficulty noted at this time. Speech Therapy evaluation ordered today. A facility form titled "Speech Therapy" evaluations dated 6/27/13 and 10/8/13 documented under the recommendations section that the resident required straws to consume liquids independently. The Comprehensive Care Plan (CCP) titled "nutritional problem" initiated 5/8/12 and last revised 10/20/13, documented interventions that should be used: offer food one item at a time; eat food with spoons; cut meats, calorie count as needed; fresh fruit daily; high calorie pudding; no added salt; weigh weekly; eat either on unit or main dining room; may wear a clothing protector; snack three times a day; may eat standing and inner lip plate. There was no documentation regarding the use of a straw initiated on 6/27/13. A physician progress notes [REDACTED]. Observation on 12/5/13 at 12:35 pm of the resident during lunch, revealed the resident had received her complete tray, and the resident was eating with a fork, contrary to the CCP. Observation of the Resident Care Card, which is used by the aides to provide personal care, revealed no documentation of using a straw (per speech therapy), having one item at a time during meals or using only spoons. During an Interview on 12/5/13 at 12:45 pm the CNA who usually cares for the resident during the day shift, stated she was unaware that the resident had choked that the resident required only one item at a time or that the resident was only to use spoons. The CNA was not aware of any changes to the resident's care plan. The CNA stated if there were changes made, it would be on a "green sheet" (communication sheet). The CNA displayed a meal ticket, which she said should include special precautions for meal consumption. The meal ticket did not include specific interventions of use of only a spoon for meals, straws for liquids or one item at a time. During an Interview on 12/5/13 at 1:30 pm the facility Administrator stated he was unable to find any "green sheets" related to the changes made to the resident's care plan related to swallowing/choking. 10 NYCRR 415.12(h)(2)

Based on medical record review and staff interviews during an abbreviated survey (Case # NY 272) it was determined that the facility was not being administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the facility failed to ensure that residents with problems swallowing were assessed, care planned and had appropriate measures to ensure supervision and safe practices were in place. Resident # 1 had experienced an episode of difficulty while eating a hot dog, wasn't breathing and turned blue/gray in color. The physician was not notified and the resident was not assessed for swallowing ability. The resident subsequently choked while eating a hot dog, requiring the [MEDICATION NAME] and CPR. Resident #2 who is at risk for choking and had recently experienced choking, was assessed and to have only one item at a time for her meal, eat with a spoon and drink with a straw. This information was not on the resident's care plan and was not conveyed to the aides. For Resident #1 this resulted in actual harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. For Resident #2 this resulted in an isolated deficient practice that is not actual harm but has the potential for more than minimal harm that is not immediate jeopardy . This is evidenced by the following : Refer to F 323 - Scope/Severity J During an interview on [DATE] at 12:20 pm the Administrator stated that he was not in the building on the morning of [DATE], and got an update from the Director of Nurses when he arrived, regarding morning report. He stated he was not aware of the concerns related to the resident on the evening of [DATE]. He stated he spoke today ([DATE]) with all three staff members that were in the resident's room on [DATE], and all stated no [MEDICATION NAME] was performed and no choking was evident. The Administrator stated he would need clarification of what "trouble with dinner" meant on the 24 hour report. If the resident was not able to breath or if there was a question about swallowing, he would have the physician order [REDACTED]. He stated that only Sunday's report was being read from the weekends. 10 NYCRR 415.26

JPH11 Based on medical record review and staff interview during the standard recertification survey the facility did not ensure that the resident environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents for two (#s- 97 and 105) of eight residents reviewed for falls. Specifically, Resident #105 had repeated falls during which supervision was not provided. The Physical Therapy (PT) recommendation upon discharge from the PT program and prior to the occurrence of these repeated falls was for Resident #105 to ambulate with a rolling walker and the supervision of one person. Resident #105 had twelve falls from February 2012 to August 2012, with two separate falls that resulted in a nasal fracture and a fracture of the right orbital. Additionally, interventions of signs being placed about the residents room required a higher level of cognitive ability than the resident was assessed as having. Resident #97 had repeated falls during which appropriate footwear and supervision was not provided. The last fall resulted in a bump and black eye. This resulted in actual harm that is not immediate jeopardy for Resident #105 and the potential for more than minimal harm that is not immediate jeopardy for Resident #97. This is evidenced by: Resident #105 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was assessed as independent with set up help only for transfers, as requiring supervision (oversight, encouragement or cueing) with set up help only for ambulation in her room, and as independent with set up help only for ambulation in the corridor. She was assessed as not being steady, but able to stabilize without staff assistance for balance during transitions and walking and used a walker for a mobility device. The resident was noted as having fallen since the prior assessment and to have had one fall with no injury and two falls with injury (except major). A PT Discharge Summary dated 2/21/12 documented that the resident had independent bed mobility, transfers and gait with a rolling walker, that she needed reminders to use her rolling walker because she forgets it and will ambulate. It noted her current status was ambulation of 200 feet with a rolling walker and the supervision of one person. A Nursing Progress note dated 2/29/12 at 9:55 am documented that the facility had an interdisciplinary team meeting in the morning to review an incident that occurred at 4:30 am. It documented a new intervention to assess the accessibility of clothing in the closet for the resident. A facility Quality Improvement Incident Report dated 2/29/12 at 4:30 am documented the resident had a non-witnessed fall and that a Certified Nursing Assistant (CNA) reported the resident was on the floor in her room. It documented that the resident had no apparent injury. The Root Cause Analysis of the incident was completed on 2/29/12 and noted that the resident was found sitting on the floor in front of her closet per the CNA. It documented that the nurse manager was to have the resident's transfer status checked along with the accessibility of clothing in the resident's closet. A facility Quality Improvement Incident Report dated 3/2/12 at 11:15 pm documented that a staff member was doing rounds and found the resident on the floor, sitting in front of her bed with non-skid socks on, but no bottoms. It noted that the room was well lit and that the resident stated "I was getting up and the floor was so slippery ". It documented that the resident's call light was not on at the time of the incident. It documented that her walker was not in reach and that incontinence was involved. The Root Cause Analysis of the incident was noted as the resident having attempted to ambulate independently in her room without a wheeled walker. The intervention to prevent reoccurrence was to have a reminder sign in the room for her to use her walker and to clip the call light to the resident when she was in bed to notify staff when she was up independently. A Nursing Progress note dated 3/3/12 at 3:45 pm documented a CNA stated the resident was on the floor