Every finding on record at Essex Center for Rehabilitation and Healthcare

Based on observation, record review, and interview 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 in the main kitchen and 3 of 3 nourishment kitchenettes. Specifically, surfaces were soiled with food particles, and/or dirt, equipment was not in good repair, thermometers were not in calibration, and the facility did not have the correct test kit to check the concentration of sanitizing solution used to manually sanitize food contact surfaces. This was evidenced by: All observations were on [DATE] from 12:05 PM through 1:10 PM. In the main kitchen: One of 3 food temperature thermometers was not in calibration at 37 degrees Fahrenheit when tested in the standard ice bath method. The test papers for checking the concentration of chemical sanitizer were dated [DATE] and were expired. The automatic dishwashing machine final rinse was 9 pounds per square inch of water pressure; the machine data plate information required the rinse to be between 15 and 25 pounds per square inch. The bulk sugar and bulk flour containers were not labeled. One 10-inch by 10-inch hole in the wall below the dishwashing machine and two wall tiles were missing by the spray hose in the dishwashing machine area. Water leaked from the dishwashing machine while in operation. Spray hose faucet was leaking in the dishwashing machine area. Cooking area utensil drawers would not open and close freely. The following items in the main kitchen were soiled with food particles and/or grime: Can opener holder. Stove/grill and drip pans. Utensil drawers. Shelving and moveable utensil rack. Handwashing sink. K-rated fire extinguisher. Floor next to walls and below cooking equipment. Walls, wall fan, and the ventilation duct covers in the dishwashing machine area. Piping and food grinder, floor drain, and floor below the dishwashing machine. The following items were observed in the unit nourishment kitchenettes: The cabinets and floor were soiled with food particles or dirt in the Unit 1 nourishment kitchenette. One spray bottle was not labeled in the Unit 2 nourishment kitchenette. The ice machine was not operational, and the refrigerator including the door gaskets, microwave oven, and floor were soiled with food particles in the Unit 3 nourishment kitchenette. During an interview on [DATE] at 1:10 PM, Food Service Director #1 stated that they would assign staff to label the bulk foods and to clean the items found in the kitchen and unit kitchenettes, discuss with staff about checking the thermometer calibration, contact the maintenance department to adjust the dishwashing machine water pressure, repair the ice machine, repair the faucet leak, utensil drawers, and wall holes/missing tiles, contact the vendor to the dishwashing machine leak, and contact the vendor to get new test papers for the chemical sanitizer. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, record review, and interview during the recertification survey, the facility did not ensure necessary housekeeping and maintenance services were provided to maintain a clean, sanitary, comfortable, and homelike environment on resident unit #s 1, 2, and 3 and the lobby/administrative areas. Specifically, floors and windows were not clean, and walls were not in good repair. This is evidenced by: During observations on 11/07/2024 at 10:38 AM through 11:40 AM, the floors in the following areas were soiled with dirt or were soiled dirt and cobwebs next to walls and in corners: Meeting Room. Ice Machine room. Director of Nursing office. Medical Records office. Activities room. Main Dining Room. Unit #1 Dirty Utility room. Unit #3 short hall foyer, long hall foyer, janitor closet & floor sink, electrical closet, and Clean Utility room. Resident room #s: 2, 10, 11, 12, 14, 101, 107, 112, 116, 118, 119, 120, 122, 124, 123, and 127. Additionally, the walls were scraped in room #s 101, 107, 116, 117, 122, and 124; and the window tracks were soiled with dirt and dead insects in room #s 101, 107, 119, 122, and 123. The undated document titled Housekeeping Aide Job Description documented that Housekeeping Aides were to clean resident room floors and walls daily and report maintenance issues to their supervisor. During an interview on 11/07/2024 at 11:41 AM, Director of Housekeeping #1 stated that they would clean the rooms and window tracks and would contact the maintenance department to repair the wall scrapes. 10 New York Codes, Rules, and Regulations 415.5(h)(4)

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the waste contained in dumpsters was not covered. This is evidenced by: During observations on 11/04/2024 at 1:21 PM, three of the 4 garbage dumpsters were not closed, and garbage was found within. During an interview on 11/04/2024 at 1: 29 PM, Administrator #1 stated that they would speak with staff about keeping the dumpsters closed after filling them. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation and interview during the recertification survey, the environment was not free from accident hazards over which the facility had control. Specifically, dangerous tools were left unattended in resident areas on unit 3. This is evidenced by: During observations on 11/06/2024 at 8:05 AM through 8:15 AM, an unattended maintenance tool cart with open access to tools such as screwdrivers was found on Unit #3 in the corridor by the library; a six-inch broad fixed blade knife was on the unenclosed middle tier shelf of the cart. There was no documented evidence in the facility Incident and Accident reports of residents having facility tools or getting tools off the facility tool carts for the past 6-months. The undated document titled Maintenance Assistant documented that maintenance staff were trained to place tools in storage upon leaving work areas. During an interview on 11/07/2024 at 12:09 AM, Director of Maintenance #1 stated that they brought their tool cart to the library area on Unit #3 when they were called off the unit. On route to greet a vendor they asked the Maintenance Assistant to move the cart to a secure area; moving the cart took about one minute but it was never appropriate to leave tool carts unattended even for one minute. During an interview on 11/07/2024 at 12:26 PM, Administrator #1 stated that they would expect all maintenance staff to place tool carts in secure areas when they must leave a work area. 10 New York Codes, Rules, and Regulations 415.12(h)(1)

Based on record review and interviews during a recertification survey, the facility did not ensure comprehensive care plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for 1 (Resident #84) of 20 residents reviewed. Specifically, for Resident #84, the facility did not ensure an interdisciplinary care plan meeting was held to review the comprehensive care plan. Resident #84 was admitted to the facility with the diagnoses of cerebral infarction (stroke), gastro-esophageal reflux disease and hemiplegia and hemiparesis following cerebral infarction (paralysis on one side after stroke). The Minimum Data Set (an assessment tool) dated 9/27/2024 documented the resident was usually understood, could usually understand others, and had a mild cognitive impairment. The Policy and Procedure titled Care Planning - Interdisciplinary Team dated 8/2019, documented the Interdisciplinary Team was responsible for the review and updating of care plans including inviting and encouraging the resident, the resident's family and/or the resident's legal representative/guardian or surrogate to participate in the development of and revisions to the resident's care plan. During an interview on 11/06/2024 at 9:53 AM, Resident #84 stated they, their spouse, and health home care coordinator were setting up all discharge needs on their own. During an interview on 11/06/2024 at 9:53 AM, Family Member #1 stated they had requested a meeting with the social worker but one had not been scheduled yet. Family Member #1 stated there had been no care plan meeting for the resident's entire stay. During an interview on 11/13/2024 at 8:49 AM, Social Worker #1 stated that families were called by them when scheduling a care planning meeting. They stated Resident #84 had not had a care plan meeting and one should have been held in mid-October 2024. Social Worker #1 stated that they did not understand how the resident was not scheduled for a care planning meeting at the appropriate time. 10 New York Codes, Rules, and Regulations 415.11(c)(2)(i-iii)

Based on observation, record review, and interview during a recertification survey and abbreviated survey (Case #NY00351614), the facility did not ensure it protected the resident's right to be free from abuse and neglect for one (Resident #68) of three residents reviewed. Specifically, the facility investigation determined the likely cause of the resident's elopement on 8/15/2024 was, they were placed in the locked utility room by a terminated employee. This is evidenced by: The Facility's Policy titled, Abuse last reviewed 6/01/2024 documented the following: the facility prohibits the mistreatment, neglect, abuse, and misappropriation of resident property by anyone. Resident #68 was admitted to the facility with diagnoses of dementia with behaviors, chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), and. schizoaffective disorder. The Minimum Data Set (an assessment tool) dated 10/12/2024, documented the resident could be understood, could sometimes understand, and had severely impaired cognition for daily decision making. The facility's investigation form dated 8/19/2024, documented that at approximately 4:15 PM on 8/15/2024 the resident was noticed missing from the secure locked unit with no indication of door alarms from secure locked unit. The resident was found in a non-patient care utility area that was equipped with a coded locked door. The resident had no injuries or any signs of distress or pain. The investigation team did not feel the resident would have been able to manipulate a keypad and guess the correct code to enter the locked area due to dementia. Corporate Communications contacted local news station and confirmed a Certified Nurse's Aide contacted the news station reporting a missing person. Four Aides were terminated between 2:15pm and 3:10 PM on 8/15/24. The State Police were contacted by the Administrator to investigate the possibility that a staff member may have placed the resident in the locked utility area and a formal deposition was given. During an observation on 11/08/2024 at 12:15 PM, the doors exiting Unit 3 were locked, requiring a keypad entry, or pushing the door resulting in an alarm. The first door to the boiler room was locked, requiring a keypad entry that resulted in an alarm. The second door was not locked; however, it was heavy and required significant effort to open. The room was very warm, and loud with multiple large pieces of equipment running. During an interview on11/08/2024 at 11:20 AM, Administrator #1 stated the code gray was called when the resident was discovered not on the locked unit when the evening meal was served. Prior to the discovery no door alarms had gone off indicating someone had opened the door without using the code. Administrator #1 found the resident in the locked utility/boiler room. All doors and alarms were tested and functioning. They were unable to determine how the resident could have gotten through the locked unit doors and into the locked boiler room without sounding any alarms. The local police department came to the facility to investigate a missing person reported to them by a news station. The news station was contacted and reported a Certified Nurse Aide called them to report a missing resident. There were 4 Certified Nurse Aides that were terminated at around 3:00 PM and the Administrator believed one of them came back into the building, put the resident in the boiler room and called the news station. A report was filed with the police, but they were unable to contact 3 of the terminated employees as they were out of state contracted staff, they had likely returned home, after being terminated. During an interview on 11/13/2024 at 11:20 AM, Assistant Administrator #1 stated they assisted with the investigation and follow-up after the incident. It was determined the resident did not elope but was put in the boiler room by one of the terminated staff. They stated they could not determine which staff because they did not have cameras in the facility. The policy was changed to include escorting terminated staff from the building and changing the entry codes immediately. 10 New York Codes Rules and Regulations 415.4(b)(1)(i)

Based on medical record review and interview during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of potential financial liability for rehabilitative services during a non-covered stay for 2 (Resident #s 56 and 74) of 3 resident records reviewed). Specifically, residents who remained in the facility and after receiving covered rehabilitative services were not provided with the Advance Beneficiary Notice of Noncoverage form for Medicare Part A and received timely notification (2-day notification) of the termination of Medicare Part A services with the required Notice of Medicare Non-Coverage form. This is evidenced by: There was no documented evidence that Resident #s 56 and 74 were informed of potential financial liability for rehabilitative services during a non-covered stay with the required Advance Beneficiary Notice of Noncoverage form for Medicare Part A and that the Notice of Medicare Non-Coverage form was given to Resident #56 two days prior to the termination of services. During an interview on 11/05/2024 at 11:51 AM, Minimum Date Set Coordinator #1 stated for Resident #s 56 and 74 and not knowing it was the incorrect form, their superiors directed them to use the Advance Beneficiary Notice of Noncoverage form for Medicare Part B and not the form for Medicare Part A; and they were not sure as to why the Notice of Medicare Non-Coverage form was not given to Resident #56 prior to the termination of services. 10 New York Codes, Rules, and Regulations 415.3 (g)

Based on observations, record review, and interviews during an abbreviated survey (Case #sNY00328017 and NY00340585), the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 3 residents (Resident #s 1, 3, and 7) of 7 residents reviewed for activities of daily living. Specifically, (a) Resident #1's appearance was unkempt, they were wearing only a t-shirt and brief, and their bed had a dried ring of a urine appearing substance on the incontinence pad. (b)Resident #3's fingernails were not clean, and their hair was greasy. (c)Resident #7's hair was greasy, their fingernails were not clean, and the upper right leg of their slacks was soiled. This is evidenced by: The Policy and Procedure titled Activities of Daily Living Care and Support revised 3/13/2024, documented activity of daily living care and support would be provided for residents who were unable to carry out Activities of Daily Living independently, with the consent of the resident and in accordance with the resident's assessed needs, personal preferences, and individualized plan of care, that included but not limited to supervision and assistance with hygiene (bathing, dressing, grooming, and oral care) and toileting. Resident #1 was admitted to the facility with diagnoses of post-traumatic stress disorder, vascular dementia (dementia caused by decreased blood flow to the brain), and diabetes. The Minimum Data Set (an assessment tool) dated 3/27/2024, documented the resident had severe cognitive deficit, could be understood, and could usually understand others. The Resident #3 was admitted to the facility with diagnoses of dementia, multiple sclerosis, and diabetes. The Minimum Data Set, dated dated dated [DATE], documented the resident had moderate cognitive impairment, was sometimes understood, and could usually understand others. Resident #7 was admitted to the facility with diagnoses of Alzheimer's Disease, need for assistance with personal care, and mood disorder. The Minimum Data Set, dated dated dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could sometimes understand others. Resident #1 During an observation on 5/1/2024 from 12:01 PM- 12:26 PM on Resident #1's unit, Resident #1 was unkempt, with only a brief and t-shirt on. Their abdomen and colostomy bag were exposed, and the bed pad was wet and had a dried ring of a urine appearing substance. The Comprehensive Care Plan for Required Assist with Activities of Daily Living related to dementia, being legally blind, and colostomy status was initiated on 10/19/2020. The care plan documented the resident was to have a shower/bath on the Monday and Thursday day shift. There was no documentation in the resident's care plan they refused care. The Certified Nurse Aide Kardex (documented the care a resident was to be provided) as of 5/08/2024 documented the resident was to have a shower or bath Monday and Thursday on the day shift. It did not document the resident refused care. The Document Survey Report dated 4/2024 documented the Certified Nurse Aide care provided daily on all 3 shifts. No resident care was documented as provided on the 7:00 AM- 3:00 PM shift for 4/04/2024, 4/18/2024, 4/24/2024, 4/29/2024, or 4/30/2024, on the 3:00 PM- 11:00 PM for 4/02/2024, 4/03/2024, 4/08/2024, 4/11/2024 4/20/2024, 4/22/2024, 4/23/2024, 4/24/2024, 4/25/2024, 4/27/2024, 4/28/2024, or 4/30/2024, or on the 11:00 PM- 7:00 AM shift on 4/01/2024, 4/05/2024, 4/10/2024, or 4/11/2024. Resident #3 During an observation on 5/03/2024 at 10:59 AM, Resident #3's fingernails were not clean, and their hair was greasy. The Comprehensive Care Plan for Required Assist with Activities of Daily Living related to confusion, and dementia was initiated on 5/30/2023. The following interventions were initiated by Licensed Practical Nurse #5: 5/26/2023- shower/bath Tuesday and Friday day shift. There was no documentation in the resident's care plan they refused care. The Certified Nurse Aide Kardex (documented the care a resident was to be provided) as of 5/09/2024 documented the resident was to have a shower or bath Tuesday and Friday on the day shift. It did not document the resident refused care. The Document Survey Report dated 4/2024 documented the Certified Nurse Aide care provided daily on all 3 shifts. No resident care was documented as provided on the 7:00 AM- 3:00 PM shift for 4/08/2024, 4/21/2024, 4/24/2024, or 4/28/2024, on the 3:00 PM- 11:00 PM for 4/2/2024 or 4/14/2024, or on the 11:00 PM- 7:00 AM shift on 4/01/2024, 4/03/2024, 4/6/2024, 4/07/2024, 4/15/2024, or 4/20/2024. Resident #7 During an observation on 5/03/2024 at 11:11 AM, Resident #7 was sitting in the hallway. Their hair was combed but greasy. Their fingernails were not clean, and the upper right leg of their slacks was soiled. The Comprehensive Care Plan for Required Assist with Activities of Daily Living related to confusion, and dementia was initiated on 9/14/2023. It documented the resident was to have a shower/bath Wednesday and Saturday evening shift. The Certified Nurse Aide Kardex (documented the care a resident was to be provided) as of 5/09/2024 documented the resident was to have a shower or bath Wednesday and Saturday on the evening shift. The Document Survey Report dated 4/2024 documented the Certified Nurse Aide care provided daily on all 3 shifts. No resident care was documented as provided on the 7:00 AM- 3:00 PM shift for 4/08/2024, 4/21/2024, 4/24/2024, or 4/28/2024, on the 3:00 PM- 11:00 PM for 4/02/2024, or on the 11:00 PM- 7:00 AM shift on 4/01/2024, 4/02/2024, 4/03/2024, 4/06/2024, 4/07/2024, 4/10/2024, 4/15/2024, or 4/20/2024. During an interview on 5/03/2024 at 2:16 PM, Certified Nurse Aide #3 stated the residents got nail care when they were washed up, or if they could not get it done then, they did nail care on rounds or during down time. Certified Nurse Aide #3 stated residents were showered on a schedule. Some showers were given on different shifts. When it was not a resident's shower day, they were washed up in their room. Certified Nurse Aide #3 stated if a resident refused their shower, they would tell the nurse and ask the resident if they wanted to get washed up in their room. During an interview on 5/03/2024 at 2:28 PM, Registered Nurse Unit Manager #3 stated nail care should be done when the residents were showered and as needed. They stated nail care consisted of trimming long nails, filing until smooth and cleaning under them. Registered Nurse Unit Manager #3 stated showers were scheduled for residents 1-2 times a week. They stated if a resident refused a shower, staff were supposed to reapproach and if the resident still refused, they were supposed to tell the charge nurse. If that failed, they were to tell the Unit Manager. They stated they put residents who refused their shower on the list for the next shift, or on the as needed list for the Certified Nurse Aides for the next day. During an interview on 6/10/2024 at 1:43 PM, Licensed Practical Nurse Manager #4 stated nail care was provided to the residents by Certified Nurse Aides, Nurses, and Activities staff. The residents were showered twice a week but did not always allow their hair to be washed. They stated Resident #3, who required total care chronically refused it. Sometimes staff could get the resident to the shower, other times they refused. They stated the resident could be combative with care. They stated Resident #3's care plan would need to be updated to document refusal of care. Licensed Practical Nurse #4 observed Resident #7's hair during this interview and stated it was greasy. They asked Resident #7 if they would allow them to wash their hair and Resident #7 stated yes. They stated the resident could be easily redirected and cooperative with care most of the time. They stated the all in one bodywash/shampoo did not always work to effectively clean the residents' hair. Licensed Practical Unit Manager #4 stated recently the team discussed the use of dry shampoo for in-between showers or if a resident's hair looked greasy, but they had not heard back if the facility would be ordering it. During an interview on 6/10/2024 at 2:11 PM, Director of Nursing #1 stated when a resident refused a shower, the Certified Nurse Aide was supposed to tell the nurse, make sure the reason for the refusal was documented, and then the Certified Nurse Aide was to reapproach the resident to shower them. They stated the nurse needed to know why a resident was refusing to be showered. Director of Nursing #1 stated they noticed there were quite a few residents whose hair was greasy, and they wondered if maybe it was the product they were using. They stated recently when they saw a resident with greasy hair and when asked why, resident stated they did not like to get their hair wet under the shower head. They stated they had purchased one inflatable shampoo board for each unit as an alternative to shampooing residents' hair in the shower. They approached the Administrator at the end of last week to discuss possibly ordering dry shampoo. The Director of Nursing stated any time residents were showered and whenever it was noticed residents' nails were dirty, nail care should be provided. They stated Resident #7 was cooperative with care but could be anxious and Resident #3 needed to be reapproached frequently for care due to refusals. They stated when Resident #3 said no, they meant no. The Director of Nursing stated refusals of care should be documented and there should be care plans in place for residents who refused care. 10 New York Codes, Rules, and Regulations 415.12(a)(2)

