Every finding on record at Evergreen Commons Rehabilitation and Nursing CTR

Based on record review and interviews conducted during a survey, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for one (Residents #1) of three residents reviewed for accidents. Specifically, for Resident #1 on 02/28/2025, Certified Nurse Aide #5 did not use two-person assistance while providing incontinence care as required in Resident #1' s Comprehensive Care Plan. Resident #1 fell out of bed and sustained a head laceration requiring three staples to close the wound. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.Findings include: The policy and procedure titled, Care Plans/Comprehensive (Person Centered), last revised February 2024, documented all staff must abide and follow the resident specific care plan. Resident #1 Resident #1 was admitted to the facility with diagnoses of malignant neoplasm of the brain (brain cancer), malignant neoplasm of the lung (lung cancer), and seizures. The Minimum Data Set (a resident assessment tool) was not completed due to the resident being in the facility for only two days. The Comprehensive Care Plan titled Activities of Daily Living/Mobility was initiated on 02/27/2025 and documented the resident was dependent on two persons for toileting hygiene and bed mobility (rolling). The Facility Investigation Summary, dated 02/28/2025, documented that Certified Nurse Aide #5 was providing incontinence care and the resident fell off the opposite side of the bed incurring a 1.5-centimeter laceration to the right parietal (side of the head, above and around the ear) scalp. Certified Nurse Aide #5 reported they assumed the resident was one assist for care based on their small stature and did not ask for assistance. Based on interview, record review, and internal investigation, the facility had determined that despite education and available resources, Certified Nurse Aide #5 provided care to this resident outside of the level of assistance they were care planned for. Emergency Department Provider Notes dated 02/29/2025 documented the resident was treated for a 2 centimeter right parietal scalp laceration that was closed with two staples. An Investigation Statement dated 02/28/2025 signed by Certified Nurse Aide #5 documented they were providing incontinence care and the resident rolled off the bed. Attempts were made to interview Certified Nurse Aide #5 and messages were left at the last known telephone number on 06/10/2026 and 06/11/2026 with no return call. During an interview on 06/10/2026 at 12:00 PM, Certified Nurse Aide #4 stated they always checked the care card before providing any care in case there were changes. If a resident was supposed to have two-assist during care, then they would find another staff before starting care. During an interview on 06/10/2026 at 12:05 PM, Licensed Practical Nurse #5 stated they usually administered medications and did not provide incontinence care but would check the care card before providing any direct care to a resident. During an interview on 06/10/2026 at 2:00 PM, Administrator #1 stated Certified Nurse Aide #5 reported the fall immediately, Resident #1 was assessed, and first aid was administered. The care plan violation resulted in Certified Nurse Aide #5 being suspended and the incident was reported to the Department of Health. Certified Nurse Aide #5 was terminated for failure to follow the care plan. During an interview on 06/11/2026 at 11:20 AM, Registered Nurse #2 stated that they did not recall this resident or incident. All staff were expected to review the resident's care card, which is in the electronic medical record and could be accessed by certified nurse aides before providing any care. During an interview on 06/12/2026 at 9:30 AM, Medical Director #1 stated that due to the resident's obtunded (reduced consciousness or alertness) state, they would not have ordered neuro checks for this resident upon return from the hospital. Medical Director #1 stated the resident's Medical Orders for Life Sustaining Treatment (MOLST), signed by the spouse on 02/27/2025 documented no vital signs, so the nursing staff appropriately did not obtain vital signs. The resident was declining rapidly with a terminal diagnosis prior to the injury. Because of the request of the spouse, no imaging or neurological work-up was completed at the hospital and there was no way to say whether the head injury contributed to the death of this terminal resident. 10 New York Codes, Rules and Regulations 415.12 (h)(1) F 600 Past Non-Compliance Based on the following corrective action taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement at the time of this survey: Resident #1: - Resident was assessed by Registered Nurse with neuro checks initiated; - Physician, Administrator, and spouse notified; - Transferred to hospital for treatment of laceration; - Investigation initiated; - Certified Nurse Aide #5 background and disciplines reviewed with no issues noted. Staff was interviewed and suspended; - Medical Director completed a chart review; - Interdisciplinary Team review with care plans updated; - House wide education was completed on 3/05/2025 for review of profile Care Card prior to care, Comprehensive Person Centered Care Plans, Fall Policy and Procedure; - Review of staffing for that shift showed there were two (2) Certified Nurse Aides, and one Licensed Practical Nurse with another person available to assist with bed mobility per plan of care' - Weekly care audits with focus on transfers and bed mobility.