in her room (date and time unknown). When asked what happened, the resident stated "I was getting up and the floor was so slippery". It documented the resident had non-skid socks on, and her room was well lit. It documented that no apparent injury was noted and that the resident was reminded to use the call light and walker while ambulating. It noted that incontinence care was provided and resident safety was maintained. A Nursing Progress Note dated 3/10/12 at 1:30 pm documented that the resident had no complaints of discomfort, and that the family was notified about a fall that occurred on 3/10/12 at 1:30 am with bruising to the resident's left thigh and hip. The 24 hour nursing supervisor report for 3/9/12 also documented that the resident fell at 1:30 am and that bruises were found on the resident's left thigh and buttock. There was no documented evidence of a facility Quality Improvement Incident Report having been completed for this fall documented in both the nursing progress notes and on the 24 hour nursing supervisor ' s report as having occurred on 3/10/12 at 1:30 pm. A facility Quality Improvement Incident Report dated 3/11/12 documented that the resident had a fall at 12:30 am. It noted that a CNA heard a bang, went to the room, and the resident was found on her back and buttocks trying to get socks on. It documented that the resident's call light was not on at the time of the incident and that she did not have non-skid socks on her feet. The Root Cause Analysis of the incident dated 3/12/12 documented the cause of the incident was the resident attempting independence, but was unable. It documented the interventions to prevent recurrence were to obtain a urinalysis, a physical therapy evaluation, and to do a sleep study. There was no Nursing Progress Note documented in the resident's medical record related to the fall on 3/11/12. A Nursing Progress Note dated 3/12/12 at 3:15 pm documented that the resident had a fall at 2:15 pm. A CNA heard a thud and the resident was found on the floor laying on her left side next to the night stand and her walker was nearby. It documented the resident stated " I don't know what happened, I was sweeping the floor." A facility Quality Improvement Incident Report dated 3/12/12 at 3:15 pm documented that a CNA heard a thud and the resident was on the floor laying on her left side next to the nightstand and that her walker was nearby. It noted that the resident did not have her call light on at the time of the incident. The Root Cause Analysis of the incident noted the cause was the resident was in her room and attempted to ambulate without her walker. The intervention to prevent reoccurrence was to keep the resident in a supervised area when not in bed and to obtain a urinalysis, a physical therapy evaluation, and to do a sleep study. An incident report dated 3/12/12 documented that the resident had a fall at 11:00 pm and was found on the floor sitting near the door of her room with non-skid socks on. It documented that the resident's call light was not on at the time of the incident. The Root Cause Analysis of the incident dated 3/13/12 documented that the cause of the incident was the resident attempted independence and that the intervention to prevent recurrence was to complete a sleep study, and to obtain a urinalysis and physical therapy evaluation. There was no nursing progress note documented in relation to the fall on 3/12/12. A Physical Therapy Evaluation dated 3/13/12 documented that the resident was at or above her previous functional level when last seen on program. It noted that the fall log was reviewed and room observation appeared to show that the resident tended to reach for items off the floor or below her knees. It noted that the resident was evaluated in the room with and without shoes and no loss of balance or transfer impairment was observed. It documented that it was recommended no items be left on the floor and that the resident's bottom two closet shelves and bottom drawers of free standing dresser be emptied. It also documented that a visual paper reminder would be placed on the resident's walker for her to always use her hands to push up from the bed/chair surfaces prior to standing. It noted that the resident's prior level of function was supervision at all times with the rolling walker and this should be continued with directional cues when the resident was ambulating with the rolling wheeled walker. A Nursing Progress Note dated 3/23/12 at 10:36 pm, documented that the resident fell at 9:15 am and had a skin tear above her right eyebrow, that the skin on the bridge of her nose was cut and that there was a bruise under her right eye. It noted that the physician's assistant ordered to send the resident to the emergency room (ER) for evaluation and treatment. A facility Quality Improvement Incident Report dated 3/23/12 at 9:15 pm documented that the resident yelled and the CNA came into her room to find her sitting on the floor with the skin above her right eyebrow lacerated and a bruise under her eye. It noted the resident's call light was not on at the time of the incident. The Root Cause Analysis of the incident was dated 3/26/12. It documented the resident lost her balance when attempting to stand independently. It documented that the intervention to prevent reoccurrence was for the Director of Nursing (DON) to send a request for a physical therapy evaluation. A Nursing Progress Note dated 3/24/12 at 7:43 pm written by the Registered Nurse(RN) Supervisor documented that the resident returned from the ER with a [DIAGNOSES REDACTED]. A Physical Therapy evaluation dated 3/29/12 documented that resident had a nasal fracture. It noted interventions to keep the rolling walker within her reach at all times, and to remove the last two drawers of her dresser to prevent the resident from using them. It documented that the resident's prior level of functioning was to ambulate 200 feet with a rolling walker and supervision of one person. It noted that she required supervision due to forgetting to use her rolling walker and tending to try to pick things up in her room and rearrange her clothes in her drawers. It noted that the resident's status continued as ambulation with a rolling walker for a distance of 200 feet with the supervision of one person. A Nursing Progress Note dated 4/5/12 at 10:36 pm documented that the resident fell at 10:00 pm and there was a new order to send her to the emergency room . A facility Quality Improvement Incident Report dated 4/5/12 documented the resident had a fall at 10:35 pm. It noted that the staff member heard a thud and walked in her room to find her on her left side, half under the bed with her non-skid socks on the floor near her bed. The resident was noted to have no call light on at the time of the incident. The Root Cause Analysis of the incident documented the cause of the incident to be the resident leaning to one side to stand, self-transferring, and removing her non-skid socks. The intervention to prevent reoccurrence was to place the bed on the other side of the room. A Physician's progress note dated 4/17/12 contained no documentation regarding the fall or her nasal fracture that occurred as a result of the fall on 3/23/12. A Nursing Progress Note dated 5/25/12 at 2:35 pm documented that the resident fell at 11:35 pm (date unspecified). It noted that the resident had bleeding above her left eyebrow, that later it was discovered the resident's right second toe nail was ripped off, and that in the morning she developed bruises on the second toe. A facility Quality Improvement Incident Report dated 5/24/12 at 11:35 pm documented that the resident was found by a Licensed Practical Nurse (LPN) lying on the floor near her cabinet on her left side, bleeding from her left eyebrow with her non-skid socks on. The resident was noted to state " I forgot to use my walker. I came to look out my door and fell ". It noted that the resident's call light was not on at the time of the incident. The Root Cause Analysis was dated 5/25/12 and documented the cause as the resident having a history of going to her room door whenever she heard a noise in the cluster. The intervention to prevent reoccurrence was to encourage the resident to keep her door open. A late