Based on record review and interviews during an abbreviated survey (Case #sNY00328017 and NY00340585), the facility did not ensure the resident had a right to personal privacy and confidentiality of their personal and medical records for 2 (Residents #1 and #2) of 2 residents reviewed for the right to personal privacy and confidentiality. Specifically, the facility did not maintain confidentially for Residents #1 and 2 when staff were texting Health Insurance Portability and Accountability Act (HIPAA)-protected information to other staff members using an application on their personal cell phones not sanctioned by the facility. This is evidenced by: The Policy and Procedure titled, Cell Phone Use last revised 10/2019, documented to maintain the privacy and confidentiality rights of our residents and to be in compliance with the Health Insurance Portability and Accountability Act, the use of any non-company issued personal electronic device, such as cellular telephones was prohibited in resident areas. Inappropriate use of a cellular device by an employee included, but is not limited to, sharing Health Insurance Portability and Accountability Act protected information via unsecured networks such as text message. Resident #1 was admitted to the facility with diagnoses of post-traumatic stress disorder (a mental health condition that's triggered by an event. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), vascular dementia (loss of memory, language, problem-solving and other thinking abilities caused by decreased blood flow to the brain), and diabetes. The Minimum Data Set (an assessment tool) dated 3/27/2024, documented the resident had severe cognitive deficit, could be understood, and could usually understand others. Resident #2 was admitted to the facility with diagnoses of epilepsy (a brain disease where nerve cells don't signal properly that causes seizures), diabetes, and chronic obstructive pulmonary disease (narrowing of airways in the lungs making it difficult to breathe). The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact, could be understood, and could understand others. During an interview 5/02/2024 at 11:36 PM, Licensed Practical Nurse #1 stated the following incident was texted to them using a texting application the facility had sent them an invitation to use the application and download it on their phone. Licensed Practical Nurse #1 read the message verbatim to the surveyor (Note: Both residents' names were written in full in the texts): - At 8:21 AM on 4/27/2024, Registered Nurse #2 texted that they had a concern regarding Residents #1 and 2. I went into a room to do an assessment (across the hall from Resident #1's room). I noticed Resident #2; they went into Resident #1's room and closed the door. After doing my assessment, I went to Resident #1's room and saw the resident lying in bed. They were already at the edge of the bed about to fall. Resident #1's shirt is up until below their breasts, their pant down up to their thighs. Resident #1 was still wearing pull up and bra on. I told them breakfast is coming and Resident #2 need to step out the room because I needed to do assessment on Resident #1. Resident #1 is back to their room now. I don't know if I need to write this up, please advise. - Then at 8:26 AM on 4/27/2024, Registered Nurse #2 texted, Resident #1 has dementia and Resident #2 I think is in the right mind. I'm also concerned Resident #1's child stops by from time to time. - At 9:31 AM on 4/27/2024, Registered Nurse #2 texted, The Certified Nurse Aide just caught them again doing the act, Resident #1 and Resident #2. ' Review of the noted texting application revealed it was not a Health Insurance Portability and Accountability Act (HIPAA)-compliant telecommunication service. During an interview on 5/03/2024 at 12:26 PM, Administrator #1 stated on 5/02/2024, they heard rumors of a sex act between Residents #1 and 2. They stated they heard a Certified Nurse Aide who no longer worked at the facility had told Certified Nurse Aide #1 about either on 4/29/2024 or 4/30/2024. They stated when they, themselves, came to the facility on [DATE], they rounded on all the units and asked questions. Administrator #1 stated the rumor was likely started from this information being shared by the staff on 4/29/2024 and 4/30/2024 as well as by the texts sent by staff that the other nurses could read. Administrator #1 stated they had started Health Insurance Portability and Accountability Act training, and that the texting application that staff were using was not sanctioned by the facility or ownership group. During an interview on 5/03/2024 at 2:09 PM, Licensed Practical Nurse #3 stated they were using a texting application they installed on their personal phone for things such as communicating with other nurses to ask if they had supplies. They stated they went to another unit to let one of the nurses know the nurse needed to be added back onto the application. Licensed Practical Nurse #3 stated they were informed that they were no longer using the application. During an interview on 5/03/2024 at 2:26 PM, Registered Nurse #2 stated they used the texting application on their personal phone. During an interview on 5/03/2024 at 2:28 PM, Registered Nurse #3 stated they did not like the staffs' use of the texting application. They stated there should have been open verbal communication. Registered Nurse Unit Manager #3 stated they did not like texts sent back and forth between staff, that it was unprofessional and a violation of the Health Insurance Portability and Accountability Act. Registered Nurse #3 stated the staff used the texting application on their personal phones, and that staff do not have work-issued cell phones. 10 New York Codes, Rules, and Regulations 415.3(d)(1)(ii)

Based on observations, record review, and interviews during an abbreviated survey (Case #s sNY00328017 and NY00340585), the facility did not ensure the resident had a right to a dignified existence for 1 (Resident #1) of 7 residents reviewed for residents' right to a dignified existence. Specifically, Resident #1's colostomy bag was exposed, their upper body was not covered, and breasts were exposed, and the resident's lower body was not appropriately clothed, as they were observed lying on their bed and walking in the hallway with only a brief on. This is evidenced by: The facility's Corporate Compliance Manual updated 7/12/2021, documented residents must be afforded their right to a dignified existence. Resident #1 was admitted to the facility with diagnoses of post-traumatic stress disorder (a mental health condition that's triggered by an event. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), vascular dementia (loss of memory, language, problem-solving and other thinking abilities caused by decreased blood flow to the brain), and diabetes. The Minimum Data Set (an assessment tool) dated 3/27/2024, documented the resident had severe cognitive deficit, could be understood, and could usually understand others. During an observation on 5/01/2024 from 12:03 PM- 12:26 PM on Resident #1's unit, Resident #1 was unkempt, with only a brief and t-shirt on. Their abdomen and colostomy bag were exposed, and the bed pad was wet and had a dried ring of a urine appearing substance. During an observation on 5/01/2024 at 1:33 PM, Resident #1 was seen in the hallway outside of their room wearing only a brief. During the afternoon of 5/03/2024, Investigator #1 stated they walked by Resident #1's room and observed their shirt pulled up with their breasts exposed. The Comprehensive Care Plan for Verbal/Physical Behaviors initiated on 8/09/2021, documented the resident may disrobe (taking their clothes off) and to redirect negative behavior as needed. The Certified Nurse Aide Kardex (an electronic system that contains directions for providing resident-specific care) as of 5/08/2024, documented to monitor/record occurrence of disrobing (taking their clothes off) and redirect the resident to their room. During an interview on 6/05/2024 at 2:16 PM, Registered Nurse #3 stated as soon as staff see Resident #1 disrobed, they would cover the resident and redirect them to their room to help them redress. They would also try to divert their attention with an activity. Registered Nurse #3 stated staff tried to find the cause that may have led to the behavior. For example, if the disrobing behavior caused by a family issue, did the resident possibly have a urinary tract infection, were they too warm, did they need to be toileted, or changed. During an interview on 6/10/2024 at 2:03 PM, Director of Nursing #1 stated Resident #1 had a history of disrobing. If the resident was observed in the hallway, staff were educated to redirect the resident to their room and help them redress. They stated the resident could become combative and staff were supposed to stay in the room with them until they were able to redress the resident since it would not be safe to leave the resident alone with their door closed. Director of Nursing #1 stated staff were educated to go into the resident's room to have them pull their shirt down if it was pulled up and their breasts were exposed. They stated they were not always on the unit so did not know if staff were consistently redirecting the resident when they exposed themselves. They stated the resident could be difficult to redirect when unclothed because Resident #1 would state they could do whatever they wanted to because of how old they were. Director of Nursing #1 stated if there was a problem redirecting the resident, they would ask other staff for assistance. 10 New York Codes, Rules, and Regulations 415.3(c)(1)(i)

Based on record review and interviews during an abbreviated survey (Case #sNY00328017 and NY00340585), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the State Survey Agency in accordance with State law through established procedures for 2 residents (Resident #1 and #2) of 2 residents reviewed for incident reporting. Specifically, an allegation of sexual abuse that involved 2 residents and alleged to have occurred on 4/27/2024 was not reported to the New York State Department of Health within 2 hours. This is evidenced by: The Policy and Procedure titled, Abuse and last revised on 12/2022, documented to notify the local law enforcement and appropriate State Agency(s) immediately (no later than 2 hours after allegation/identification of allegation) by Agency's designated process after identification of alleged/suspected incident. An addendum to the Intake Information form dated 5/06/2024, documented the facility reported the allegation of sexual abuse alleged to have occurred on 4/27/2024 to the New York State Department of Health on 5/03/2024. During an interview on 5/02/2024 at 11:36 AM, Licensed Practical Nurse #1 stated they came to work at 11:00 PM on 4/27/2024. They received a report from the evening nurse who did not work the day shift on 4/27/2024. Licensed Practical Nurse #1 stated they received information second hand about the alleged incident so the next morning (4/28/2024) they asked the staff that had been working on the day shift of 4/27/2024 what had happened. They were told by Registered Nurse #2 they had to remove Resident #2 from Resident #1's room because it looked suspicious. Resident #1 had their shirt pulled up, their brief was on, but their slacks were pulled down. Licensed Practical Nurse #1 stated they would report abuse to the Administrator who was the abuse coordinator for the facility. During an interview on 5/03/2024 at 11:27 AM, Director of Nursing #1 stated they had received no reports of a sexual act between Resident #s 1 and 2. They stated they would have expected the Complainant who reported the alleged incident to the New York State Department of Health to have reported it to facility Administration so they could have kept the residents safe. It was upsetting that the Complainant did not do that. During an interview on 5/3/2024 at 12:26 PM, Administrator #1 stated at 10:29 AM on 4/27/2024, they received a text message from Licensed Practical Nurse #2 who asked them to call Registered Nurse #2. Administrator #1 stated they attempted to call Registered Nurse #2, but they did not answer so they called Business Office Manager #1 who was the manager on duty assigned to be in the building on 4/27/2024. The Administrator asked them if they had heard about any issues on Unit 3 because they could not reach Registered Nurse #2. The Administrator stated that was when they were told that Resident #2 was found in Resident #1's room with the door closed. At that time, they notified Regional Administrator #1 and Regional Clinical Director #1 of the alleged incident. They stated they were not aware until 5/02/2024 that Resident #2 was in Resident #1's room twice with the door closed on 4/27/2024. They would have expected to be informed of both incidents. They stated as soon as staff were aware, whether by eyewitness, overhearing anything, by resident or family reports for example, staff were to contact the Director of Nursing or Administrator. The Administrator stated the facility had 2 hours to report abuse to New York State Department of Health. The Administrator stated they had called their regional team and reported that their findings were not definitive. They stated their regional team told them the incident did not meet the criteria for reporting because there was not a witness that anything had occurred. 10 New York Codes, Rules, and Regulations 415.4(b)

Based on observation, record review, and interviews during the recertification survey dated 12/11/22 through 12/19/22, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and three (3) of 3 unit kitchenettes. Specifically, the automatic dishwashing machine was not operating within the manufacturer's specifications, equipment and floors required cleaning, and the main kitchen refrigerator doors and the Unit 1 kitchenette wall were in disrepair. This is evidenced as follows: During observations on 12/11/22 at 12:12 PM, in the main kitchen drawers, shelving, roll-in refrigerator, K-rated fire extinguisher, storage room floor, top of the dishwashing machine, dishwashing machine room wall fan and ceiling vents, and the floors under cooking equipment and preparation sink and in the walk-in freezer were soiled with a black build-up or food particles. The walk-in refrigerator door would not close, and the gasket on the dairy refrigerator was split. The automatic dishwashing machine final rinse registered 190 degrees Fahrenheit (F) at 47 pounds per square inch (psi) water pressure; the automatic dishwashing machine information data plate states that the minimal final rinse water pressure is to be 20 psi (plus or minus 5 psi). During observations on 12/11/22 at 1:05 PM, the refrigerators in the Unit 1, Unit 2, and Unit 3 kitchenettes were soiled with food particles. In the Unit 1 kitchenette, the microwave oven, cabinets, fire extinguisher, and floor under the refrigerator were soiled with food particles, and the wall was peeling under the light switch. During an interview on 12/11/22 at 1:31 PM, the Administrator stated that the soiled items will be cleaned today, the facility will have the refrigerator gasket replaced, the walk-in refrigerator door will be repaired, maintenance will check the final rinse water pressure on the dishwashing machine, and the Director of Food Service will be consulted about updating the cleaning schedule. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-1.112, 14-1.113, 14-170