Based on record review and interviews conducted during survey, the facility failed to ensure residents were free from abuse and neglect for one (Resident #2) of three residents reviewed for abuse and neglect. Specifically, for Resident #2, on 01/31/2025, Certified Nurse Aide #1 verbally abused Resident #2 with the use of profanity during care and threatening to hit Resident #2.Findings include: The policy and procedure titled, Freedom from Abuse, Neglect, and Exploitation, last revised April 2026, documented its purpose was to ensure residents were free from abuse, neglect and exploitation. The policy also documented the definition of abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, non-consensual sexual contact of any kind, physical abuse, mental abuse, including abuse facilitated or enabled through the use of technology. Willful is defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Resident #2Resident #2 was admitted to the facility with diagnoses of unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a progressive decline in mental ability that impairs memory, thinking reasoning and communication skills to the point where it interferes with a person's daily life and independence). The Minimum Data Set, dated [DATE], documented the resident could be understood and could understand others and was severely cognitively impaired. Review of the statement in the facility investigation file dated 01/31/2025 signed by Licensed Practical Nurse #2, documented during their medication pass, they were standing in front of Resident #2's room and overheard Certified Nurse Aide #1 in the room using profanity and stating, hit me and see what happens. Licensed Practical Nurse #2 went toward the room and heard continued use of profanity, I'm tired of this with you, you're not going to keep hitting me. They shouted to Certified Nurse Aide #1 and entered the room and told Certified Nurse Aide #1 that they needed to leave the room and stood between the aide and the resident. Certified Nurse Aide #1 stated, again using profanity, This is not going to keep playing with me. I'm tired of this and if they hit me again, I am going to hit them back. Certified Nurse Aide #1 then left the room. Conclusion of Investigation Statement signed by Administrator #1 on 01/30/2025, documented based on staff interviews, record review and an internal investigation, the facility determined that a witnessed verbal statement was made in a resident area, which was deemed unacceptable behavior. Certified Nurse Aide #1 was unable to appropriately manage their frustration while interacting with a combative resident. During an interview on 06/10/2026 at 11:37 AM, Staff #4 stated that they have received education on abuse prevention and resident rights. Staff #4 stated it was covered annually and sometimes monthly. Staff #4 stated if they witnessed abuse or suspected it, they would stop the abuse immediately and make sure the resident was safe before reporting it to the supervisor.10 New York Codes, Rules, and Regulations 415.4(b) F 600 Past Non-ComplianceBased on the following corrective action taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement at the time of this survey: Resident #2: Director of Nursing and Administrator notification. Family notification of Family Member #1 on 01/30/2025. Investigation initiated. Family and Medical Doctor notification. Staff interviews conducted. Report made to New York State Department of Health. Certified Nurse Aide #1 interviewed and terminated. Certified Nurse Aide #1 suspended pending investigation and subsequently terminated after facility did not hear back from them after two attempts to contact them. Certified Nurse Aides #1's discipline file reviewed with no concerns and/or related disciplines. Registered Nurse Assessment completed on Resident #2 with no physical injuries noted. Registered Nurse Assessment completed on Certified Nurse Aide #1's assignment with no concerns noted. Updated Pain Assessment completed, pain noted in the left hip secondary to recent fracture. Updated Abuse Assessments completed. Urinary tract infection, Situation, Background, Assessment, and Recommendation completed. Medication review completed with new orders for Oxycodone (a powerful, semi-synthetic opioid pain medication prescribed to treat moderate-to-severe pain) every 6 hours for seven days. Full house abuse education initiated including resident rights. Completed 02/2025 Social Work follow up with no signs and/or symptoms of emotional distress; Social Work follow up on all Wynantskill Way residents with no concerns and/or signs of emotional distress; Appropriate care plans updated: Pain, Abuse & Psychosocial Well-Being; Abuse policy reviewed with no changes made; Quality Assurance Performance Improvement audit initiated on observation of care.