entry Nursing Progress note dated 6/5/12 documented that on 6/4/12 evenings a CNA yelled around 10:50 pm and that a LPN ran to the cluster and saw the CNA with the resident, sitting with her back to the bathroom, facing the bed and that there was a pool of blood surrounding her. It documented that she had a laceration above her right eye and that it was swollen shut. It then noted that emergency medical services arrived to get the resident soon after. A Nursing Progress Note dated 6/5/12 at 9:13 pm documented that the emergency room was called and said the resident was coming back to the facility with a subtle nasal fracture. A facility Quality Improvement Incident Report dated 6/4/12 at 10:50 pm, documented staff heard the resident yelling, ran to the room, and found the resident sitting on her bottom on the floor with her legs stretched out in front of her. It noted that the resident had no call light on at the time of the incident. The Root Cause Analysis of the incident dated 6/5/12 noted the cause of the incident was the resident had no personal safety conception and the intervention to prevent reoccurrence a reevaluation of her sleep medication. A physician's note dated 6/11/12 documented by the nurse practitioner noted that the resident had a recent left seventh rib fracture and a right orbital fracture from a fall on 6/4/12. It documented that the resident's ambulatory status was one assist with a gait belt and a rolling walker, but that she remained non compliant with this. It noted that she seemed to be recovering well from the most recent fall and that there were no other issues or concerns. A physician's order [REDACTED]. A Nursing Progress Note dated 6/17/12 documented facial bruising continued and noted that the resident had a fall at 6:45 pm. It documented the supervisor assessed and no injuries were noted. A facility Quality Improvement Incident Report dated 6/17/12 at 7:00 pm documented that the resident was found just inside the doorway to her room on her bottom sitting upright against the closet door. It noted that resident's call light was not on at the time of the incident. The Root Cause Analysis of the incident was dated 6/18/12 and noted the cause as the resident attempted to leave her room independently without her wheeled walker. It documented the intervention to prevent reoccurrence was to put a sign on her door to keep it open. A Nursing Progress Note dated 8/10/12 at 10:33 pm documented that the resident was found sitting on the floor with no injuries found. A facility Quality Improvement Incident Report dated 8/10/12 at 6:40 pm, documented that the resident was found sitting on the floor in front of her cabinet, with her walker near the window. The resident was noted to have no call light on at the time of the incident. The Root Cause Analysis was dated 8/13/12 and documented the cause to be the resident attempting independence and losing her balance. The intervention to prevent reoccurrence was to follow up with a urinalysis and monitor her temperatures for three days with the nurse manager to conduct a sleep study for one week. The current Cardex (a form referenced by the Certified Nursing Assistants to provide care to the residents) was undated. It documented that the resident was occasionally incontinent of bowel and bladder, wore pull up briefs for incontinence, independent in transfers without a gait belt, and required supervision with ambulation and a rolling walker. The resident on an every two hour toileting program. It noted that the resident was alert and oriented, but confused and forgetful. It noted that the resident was at high risk of falls. It documented (undated) fall prevention approaches that included: non-skid strips in the room at the chair, toilet and bed; non-skid socks; no items or clothes in the bottom two drawers of the closet or in the bottom shelf of the free standing dressers; no free items on the floor; a water pitcher filled every shift; a walker with the resident at all times even when in the wheelchair; no slippers; a call light clipped to the resident in her room; to keep the resident in the cluster when out of bed; and to keep the door open when the resident was in the room. Additional interventions that were documented on 3/13/12 that the resident was to not be in her room unless in bed and on 5/29/12, that the resident was to be encouraged to keep her door open. During an interview on 8/27/12 at 2:35 pm, the LPN for the unit stated that the resident forgot her walker all the time. She stated the intervention they use to prevent her from falling besides the non-skid strips in her room was just to try to remind her to use her walker all the time. The resident was observed to be sitting in a recliner chair on 8/28/12 at 6:30 am in the core area of the unit cluster. She was noted to be asleep with her walker in front of her. Her room was observed with non-skid strips in front of her bed and chair, there was an orange sign in the resident's nightstand that stated "Remember to use your walker! Use it at all times!". The bottom two drawers of the night stand had clothing and paper items in them. There was a green sign on the wall above the resident's bed that stated "Please remember to use your walker! Do not walk without it!". There were items in the bottom two shelves of her television stand and clothing in the bottom two drawers of the resident's closet. There was a yellow sign on the back of the door that stated "Remember to use your walker! So you don't fall and get hurt!" The was a sign on the outside of the door to keep it open at all times. During an interview on 8/28/12 at 6:35 am, the 11:00 pm to 7:00 am CNA stated the resident came out of her room last night at 1:00 am and she sat the resident in the recliner chair in the cluster so they could keep an eye on her. She stated the resident had a history of [REDACTED]. She stated that she always left the walker right beside the resident and kept a close eye on the resident. She stated she always checked on the resident often during the night and when asked what that meant, she stated she checked on the resident every two hours when doing rounds. She stated she believed the resident was allowed to be independent in getting up and walking, but stated she did forget her walker a lot so they have to provide her with frequent reminders when they saw this. She stated this resident liked her independence so they just kept an eye on her and intervened as needed. During an interview on 8/28/12 at 7:57 am, the Registered Nurse Unit Manager stated that this resident had a number of falls. She stated that the resident had a walker, but frequently got up to ambulate without it and that they have to remind her often to use it. She stated a new intervention that they tried was having the door to her room open because she had always been a very private person and liked to close her door all the time. She stated that this resident's transfer status was noted as independent, but that her ambulation status was supervision. She stated she didn't know why the resident required supervision with ambulation, but that maybe it was because of all her falls. She stated that any time someone saw the resident getting up, staff would go over to her to guide her to her walker. She stated interventions to prevent falls were non-skid strips in her room, non-skid socks and to not put clothes in her bottom drawers. However she stated the resident would rearrange items herself in her room and put them back in the bottom drawers. She stated that the staff should be encouraging the resident to keep her door open, should be keeping the walker with the resident at all times, and should be keeping the call light clipped to the resident for her use when in the room even though she does not use it. She stated that the signs on the outside and inside of the room were for the resident to read. She then stated that she although she didn't think the resident got up and read them prior to the falls, she believed that if the signs were pointed out to the resident, then the resident would read them. She stated the signs were simply there for reminders should she look at them. During an interview on 8/28/12 at 9:00 am, the physical therapist stated that the resident had dementia and that