Based on observation, record review and interviews during the recertification survey, the facility did not ensure a clean, comfortable, and homelike environment for 2 of 3 resident units (units 1 and 2) reviewed for environment. Specifically, for Unit 1, the facility did not ensure the hallway did not have a strong odor of urine, and the floors of the hallway and main dining area were not dirty on 12/11/22. Specifically, for Unit 1, the facility did not ensure the floors in the hallway and dining area was free from dirt and debris (crumbs, tissues, small colored discs, empty, ripped plastic packaging, and sticky areas) and the hallway and dining area were free from the odor of urine and for Unit 2, the facility did not ensure the floors of the hallway were free from dirt and debris (food crumbs, and shiny/sticky areas) and the hallway and dining area had a strong odor of urine. This is evidenced by: Finding #1 For Unit 1, the facility did not ensure the floors in the hallway and dining area were free from dirt and debris (crumbs, tissues, small colored discs, empty, ripped plastic packaging, and sticky areas) and the hallway and dining area were free from the odor of urine. During observations and interviews on: - 12/11/22 at 12:06 PM, the floor in the main dining room was dirty; food crumbs, tissues, small colored discs, empty, ripped plastic packaging, and sticky areas were present on the floor. - 12/11/22 at 12:10 PM, a strong odor of urine was present in the hallway. -12/11/22 at 12:22 PM, the sitting area for residents that required assistance with meals had a strong urine odor. One resident was sitting in a chair with a bedside tray. The white floor surrounding the resident had a grey haze and was sticky. Two chairs by the desk in the area had flowered cloth seats that were discolored and spill stained seats. Interviews During an interview on 12/11/2022, Certified Nursing Assistant (CNA) #4 stated carts for soiled linen in the halls contributed to strong urine odors. Residents are changed as often as possible. Shortages on staffing limit the number of changes that can be done especially on the weekend. Housekeeping is responsible for the floors. If there are food spillage after meals, we call housekeeping to come clean but there are not a lot of staff on the weekend or at night. During an interview on 12/12/2022 at 9:30 AM, Housekeeper #1 stated the residents' rooms and bathrooms are cleaned daily. How often depends on staff. We do the best we can but a strong urine odor in the facility is common. During an interview on 12/12/2022 at 10:20 AM, Licensed Practical Nurse Unit Manager (LPNUM) #3 stated there is usually 1 CNA and 1 LPN on the unit for over 20 residents. Residents are checked and changed as often as we can. Urine odor is noticeable on most days. Floors get dirty because the residents eat in their rooms and things get spilled frequently. We are short staffed and always working to keep things clean and as odor free as possible. Finding #2 The facility did not ensure the floors of the hallway were free from dirt and debris (food crumbs, and shiny/sticky areas) and the hallway and dining area had a strong odor of urine The Unit 2 hallway and dining area had a strong odor of urine on 12/11/22 at 12:22 PM, 12/12/22 at 9:07 AM, 12/14/22 at 8:31 AM, and 12/15/22 at 10:33 AM. During observations and interviews on: - 12/11/22 at 12:22 PM, brown fluid was present on the top counter at the nursing station, multiple dirty areas were present on the floor in the hallway. - 12/12/22 at 9:07 AM, the floors were dirty, and crumbs were scattered throughout the floor between rooms 25 - 34 and near the common area. Interviews During an interview on 12/14/22 at 9:15 AM, Registered Nurse (RN) #1 stated the number of incontinent residents on Unit 2 made it very difficult to keep them all clean and dry, even when staff checked and changed them every two hours. During an interview on 12/15/22 at 12:24 PM, Certified Nurse Aid (CNA) #2 stated they noticed Unit 2 had an overall odor of urine a few days ago. They thought the odor was coming from the residents' beds. They had not reported the odor to anyone recently, but they had reported this to the Unit Manager in the past. In the past when they had reported the urine odor on the unit, the facility cleaned some of the bed mattresses. During an interview on 12/15/22 at 2:12 PM, Licensed Practical Nurse Unit Manager (LPNUM) #1 stated when they arrived on Unit 2 today, there was a strong odor of urine throughout the unit. This was not new, as family members had complained about this in the past as well. There were a lot of incontinent residents on the unit; this was the biggest source of the odor. Staff performed check and changes on these residents every 2 hours to try and manage this, but the volume of incontinent residents was very high. During an interview on 12/15/22 at 3:08 PM, the Director of Nursing (DON) stated that they had noticed that Unit 2 had a strong odor of urine, and that this had been an ongoing issue on this unit for several months. This had been a challenge to deal with, as so far none of the efforts the facility had made to improve the odor have had a lasting impact. 10 NYCRR 415.5(h)(2)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure 1 (Resident #75) of 2 residents reviewed for advance directives had the right to formulate advance directives. Specifically, Resident #75's the facility did not ensure the residents representative was court appointed under State law to act on the resident's behalf. This is evidenced by: The Policy and Procedure titled Advanced Directives, last revised 2/19, documented appropriate primary decision-makers are a conservator of the resident's person, or agent(s) named in health care proxy. Resident #75 Resident #75 was admitted to the facility with the diagnoses of autistic disorder, dysphagia, and severe intellectual disability. The Minimum Data Set (MDS - an assessment tool) dated 10/12/22, documented the resident was severely cognitively impaired, rarely/never understood others and was rarely/never understood. Resident #75's medical record did not include a Health Care Proxy (HCP), a Medical Order for Life Sustaining Treatment (MOLST) and did not include documentation regarding a conservatorship or guardianship. Resident #75's face sheet dated 6/28/2022, documented the resident's primary contact person's relationship with the resident was their caregiver. A Progress Note titled Social Service Documentation dated 10/3/22 at 3:59 PM, documented Resident #75 did not have a court appointed guardian and was not responsible for self. During an interview on 12/12/2022 at 9:25 AM, the group home care giver (GHCG) stated they were listed as a person to contact and the facility notifies them if anything is wrong with the resident. There was no legal or formal document that designated them legal guardian or health care proxy. The GHCG stated they had attended Interdisciplinary Team (IDT) Meetings (meetings with designated representatives to address care needed) and had been contacted by the facility social worker to address Resident #75's Advanced Directive. During an interview on 12/14/2022 at 1:24 PM, the Licensed Practical Nurse Unit Manager (LPNUM) #3 stated the resident had no family. The resident was admitted to the facility after an acute hospital stay. The group home that Resident #75 previously resided at was unable to care for the resident after a peg-tube (Percutaneous Endoscopic Gastrostomy tube) was placed. The person designated for decision making was a care giver at the group home. The social workers are the people who take care of legal documentation for the residents. LPNUM #3 stated the care giver was listed on Resident #75's face sheet and was notified if anything was wrong with the resident. The Director of Social Worker had just resigned and LPNUM #3 believed someone from administration was taking their place. During an interview on 12/15/22 at 11:27 AM, the Director of Admissions stated the medical record did not include documentation of who was authorized to make decisions for Resident #75. During an interview on 12/15/22 at 11:45 AM, the Administrator stated the facility did not have any documentation stating who is authorized to be the decision maker for Resident #75. The Administrator an ethics committee would be convened to discuss Resident #75. 10NYCRR 415.3(c)(1)(iii)

Based on observation, record review, and interview during the recertification and an abbreviated survey (Case #NY00289586), conducted on 12/11/2022 through 12/16/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs for 3 (Resident #'s 11, 22, and #48) of 22 residents reviewed for Comprehensive Care Plans (CCPs). Specifically, for Resident #11, the facility did not ensure a CCP required to address urinary incontinence was implemented as goals and interventions changed; for Resident #22, did not ensure a CCP that addressed the resident's right lower leg cellulitis requiring treatment was implemented; and for Resident #48, did not ensure a low bed was provided as of 12/14/22, as documented on their care plan. This is evidenced by: The Policy and Procedure (P&P) titled Care Plans - Comprehensive, revised 10/2019, documented the comprehensive, person-centered care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #11: Resident #11 was admitted to the facility with diagnoses of anemia, urine retention, and ulcerative colitis. The Minimum Data Set (MDS - an assessment tool) dated 10/11/22, documented the resident was cognitively intact, was usually able to understand others and was usually able to make themselves understood. A Provider Note dated 1/13/2022 documented the following: Burning with urination, repeat urine culture, first contaminated, monitor for chills and fever, urinary retention with incomplete emptying, formerly with Foley catheter since removed, remains on Oxybutynin (urinary antispasmodic) and use of Pure wick urinary collection system at HS (hour of sleep). A physician's order dated 9/23/2021 documented the following: Apply Pure wick Collection System at HS for urine collection and skin breakdown at bedtime. An electronic Treatment Administration Record (e-TAR) for January 2022, documented the following: Apply Pure wick Collection System at HS for urine collection and skin breakdown at bedtime. Start date 9/23/2021 - End Date 4/11/2022 An MDS dated [DATE] documented Resident #11's care did not include an indwelling catheter for diagnosis of neurogenic bladder. A Provider Note dated 1/13/2022 documented the following: Burning with urination, repeat urine culture, first contaminated, monitor for chills and fever, urinary retention with incomplete emptying, remains on Oxybutynin, Pure wick collection system for urine collection and skin breakdown and urinary incontinence. The e-TAR for October 2022 documented the following: Apply Pure wick Collection System everyday shift for urine collection and skin breakdown and urinary incontinence, remove when getting out of bed. Start date 10/07/2022 - End Date 10/26/2022 The e-TAR for October 2022 documented the following: Apply Pure wick Collection System at HS for urine collection and skin breakdown at bedtime. Start date 10/07/2022 - End Date 10/26/2022 The CCP for urinary incontinence did not include documentation of current goals and interventions from October 2022 after discontinuation of a system that was used to maintain urinary collection and skin breakdown. During an interview on 12/14/2022 at 1:35 PM, the Licensed Practical Nurse Unit Manager (LPNUM) #3 stated the resident had history of urinary tract infections and incontinence. The resident came in with a Foley catheter that was removed after a UTI and the facility began using a new system for incontinence care for Resident #11. That system did not involve indwelling placement of a catheter. The system was discontinued in October 2022 and 2-hour toileting was put in place. The residents CCP for urinary incontinence had not addressed the changes made. The LPNUM #3 could not do CCP, and the Registered Nurses (RNs) were responsible for the implementation and changes needed for the residents CCP's. The changes needed are discussed in Interdisciplinary Team (IDT) Meetings and hopefully updated as necessary. During an interview on 12/14/2022 at 4:35 PM, the Assistant Director of Nursing (ADON)stated there had been many staff changes and the CCP had been identified as an area that required attention. The residents CCP needed to be reviewed and updated with current treatment and goals when this changes. The current CCP for urinary incontinence had not included changes made for Resident #11 to evaluate if the residents' goals were being met as changes occurred. Resident #22 Resident #22 was admitted to the facility with diagnoses of venous insufficiency, edema, and osteoarthrosis. The Minimum Data Set (MDS - an assessment tool) dated 11/20/22, documented the resident was cognitively intact, was able to understand others and was able to make themselves understood. A CCP signed as initiated by LPNUM #3 on 10/21/22 for Infection Cellulitis to Right Lower Extremity (RLE). The CCP did not include follow up with goals and interventions to address cellulitis or infection of the RLE as the RN had not signed off on the CCP as needed to implement the CCP. Resident #22 was receiving treatment with compression therapy for the unresolved condition. During an observation on 12/14/2022 at 2:23 PM, Registered Nurse #5 provided wound care to Resident #22. Treatment to both the RLE and LLE was completed as ordered and wrapped with ace wraps. The e-TAR for 12/2022 documented the following: RLE cleanse with Normal Saline (NS) and gently pat dry, Apply Eucerin cream with compression therapy. A Nursing Progress note dated 12/8/2022 documented the following: A weekly skin monitoring has been complete for Resident #22. The resident has previously noted skin alteration(s). Left lower leg (front) - LLE is improving with the current treatment. Mild to moderate serosanguinous discharge noted. No greenish discharge noted. No foul smell noted., Right lower leg (front) - RLE is stable with the current treatment. WCTM (wound care team meeting). During an interview on 12/14/2022 at 1:45 PM, LPNUM #3 stated the resident had history of vascular ulcers. The residents CCP for cellulitis had been put in place by LPNUM #3 but could not be completed until an RN assessed the skin, reviewed the treatment and added resident specific goals and interventions needed for the residents CCP. The LPNUM #3 could not provide documentation to support the CCP for RLE cellulitis had been completed. During an interview on 12/14/2022 at 4:55 PM, the Assistant Director of Nursing (ADON) reviewed Resident #22's CCP for RLE cellulitis. The ADON could not provide any further documentation to support the residents CCP had been addressed by an RN. LPNs cannot complete a CCP because that requires a resident assessment. A CCP for the resident's diagnosis of right lower extremity cellulitis should have been implemented at the time it was discovered. Resident #48: Resident #48 was admitted to the facility with diagnoses of repeated falls, dementia, and osteoporosis. The MDS dated [DATE], documented the resident had severely impaired cognition, was usually able to understand others and was able to make themselves understood. The Fall Risk Evaluation, dated 10/31/22 at 7:30 PM, documented for a low bed to be initiated as an intervention to decrease the risk for falls. The CCP for falls, revised 11/20/22, did not include a low bed as a fall prevention intervention. During an observation on 12/14/22 at 11:07 AM, Resident #48 had a one of the facilities regular beds. During an interview on 12/14/22 at 11:07 AM, Certified Nursing Assistant (CNA) #1 stated they were not aware of a low bed currently being used for Resident #48. CNA #1 confirmed with one of the nurses, the bed currently in use in Resident #48's room was one of the facility's regular beds, and not a low bed. During an interview on 12/15/22 at 1:50 PM, LPNUM #1 stated after a resident falls, any follow up interventions that were documented in the Fall Risk Evaluation needed to be documented in the resident's CCP and implemented as soon as the CCP was updated. They reviewed Resident #48's CCP and stated there was no documentation of a low bed as a fall prevention intervention. On 10/31/22, the low bed intervention should have been added to Resident #48's care plan and communicated to the unit manager or supervisor when it was added. During an interview on 12/15/22 at 2:43 PM, the Director of Nursing (DON) stated after a fall, any new interventions needed to be added to the CCP and implemented immediately. On 10/31/22, the low bed should have been added to the CCP and provided for Resident #48 as soon as the bed was available. If there were any issues obtaining a bed, or if the resident refused the low bed, a progress note should have been written; there was no documentation of the resident refusing the low bed or staff attempting to obtain the low bed. 10 NYCRR 415.11(c)(1)