Based on observations, interviews and record reviews during the Abbreviated Survey (complaint #2656654), the facility did not ensure that all alleged violations of resident abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health as required. This was evident for 1 of 3 residents reviewed for abuse (Resident #1). Specifically, a resident was transported to dialysis and returned to the facility and was pronounced deceased shortly after. The facility did not report the events leading to the death of Resident #1 to the New York State Department of Health as required.This is evidenced by:A facility policy titled Reporting and Investigating Resident Accident/Incidents, dated [DATE], documented that all occurrences which were not consistent with the routine operations of the facility and care of the residents that had or may have caused physical injury or harm would be reported, reviewed and thoroughly investigated. If an incident occurred that was related to an allegation of possible abuse; all additional abuse investigation materials were also completed. A completed Accident/Incident Report should have included a copy of the updated care plan and Certified Nurse Aide profile so as to confirm interventions were taken as the result of the incident.For any and all injuries of unknown origin a completed and through Accident and Incident report must be completed. Proper notifications to family, Director of Investigations and Administrator must take place for investigative purposes.A. Federal regulation: 42 CFR 483.13 An injury should be classified as an injury of unknown source when both of the following conditions were met: a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident.b. The injury is suspicious because the extent or location of the injury, or the location of the injury(e.g., the injury was located in an area not generally vulnerable to trauma), or the number of injuries observed at one particular point in time, or incidences of injuries over timeB. The following two elements must be present for an incident to be reportable to the New York State Department of Health and Director of Investigations and Administrator must be made aware As Soon Aa Possible: a. Injury without known incident. b. Facility unable to rule out abuse or care plan violationThe completed Accident/Incident Report would be submitted to the Director of Nursing, Administrator and Medical Director to sign and then filed accordingly within the Director of Investigations office.The facility policy titled Renal Dialysis dated [DATE], last reviewed at 5/2025, documented that all residents were to be sent to the dialysis center with a communication book that had the Interfacility Report completed prior to transporting. The dialysis unit would complete its section and a Dialysis Information Sheet. The notebook was to be returned from dialysis with the Resident.Resident #1 was admitted to the facility with diagnoses including chronic kidney disease on dialysis (kidneys no longer function to filter the blood of toxins, requiring manual filtration of the blood by a machine), cellulitis of right lower leg (an infection causing redness and irritation), malignant neoplasm of endometrium (cancerous cells formed on the lining of the uterus that has spread to other body areas). The Minimum Data Set assessment (an assessment tool) dated [DATE] documented the resident was able to be understood, understand others, and was minimally cognitively impaired.On [DATE], Resident #1 left the facility around 11:00 AM to go to hemodialysis, returning at approximately at 6:41 PM. When assessed upon their return, Resident #1 was found to be absent of respirations, had no pulse and was pronounced deceased at 6:50 PM. There was no documented evidence that the facility reported what happened to Resident #1 to the New York State Department of Health. In a facility provided video dated [DATE] at 12:00 PM, Resident #1 appeared to be exiting the facility in a wheelchair with an oxygen tank on the back of the seat, sitting upright, and communicating with both the facility staff member helping them onto the transport bus and the person driving the transport bus while being placed on the bus. In a facility provided video dated [DATE] at 6:00 PM, Resident #1 appeared to be returning to the facility. Resident #1's friend was visible in the frame, appearing to be waiting for Resident #1 to be unloaded from the transport bus. As Resident #1 was rolled out of the bus and handed off to their friend, it was notable that Resident #1 was slumped over to the left, wrapped in a blanket, wearing a mask. Oxygen tubing could be viewed underneath the mask on Resident #1's face. Resident #1 was not seen interacting with the transport driver, or their friend as they were rolled into the facility. A facility provided statement from Resident #1's friend dated [DATE] at 7:15 PM, documented that 1:20 PM, Resident #1 arrived at the dialysis center at 1:20 PM and was very uncomfortable and crying. Friend #1 wrote that Resident #1 was disoriented but knew their name, knew their address and recognized Friend #1. At 5:30 PM, Friend #1 documented in their note that they arrived at the dialysis center to meet Resident #1 and accompany them back to the facility (Friend #1 drove in their personal vehicle, Resident #1 rode in the facility provided transport bus). Friend #1 documented that Resident #1 appeared to be unconscious, was not moving and did not respond to their friend. The dialysis staff that brought Resident #1 to Friend #1 in the waiting area reportedly said to Friend #1 that Resident #1 was