physical therapy had her on program until 2/21/12 for a treatment related to a broken hip. She stated that at the time of her discharge from therapy the resident required supervision and reminders to use her rolling walker when ambulating because she would frequently forget to use the walker. She stated the resident should always have supervision and eyes on her to make sure she uses her walker. She stated therapy staff was not always involved in interdisciplinary team discussions about falls and that the therapy department was only aware of the first nasal fracture. She stated that it was facility policy that the therapy staff were supposed to be notified any time after two falls have occurred with a resident. She stated she could see how this resident's falls were occurring when she was not supervised if each of the falls were noted as unwitnessed. She stated that therapy had recommended in the past to take everything out of the bottom two drawers, but stated then that the resident put things back in the drawers and this didn't work. She stated that the signs were just another thing tried because the resident's falls were so difficult to manage, but she could see how it was likely that this resident with dementia did not look at and respond to these signs prior to the falls she had. During an interview on 8/28/12 at 10:45 am, the Director of Nursing stated that this resident had been a frequent faller, but had improved with less falls occurring. She stated short of one on one supervision, she did not know what could be done and that the facility could not give this resident 24 hour supervision. She stated the staff were aware the resident was at high risk for falls and just knew to monitor this resident more frequently. She stated she could provide no documented evidence of how this resident was provided with increased supervision in response to her falls and could just say that all residents at the facility were supervised and monitored by the staff. She stated they can not have their eyes on every resident 24 hours a day to prevent falls. She stated that this resident with dementia likely didn't remember to read the signs posted around her room as she got up to walk, but that they were put in there as one chance that it may work to remind her to use her walker. She stated that the call light was not pinned on the resident for her to use as a way to intentionally get staff assistance, but rather as way to light her call light above her door when it was pulled out of the wall as she got up and so then staff would then ultimately go check on her. The DON stated that the facility was a restraint and alarm free environment and stated that the regulations stated that residents have the right to be independent. She stated she felt the interventions put into place were sufficient. During an interview on 8/28/12 at 11:55 am, the day shift CNA stated that this resident was at high risk for falls. She stated they needed to keep an eye on the resident when she was up and ambulating. She stated that the resident walked independently with the rolling walker, but required supervision, which meant that they needed to have an eye on the resident at all times. She stated that she was the one CNA on the cluster of the unit with 15 resident beds. When asked how this resident was supervised when she was either away from the unit or behind closed doors taking care of another resident, she stated that this resident then went without any supervision for some periods of time. During an interview on 8/29/12 at 1:05 pm, the Medical Director stated that he would expect that the facility would take reasonable precautions to prevent falls and injuries from falls. He stated from his perspective he would look solely to see if anything was going on with the resident medically and would expect the facility staff to determine appropriate facility methods to put into place to prevent falls and injuries from falls. During an interview on 8/29/12 at 1:45 pm, the Administrator stated she did not know what supervision meant from a regulatory standpoint. When the Administrator was informed that the facility therapist defined supervision as keeping an eye on the resident at all times, she stated this was not possible and that they could not do this, short of providing one on one supervision to the resident. She stated that she believed the staff being informed that the resident was at high risk for falls was adequate to make the staff more attentive to watching this resident for unsafe maneuvers. Resident #97 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS of 7/10/12 assessed that the resident rarely understands or was understood and had severely impaired cognitive skills for decision making. It documented that the resident had 2 or more falls without injury since the last assessment. The Comprehensive Care Plan (CCP) for potential for falls with a start date of 11/29/11 documented falls on 6/3/12 where the resident was sitting on the floor of her room uninjured; on 6/8 and 6/9 the resident was found sitting on the floor in her cluster; on 6/23/12 the resident lost her balance and fell with no injury; on 7/9/12 the resident lost her balance and fell ; On 7/23/12 the resident slid out of her chair; on 7/25/12 the resident slipped and fell by the stage and had inappropriate footwear on; on 8/1/12 the resident sttempted to sit on a couch and fell . An approach on the CCP was that the resident wear appropriate footwear and was dated 5/25/12. A Physical Therapy (PT) evaluation dated 5/17/12 documented that the resident had falls on 4/16 and 4/26 and the goal was to prevent falls in the future. The recommendations were: 1. discontinue the crash pad by the bed as this was a fall hazard since the resident gets up and ambulates on her own, 2. the resident must wear her black shoes when out of bed to improve her balance,stability and gait. She should not wear non skid socks. This evaluation further documented the resident needed supervision of 1 staff person for ambulation. There was a communication sheet ( not a formal document) used by certified nurse aides (CNAs) that documented on 5/1/12 the resident needs to wear black shoes when out of bed. Then on 6/11/12 it again documented black shoes on when out of bed. The Cardex sheet ( used by CNAs to provide needed care to the resident) undated with none of the interventions dated was written in pencil and appeared to have been erased in parts. Under Ambulation Ability it documented supervision, no gait belt, no assistive devices, 100-250 feet ad lib to/from the cluster. Under Special Care it documented high risk of falls, non skid socks only when ambulating on unit, do not but black shoes on, velcro slippers when available. An Incident Report dated 6/3/12 documented at 5:00 am the resident was found sitting on the floor near the wall in her room. It documented that the resident had non skid socks on and had sat in the recliner prior to the fall. The report documented this was an unobserved fall. An Incident Report dated 6/8/12 documented that at 5:20pm the resident was sitting on buttocks next to a chair in the Whiteface Cluster. It documented the resident non skid socks on and appeared to be trying to sit in a chair but lost balance. The report documented this was an unobserved fall. An Incident report dated 6/9/12 documented that at 4:00pm the resident was found sitting on the floor in her cluster. It documented she had non skid socks on and fell in the cluster. The report documented this was an unobserved fall. A Physical Therapy evaluation dated 6/14/12 documented that for both falls the resident had on non skid socks and to reinforce wearing her black shoes. It documented the resident must wear black shoes. It documented the resident needed supervision for ambulation. An Incident Report dated 6/23/12 documented at 2:45pm the resident had been lying on the couch, stood up and fell backward against the TV and down onto the floor. It documented the resident had non skid socks on and the cause of the fall was the resident did not have black shoes on. A PT evaluation dated 6/29/12 documented that PT services would be provided for 3-5 weeks to improve balance, pick up items from the floor, carry books, increase lower extremity strength and prevent