Based on interviews during the recertification survey dated 12/11/22 through 12/19/22, the facility did not notify The New York State Department of Health (NYSDOH) of an occurrence where the health and safety of residents are endangered. Specifically, the facility did not ensure the facility's investigative report was submitted to the NYSDOH no later than 5 days of a fire incident. This is evidenced as follows: A document titled Emergency Prep last updated on 2/2020 documented the following: POLICY: The facility has a designated procedure for fires and explosions that shall be followed if such an emergency arises. Staff receives training at least annually on fire procedures (R.A.C.E.) and the use of fire extinguishers a. All employees are trained to utilize the R.A.C.E. Procedure and notify the Fire Department of the exact circumstances of the situation. b. All staff receives training in the proper use of fire extinguishers. Fire extinguishers are located in every corridor of the facility. The extinguishers, type A, B, or C, can be utilized on these classes of fire within the facility. c. When a fire is discovered, begin firefighting procedures if it is safe to do so. Safety is the first priority. Do not endanger your personal safety or the lives of others trying to extinguish the fire. d. Do not try to extinguish the fire if it is spreading rapidly or the area is too hot, too smoky, or otherwise too dangerous (e.g., because of collapsing walls or falling debris). e. Activate the ICS to manage the incident, if necessary. The most qualified staff member (in regard to the Incident Command System) on duty at the time assumes the Incident Commander position. f. Notify 911 to alert the emergency response system that an emergency situation is in progress. Provide the 911 dispatcher with as much relevant information as possible. g. Notify the Administrator and Director of Nursing if they are not on the premises. During Resident Council interviews on 12/12/22 at 10:41 AM, Resident #9 and Resident #59 stated they heard there was a fire in a trash can in the basement during the night shift about a month ago. Resident #9 and Resident #61 stated they smelled smoke that evening. Resident #9 stated that a Code Red was not made and residents were not directly informed by staff that there was a fire. Resident #9 stated this was reported to the Ombudsman who investigated the incident. Resident #9 stated the residents were concerned that the fire had not been reported. During an interview on 12/13/2022 at 8:30 AM, the facilities Ombudsman stated residents had reported smelling smoke over a month ago and expressed concerns that staff may be smoking in the facility at night. Further investigation by them provided evidence that a possible fire event had occurred in the basement. The exact day and time of the event was not provided and details of what had happened was unclear. The Ombudsman stated they had spoken with the Administrator (ADMIN) who was aware an event had occurred. During an interview on 12/12/22 at 3:16 PM, the Director of Maintenance (DM) stated that on 11/22/22 during the evening shift, the Licensed Practical Nurse (LPN) for Unit #3 smelled something coming from the basement, on further investigation LPN #3 went down to the basement with 2 other staff members and found a trash can in the mechanical room was smoldering. No Alarms had activated and the staff members immediately put it out using the mechanical room fire extinguisher. The DM was notified as was the ADMIN, and both responded to the facility within 15 minutes. The Fire Department was notified and felt there was no need to come to the facility. The State Police were notified, at the suggestion of the Fire Department, to rule out suspicions of wrong doing. No code Red had been called. Employees had followed protocol and an investigation was started to determine the cause. The DM was not aware if any residents expressed concern or if they were aware of the incident. During an interview on 12/12/22 at 3:34 PM, the ADMIN stated that on the evening of 11/22/22 they were notified of a possible fire incident at the facility and responded by immediately going to the facility. After smelling smoke on Unit #3, Staff investigated and had found a plastic garbage can with debris smoldering in the mechanical room. No open flame was reported but the staff used a fire extinguisher in that room to ensure no fire would occur. The ADMIN called 911 asking for a Chief Fire Officer who declined to respond at that time. The Fire Department is a voluntary department and the facilities emergency alarm had not alarmed prior to staff containment with use of the fire extinguisher. State Police were notified to investigate the fire incident in the basement that evening to rule out accident or deliberate setting of a fire. The facility was conducting an investigation and was waiting to hear back from the State Police on their investigation of how it occurred. The Administrator stated that the facility did not notify New York State Department of Health (NYSDOH) of this incident. The ADMIN had not been aware this was required. 10 NYCRR 415.4(b)(2)

Based on observations, interviews and record reviews during a recertification and an abbreviated survey (Case #NY00298692), survey 12/11/2022 through 12/19/2022, 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 1 (Resident #47) of 5 residents reviewed for ADL's. Specifically, for Resident #47, who required extensive assistance of staff for ADL care, the facility did not ensure the resident was received showers and had their hair washed as documented on the resident's care plan. This is evidenced by: The Policy and Procedure (P&P) titled ADL Support, dated 10/2019 documented, residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out ADL's independently will receive services necessary to maintain good nutrition, grooming and personal and oral hygiene in accordance with the plan of care. The Policy and Procedure (P&P) titled ADL- Personal Hygiene dated 10/2021 documented, resident bath or shower will be scheduled per resident preference but at least weekly per the unit shower schedule and a bed bath will be provided on non-shower days. The Policy and Procedure (P&P) titled ADL- Bath (Shower) dated 7/2019 documented it was facility's policy to shower residents, to cleanse and refresh the resident, observe skin, and to provide increased circulation. The Policy and Procedure (P&P) titled Charting and Documentation - Certified Nursing Assistant (CNA) dated 2/2020 documented CNAs are encouraged to document care as close to completion of task as possible, if not, must be documented by the end of the shift. Resident #47: Resident #47 was admitted to the facility with diagnoses of cerebral vascular accident (CVA), diabetes mellitus, and hypertension. The Minimum Data Set (MDS= an assessment tool) dated 10/1/2022 documented the resident had severe cognitive impairment and was sometimes able to make their needs known. The Comprehensive Care Plan (CCP) titled, Activities of Daily Living documented the resident required extensive assistance of one staff member with bathing and dressing, and showers were scheduled on Wednesdays and Saturdays on the 7AM-3PM shift. The document titled CNA accountability dated 12/14/2022 at 9:30 AM documented the resident was provided a bed bath, with extensive assistance of one staff. This document was requested on 12/14/2022 at 3:51 PM and was provided by the facility on 12/15/2022 at 10:16 AM. On 12/14/2022 at 10:30 AM, the electronic medical record documented that a shower was provided and was signed by CNA #3 at 9:32 AM. During an interview on 12/14/2022 at 10:25 AM, Licensed Practical Nurse (LPN) #2 said residents' hair should be washed during the shower, if a shower was refused a bed bath should be provided instead. On 12/14/2022 at 10:36 AM, Resident #47 was in a wheelchair leaned forward and resting their head on the nurse's desk, their hair was uncombed and appeared greasy. LPN #2 asked resident #47 if they had their hair washed that morning during their shower, and resident #47 lifted their head and responded no, what shower? During an interview on 12/14/2022 at 10:36 AM, Resident #47 said they had not had a shower or bed bath before going to therapy that morning. During an interview on 12/14/2022 at 10:41 AM, LPN #2 said the resident was not showered and did not have their hair washed. Staff should have showered and washed resident #47's hair as per the shower schedule and the CCP. Staff should not have signed that the shower was done at 9:32 AM when it was not done. During an interview on 12/14/2022 at 10:43 AM, CNA #3 said they did not give resident #47 a shower but did give a bed bath that morning. When questioned as to why they signed for a shower at 9:32 AM, CNA #3 said they signed for all care at the same time. During an interview on 12/14/2022 at 1:44 PM, RNUM #1 said staff have been reminded to document all care provided before the end of the shift, however staff should never document for care before it was provided, pre documenting is unacceptable, reeducation is needed. During an interview on 12/14/2022 at 2:13 PM, RNUM #1 said before lunch today, resident #47 requested to have their hair washed but refused a shower. Resident #47 said they were tired and in pain after having physical therapy that morning. RNUM#1 said the resident was medicated for pain, hair was washed and after lunch went back to bed to rest. On 12/14/2022 at 2:20 PM, Resident #47 was observed in bed, appeared to be sleeping, hair appeared to have been washed and combed and did not look greasy. During an interview on 12/15/2022 at 11:30 AM, the Administrator said residents should receive showers as scheduled. The unit managers were responsible to monitor the shower schedules to ensure resident care was provided and documented. Resident care should be provided and then documented, it is not acceptable to document that care was provided before it was done, this would result in disciplinary action and reeducation. During an interview on 12/15/2022 at 11:48 AM, the Assistant Director of Nursing (ADON)/Nurse Educator said washing of resident's hair should be included with the shower unless specified not to wash hair, for example, if a resident attends the hairdresser regularly. If a shower was refused or not given for any reason staff should have reported this to their supervisor and documented in the electronic record that the shower was not provided and the reason why. During an interview on 12/15/2022 at 11:55 AM, the ADON/Nurse Educator said the CNAs should document the care provided by the end of the shift, and should never document care before it was provided, that is falsifying documentation. The unit managers monitor CNAs documentation and should report concerns to the nurse educator for follow up and further education. 10NYCRR415.12(a)(3)

Based on observation, record review, and interviews during a COVID-19 Focused Infection Control Survey on 11/04/2021 through 11/8/2021, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of COVID-19 on 1 (Unit 3) of 3 units reviewed. Specifically, the facility did not ensure staff assigned to and providing care for a resident with confirmed [CONDITION(S)]-CoV-2 Infection (COVID positive) wore the NIOSH approved N95 mask that they were fit tested with, did not ensure staff performed hand hygiene prior to and after providing care to a resident with a confirmed [CONDITION(S)]-CoV-2 Infection, before gathering personal protective equipment (PPE) from multipurpose isolation carts before and after providing resident care, after adjusting the placement of their surgical mask and after donning (put on), doffing (take off)) and disposing of PPE, and performed proper donning and doffing of PPE prior to entering and exiting a resident who was COVID-19 positive's room. This is evidenced by: 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 10/14/2021, documented the resident had moderate cognitive impairment for daily decision making. The resident was tested for COVID on 10/28/2021 and a [CONDITION(S)]-CoV-2 Infection was confirmed. The New York State Department of Health (NYSDOH) Health Advisory titled COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities dated 3/13/2020 and revised 7/10/2020, documents that when there are confirmed COVID-19 positive cases in a nursing home: All residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e., do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The Center for Disease Control (CDC) guidance titled Transmission-Based Precautions (undated), documented: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and properly discarding before exiting the patient room is done to contain pathogens. The Centers for Disease Control and Prevention (CDC) guidance titled Using Personal Protective Equipment (PPE), updated 8/19/2020, documents that gloves and gown shall be removed (doffed) before exiting a patient's room and hand hygiene performed thereafter. (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. The Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, dated 2/23/2021, recommended the following additional strategies to minimize chances for exposure to COVID-19: Hand Hygiene: HCP [healthcare personnel] should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. Per CDC guidance, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 3/29/21, recommended PPE when caring for residents with suspected or confirmed COVID-19 includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection The CDC guidance updated 9/10/2021, titled Infection Control for Nursing Homes Nursing Homes and Long-Term Care Facilities, Summary of Recent Changes Recommendations supplement CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic and are specific for nursing homes, including skilled nursing facilities is as follows: Health care Professionals (HCP) caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 Infection should use full PPE (gowns, gloves, eye protection, and a NIOSH- Approved N95 or equivalent or higher respirator). The Centers for Disease Control Infection Control Guidance dated 9/10/2021 documented that Health Care Personnel (HCP) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). A facility policy titled Hand Hygiene, last revised 12/2019 documented, it is expected that staff wash/sanitize hands before donning (put on) and after doffing PPE, before and after each task. Hands are to be washed with water and soap or alcohol-based hand sanitizer for 20 seconds creating friction to all surfaces, including palms, back, fingers and under nails. Hand hygiene should be performed before and after glove use. Hand hygiene is the final step after removing PPE. During an observation on Unit #3 on 11/04/2021 at 12:25 PM, Certified Nursing Assistant (CNA) #2 delivered a food tray to Resident #1 who was in their room with the door closed in the red zone (COVID designated zone). After placing the food tray on an overbed table outside the room, CNA #2 gathered a gown, white mask, and face shield from the isolation cart, placed the items on top of the trash bin outside the room, removed gloves from the isolation cart outside another room and continued to don and doff the PPE. CNA #2 was wearing a blue surgical mask that was on when entering the red zone, applied the white mask over the surgical mask, applied the face shield, and gloves. CNA #2 did not perform hand hygiene. CNA #2 picked up the food tray on the outside overbed table and then entered the room. The resident's door was left open, and CNA #2 was observed adjusting the residents' position with a pillow prior to setting up the resident's meal tray. CNA #2 did not perform hand hygiene prior to gathering the PPE and donning PPE before entering the room. A sign posted on the door of Resident #1's room instructed staff entering to hand wash and don PPE which included an N95 NIOSH face mask and face shield. A sign posted on the wall 2 rooms before Resident #1's room, designated the rooms beyond that point as the Red Zone. Hand sanitizer was available on the isolation cart and on the wall one room past Resident #1's room. During an observation on Unit #3 on 11/04/2021 at 12:45 PM, CNA #2 exited Resident #1's room wearing all PPE donned before entering the room. CNA #2 closed the door to the room before removing the gloves used while giving direct contact care. CNA #2 removed their gloves by pulling the first glove off from the fingertips and removed the second glove by pulling the glove off from the top of the fingers with the ungloved hand. Hand hygiene was not performed after glove removal. CNA #2 then doffed the used gown by untying the back of the gown and pulling the gown off using their ungloved hands while holding the gloves, put the used gown in the trash container outside the room, pushed the gown down in the trash container with ungloved hands, removed the face shield and outer white mask, lifted the top of the trash container with ungloved hands and put them in the trash container. CNA #2 adjusted the surgical mask covering their face. No hand washing was performed after doffing and disposing of the used PPE or adjusting the surgical mask. CNA #2 left the Red zone which separated the COVID positive resident rooms from the COVID negative resident rooms without performing hand hygiene. During observation of direct care of a resident that was positive for COVID positive on 11/4/2021 between 12:25 PM and 12:45 PM, CNA #2 was observed to be wearing a white mask that looped directly over the ears and bore markings identifying it as a KN95 mask. The mask was not marked identifying it as a N95, NIOSH mask. The mask was observed to be removed from the isolation cart outside Resident #1 in the designated Red Zone. A form titled Respiratory Fit Test dated 10/15/2021, provided by the Administrator documented CNA #2 passed a fit test. The form was signed by the Infection Control Registered Nurse (ICRN) and documented the following information: Fit check, negative pressure, passed with initials AR, ICRN) other, mask documented was Kn95. The form did not include documentation of an N95 NIOSH. CNA #2 last name was incorrect on the form but was signed by CNA #2 and dated 10/15/2021. Three other staff members who were fit tested had the same documentation recording as passed with a Kn95 mask and the form did not include documentation of an N95 NIOSH approved mask. A progress note dated 10/28/2021 in Resident #1's medical record documented Resident #1 tested positive for COVID at the ER (emergency room ). During an interview on 11/04/21 at 10:50 AM, the Director of Nursing (DON) stated there were currently three residents in the facility that were positive for COVID-19 and on isolation. The positive residents on isolation were on Unit #3 at the end of the hall that was designated as the Red Zone with a sign to alert staff. A fourth resident was also housed on Unit #3 and was on quarantine for a positive exposure. The doors to these room were always kept closed during care. Dedicated staff was caring for the positive residents and were required to wear full PPE for direct care which included an N95 mask, gown, gloves, and a face shield or goggles before entering the room and remove all PPE before leaving the positive residents' room. Signage was placed on the door and walls of those rooms with instructions on PPE donning and doffing. Isolation carts for those COVID positive residents with the need for supplies were placed outside each room. During an interview on 11/4/2021 at 12:50 PM, CNA #2 stated, I don't want to wash my hands using the sanitizer on top of the isolation cart, it may be contaminated because the resident has COVID. I use the pump at the end of the hall past the Red Zone. CNA #2 stated they were a contract person and had only been at the facility for three weeks. CNA #2 stated they were assigned to the hall that had COVID positive residents and were aware that PPE was required. CNA #2 stated I try to do the residents that are COVID negative first and then take care of the residents on isolation and quarantine. CNA #2 stated in-services were done, and signs were on the door, but donning and doffing was confusing, and no one was available to help when the staff must gown and glove to enter a room or take things off when leaving the room. The trash receptacle was full, so I pushed it down with my hand. No one told me the door needed to be closed while I was just setting up the food tray or that PPE needed to be taken off in the room. The trash can is outside the door. CNA #2 stated they didn't think the door handle needed to be wiped because she/he had gloves on. CNA #2 then wiped the door handle. CNA #2 stated the facility fit tested the CNA and gave CNA #2 a mask to wear if CNA #2 was to care for a resident who was COVID positive. CNA #2 stated the mask they were fit tested for had not been used for Resident #1. I used the ones in the cart, no one told me I had to use the other one. CNA #2 was not able to identify the type of mask they were fit tested for. During an interview on 11/4/2021 at 12:58 PM, the Administrator stated staff should wash their hands immediately after leaving a resident's room whether they have COVID or not. The trash receptacles outside the room are for the used PPE and once the PPE is placed in the trash receptacle staff should immediately wash their hands. Inservice is given to every employee. The Administrator stated they were not sure who provides in-services with contract staff and that CNA #2 would need to be reeducated. During an interview on 11/4/2021 at 1:10 PM, the Licensed Practical Nurse Unit Manager (LPNUM) #1 stated the Cart Nurse for the hall where the COVID positive resident rooms are should be monitoring the staff to ensure PPE protocol is followed. The CNA's decided who was going to do that end of the hall. All staff are aware that caring for residents' that are COVID positive requires passing a fit test for an N95 facemask and training on proper donning and doffing of PPE. LPNUM #1 stated that it was not their job to monitor staff for that. During an interview on 11/4/2021 at 1:18 PM, the LPN #1 Cart Nurse for the COVID designated hallway stated it is not my responsibility to monitor staff for proper use of PPE. If I see them doing something the wrong, I will let them know, but I am in and out of rooms passing medications and doing treatments and can't watch everything. The LPNUM oversees that. I don't know who made the assignments, but the people who care for the COVID positive residents need to be fit tested , have an N-95 mask, and PPE before going in the room. Handwashing should also be done before going in the isolation cart to remove items needed and performed when leaving the room. Hand washing should be the last thing you do when you dispose of your PPE in the trash. Donning should be done before going in the room and doffing should be done before exiting the room, however the receptacles for used PPE are in the hall. During an interview on 11/04/2021 at 1:45 PM, the Infection Control Registered Nurse (ICRN) stated all staff were expected to perform hand hygiene before donning and after doffing PPE and before touching a clean multi-resident use area such as a linen cart or PPE cart. The ICRN stated CNA #2 would need to be reeducated on donning and doffing PPE. The ICRN was not sure what training CNA #2 was given before beginning employment or if CNA #2 was fit tested and provided an N-95 mask, but the masks and gowns and instructions were on the unit. If a staff member was going to care for a resident who was COVID positive, they needed to be fit tested . The LPNUM should have been monitoring staff for compliance with the facilities regulation. The ICRN stated they were the person responsible to place the masks in the isolation carts and could not identify what mask CNA #2 was given and was unsure what masks were being put in the isolation carts outside the Covid positive residents room. The carts would need to be checked to ensure the NIOSH N95 mask were the only masks being kept there. The isolation carts were for use for the resident's who were COVID positive. COVID positive and were placed in the Red Zone. During an interview on 11/4/2021 at 2:30 PM, the Director of Nursing (DON) stated the Unit Managers should be monitoring the staff for proper application of PPE. If someone is observed not following the infection control protocol going in and out of rooms, they need immediate correction. We are currently looking for a Registered Nurse Unit Manager to better monitor staff. The DON stated staff had been fit tested for N95 masks by the Administrator. The DON could not identify what masks were being used by staff. Only the staff that passed the fit test for an N95 mask could take care of the residents who were COVID positive. During a follow up interview on 11/4/2021 at 3:00 PM, the ICRN stated they assisted the Administrator in fit testing the staff when the COVID outbreak took place. I am not sure what mask was given to CNA #2; I would have to look at the test. Only those fitted for N95 were to care for the residents' who were COVID positive. The ICRN stated she fills the carts daily with masks, could not identify what masks were in the isolation carts, and was not sure what masks had been used for fit testing. The ICRN brought in several types of masks the facility was using but stated there was confusion about masks. When assignments are made for the day the Unit Managers should make sure the CNA's caring for the residents' who are COVID positive have the right mask. CNA #2 was removed from caring for all residents in the Red Zone today after it was identified that the mask used to care for the residents who were COVID positive was not the one approved on the fit test and was not the one provided to CNA #2 at that time. During an interview on 11/04/2021 at 4:30 PM, the Administrator stated the type of masks documented on the Fit test form for CNA #2 and several other staff was recorded incorrectly. It documented Kn95 because that was what the box the masks were in was marked. Had they looked at the mask they would have realized the proper masks had N95 NIOSH printed on them. We initially fit tested when COVID began and could not get those masks. When the outbreak happened in October, we retested staff with various masks that were currently available. Even though the documentation on the form documented Kn95, staff were given the type of N95 mask that they passed (the fit test) on. Only staff that were fit tested and passed could care for residents' who were COVID positive. Direct care staff were supposed to use the NIOSH approved N95 mask they were given. CNA #2 had not used the correct mask. All the KN95 masks were removed from the isolation carts outside the COVID positive rooms to prevent further confusion and CNA #2 needs to be reeducated. 10 NYCRR 415.19(a)(1) 10 NYCRR 415.19(b)(4), 400.2