crying and yelling then fell asleep finally while receiving their treatment. Friend #1 further documented that upon arriving to the facility, Friend #1 was alarmed Resident #1 was noted to be limp and drooling. Friend #1 documented that they brought Resident #1 to the nursing station, and they were quickly attended to. A facility provided form titled Dialysis Communication Sheet, dated [DATE], documented that Resident #1 had vital signs taken prior to leaving the facility for dialysis at 11:00 AM. The section of the sheet that was supposed to be filled out by the dialysis center, before the resident returned to the facility, was noted to be blank. This was noted to be true for the previous Dialysis Communication Sheet, dated [DATE] as well. During an interview on [DATE] at 12:37 PM, Certified Nurse Aide #1 stated that when a resident goes to dialysis, they get the residents up, washed and dressed. They might get the oxygen tanks or dialysis book if needed. When asked if they ever write anything in the dialysis book, Certified Nurse Aide #1 stated no. During an interview on [DATE] at 12:38 PM, Licensed Practical Nurse #1 stated that they did not remember Resident #1. Licensed Practical Nurse #1 was observed to have the dialysis sheet for Resident #2 in their hand when approached. Licensed Practical Nurse #1 was asked to review the procedure of getting a resident ready for dialysis and receiving a resident back from dialysis. Licensed Practical Nurse #1 stated that they fill out the top of the sheet (observed to be filled out for [DATE]), and dialysis fills out the bottom of the sheet (sheet noted to be filled out for [DATE]). When asked what Licensed Practical Nurse #1 would do if dialysis did not fill out their portion of the sheet, Licensed Practical Nurse #1 stated that they would call the dialysis center to get the information. When asked what they would do if they were unable to reach anyone at the dialysis center, Licensed Practical Nurse #1 stated they would let the supervisor know so they could continue to try and get the information. During an interview on [DATE] at 1:02 PM, Director of Nursing #1 stated that Resident #1 had only been at the facility for a week. Director of Nursing stated that Resident #1's friend accompanied them to dialysis. When Resident #1 returned, they were unconscious. If the resident had been a full code, the facility would have coded Resident #1 when they arrived at the nurse's station and were seen by facility staff. During an interview on [DATE] at 1:15 PM, Assistant Director of Nursing #1 stated that they saw Resident #1 rolling down the corridor and stated to Friend #1 that they looked sleepy. Friend #1 stated very. About 15 minutes later, a nurse called Assistant Director of Nursing #1 to say they needed to contact the funeral home because Resident #1 had passed. Assistant Director of Nursing #1 called the dialysis center around 6:40 PM and no one answered the phone. Resident #1 had gone to two dialysis treatments since arriving at the facility. The dialysis facility did not fill out their section of the paperwork either time and would not answer the phone when staff called. Assistant Director of Nursing #1 stated they did not know what happened during dialysis. No other residents were currently using the same dialysis facility, so there was no other resident to compare the care to. During an interview on [DATE] at 2:31 PM, Registered Nurse #1 stated that they were on another unit when Licensed Practical Nurse #2 called them to come assess Resident #1. Registered Nurse #1 stated that when they arrived to the unit, Resident #1 was still in the chair, in the common area, and the staff were attempting to get vitals and assessing their condition. Registered Nurse #1 stated that they observed the resident to be mottling in their hands and fingers. Registered Nurse #1 took a statement from Friend #1, checked the dialysis communication book, and noted that the dialysis section was blank. Registered Nurse #1 stated both they and the Assistant Director of Nursing #1 both tried to call the dialysis center and never got an answer. During an interview on [DATE] at 3:24 PM, Licensed Practical Nurse #2 stated that Resident #1 was brought back to the floor by Friend #1. Licensed Practical Nurse #2 stated that they normally did vital signs, and a finger stick upon a resident's return from dialysis. Licensed Practical Nurse #2 stated that they believed Resident #1's fingerstick was within normal limits. Resident #1 was not really responding to Licensed Practical Nurse #2 at the time. Friend #1 stated that Resident #1 had been unresponsive since dialysis. Licensed Practical Nurse #2 stated that the vital sign machine wasn't reading Resident #1's blood pressure and stated they could not recall if they were able to get an oxygen reading. During an interview on [DATE] at 2:16 PM, Director of Transportation #1 stated that they usually just have to make sure that transportation arrangements were made correctly. The transportation bus was part of the local CDTA bus system. The drivers were not medically trained and would not necessarily know what to look for if a resident had a change of condition that wasn't obvious. Typically, dialysis residents have a bag on the back of their chair that has a bagged lunch or breakfast, a blanket and their dialysis book. If they are on oxygen, the facility sends two tanks with the resident to account for any extra wait time, so they don't run out. During an interview on [DATE] at 9:58 AM, Registered Nurse #3 stated that for residents going to dialysis, they typically