falls. It further documented the need for supervision of 1 staff person for ambulation. A PT evaluation dated 7/9/12 documented under nursing recommendations that the resident must wear black shoes when out of bed with thin socks, and CNAs have been educated. An Incident report dated 7/23/12 documented at 5:30pm the resident was trying to get up from a chair and fell . It documented the resident had non skid socks on. An Incident Report dated 7/25/12 documented at 5:40pm the resident slipped in the auditorium and fell . It documented the resident had slippers on and the cause of the fall was the resident was wearing improper footwear. On 7/31/12 a PT evaluation documented that a podiatry evaluation was recommended for the resident because of a bunion pressure area and that the black shoes no longer appeared to fit properly causing discomfort. The recommendation was for the resident to wear non skid socks until the podiatrist looked at the resident and prescribed new shoes. The Cardex (used by CNAs to provide needed care) was updated at that time. This evaluation further documented that the resident needed supervision when ambulating. An Incident report dated 8/1/12 at 7:50am documented that it appeared the resident attempted to sit on a couch in the auditorium, misjudged and ended up sitting on the floor. It documented this was an unobserved fall. An Incident Report dated 8/18/12 at 7:30pm documented the resident was found lying on her left side near the recliner in the Whiteface Cluster ( not the resident's cluster) with a big bumpy area on the right forehead. This was an unobserved fall according to the report. This resident was observed during the days of survey to have a large area of black and blue around her right eye with it extending down her cheek. During interview on 8/29/12 at 6:39am the resident's night CNA stated that the resident sleeps with non skid socks on and that she gets up several times a night. She stated she did not remember a time the resident was not supposed to wear non skid socks. She stated she was only able to put the black shoes on the resident a couple of times. She stated they kept telling us to use them but she thought they hurt the resident. She stated she let her day supervisor know maybe a month ago. During the interview on 8/29/12 at 9:04am the resident's day CNA stated that the resident recently got new shoes but she did not know exactly when. She stated before that the resident's Cardex had black shoes on it that the resident was to wear. She stated that she would find the resident with the black shoes on over the non skid socks at times and thought that was why the shoes were too tight. She stated nights gets the resident up. She stated that sometimes the resident would only have the non skid socks on. She was asked if the resident needed to be supervised. She said yes and that supervision meant that she should be watched at all times. She

Based on staff interviews, resident interviews and medical record review during a partial extended abbreviated survey (Case #NY 285), facility staff failed to protect residents from potential abuse, neglect, and mistreatment. The facility failed to ensure that injuries of unknown origin, allegations of abuse, and staff actions that constituted potential, if not actual abuse, neglect or mistreatment, were investigated in accordance with facility policies and procedures (developed to ensure compliance with these requirements). Specifically, for 2 (Resident #'s 1 and 2) of 9 residents reviewed, the facility failed to identify a situation of potential abuse or neglect when Resident #2 reported to a Registered Nurse Supervisor (RNS #1) that the LPN refused to provide [MEDICAL CONDITION] care, failed to prevent potential neglect when a Licensed Practical Nurse (LPN) was allowed to continue to care for Resident #2 after the resident reported to a RNS #1 that the LPN refused to provide [MEDICAL CONDITION] care. In addition, the facility failed to investigate Resident #2's complaint that a Certified Nursing Assistant removed his Passy-Muir valve (a speaking valve for use with a [MEDICAL CONDITION]), preventing him from speaking. The facility also failed to thoroughly investigate Resident #1 injuries of unknown origin including bruises and facial lacerations. Interviews with supervisory personnel revealed that alleged abuse and injuries of unknown origin were to be investigated at the direction of the Interdisciplinary Team (IDT), which meets Monday through Friday. This is a repeat deficiency from the standard recertification survey of 9/30/10. This resulted in Immediate Jeopardy and Substandard Quality of Care to the health and safety of residents and had the potential to effect all 121 residents residing in the facility. This was evidenced by: Resident #2: This resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident with intact long and short term memory, able to understand and be understoodand with intact cognition. The Policy and Procedure (P&P) for Abuse Prevention dated 10/3/08, documented that upon knowledge of suspected abuse, the Nursing Supervisor was to begin an investigation to determine if there was reasonable cause to believe that physical abuse, mistreatment, or neglect had occurred. Upon having reasonable cause to believe that abuse, mistreatment or neglect had occurred, the administrator and the Department of Health were to be notified immediately. Upon knowledge of a report, the administrator or the Director of Nursing (DON) was to begin an internal investigation. While the investigation was in progress, the alleged abuser was not to have contact with the alleged victim and was to be assigned to an area that did not involve resident care or was to be suspended pending investigation results. The resident care plan titled Communication dated 11/3/10 documented that the resident had difficulty making himself understood due to a tracheotomy, wears a Passy-Muir valve and that the resident also communicated via computer and telephone. Finding #1: The facility failed to identify abuse and neglect, and failed to prevent further potential abuse by allowing the employee accused of abuse, neglect and mistreatment to continue to provide direct care to the resident, when Resident #2 reported to Registered Nurse Supervisor (RNS) #1 that Licensed Practical Nurse (LPN) #2 refused to provide [MEDICAL CONDITION] care upon his request. The facility's form titled "Alleged Abuse or Suspected Abuse Report Confirmation" documented an allegation of abuse or suspected abuse which occurred on 2/27/11 between 12:00 am and 7:00 am. The form documented a complaint from Resident #2 that LPN #2 on the night shift for 2/26/11 into 2/27/11 refused to suction him. The form documented "It is the responsibility of the reporter to immediately notify the facility administrator of any alleged or suspected violations of abuse." A section of the report documented that the facility administrator and director of nursing were notified on 2/27/11 at approximately 4:30 pm, approximately fourteen hours after the alleged incident began. Additional timelines documented in the report, revealed the resident was interviewed on 2/28/11 at 2:30 pm, approximately thirty-six hours after the alleged incident began. In a statement dated 2/28/11, RNS #1 documented that she was called to the unit on 2/27/11 at 1:00 am at the request of Resident #2. The RNS #1 documented that the resident's pulse was slightly increased and he appeared anxious and she directed LPN #2 to suction the resident. The RNS #1 documented that she was contacted by LPN #2 at 2:30 am at the request of the resident, responded to the resident and the resident reported that LPN #2 would not suction him and he could not breathe. The RNS #1 documented that she assessed the resident's breathing, confirmed that he needed to be suctioned and directed LPN #2 to suction the resident. The RNS #1 documented that LPN #2 did not move from the computer and needed to be directed again to suction the resident. LPN #2 complied at this time. The RNS #1 documented that she was called again at 3:30 am, responded to the resident and suctioned him as the LPN #2 would not do it. The RNS #1 documented that the resident's mother contacted the facility at 4:00 am and informed her