Based on record review and observation during an abbreviated survey (Case #NY 693) the facility did not ensure the resident's right to be free from abuse for 1 (Resident #5) of 5 residents reviewed for abuse. Specifically, the facility did not ensure Resident #5 was free from abuse when Certified Nursing Assistant (CNA) #1 lifted and twisted the resident's right arm behind the resident's back and pushed the resident down the hall from behind. This is evidenced by: The Policy and Procedure (P&P) for Abuse dated 9/2012, with a revision date of 2/2019 documented the facility prohibited the mistreatment, neglect, and abuse of residents. Physical abuse included holding roughly, kicking, hitting, slapping, pinching, scratching, spitting. It also included controlling behavior through corporal punishment. Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 4/6/2021 documented the resident had severe cognitive impairment and sometimes could make self-understood and understand others. The Comprehensive Care Plan (CCP) dated 10/17/18 documented the resident had confusion and that for all activities of daily living (ADL) including wandering on the Unit staff were to explain what they were going to be doing and to provide verbal prompting and cueing. A written statement dated 5/3/21 at 5:20 PM by Activity Aide (AA #1), and included with the facility investigation, documented Resident #5 was trying to exit Unit 2 and AA #1 was trying to redirect the resident away from the door and calm the resident. While still at the doors with the resident, CNA #1 approached the resident and took a hold of the resident's wrists. The CNA escorted the resident down the hallway while still holding the resident's wrists. The resident yelled out and spat in the CNA's face. When the CNA let go of the resident's wrist the resident approached Licensed Practical Nurse (LPN) #1 to show the LPN their wrists. A Registered Nurse (RN) assessment dated [DATE] at 9:41 AM, written by RN #1, documented there was no bruising, redness or swelling of Resident #5's wrists, and the resident did not verbalize any injury or pain at that time. When RN #1 touched the resident's right wrist, the resident flinched away from the RN. This was reported to the physician and requested an X-ray of the right wrist. A Nursing Progress Note dated 5/4/2021 at 8:15 PM, written by RN #1, documented Resident #5 was seen by Nurse Practitioner (NP) #1 who ordered the resident to have both wrists X-rayed. The facility investigation dated 5/4/2021 documented that CNA #1 redirected Resident #5 away from an exit door by pulling the resident down the hallway by the wrists. A skin assessment was completed and there was slight swelling. The facility's conclusion was that the abuse allegation was founded based on CNA #1's statement that the CNA pushed Resident #5 down the hall by the wrists. During an interview on 5/13/2021 at 1:17 PM Registered Nurse Unit Manager (RNUM) #1 stated Activities Aide (AA) #1 witnessed CNA #1 pulling Resident #5 back onto the Unit by the resident's wrists. During an interview on 5/21/21 at 1:10 PM Activity Aide (AA #1) stated Resident #5 was pushing on the door to Unit 2. AA #1 began to redirect the resident when CNA #1 grabbed the resident's wrists and, while facing one another, forcefully pushed the resident backwards down the hall. CNA #1 had a tight grip on the resident's skin and twisted the skin back and forth, and the resident screamed in pain and spat in CNA #1's face. Then CNA #1 spun the resident around and twisted the resident's right arm behind the resident's back and lifted the arm so that the resident's hand was in the middle of their back and pushed the resident down the hall from behind. Resident #5 again screamed in pain. When they got to the nurse's station CNA #1 let go of the resident. CNA #1 stood at the nurse's station shaking and told Resident #5 that if they were not a resident, the CNA would have punched the resident for spitting in the CNA's face. Resident #5 showed the LPN #1 their wrist. During an interview on 5/13/2021 at 12:20 PM the Administrator (ADM) stated an investigation was completed and determined CNA #1 abused Resident #5. CNA #1 admitted grabbing the resident's wrists and pushed the resident down the hallway, which was abuse. 10 NYCRR 415.4 (b)(1)(i)

Based on staff interviews and record review conducted during an abbreviated survey (Case #s NY 407 and NY 057) the facility did not ensure that required documentation was sent to the receiving provider in a hospital transfer for 2 (Resident #s 12 and 4) of 3 residents reviewed for transfers. Specifically, for Resident #s 12 and 4, transfer paperwork did not accompany the resident to the hospital. This was evidenced by: The facility policy on Transfer/Discharge Process dated 3/2018 documented that, when a resident was transferred or discharged from the facility, pertinent information regarding the transfer/discharge was to be documented in the medical record, including a summary of the resident's current medical status. For transfers to the hospital, the nurse was to ensure the appropriate details of the hospital transfer were documented in the resident's medical record. The hospital receiving the resident was to be provided with all needed information to ensure a safe and effective transition of care, including pertinent lab results, and the current medical/physical/psychosocial condition. Resident #12: Resident #12 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact. The Transfer to the Hospital Form dated 10/4/20 at 9:00 PM by RN #2 documented the reason for the transfer was abnormal kidney function, and the relevant diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #12's record revealed there was no transfer summary, and nursing progress notes from 10/2/20 through 10/4/20 lacked documentation of the resident's pending labs, and current condition. During an interview on 10/28/20 at 11:58 AM the hospital Physician's Assistant (PA) stated that, when Resident #12 was transferred to the hospital, only a transfer form that documented critical labs came with the resident. The PA also stated a transfer summary, nursing notes, and medication and treatment administration records should have been sent with the resident on transfer to the hospital so hospital staff would know what was happening with the resident. During an interview on 10/16/20 at 11:35 AM with the Director of Nursing (DON) and the ADM, the DON reviewed Resident #12's medical record and stated there was no nursing progress notes from 10/2/20 through 10/4/20, and there was no transfer summary, there was only a transfer form that documented the resident had abnormal labs. She also stated there was no documentation of what records or documents were sent to the hospital on 10/4/20 in the resident's record, and she was not sure what documentation was sent with the resident when Resident #12 was transferred to the hospital. During an interview on 10/16/20 at 11:25 AM the Administrator (ADM) stated that when a resident was transferred to the hospital, Physician (MD) orders, progress notes and other necessary information should be sent with the resident. Resident #4: Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the resident had severely impaired cognition, could make him/herself understood and could understand others. A complaint from an unnamed source documented that on 11/30/2020, Resident #4 was brought to the hospital on a stretcher a by Certified Nursing Aide (CNA). There was no nurse report called ahead of time to let the hospital know the resident was coming, and no paperwork came with the resident, and the CNA who brought the resident was not able to tell hospital staff the resident's name. When paperwork did arrive, there was no nursing home-to-hospital transfer report form. An undated, unsigned facility investigation documented that on 11/30/20 Licensed Practical Nurse (LPN) #4 notified the DON that Resident #4 was in respiratory distress and was sent to the hospital without medical paperwork including the Medical Orders for Life-Sustaining Treatment (MOLST), which arrived 1 to 2 minutes after the resident was transferred to the emergency room . During an interview on 12/9/20 at 12:40 PM the Director of Nursing (DON) stated LPN #4 called her to report Resident #4 was not doing well and she wanted a video call with the resident. Resident #4 looked like he/she was in respiratory distress and she instructed LPN #4 to call the hospital and ask if it would be ok to transport the resident through the breezeway connecting the facility with the hospital. LPN #4 sent the resident to the hospital with CNA #s 1 and 2. LPN #4 stayed behind to prepare the paperwork and took it to the hospital shortly thereafter. During an interview on 12/9/20 at 3:24 PM CNA #1 stated she Resident #4 was unable to take a breath and was pale. She got LPN #4 who put oxygen (O2) on the resident and called the DON. LPN #4 instructed her CNA #2 to take Resident #4 to the hospital through the breezeway. When CNA #s 1 and 2 arrived at the hospital, they reported that Resident #12's paperwork was on the way. During an interview on 12/11/20 at 3:10 PM LPN #4 stated Resident #4 was having difficulty breathing. LPN #4 applied oxygen on the resident and then called the DON. LPN #4 stated he instructed CNA #1 and #2 to quickly bring the resident over to the hospital. LPN #4 stated he stayed back to prepare the paperwork and brought it over within a couple minutes. 415.3(h)(1)(i)(a-c)