that LPN #2 would not suction the resident and that the staff would not allow or assist the resident to contact his mother. In a statement by the resident's mother she documented that she was contacted on 2/27/11 at 4:00 am by a friend of the resident., The friend had been contacted by the resident via Facebook (a social networking site). The resident reported to his mother that LPN #2 was refusing to suction him and that the nurse was also refusing to let the resident call his mother. The mother documented that she contacted the facility and spoke with LPN #2 who would not answer her when she questioned LPN #2 about refusing to suction the resident. When the resident's mother asked to be transferred to the supervisor, LPN #2 hung up on her. The resident's mother documented that she called the facility back, and spoke with the RNS #1 who stated that the resident would be suctioned as needed. During an interview on 3/17/11 at 11:15 am, the resident stated that on 2/27/11 LPN #2 refused to suction him when he requested. The resident stated that LPN #2 would not respond to him, therefore he yelled from his room that he needed assistance. The resident stated that at some point, he believed between 3:00 am and 4:00 am, LPN #2 did come into his room but refused to allow or assist him in calling his mother. The resident stated that he used Facebook to communicate with a friend of his and requested that the friend contact his mother and have her call the facility. The resident stated that during the night he was scared and that he did not feel safe in the care of LPN #2 and CNA #1. During an interview on 3/17/11 at 11:30 am with the RNS #1, she stated that LPN #2 came on duty, was not in a good mood and had stated that she was not in the mood to put up with Resident #2 all night. The RNS #1 stated that she informed LPN #2 that she would be on another unit and if she needed assistance to call her. The RNS #1 stated at approximately 1:30 am, LPN #2 contacted her and stated that the resident was requesting suctioning and the LPN #2 thought suctioning should only occur only once every two hours. The RNS #1 stated that she responded to the resident, confirmed that he needed suctioning and directed LPN #2 to suction him. The RNS stated that LPN #2 ignored her first directive, she again directed LPN #2 to suction the resident. LPN #2 complied at this time. The RNS #1 stated that she returned to her unit and at around 3:30 am, she received another call from LPN #2 stating that the resident was requesting suctioning. The RNS #1 stated that she responded to the resident again and, because he was in need of suctioning again, and because LPN #2 would not suction him, RNS #1 suctioned him herself rather than dealing with LPN #2. RNS #1 then told the resident to call her if he needed assistance and went back to her unit. RNS #1 stated she received a call from the resident's mother at 4:00 am, reporting that she had communicated with her son, he was afraid and was in need of suctioning. The RNS #1 stated that she remained on her unit and called LPN #2 and directed her to suction the resident upon his request. The RNS #1 stated she did not return to the unit until 6:30 am, and assumed that the situation was taken care of because she gave LPN #2 a directive and assumed that she would comply. The RNS #1 stated that she did not contact the Administrator or DON regarding the resident's statements that LPN #2 was refusing to suction him at any time during the shift because she thought the situation was taken care of. RNS #1 stated that she did not document these events. The RNS #1 stated LPN #2's refusal to provide suctioning constituted neglect, however, that she did not remove LPN #2 from duty because "it is so hard with staffing, if I remove one of the nurses, I would have to pick up the slack on that unit and residents would not be properly cared for." The RNS #1 stated that she, "was not aware of a lot of what was going on, and, I was the supervisor." The RNS #1 stated that she was unaware of the allegations that the resident's Passy-Muir valve was removed and, if his Passy-Muir valve had been removed, he would not be able to communicate to call for assistance. The RNS #1 stated that if there was a problem, she assumed that the staff would make her aware of it, "things got out of control" and she wished she could have been on that unit all night and wished that she had not trusted LPN #2 to do as she directed. During an interview on 3/17/11 at 1:50 pm, the DON stated LPN #2 had just recently become an LPN but had not worked as an LPN until she was hired by the facility in December. When questioned if the LPN had the knowledge and skills to conduct suctioning, the DON stated, "I don't know." When the surveyor requested evidence of facility verification of the LPN's competency in nursing skills, the DON stated that after a search of facility records, the competency verification could not be located and that she was not sure of LPN#2's competencies. During an interview on 3/17/11 at 3:50 pm, the Social Worker (SW) stated that on 3/4/11, the DON asked her to speak with the resident because he had complained that an LPN had refused to suction him. The SW stated that she met with Resident #2 on 3/4/11 and he reported that LPN #2 refused to suction him, refused to allow him to call his mother and that at one point LPN #2 suctioned him and told him that there would be no more suctioning this shift. The SW stated that she could tell by the resident's facial expression that he was upset. Resident #2 told the SW that this was frustrating because he has got to depend on staff for his care. The SW stated that she did not know about this incident until 3/4/11. The SW stated that she informed the DON of the information she obtained during the meeting with Resident #2. During an interview on 3/17/11 at 4:10 pm the DON stated that she was contacted on the afternoon of 2/27/11 and advised that Resident #2 made allegations that he was neglected by LPN #2. The DON stated that she contacted the Administrator and they determined that because LPN #2 was not scheduled for work on 2/27/11, they would initiate the investigation on 2/28/11. The DON stated that when she interviewed Resident #2 on 2/28/11, the resident stated LPN #2 repeatedly refused to suction him upon his request. During an interview on 3/18/11 at 1:30 pm, LPN #2 stated that she reported to work for the 11:00 pm - 7:00 am shift and had personal problems prior to arriving at work. LPN #2 stated that when she reported to work, Resident #2 was ringing his call bell a lot and she stated to her co-workers, "I am not in the mood to put up with him tonight." LPN #2 stated she received report that the resident was anxious and had just been suctioned. The LPN stated that very early in her shift she responded to the resident and noted that he was "extra phlegmy" and she had suctioned him. LPN #2 stated that the resident was continuously asking to be suctioned, however, she learned in LPN school that you should only suction once every 2 hours and she stated that she told Resident #2 this when he requested suctioning repeatedly. The LPN stated that at some point around 3:00 am, the unit started to get busy and therefore she told the resident that she would not be able to suction him for the remainder of the night. During an interview on 3/18/11 at 4:30 pm with the Administrator, she stated that staff were supposed to report any allegation of abuse, neglect or mistreatment to her immediately so that an investigation could be initiated to protect residents from potential further abuse. The Administrator stated that she was contacted at home on 2/27/11 and was informed that Resident #2 alleged that LPN #2 refused to suction the resident upon request throughout the previous evening. The Administrator stated that she and the DON decided that the DON would initiate the investigation on 2/28/11. The Administrator stated that if she were conducting the investigation, she would have immediately removed the accused, LPN #2, from care, and would have educated the RNS on the steps to take when a resident alleged abuse or neglect. The Administrator stated that maybe she should investigate all incidents of abuse, neglect or mistreatment. During an interview on 