Based on record review and staff interview for an abbreviated survey (Case #NY 162), the facility did not ensure each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used without adequate monitoring. Specifically, for Resident #2, the facility did not ensure the resident received regular blood tests (PT/INRs) to monitor how quickly the resident's blood clotted while the resident was receiving [MEDICATION NAME], an oral anticoagulation medication prescribed for the treatment of [REDACTED]. The resident received [MEDICATION NAME] without monitoring from admission to the facility post hospitalization on [DATE] through 4/13/18 resulting in the administration of a medication to counteract the potential overdose of the [MEDICATION NAME] and subsequent hospitalization . This is evidenced by: Refer to F Tag 635 Resident #2: The resident was admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact. The Policy and Procedure (P&P) for Orders for Anticoagulation (use of a blood thinner) revised on 4/2015, documented the physician would order PT/INRs for [MEDICATION NAME] use daily upon initiation of [MEDICATION NAME] until stable; then two-three times weekly until a stable dosage is reached; then at least weekly for one month. The P&P for Admissions and Re-Admissions to the Facility, updated in (MONTH) (YEAR), documented that prior to, or at the time of admission, the facility needed routine care orders to maintain or improve the resident's function. The hospital Medication Administration Record [REDACTED]. The hospital Discharge Summary dated 3/23/18, documented a PT/INR was to be drawn on 3/26/18 and 3/29/18 and the results faxed to the healthcare provider. The goal for the therapeutic level of the INR was 2-3. The resident was discharged to the facility on [MEDICATION NAME] 4 mg, one tablet daily. A physician's orders [REDACTED]. There were no physicians orders for PT/INRs to be drawn on 3/26/18 and 3/29/18. The Comprehensive Care Plan (CCP) initiated on 3/26/18, by the Registered Nurse Unit Manager (RNUM), for the risk of bleeding secondary to nonsteroidal anti-[MEDICAL CONDITION] drugs (such as [MEDICATION NAME], Aleve, etc.) and anticoagulant use documented the resident would be free from side effects of anticoagulant medications, and lab values would be within normal limits. The PT/INR was to be monitored and the physician notified of abnormal findings. Review of medical record did not include documentation that PT/INRs were done prior to 4/14/18, when the resident presented with coffee ground emesis (vomit), dark colored stool, and bleeding gums. A physician's orders [REDACTED]. The next laboratory draw date was 4/11/18. The resident's medical record did not include documented evidence that an INR was drawn on 4/11/18. A Laboratory Requisition slip dated 4/13/18, documented the request for a PT/INR and that the PT/INR was obtained on 4/14/18. The results of the PT/INR done on 4/14/18 at 5:21 pm, were 136.6 (PT- normal range 11.8- 14.3), 14.69 (INR). The goal for the therapeutic level of the INR was 2-3. A Nurse's Note dated 4/14/18 at 7:13 pm, written by the Registered Nurse Supervisor (RNS), documented lab results for the PT/INR were received. The INR was 14.69. The provider on-call was notified immediately. an order for [REDACTED]. The Medication Assistance Records (MARs) for (MONTH) (YEAR)-April (YEAR), documented the resident was administered [MEDICATION NAME] 4 mg by mouth every evening from 3/24/18-4/13/18. It was not administered on 4/14/18 based on the PT/INR results. A Nurse's Note dated 4/15/18 at 7:33 am, written by the Director of Nursing (DON), documented the resident had coffee ground emesis and black stool that had started on 4/14/18. The resident was lethargic, had increased weakness, was nauseated, had diarrhea, and had been vomiting. The symptoms had worsened and the resident was sent to the hospital. The hospital lab results dated 4/15/18 at 10:52 am, documented the resident's Hemoglobin (the red blood cells that carry oxygen to the body's tissues) was 7.2. The normal range was 12.0-16.9. The Hematocrit (the volume of red blood cells in the total blood volume) was 21.8. The normal range was 36.0%-46.0%. A Nurse's Note dated 4/15/18 at 12:20 pm, written by the RNS, documented the hospital notified the facility the resident was being admitted for a low Hemoglobin and Hematocrit. The lab results on 4/15/18, documented the resident received 2 blood [MEDICAL CONDITION] in the hospital on [DATE], The hospital Discharge Summary dated 4/20/18, documented the discharge [DIAGNOSES REDACTED]. During an interview on 5/3/18 at 4:40 pm, the RNUM stated the 3/26/18 and 3/29/18 lab orders for the PT/INR on the hospital Discharge Summary were never entered into the computer. She did the resident's admission and entered the hospital discharge orders, but missed the PT/INR orders. During an interview on 5/4/18 at 10:21 am, the Director of Nursing (DON) stated the RNUM did the resident's 3/23/18 admission assessment and orders and was ultimately responsible for reviewing, and calling the physician for orders. The RNUM was also responsible for tracking [MEDICATION NAME] dosing and PT/INR results in the [MEDICATION NAME] tracking book. Lab work was drawn every Wednesday by the hospital lab staff. During an interview on 5/4/18 at 11:06 am, the resident stated she had recently been started on [MEDICATION NAME] when she was in the hospital (in March), because she had blood clots in her lungs. She stated when she was admitted to the facility, her [MEDICATION NAME] was not monitored and it caused her issues. She stated when she asked the RNUM why she wasn't getting lab work done, she told her, It's being done every Wednesday. At first, when she started vomiting, staff told her she had a GI bug. She was sent to the hospital the day after she started vomiting (4/15/18). Prior to 4/14/18, there was no documented lab work for PT/INR monitoring. During an interview on 5/4/18 at 2:19 pm, MD #1, who shared Medical Director responsibilities, stated he would have wanted the resident's PT/INR checked within a few days of admission. He stated it would have been reasonable to draw the PT/INR on 3/26/18 and 3/29/18. He stated the long delay in checking the resident's PT/INR was unacceptable and could have led to the resident's GI bleeding. When he ordered the PT/INR on 4/9/18, he would have expected it to be drawn on the next regular lab day (4/11/18). During an interview on 5/7/18 at 8:59 am, the Lab Team Leader stated routine labs for the facility are drawn on Wednesdays; however, a phlebotomist (a person qualified to draw blood) can go to the facility any time a lab draw is needed. She stated the resident's blood was drawn for a PT/INR on 4/14/18 by the nursing home nurse and dropped off at 4:55 pm. The results were done at 5:21 pm and called to the RNS at that time. During an interview on 5/7/18 at 1:30 pm, the RNUM stated the MD ordered a weekly PT/INR on 4/9/18 when he saw the resident for her admission physical. The RNUM did not know why a lab requisition for the PT/INR was not completed for the next lab day, 4/11/18, but was aware the lab wasn't done that date. She stated the lab told her they were short of help; however, the resident could have been taken to the lab for her blood work, or a nurse could have drawn the blood and taken it to the lab. She wrote a lab requisition for the lab on 4/13/18. On 4/14/18, she just happened to stop by the facility. The staff reported to her the resident had coffee ground emesis and dark stools. It was about lunch time when she was there. When she went to see the resident, she witnessed the resident dabbing at her gums with a napkin because they were bleeding. A PT/INR was done, and the results were 14.69. She stated the resident had refused PT/INR draws prior to 4/14/18, but she did not document the refusals. She stated on 4/14/18, she explained to the resident the importance of having the PT/INR done. During an interview on 5/7/18 at 1:57 pm, Licensed Practical Nurse #2 stated she worked from 7:00 am-3:00 pm on 4/14/18. The resident vomited what looked like coffee grounds. She called the MD at approximately 9:00 or 10:00 am. The MD ordered a PT/INR. During an interview on 5/7/18 at 2:18 pm, LPN #1 stated she took the blood right to the lab after LPN #2 drew it. She stated she delivered it sometime between 12 noon and 3:00 pm. She put it in the bin where the sign stated to place specimens. The lab called and said they couldn't find it, so she told them where it was. During an interview on 5/7/18 at 3:07 pm, the DON stated the 4/9/18 order for the PT/INR should have been drawn on 4/11/18. It was missed. During an interview on 6/6/18 at 1:56 pm, LPN #2 stated the RNUM had told her on 4/14/18, that the resident had been refusing the PT/INR lab draws prior to that time. When the RNUM told her this, she didn't realize at that time, there were no orders for the PT/INR (until 4/9/18), and there were no lab requisitions for a PT/INR to be drawn; therefore, the resident couldn't have refused to have the lab work done. When she called the on-call provider on 4/14/18, she reported to him the resident had brown emesis and dark, loose diarrhea and he ordered the PT/INR. During an interview on 6/6/18 at 4:18 pm, the Registered Nurse Supervisor (RNS) stated she worked on 4/14/18. She was notified the lab could not find the resident's blood specimen for the PT/INR. Eventually, it was located and she received the results at approximately 5:30 pm. She called the on-call provider, Nurse Practitioner (NP) #3, who ordered Vitamin K and stated he wanted the resident to eat leafy greens. She stated that because the resident was not bleeding at the time she reported the INR results to the NP, he did not send her to the hospital, and said to continue monitoring her. She stated when she received the lab results, staff told her the resident had vomited earlier in the day. During an interview on 6/13/18 at 11:14 am, the Medical Director stated he was very concerned about this incident because of the lack of monitoring. The order for the PT/INR should have been written from the hospital discharge summary, and completed as ordered (3/26/18 and 3/29/18). When a person is taking an anticoagulant, it takes longer for bleeding to stop if they are injured, or have other medical issues that could cause bleeding. The resident's elevated INR contributed to her bleeding more, than if she had not been on an anticoagulant. He stated if he had been called on 4/14/18, he would have ordered a PT/INR and a Complete Blood Count (CBC) to check for [MEDICAL CONDITION] (low hematocrit and hemoglobin). 10 NYCRR 415.12(l)(1)

Based on record review and staff interview during an abbreviated survey (Case # NY 162), the facility did not ensure it notified the physician in a timely manner when there is a significant change in the resident's physical status (a deterioration in health in either life threatening conditions or clinical complications) for one (Resident #1) of three residents reviewed. Specifically, for Resident #1, the facility did not notify the physician for direction regarding a change in condition noted on [DATE] regarding 2 toes on the resident's right foot and for subsequent changes in condition of the toes on [DATE], [DATE], [DATE], [DATE] and on [DATE]. The resident was seen by the physician on [DATE] for a routine monthly provider visit and an urgent vascular consult and a blood thinner were ordered. The resident was seen by the vascular physician for consult on [DATE], sent to the hospital and admitted . This is evidenced by: Refer to F842-D: Resident records Resident #1: The resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact. The Policy and Procedure for Change in a Resident's Condition or Status (undated), documented that licensed nursing staff, will notify the attending physician or on-call physician when there was a significant change in the resident's physical condition. A significant change in condition was defined as a change in the resident's status that would not normally resolve itself without intervention, or by implementing standard disease related clinical interventions. A Registered Nurse (RN) or the Charge Nurse will document the information relative to the changes in the resident's medical condition in the medical record. A Comprehensive Care Plan (CCP) initiated on [DATE], titled Resident is at risk for impaired skin integrity related to Diabetes Mellitus, fragile skin, [MEDICAL CONDITION] documented an intervention to report to MD any signs of deterioration or significant change to area of impairment. A Comprehensive Care Plan (CCP) initiated on [DATE], for history of lower extremity vascular wounds (wounds caused by poor circulation), included interventions for wound care as ordered by the MD (medical doctor), monitoring, and reporting changes such as deterioration of the wound, or pain. A Nurses Note dated [DATE] at 10:35 pm, written by Licensed Practical Nurse (LPN) #1, documented the resident appeared to have bruising on the tip of the right big toe and second toe. A Nurses Note dated [DATE] at 12:16 pm, written by LPN #2, documented the right foot near the toes was slightly swollen with some redness noted. No source of injury noted. Registered Nurse (RN) was made aware. Will continue to monitor for changes. A Nurses Note dated [DATE] at 3:58 pm, written by LPN #1, documented the resident's right foot appeared swollen and red near the toes, cool to touch, and two bruises noted on the big toe and second toe. Fourth toe appeared to have a soft fluid like area on the side and tip of the toe. Orders from the Nurse Practitioner (NP) dated [DATE], documented to apply skin prep (a skin protectant) to the right first and second toes for wound prevention, and a Derma Gauze Hydrogel dressing to the left first, and right third toes every evening for vascular wounds. A Nurses Note dated [DATE] at 9:38 pm, written by LPN #1, documented the big toe, second, and fourth toes remained a black/purple color. A Nurses Note dated [DATE] at 9:51 pm, written by LPN #1, documented the left toes appeared to have a purple tint bilaterally. The third toe had a small pea size area that appeared to be fluid filled. A Care Plan Meeting held on [DATE] at 12:00 noon, for a Quarterly review, did not include documentation regarding the changes in condition of the resident's toes. A Nurses Note dated [DATE] at 10:59 pm, written by LPN #1, documented the resident's left foot big toe appeared to have increased purple/black coloring as well as toe 2, 3 and 4. The resident stated they were sore. An RN (Registered Nurse) Assessment Nurses Note (late entry note) dated [DATE] at 12:29 pm, written by the Registered Nurse Unit Manager (RNUM), documented the resident's left foot was cool to touch and had pulses. The resident's left great toe, second, and fourth toes had a small amount of light purple bruising that was improved from last week's wound rounds. The Routine Monthly Provider Visit Note dated [DATE], written by MD #1 documented the resident was complaining of right foot pain and has some ischemic (restriction in blood supply to tissues) digits on the right toes seemingly early stages of perhaps dry gangrene (condition that occurs when body tissue dies and needs immediate treatment). It is painful. He has second, third along with fifth distal phalangeal (toe) necrosis (dead) that are dry not wet, and cold to touch. Seemingly, an ischemic digit, likely vascular. A vascular consult will be obtained as soon as possible within this week. The MD discussed the importance of urgency with nursing. [MEDICATION NAME] (a blood thinner) was ordered due to the poor circulation in the resident's toes. A Nurses Note dated [DATE] at 12:33 pm, written by the RNUM, documented the left foot was red, cool to touch, and the resident complained of pain with palpation of pulses. Pulses present. The resident's left first, second, and fourth toes were black and necrotic. MD at bedside and a vascular consult was ordered. A General Nursing Note dated [DATE] at 1:35 pm, documented the resident would see the vascular doctor today. A Nurses Note dated [DATE] at 11:33 am, written by the RNUM, documented the vascular surgeon notified the facility that the resident was being admitted to the hospital for further evaluation of right foot. The hospital Discharge Summary dated [DATE], documented the resident's [DIAGNOSES REDACTED]. Options for treatment included an above the knee amputation, or comfort care. The resident declined surgery knowing it would potentially shorten his life. The resident was discharged and returned to the facility on comfort care. A Nurses Note dated [DATE] at 12:17 pm, written by the RNUM documented the resident was readmitted to the facility on comfort care, post-hospitalization for an acute ischemic foot. The resident's right great toe, 2nd, 3rd, and 4th toes were necrotic, and pulses were absent. The resident complained of severe pain and was prescribed [MEDICATION NAME] (a narcotic pain medication) every four hours for pain. A Progress Note dated [DATE] at 12:20 pm, written by the Social Worker, documented the resident repeatedly told her he wanted to get the surgery; there was no choice because he did not want his leg to get worse. The SW documented the resident understood his decision, and possible outcome. The nurse would notify the MD. A Nurses Note dated [DATE] at 5:01 pm, written by the Director of Nursing (DON), documented the resident was transferred to the hospital for the above the knee amputation. The Hospital Discharge Summary dated [DATE], documented the resident underwent [REDACTED]. The discharge [DIAGNOSES REDACTED]. A hospital Nurses Note dated [DATE] at 10:15 pm, written by the (Registered Nurse) RN, documented the resident died at 10:00 pm. During an interview on [DATE] at 2:48 pm, the RNUM stated she had looked at the resident's toes prior to [DATE], because she was worried, but did not document an assessment or call the MD. When she assessed the resident's toes on [DATE], she stated they looked like they had been run over by a wheelchair, but did not notify the MD. She stated somebody probably should have called the MD on [DATE], when it was documented the RN was made aware, then the MD could have seen the resident sooner. During an interview on [DATE] at 3:25 pm, the Director of Nursing (DON) stated LPNs should be reporting changes in condition to an RN. The Registered Nurse Supervisor (RNS) obtained orders from the NP for the treatment of [REDACTED]. There was a lack of RN follow up. During an interview on [DATE] at 2:05 pm, MD #1 stated that when the MD visit was made on [DATE], an emergency vascular consult was ordered, and if the resident could not see the vascular doctor immediately, the resident was to be sent to the emergency room . MD #1 stated he was not notified of the resident's change in condition prior to the [DATE] visit. If he had been notified sooner, more could have been done to slow the progression of the gangrene. A vascular consult and vascular studies could have been ordered and completed sooner. The order for [MEDICATION NAME] was a drop in the bucket, compared to what could have been done for the resident if the MD had been notified during the developing stages of the illness. There was a need to explore communication between nursing and the medical providers. During an interview on [DATE] at 1:59 pm, LPN #1, who worked 3:00 pm-11:00 pm, stated she had initially reported the concern regarding the resident's toes to the RNUM on [DATE]. She told her several times over the course of a few weeks. She stated LPNs can call the MD with concerns, but she did not, because she thought LPN #2, who worked the 7:00 am-3:00 pm shift, had notified the MD. During an interview on [DATE], LPN #2, who worked 7:00 am-3:00 pm, stated she reported the resident's discolored toes to the RNUM. She stated some time went by before any action was taken. LPNs can call the MD with resident problems, but she did not call the doctor because she had reported it to the RNUM and thought she would follow-up. During an interview on [DATE] at 11:31 am, the Medical Director stated nursing should have reported the discoloration of the resident's toes on [DATE]. He stated the LPN should have reported the change to an RN on [DATE], and the RN should have assessed, documented, and called the doctor. He stated it was human error; Each person thinking another had called the doctor. He stated staff education was needed for detecting subtle changes in a resident's condition that should be reported to the doctor. 415.3(e)(2)(ii)(b)

br>Based on medical record review and staff interviews during a recertification survey, the facility failed to provide a Quality Assessment and Assurance (QAA) Program that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents. Specifically, the facility QAA program failed to identify that there was not effective systems in place to ensure residents who were identified as at risk for unsafe wandering and elopement, were accurately and timely assessed, care planned in a timely manner and monitored in a timely manner. This resulted in no actual harm, but there was a potential for serious harm for all residents in the facility and this resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This was evidenced by: Refer to F 309 - Quality of Care - Scope/Severity K During an interview on 8/18/15 at 4:50 pm, the Director of Nursing (DON) stated that the former Administrator was the chairperson for the Quality Assurance Committee (QAC), however, she had participated in the QAC. The DON stated the system in which residents are assessed, care planned and monitored for elopement risk had not been an issue identified by QAC. The DON stated that a mock survey in June 2015 resulted in the new Elopement Risk Evaluation Form being used for all new residents. 10 NYCRR 415.27(a-c)

br>Based on medical record review and staff interviews, during an abbreviated survey, it was determined that the facility failed to be 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 effective systems were in place to ensure residents who were identified as at risk for unsafe wandering and elopement, were accurately and timely assessed, care planned in a timely manner and monitored in a timely manner. This resulted in no actual harm, but there was a potential for serious harm for all residents in the facility and this resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This was evidenced by: Refer to F 309 - Quality of Care - Scope/Severity K Refer to F 520 - Quality Assessment and Assurance - Scope/Severity K During an interview on 8/17/15 at 10:00 am, the Acting Administrator (AA) and Director of Nursing (DON) provided a Transponder Book and stated that the residents listed identified all of the resident's in the facility who have been issued transponders for unsafe wandering/elopement risk. Review of the Transponder List on 8/17/15 against the Order Listing Report dated 8/3/15 for Transponders revealed that Resident #7 and Resident #8 were identified on the transponder list however did not appear on the Order Listing Report. In an interview on 8/17/15 at 4:15, the AA stated that she took over the position in the afternoon on 8/7/15. The AA stated that while in her corporate position on 8/3/15, she ran a computer report of all residents who had orders for transponder monitoring and assumed that the list included all resident's in the facility who were identified as at risk for wandering. The AA stated that the list was forwarded to each of the Unit Managers to ensure all systems were in place for residents at risk for wandering. The AA stated that she had not followed up with the Nurse Managers. In an interview on 8/18/15 at 12:25 pm, the Acting Administrator stated the form (Elopement Risk Evaluation Form) is very difficult to interpret and it is being worked on today. 10 NYCRR 415.26

Based on observation, record review and staff interviews, during an abbreviated survey (NY 685), the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well-being in accordance with the comprehensive assessment and plan of care. Specifically, the facility failed to ensure that effective systems were in place to ensure residents who were identified as at risk for unsafe wandering and elopement, were accurately and timely assessed, care planned in a timely manner and monitored in a timely manner. Inaccurate elopement risk assessments were identified for two (2) (Resident #'s 3 and #8) of eight (8) residents, two (2) (Resident #'s 7 and 8) of the eight (8) residents reviewed and identified as at risk for unsafe wandering, did not have timely care plans and five (5) (Resident #'s 2, 5, 6, 7 and #8) of eight (8) residents reviewed and identified as at risk for elopement, were not being monitored timely, and specifically three (3) (Resident #'s 5,7 and #8) were not being monitored at the time of the on-site survey. This resulted in no actual harm, but there was a potential for serious harm for all residents in the facility and this resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. The Policy and Procedure titled Elopement, Risk Prevention and the Management of Missing Residents initiated on 7/15/14 and last updated in August 2015, documented that the facility maintains a process to assess all residents for risk of elopement, implement prevention strategies for those identified as an elopement risk, institute measures for the resident identification at the time of admission, and conduct a missing resident procedure. The Policy guidelines for the Evaluation of Risk, Procedural Component, documents that an elopement risk evaluation is completed by the nursing staff on all residents on admission, re-admissions, quarterly and upon a change of condition. The policy documented that a facility-approved risk evaluation scoring tool is utilized. The evaluation is based on various risk factors that may precipitate an elopement event and the risk score includes defined parameters. If the total score on the elopement risk evaluation tool is ten (10) or greater, the resident should be considered at risk for elopement and prevention protocols should be followed and documented in the care plan. The Elopement Risk Evaluation Form instructs that residents should be assessed for elopement risk status in seven (7) clinical areas (Mobility, Mental stability, Emotional status, History of Elopement Attempts, Behavior Modification, Medications (antipathetic, Mood Altering), Diseases (Dementia, any type mental illness), which best describe the resident in the appropriate assessment column. The numbers in the columns should be added to obtain the total score. If the total score is ten (10) or greater, the resident should be considered at risk (for elopement), and prevention protocols should be followed and documented on the care plan. The Policy Prevention interventions for Elopement included; implementation of a wander bracelet, safety locks or key pad entry that restricts access to dangerous areas, door alarm codes are changed routinely, and each resident alert device is checked every shift for placement and weekly for functioning, and documented in the Medication Administration Record [REDACTED]. Additionally, prevention strategies are listed in each resident's plan of care and reviewed by the interdisciplinary team on at least a quarterly basis, or with a change in condition, for effectiveness of prevention strategies. The review of the eight (8) resident records reviewed revealed two (2) different forms were utilized to assess residents' risk for elopement. One form titled Elopement Risk Evaluation, undated, is as described above. (Resident #'s 3, 5 and #6) The other form titled Elopement Risk Assessment, undated, lists four categories for assessment; A. Mobility Status (Is the resident independently mobile with or without assistive devices?), B. Background History of Elopement, C. Potential Exposure Review ([DIAGNOSES REDACTED]. Overall Assessment (total number of yes and no responses from B and C above) and E. Plan of Care (Code Alert Transponder applied?) (Resident #'s 2, 5, 7, and #8) Finding #1 Two (2) (Resident #'s 7 and 8) of eight (8) residents reviewed were identified as at risk for unsafe wandering, however, these resident did not have timely care plans. The Policy and Procedure titled Elopement, Risk Prevention and the Management of Missing Residents initiated on 7/15/14 and last updated in August 2015, documented interventions that included, implementation of a wander bracelet, safety locks or key pad entry that restricts access to dangerous areas, door alarm codes are changed routinely and each resident alert device is checked every shift for placement and weekly for functioning and documented in the Medication Administration Record [REDACTED]. Additionally, prevention strategies are listed in each resident's plan of care and reviewed by the interdisciplinary team on at least a quarterly basis, or with a change in condition for effectiveness of prevention strategies. During an interview on 8/17/15 at 10:00 am, the Acting Administrator (AA) and Director of Nursing (DON) provided a Transponder Book and stated that the residents listed identified all of the residents' in the facility who have been issued transponders for unsafe wandering/elopement risk. Review of the Transponder List on 8/17/15, against the Order Listing Report for Transponders dated 8/3/15, revealed that Resident #7 and Resident #8 were identified on the transponder list, however, did not appear on the Order Listing Report. In an interview on 8/17/15 at 4:15, the AA stated that while in her corporate position on 8/3/15, she ran a computer report of all residents who had orders for transponder monitoring and assumed that the list included all residents in the facility who were identified as at risk for wandering/elopement. The AA stated that the list was forwarded to each of the Unit Managers to ensure all systems were in place for residents at risk for wandering/elopement. The AA stated that she had not followed up with the Nurse Managers. Resident #7 The resident was admitted to the facility on [DATE], diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5/15, severe impaired cognition. The Elopement Risk Assessment form dated 1/13/15, indicated that a code transponder was applied. Review of the Treatment Administration Records, revealed the monitoring for placement of the transponder every shift, was not initiated until 8/17/15. The Comprehensive Care Plan (CCP) dated 8/17/15, documented the Potential for Elopement due to Dementia and unsafe wandering. Actions documented on the CCP included a transponder and to check every shift to ensure transponder is in place. In an interview on 8/17/15 at 11:35 am, LPN #2 was asked if Resident #7 had a transponder, LPN #2 reviewed the computer and stated there were no monitoring orders in place, so she would have to check. LPN #2 took the surveyor to the resident's room, and after observing both ankles, found a transponder on her left ankle. In an interview on 8/17/15 at 2:45 pm, the Acting Administrator and Director of Nursing stated that it was the Unit Managers responsibility to assess the residents risk for elopement and if indicated to apply a transponder, establish a care plan and enter the orders into the computer for the monitoring the resident each shift. Resident #8: The resident was admitted to the facility on [DATE], diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13/15, cognitively intact. The Elopement Risk assessment dated [DATE], documented five (5) categories of assessment; Mobility Status, Background History of Elopement, Potential Exposure Review, Overall Assessment and Plan of Care. Each category had a corresponding YES or NO column. The resident's Mobility Status documented an X in the NO column. The Mobility Status column directions state that when the answer to whether the resident is independently mobile with or without assistance is NO, do not proceed further. Therefore there were no documented entries in the categories for; Background History of Elopement, Potential Exposure Review, Overall Assessment and Plan of Care. The Plan of Care section of this form asks whether Code Alert transponder applied? with columns for staff to enter an X for YES or an X for NO. This column documented an X for YES and an X with a strikethrough and error in the no column. The Comprehensive Care Plan (CCP) dated 7/22/15, documented the potential for elopement, due to exit seeking behavior and Dementia. It documented a transponder to the left ankle. The resident was observed on 8/17/15 at 1:35 pm, with a transponder noted on the left ankle. Review of Treatment Administration Records, revealed the monitoring for placement of the transponder every shift, was not initiated until 8/17/15. During an interview on 8/17/15 at 11:00 am, LPN #1 stated that she was the nurse assigned to Resident #8 and when asked if the resident had a transponder, LPN #1 reviewed the computer and stated that there were no monitoring orders so she did not think so, but did not know, and the resident was out at an appointment. During an interview on 8/17/15 at 11:05 am, the Unit Manager stated that Resident #8 had a care plan for elopement/wandering and was not sure if Resident #8 had a transponder on. The Unit Manager stated that the resident was at an appointment outside of the facility and we would need to check upon his return. During an interview on 8/17/18 at 2:30 pm, the Assistant Director of Nursing (ADON) stated that she conducted the Elopement Risk Assessment on 5/12/15 and found the resident not at risk. The ADON reviewed the Elopement Risk Assessment and stated that she could not explain why there was a strikethrough, and notation of error, nor the X in the Yes column (transponder applied.) The ADON stated there is not another dated assessment, therefore, she was not sure why, or when the transponder was placed on the resident. In an interview on 8/17/15 at 2:45 pm, the Acting Administrator (AA) and Director of Nursing (DON) stated that it was the Unit Managers responsibility to assess residents risk for elopement and if indicated, to apply a transponder, establish a care plan and enter the orders into the computer for the monitoring the resident each shift. Finding #2 Five (5) (Resident #'s 2, 5, 6, 7 and #8) out of eight (8) residents reviewed were identified as at risk for unsafe wandering, however, were not being monitored timely. Resident #5: The resident was admitted to the facility on [DATE], diagnosed with [REDACTED]. The resident was identified with cognitive impairment. The Elopement Risk Evaluation Form dated 8/5/15, assessed the resident as at risk for elopement. The Comprehensive Plan of Care dated 8/5/15, documented the Potential for Elopement related to Dementia and unsafe wandering. The Actions on the CCP included an entry for a transponder and an entry to check every shift to ensure the transponder was in place. Review of Treatment Administration Records, revealed the monitoring for placement of the transponder every shift, was not initiated until 8/17/15. In an interview on 8/17/15 at 2:15 pm, the DON stated that she had asked the Unit Managers to provide her with a list of resident's with transponders. Resident #5 was recently admitted and identified by the Unit Manager as an elopement risk, however, it did not appear that she was being monitored, but she would make sure that the resident had monitoring orders entered. In an interview on 8/17/15 at 2:45 pm, the AA and DON stated it was the Unit Managers responsibility to assess the residents risk for elopement and if indicated, to apply a transponder, establish a care plan and enter the orders into the computer for the monitoring the resident each shift. Resident #7: Resident #7 was admitted to the facility in 1/13/15, diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5/15, severe cognitive impairment. The Elopement Risk assessment dated [DATE], assessed the resident as at risk for elopement and a code transponder applied. The Comprehensive Care Plan (CCP) dated 8/17/15, documented the potential for elopement due to Dementia and unsafe wandering. The Actions on the CCP included an entry for a transponder and an entry to check every shift to ensure the transponder was in place. Review of Resident #7's Treatment Administration Records, revealed the monitoring for placement of the transponder every shift, was not initiated until 8/17/15. In an interview on 8/17/15 at 11:35 am, LPN #2 was asked if Resident #7 had a transponder, LPN #2 reviewed the computer and stated there were no monitoring orders in place, so she would have to check. LPN #2 took the surveyor to the resident's room, and after observing both ankles, found a transponder on her left ankle. In an interview on 8/17/15 at 2:45 pm, the Acting Administrator and DON stated that it was the Unit Managers responsibility to assess resident's risk for elopement and if indicated to apply a transponder, establish a care plan and enter the physician orders [REDACTED]. Resident #8: The resident was admitted to the facility on [DATE], diagnosed with [REDACTED]. The Minimum (MDS) data set [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13/15, cognitively intact. The Elopement Risk assessment dated [DATE], documented five (5) categories of assessment; Mobility Status, Background History of Elopement, Potential Exposure Review, Overall Assessment and Plan of Care. Each category had a corresponding YES or NO column. The resident's Mobility Status documented an X in the NO column. The Mobility Status column directions state that when the answer to whether the resident is independently mobile with or without assistance is NO, do not proceed further. Therefore there were no documented entries in the categories for; Background History of Elopement, Potential Exposure Review, Overall Assessment and Plan of Care. The Plan of Care section of this form asks whether Code Alert transponder applied? with columns for staff to enter an X for YES or an X for NO. This column documented an X for YES and an X with a strikethrough and error in the no column. The Comprehensive Care Plan (CCP) dated 7/22/15, documented the Potential for Elopement due to exit seeking behavior, Dementia and a transponder to the left ankle. The resident was observed on 8/17/15 at 1:35 pm, with a transponder on the left ankle. Review of Treatment Administration Records, revealed the monitoring for placement of the transponder every shift, was not initiated until 8/17/15. In an interview on 8/17/15 at 11:00 am, LPN #1 stated that she was the nurse assigned to Resident #8 and when asked if the resident had a transponder, LPN #1 reviewed the computer and stated that there were no monitoring orders in place, so she did not think so, but did not know, and the resident was out at an appointment. In an interview on 8/17/15 at 2:45 pm, the Acting Administrator and Director of Nursing stated that it was the Unit Managers responsibility to assess residents risk for elopement and if indicated to apply a transponder, establish a care plan and enter the orders into the computer for monitoring the resident each shift. Finding #3: Two (2) (Resident #'s 3 and #8) of eight (8) residents reviewed had inaccurate elopement risk assessments. Resident #3: The resident was admitted to the facility on [DATE], diagnosed with [REDACTED]. The resident was assessed with [REDACTED]. The resident's Elopement Risk Evaluation Form dated 7/31/15, signed by the Assistant Director of Nursing, documented that the resident propels self with some assistance (score of 2) and voices desire to leave (score of 4). Behavior modification was documented as no behavior (score of 0). The medications (antipsychotic, mood altering) was documented as none of these (score of 0). The resident's total risk of elopement score equaled 6. The CCP for Falls dated 7/31/15, documented the resident is at risk for falls due to narcotic use for pain management and medications for antianxiety use. The CCP for [MEDICAL CONDITION] Drug Use dated 7/31/15, documented the resident will be monitored for mood and therapeutic response to medication for anxiety. The Care Card dated 8/1/15, signed by the Assistant Director of Nursing (ADON), documented that the resident is independent with wheelchair mobility and is not allowed to be outside unattended. Behaviors are documented as non-compliant. A Nurse's note dated 8/1/15 at 3:10 pm, documented that at 1:30 pm, a Certified Nurse Assistant (CNA) received a report from this resident, who stated he flipped his wheelchair while outside, but didn't want her to report it, because he was afraid he wouldn't be allowed outside to smoke. The resident stated my chair caught on the sidewalk and tipped backwards. I got myself and my wheelchair back up, sat in it for a while, then went inside and told the CNA. The note further documented that the resident went for x-rays at the hospital and upon returning, he let himself outside to smoke. This nurse explained that since he had a fall, that he should have someone with him when he is outside. Resident became upset and stated I will just leave against medical advice (AMA). The note further documented that the nurse explained how unsafe it is to allow him outside, the resident understood, but continued to say that he is going to leave AMA. The Accident Incident Report form dated 8/1/15 at 1:30 pm and signed by a registered nurse, documented the resident was outside and flipped his wheel chair. The recommended steps to prevent recurrence documented the resident was not allowed to be outside unattended. The Incident/Accident Statement Form dated 8/1/15. It documented no witnesses to the incident. The physician's orders [REDACTED]. The physician's orders [REDACTED]. (Pain scale rating 0 to 10 points for patient self reporting of pain with 0 rated as no pain and 10 rated as severe pain). The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of Resident #3's August 2015 Medication Assistance Record (MAR), documented a minimum of one daily dose of Diazapam between 8/1/15 through 8/18/15, with the exception of 8/2/15 and 8/17/15. Review of Resident #3's August 2015 MAR, documented a minimum of one daily dose of [MEDICATION NAME] between 8/1/15 through 8/18/15, with the exception of 8/16/15 and 8/18/15. Review of Resident #3's August 2015 MAR, documented a minimum of one daily dose of [MEDICATION NAME], between 8/1/15 through 8/18/15. The Elopement Risk Evaluation Form dated 8/10/15, signed by the Director of Nursing (DON), documented that the resident propels self with some assistance (score of 2) and the resident voices desire to leave (score of 4). The medications (antipsychotic, mood altering) was documented as none of these (score of 0) and Behavior modification documented no behaviors (score of 0). The total risk for elopement score equaled 6 points. In an interview on 8/18/15 at 10:30 am, the Physician's Assistant (PA) reviewed this resident's medications. The PA was asked to identify any [MEDICAL CONDITION] or mood altering medications noted in the review of the medications and the PA stated, the [MEDICATION NAME], the [MEDICATION NAME] (Diazapam) and the [MEDICATION NAME]. In an interview on 8/18/15 at 12:00 pm, the DON reviewed this resident s medications and when asked to identify any [MEDICAL CONDITION] or mood altering medications from the medication review, the DON stated, [MEDICATION NAME] (Diazapam), Dilauded, and [MEDICATION NAME]. The DON reviewed the Elopement Risk Evaluation Form dated 8/10/15. She stated she conducted this assessment upon the resident's return from an Against Medical Advice (AMA) discharge. The DON reviewed her entry of 0 for medications. She stated that the resident had been on some of his medications for a very long time. She did not see them as mood altering medications, therefore, did not indicate the score for two or more of these meds. The assessment score for two or more medications (antipsychotics, mood altering) totaled a score of 4 (when added to the resident's previous score of 6 which did not include points for medications, the resident's elopement risk score equaled 10). The DON was asked about the assessment of behaviors as indicated on the Elopement Risk Evaluation Form which is documented as no behaviors noted. The DON stated the resident has manipulative, drug seeking behavior, the resident lies and alters what is said. The DON stated the resident went AMA, because he didn't want to comply with not being allowed to go outside by himself and needed to be supervised when smoking, because he had an unwitnessed fall outside in his wheelchair. The DON stated when she looked at the behavior part of the assessment, she thought more of Dementia type behaviors rather than all behaviors, but I get it. The DON stated that the Elopement Risk Evaluation Form was initiated in the facility in June, after a mock survey. The DON stated the form was discussed, but no training was done on how to fill it out correctly, so that everyone is on the same page. In an interview on 8/18/15 at 12:25 pm with the Acting Administrator (AA), the AA reviewed the resident's medications. The AA was asked to identify any [MEDICAL CONDITION] or mood altering medications from the resident's medication list. The AA stated, Diazapam ([MEDICATION NAME]), Claudia, Trauma. The AA reviewed the Elopement Risk Evaluation Form for this resident and stated we discussed this last night, I was there for the discussion of Resident #3's previous AMA, we questioned whether he would elope versus going AMA again, however, I don't recall medications being discussed while I was there, but we are discussing the definition of mood altering. The AA stated that she did not stay in the room for the entire discussion, and does not know what happened with it. The AA stated, the form (Elopement Risk Evaluation Form) is very difficult to interpret and is being worked on today. Resident #8: The resident was admitted to the facility on [DATE], diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13/15, cognitively intact. The Elopement Risk assessment dated [DATE], documented five (5) categories of assessment; Mobility Status, Background History of Elopement, Potential Exposure Review, Overall Assessment and Plan of Care. Each category had a corresponding YES or NO column. The resident's Mobility Status documented an X in the NO column. The Mobility Status column directions state that when the answer to whether the resident is independently mobile with or without assistance is NO, do not proceed further. Therefore there were no documented entries in the categories for; Background History of Elopement, Potential Exposure Review, Overall Assessment and Plan of Care. The Plan of Care section of this form asks whether Code Alert transponder applied? with columns for staff to enter an X for YES or an X for NO. This column documented an X for YES and an X with a strikethrough and error in the no column. The Comprehensive Care Plan (CCP) dated 7/22/15, documented the potential for elopement due to exit seeking behavior and Dementia. The CCP documented a transponder to the left ankle. The resident was observed on 8/17/15 at 1:35 pm, with a transponder on the left ankle. Review of the Treatment Administration Records, revealed the monitoring for placement of the transponder every shift, was not initiated until 8/17/15. During an interview on 8/17/18 at 2:30 pm, the Assistant Director of Nursing (ADON) stated that she conducted the Elopement Risk Assessment on 5/12/15 and found the resident not at risk. The ADON reviewed the Elopement Risk Assessment and stated that she could not explain why there was a strikethrough, and notation of error, nor the X in the Yes column (transponder applied.) The ADON stated there is not another dated assessment, therefore, she was not sure why, or when the transponder was placed on the resident. 10 NYCRR 415.12