3/18/11 at 4:31 pm, the Registered Nurse Manager (RNM) for Resident #2's unit stated that on 2/28/11, Resident #2 reported to her that LPN #2 refused to suction him. The RNM stated that if LPN #2 refused to suction resident upon his request, then refused a directive by RNS #1 to suction the resident, her actions were neglectful and therefore she should have been immediately removed from resident care. The RNM stated that the RNS #1 should have removed LPN #2 from resident care. Finding #2: Resident #2 alleged that CNA #1 removed his Passy-Muir valve so that he could not speak. The facility failed to conduct an investigation into the allegation of abuse as reported by Resident #2. In a statement prepared for the investigation dated 2/27/11, the resident's mother documented that she visited the resident on 2/27/11 and the resident informed her that during the night, CNA #1 removed his Passy-Muir valve so that he could not talk. During an interview on 3/17/11 at 11:15 am, the resident stated that at some point during the night, CNA #1 removed his Passy-Muir valve so that he could not talk. The resident stated he believes that the Passy-Muir valve was removed for an hour and that he did not feel safe in the care of LPN #2 and CNA #1. During an interview on 3/17/11 at 11:30 am with the RNS #1, she stated that she was unaware of the allegations that the resident's Passy-Muir valve was removed and, if his Passy-Muir valve had been removed, he would not be able to verbally call for assistance. The RNS stated that if there was a problem, she assumed that the staff would make her aware of it, "things got out of control" and she wished she could have been on that unit all night. During an interview on 3/17/11 at 3:50 pm, the SW stated that on 3/4/11, she spoke with Resident #2 and he reported that CNA #1 removed his Passy-Muir valve so that he could not call out anymore. The SW stated that she informed the DON of the information she obtained during the meeting with Resident #2. During an interview on 3/17/11 at 4:10 pm the DON stated that when she interviewed Resident #2 on 2/28/11, the resident stated CNA #1 removed his Passy-Muir valve "so that he could not talk". The DON stated that she did not investigate the allegation against CNA #1 and stated that she believed that there was a personality conflict between the resident and CNA #1 and that she was consumed and focused on the fact that removal of a Passy-Muir valve was outside the scope of practice of a CNA. During an interview on 3/18/11 at 4:30 pm with the Administrator, she stated that the DON advised her on 2/28/11 that the resident further alleged that CNA #1 removed his Passy-Muir valve "so that he could not speak" and provided the resident's statement for her review. The administrator stated that the DON was responsible for conducting the investigation, that the DON kept her informed of the issues, and therefore, she did not assist with the investigation. The Administrator stated that this investigation was the first investigation that the DON had conducted since being hired by the facility. The Administrator stated that she showed the DON the forms that needed to be filled out, told her to interview the staff involved in the incident and to obtain statements. The Administrator stated she questioned the DON about the keeping the CNA working, stated, "I should have directed that the CNA be sent home but I didn't," because it was the DON's investigation and she relied on the DON's judgement. The Administrator stated that she did not direct the DON to discipline, counsel or reeducate any of the staff, and to her knowledge none had been done. The Administrator stated she would have initiated an investigation into the allegation that CNA #1 removed the Passy-Muir valve to prevent the resident from speaking and would have removed CNA #1 from direct care pending the outcome of the investigation. The administrator stated that maybe she should investigate all incidents of abuse, neglect or mistreatment. During an interview on 3/18/11 at 4:31 pm, the RNM stated that she interviewed the resident on 2/28/11 and he stated that CNA #1 removed his Passy-Muir valve so that he could not talk anymore. The RNM stated she did not follow up with CNA #1 regarding the allegation because she thought the Administrator and DON were investigating the allegation. Resident #1: The facility failed to thoroughly investigate injuries of unknown origin including bruises and facial lacerations. The facility failed to operationalize policies and procedures when RNS #2 failed to initiate an investigation upon discovery of injuries of unknown origin and when the IDT failed to ensure RNS #2 conducted an investigation to rule out abuse, neglect or mistreatment. Finding 1: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have severely impaired cognitive decision making skills. The Policy and Procedure (P&P) for Accident/Incident Reporting dated 11/4/10, documented that every employee had the responsibility of reporting every incident immediately to their supervisor. The Accident and Incident Report Form (I&A) was to be initiated at the time of the incident by the Charge Nurse/Supervisor. The Nurse Manager, Charge Nurse, or designated Administrative Supervisor, upon notification and receipt of the I&A, was to conduct an investigation. Completed I&A's were to be forwarded to the Director of Nursing (DON) within 24 hours after being reviewed by the Nurse Manager. The DON was to ensure that all I&A's were submitted to the Interdisciplinary Team (IDT). The IDT was to conduct a root cause analysis, followed by corrective action to be taken to prevent reoccurrence. In instances where the IDT is unable to complete a root cause analysis due to incomplete information on the I&A, the I&A was to be returned to the licensed staff member on duty at the time the incident occurred. The licensed staff member was to supply the requested information in writing to the DON by completion of his/her next scheduled shift. Upon completion of the report, the DON was to bring the I&A back to the IDT for review. The Policy and Procedure (P&P) for Abuse Prevention dated 10/3/08, documented that employees were required to report injuries of unknown origin immediately (as soon as possible, not to exceed 24 hours after discovery of the incident) to the facility administrator. The undated Comprehensive Care Plan (CCP) for Risk for Verbal or Physical Abuse documented that the resident had socially inappropriate, disruptive behaviors that were intrusive to others and was unable to assess hazardous situations. On two occasions this resident stated she was struck by other residents. One approach listed on this CCP was to observe for signs that this resident may have been a victim of unobserved abuse such as unexplained injuries. Any observations were to be reported to the charge nurse. The undated CCP for Behavioral Symptoms documented that the resident had unpredictable aggression toward others, and was resistive to care. The CCP documented several incidents of behaviors beginning 3/21/10. On 1/20/11 this resident allegedly struck another resident. On 1/28/11 the resident was combative toward staff during care. The undated CCP for Impaired Decision Making related to dementia documented that on 1/19/11 the resident was found at 8:30 (am or pm was not documented) with a bruise on the nose, dried blood, a split lip and an abrasion on her knee. Dried blood was found on her bed. A nurses note dated 1/19/11 at 1:43 pm documented that a housekeeper reported that this resident had a bloody lip. A Certified Nursing Assistant (CNA) found that the resident also had a bruise on the bridge of her nose, dried blood in her nostrils, and had skinned her right knee which was painful to touch. There was a small amount of blood on the floor next to her bed. An I&A dated 1/19/11 at 8:30 am documented that the actual location and cause of injuries was unknown. There were two boxes at the top of the form, the box next to "Fall" was circled and a question mark (?) was written in the circle. The "Observations of the event scene" section, documented that the resident was found with dry blood around her nose, a black and blue mark over her nose and an abrasion on her right knee. The resident's lip was