Based on observation, medical record review and staff interview, the facility did not ensure that a resident maintained acceptable parameters of nutritional status for 1 (# 65) of 14 residents reviewed for weight loss during the standard recertification survey. Specifically the residents initial weight loss of 10 pounds (lbs) (6.75%) was not addressed timely,and the residents weight continued to trend down for a total weight loss of 18 lbs (12%). This significant weight loss resulted in actual harm to Resident # 65 that is not immediate jeopardy. The findings are: Resident #65 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS also identified the residents height as 68 inches and weight as 135 pounds, and noted a significant weight loss. The residents weight record revealed the following weights: June 2011, 148 pounds, July 139 pounds with a reweight of 138, August 135 pounds (no reweight documented), September 132 pounds with a reweight of 120, and October 130 (no reweight documented). The facilities policy and procedure titled "weights", revised on 7/2008 identified that residents were to be weighed, per physican order to monitor nutrition status, fluid changes etc. Under procedure it was documented that if there was a +/- 3 pound difference from the previous weight, a reweight was to be obtained. The criteria for determining significant weight loss was 5% in one month, with severe loss being more then 5%, 7.5% in 3 months with greater then 7.5% being a severe loss and 10% in 6 months with greater then 10% being a severe loss. The physican was to be notified of weight loss as appropriate. Dietary was to notify the interdisciplinary team members of all significant weight changes on a monthly form. Nutritional progress notes were to be completed indicating that the resident had experienced a significant weight change. Nutritional interventions will be implemented by the registered dietician (RD) based on resident acceptance and need. The Care Plan to be adjusted as necessary. Other disciplines are to be involved as needed i.e.: social services involvement for depression, medical involvement for medication evaluation, etc. The Comprehensive Care Plan (CCP) for nutritional status initiated 12/2009 documented that the resident received a therapeutic diet due to dysphagia and esophogeal stricture. The goals were that the reisdent's nutritional status would improve by next review and that a gradual weight gain was desirable (greater then 144 lbs with his ideal body weight at 144- 164 lbs) The residents diet was noted to be healthy heart moist ground, he ate all of his meals on the unit, was independent after set up, with supervision to encourage to slow down, lab tests as ordered, provide with menu, encourage daily selections, oral care after meals, weight once a month, monitor for dysphagia, update physican for possible need for follow up dilatation, and monitor the effect of medications on appetite and body weight. The care plan had been evaluated on the following dates 6/11 weight was noted as 149, 8/11 (initialed with no specifics) 9/11 weight was noted as 135, down significantly over last three months and nourishments were started three times a day. The physicians progress notes dated 7/20/11 completed by the physicians assistant (PA), documented the residents weight at 140 lbs, down 8 lbs from last progress. The PA noted that resident had some weight loss, and the registered nurse (RN) reported good appetite. Re-checking the weigh was requested. The nurses notes on 8/14/11 at 6:00 am, documented that the resident used to come to the nurses station 3-4 times a night requesting a sandwich and soda, and would eat 100% each time. The resident had not been noted to do that for the past 6-8 weeks, and had been sleeping at night. A note dated 8/15/11 at 3:30 am documented that the resident had come down to the nursing station two times, ate a whole egg salad sandwich and peanut butter sandwich and 8 ounces (oz) soda. A note dated 8/16/11 at 6:00 am documented the resident ate an egg salad sandwich and 8 oz soda. A note dated 9/2/11 at 6:00 am documented that the resident had eaten 4 oz of chocolate ice cream, a ham salad sandwich, 4 oz grape juice and 4 oz soda. The physicians orders dated 9/12/11 documented the resident was on a cardiac moist diet. A nurse's note dated 9/24/11 documented the resident ate an egg salad sandwich and 8 oz grape juice. A note dated 9/25/11 documented that the resident was requesting something, he was given ham salad sandwich, and stated "I can't eat that I have no teeth." A note dated 9/26/11 documented that the resident refused supper. A note dated 9/30/11 documented that the resident refused to eat breakfast and lunch, stating "I can't eat that I have no teeth". The resident was reminded that the food was ground, and he still refused to eat. A note dated 10/5/11 documented the resident refused supper. Notes dated 10/7/11 and 10/12/11 also documented that the resident refused supper. The ADL Flow records documented meal intake for June 2011 out of 90 possible meals,13 were left blank. Of the 77 documented the resident ate less then 75% of his meals 53 times. For July of 2011, of 93 possible meals, 17 were left blank. Of the 76 meals documented the resident ate less then 75% of his meals 43 times. For August of 2011 of 93 possible meals, 19 were left blank. Of the 74 meals documented the resident ate less then 75% of his meals 47 times. For September of 2011 of 90 possible meals, 22 were left blank. Of the 64 meals documented, the resident ate less then 75% of his meals 51 times. The dietary notes documented on 8/9/11 a dietary recommendation to the physican identifying that the resident had lost some weight, staff indicated that the resident wasn't eating as well and says "I can't eat that, I have no teeth", and at times doesn't even attempt to eat meals, just looks at them and assumes he cannot. The dietary recommendation was to consider downgrade to moist ground, and if intake shows no further improvement consider pureed. Staff felt his intake was down since teeth extraction. A 9/13/11 diet order form documented the following interventions were to be added: 10:00 am 1/2 sand (ground/peanut butter) with milk, 3:00 pm mighty shake and nighttime increased protein cookie/soft cookie and milk. A dietary assessment dated [DATE] documented the resident was on a healthy heart moist ground diet, with no changes in dental status. Intake was 100% at breakfast, 50% for lunch and 25% for dinner, and the resident ate independently with set up. The residents current body weight was 135 lbs, noting also he had been 138 lbs the past month. The last labs were done on 7/1/11. The problem identified was significant weight loss. The action taken was to monitor weights, intake, and add nourishments. The goal was to gain or maintain weight. The resident was to continue to receive a regular no added salt (NAS) with moist ground texture diet. It was documented that the resident was tolerating the texture well, and the oral intake seemed to improve once the texture was changed. Staff reported no signs or symptoms of pain or difficulty chewing or swallowing. The resident was observed by the dietician at mealtimes with no problems. Lastly, the note documented that the resident had lost a significant amount of weight over the last three months. Staff reported he doesn't come up to nursing station as frequently asking for snack, as he was sleeping more now. A physicians progress note dated 9/20/11 documented the residents weight was 132 lbs, down 8 lbs from last progress note. The problems noted were that the resident had teeth removed 6 months prior, and the dentist wanted to wait to (fit the resident for dentures) but the resident now had a bone spur that needed to be removed before he can be fitted for dentures. The resident was noted to constantly repeat that he had no teeth and that he would not eat at times. Lastly it noted the resident had weight loss but was doing better with appetite at present. The resident was observed on 10/18/11 at 9:15 am, in his room, in bed. The surveyor asked the resident how his breakfast was, and he stated "I can't eat". The resident was again observed on 10/18/11 at 12:20 pm, he was sitting at the nurses station eating lunch. The resident was easily distracted, would take a few bites of food and get up to walk away. He did this three times, each time a staff member brought him back to the nurses station and encouraged him to eat. During an interview on 10/18/11 at 10:10 am the Registered Nurse Manager (RNM) stated the resident had his teeth removed several months ago, and had recently realized he did not have any teeth. The RNM stated she was aware of the residents weight loss. The RNM stated she viewed the fact that the resident was not asking for food as frequently as a positive thing, as in the past staff had to discourage the resident from eating as much. The RNM stated that the dietician looks at weights all the time, and she (RNM) does not always look at them. When reviewing the chart with the surveyor, the RNM stated she was not aware of the 8/14/11 nurses note documenting a significant change in the residents nighttime intake, until the surveyor brought it to her attention. She stated she could see how the residents weight loss was not good, but that staff had been viewing it differently and it was missed. During an interview on 10/18/11 at 10:40 am the Registered Dietician (RD) stated she made her first recommendation to the physican of a puree diet in August. She assumed that this had been followed through on. She began nourishments in September, and not prior as she was focused on getting the resident back in the routine of approaching staff for food. The RD stated normally she would initiate weekly weights for monitoring, and possibly Med Pass 2.0 ( a nutritional supplement) as this is an easy way to get extra nutrition for residents. She stated typically these interventions would begin right away after a weight loss is noted, and in this case that would have been July. She was not able to state why these things hadn't been started, but did state they should have been. During an interview on 10/19/11 at 9:15 am a Certified Nurses Aide (CNA) stated she was familiar with the resident. The CNA stated they rotate through assignments monthly. She stated the resident was always inconsistent with food, sometimes would eat sometimes wouldn't even with encouragement. More recently she noticed he wasn't eating as well, and she told the nurse. After that nourishments were started. She indicated that CNA's do resident weights, and normally a fluctuation of 3 pounds up or down would require a reweigh within 24 hours. She stated usually anyone with a significant weight loss would be placed on weekly weights. During an interview on 10/19/11 at 7:40 am, via telephone, the licensed practical nurse (LPN) who wrote the 8/14/11 note, stated that when she came back from a medical leave she noted a significant change in the residents eating pattern on the night shift as well as a weight loss. The LPN stated she informed the RNM of her concerns. During an interview on 10/19/11 at 7:30 am the attending physican stated that he sees the residents every two months, and that sometimes a PA will see them in between. He stated he relies on nursing to convey significant issues to him, and that he is always available as he is at the facility almost daily. He stated typically for a resident losing weight, he would order lab work to rule out metabolic issues, would order dietary consult and possibly a swallow evaluation if indicated. Upon review of the chart, the physican stated that the PA saw the resident in July, and he (the physican) in September. After looking at his note, he stated he was not aware of the full extent of the weight loss, as it indicated 8 pounds since last review, and this was not a total review. The physician stated the resident always had a good appetite and it would be unusual for him not to eat. He was aware of the 8/9/11 diet recommendation, as he signed off on it, but did not know it wasn't followed through on. He stated this was a problem for this resident, and it should've been addressed, but it fell through the cracks. He believed that better communication could have occurred. 10NYCRR 415.12(i)(1)