split and had dry blood on it and droplets of blood were found on the side of the bed. The description was signed by a CNA. It was documented on this I&A that the resident was out of bed and was alert and confused. In the interventions section of the I&A, it was documented that the CNA had been interviewed. No statements from staff were attached to the I&A. The signature spaces for the DON, Physical Therapist, Safety Chairperson and the Administrator were unsigned. When the I&A was provided to the surveyor, there was a note attached to it that stated that statements were needed. The 24 Hour Supervisor's Report dated 1/19/11 documented that the resident had a bruise across her nose, a split lip, dry blood around the nose and a scrape on the right knee. The cause was unwitnessed. In the "Why on Report" section, the word "Fall" was circled and a question mark (?) was written in the circle. During an interview on 3/18/11 at 1:55 pm, RNS #2 stated he initiated an I&A on 1/19/11 for Resident #1 for an injury of unknown origin. RNS #2 stated that he had the CNA that discovered the injuries complete a portion of the I&A and then the I&A went to the IDT. RNS #2 stated that the IDT makes a determination if further investigation is necessary. RNS #2 stated that he was not directed to conduct an investigation into this incident. The RNS #2 stated that he would only begin an investigation if he deemed an allegation credible. RNS #2 stated that for lucid residents, he would investigate aggressively, but for resident's with cognitive impairment, he would first need to determine if the allegation is credible. RNS #2 then gave an example of a resident that continuously reports abuse. RNS #2 stated he would not investigate for this resident because the resident is demented. During an interview on 3/18/11 at 2:32 pm the DON stated that there was not an investigation of this resident's injuries of unknown origin on 1/19/11. When the DON reviewed the I&A, she stated that she did not know the cause of the injuries or what happened, but that the I&A read like the resident was beaten. She stated that the I&A came to the IDT but there were no statements attached to it. A note was put on the I&A that RNS#2 needed to get statements from the staff. The DON stated that she did not know why statements had not been obtained and that this should have been investigated. During an interview with the DON on 3/18/11 at 4:15 pm stated that it was expected that the nurses and the RNS's were to start I&A's for injuries of unknown origin, falls, and allegations of abuse. If abuse was observed, the offending staff member was to be removed from care and the Administrator and the DON were to be notified immediately. For injuries of unknown origin, an I&A was to be started, and the IDT, which met Monday through Friday, would review it to determine if an investigation was required. The DON stated that the I&A for the injuries on 1/19/11 were reviewed in the IDT meeting and it was determined that the RNS needed to get statements from staff. She stated that, for reasons she did not know, it appeared that the I&A was not returned to the RNS, and that an investigation was not done. Finding 2: A nurses note written by a Licensed Practical Nurse (LPN) #3 on 2/11/11 at 6:31 pm, documented that the resident was found to have a large bruise on the back of her right shoulder and arm bruises were also noted. This was a late entry for bruises found on 2/8/11, three days after finding the bruises. The LPN did not document the time that the bruises were found. The 24 Hour Supervisor's Report dated 2/8/11, documented that during the 11:00 pm to 7:00 am shift, the resident was combative. During the 3:00 pm to 11:00 pm shift (evening shift) the resident refused her shower and was combative with care. During an interview on 3/21/11 at 1:57 pm the DON stated that there was no I&A, but one should have been completed when bruises were found on this resident on 2/8/11. She also stated that an investigation should have been done into the cause of the bruises. During an interview on 3/21/11 at 2:20 pm with LPN #3, she stated that on the evening shift on 2/8/11, she found large bruises on this resident. She stated that she did not measure the bruises, did not notify the RNS, did not document this on the 24 Hour Supervisor's Report and did not complete an I&A, contrary to facility policy/procedure. She stated that she did not know what caused the bruises. She did not complete an I&A because that was only done if a nurse witnessed a fall or a resident-to-resident altercation, contrary to facility policy/procedure. During an interview with LPN#5 on 3/17/11 at 4:50 pm, she stated that if she found bruises on a resident, she would report this to an RNS or RNM. She stated that she would not write an I&A because it was her understanding that I&A's were to be completed for falls. If she saw an abuse happen, she would immediately report it to an RNS but would not complete an I&A. During an interview with LPN#4 on 3/21/11 at 5:08 pm, she stated that I&A's were primarily for falls and that injuries of unknown origin were to be reported to the RNS on duty. During an interview with LPN#6 on 3/22/11 at 9:45 am, she stated that she would report abuse immediately to the RNM, after intervening. She stated that she would not complete an I&A for abuse, because that would be done by the RNM. She also stated that if she found injuries on a resident, she would report these to the RNM. LPN#6 stated that I&A's were mostly for falls. 10NYCRR 415.4(b)(1)(ii)

Based on observation, record review and staff interview, the administrator failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being for each resident, during a partial extended abbreviated survey (#NY 285). Specifically, the administrator failed to ensure that the Abuse Prevention Program policy was operationalized and the facility failed to have systems in place to ensure thorough investigations were preformed after it was reported that Resident #1 was observed with injuries of unknown origin and Resident #2 reported allegations of abuse, neglect and mistreatment by a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA). The facility's failure to thoroughly investigate to determine if abuse and neglect had occurred placed all of the residents at risk. This resulted in no actual harm but had the potential for serious harm that is Immediate Jeopardy to residents health and safety. This is evidenced by: Abuse - F225 Scope/Severity J During an interview at 3/18/11 at 4:30 pm the Administrator stated that this investigation was the first investigation that the DON had conducted since being hired by the facility. The Administrator stated that the Director of Nurses(DON) was responsible for conducting the investigation for Resident #2 and although she received information from the DON, she did not assist the DON in the investigation, relied on the DON's judgment, and did not direct the DON to take additional action regarding the allegations that a CNA removed Resident #2's Passy-Muir valve so that he could not talk. The Administrator stated she would have immediately removed the accused LPN from care, would have educated the Registered Nurse Supervisor (RNS) on the steps to take when a resident alleged abuse or neglect and would have investigated the allegation that the CNA removed the Passy-Muir valve to prevent the resident from speaking. The Administrator stated that maybe she should investigate all incidents of abuse, neglect and maltreatment. During an interview on 3/18/11 at 2:32 pm the DON stated that an investigation of Resident #1's injuries of unknown origin on 1/19/11 was not completed. When the DON reviewed the I&A, she stated that she did not know the cause of the injuries or what happened. She stated that the I&A came to the IDT but there were no statements attached to it. A note was put on the I&A that the Registered Nurse Supervisor (RNS) needed to get statements from the staff. The DON stated that she did not know why statements had not been obtained and that this should have been investigated. The Administrator stated that she showed the DON the forms that needed to be filled out, told her to interview the staff involved in the incident and to obtain statements. 10NYCRR415.26