pack lunch, the dialysis communication book and a blanket in a bag that goes on the back of the chair. When asked about the incident and if a report was filed, Registered Nurse #3 stated that they couldn't say if there was an investigation report done, the Supervisor was there and handled it. Receptionist #1 joined the conversation and stated that an unnamed Social Worker from the dialysis center called to request a copy of Resident #1's Advanced Directives. During an interview on [DATE] at 11:13 AM, Director of Nursing #1 stated that there was no documentation of what gets packed up with the resident, no checklist of items. There was no facility investigation done regarding what happened to Resident #1. If there had been a change of condition on the property, they would have done report, initiated Cardiopulmonary Resuscitation, called the doctor, etc. If there was a change in condition at dialysis, they should have sent Resident #1 to the emergency room and not back to the facility. Resident #1 arrived with no pulse or respirations and was a Do Not Resuscitate, therefore there was nothing to investigate. It did not occur to the Director of Nursing #1 that the incident should have been reported to the New York State Department of Health. During an interview on [DATE] at 11:34 AM, Registered Nurse #4 stated that they were doing an admission on the unit when Resident #1 arrived. Licensed Practical Nurse #2 was taking vital signs in the common area, as was common practice for residents returning from dialysis. Licensed Practical Nurse #2 asked Registered Nurse #4 to check Resident #1 for a pulse because they were struggling to find one. Registered Nurse #4 stated that they told Licensed Practical Nurse #1 that Resident #1 was pulseless, and that their lips were blue. Friend #1 told Registered Nurse #2 that Resident #1 had been like that since dialysis brought Resident #1 out. During an interview on [DATE] at 12:21 PM, Administrator #1 stated that the Assistant Director of Nursing #1 had attempted to reach out to the dialysis center but was unable to speak to anyone. Administrator #1 stated that based on what happened, no investigation was done because it was believed that Resident #1 did not pass here, they passed at dialysis and the facility had tried to follow up with dialysis, even though they didn't answer them. When asked what rose to a reportable level, Administrator #1 stated injuries of unknown origin, falls with fracture, abuse concerns, but in hindsight, Administrator #1 stated they should have looked into it harder as they were overall responsible for the residents. 10 New York Code Rules and Regulations 415.4 b (2)

Based on observations, interviews and record reviews during the survey (complaint #2656654), the facility did not ensure that all alleged violations of resident abuse, neglect, exploitation, or mistreatment were investigated as required. This was evident for 1 of 3 residents reviewed for abuse (Resident #1). Specifically, a resident was transported to dialysis and returned to the facility and was pronounced deceased shortly after. The facility did not thoroughly investigate the events leading to the death of Resident #1. This is evidenced by: A facility policy titled Reporting and Investigating Resident Accident/Incidents, dated [DATE], documented that all occurrences which were not consistent with the routine operations of the facility and care of the residents that had or may have caused physical injury or harm would be reported, reviewed and thoroughly investigated. If an incident occurred that was related to an allegation of possible abuse; all additional abuse investigation materials were also completed. A completed Accident/Incident Report should have included a copy of the updated care plan and Certified Nurse Aide profile so as to confirm interventions were taken as the result of the incident.For any and all injuries of unknown origin a completed and through Accident and Incident report must be completed. Proper notifications to family, Director of Investigations and Administrator must take place for investigative purposes.A. Federal regulation: 42 CFR 483.13 An injury should be classified as an injury of unknown source when both of the following conditions were met: a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident.b. The injury is suspicious because the extent or location of the injury, or the location of the injury(e.g., the injury was located in an area not generally vulnerable to trauma), or the number of injuries observed at one particular point in time, or incidences of injuries over timeB. The following two elements must be present for an incident to be reportable to the New York State Department of Health and Director of Investigations and Administrator must be made aware As Soon Aa Possible: a. Injury without known incident. b. Facility unable to rule out abuse or care plan violation The completed Accident/Incident Report would be submitted to the Director of Nursing, Administrator and Medical Director to sign and then filed accordingly within the Director of Investigations office. The facility policy titled Renal Dialysis dated [DATE], last reviewed at 5/2025, documented that all residents were to be sent to the dialysis center with a communication book that had the Interfacility Report completed prior to transporting. The dialysis unit would complete its section and a Dialysis Information Sheet. The notebook was to be returned from dialysis with the Resident. Resident #1 was admitted to the facility with diagnoses including chronic kidney disease on dialysis (kidneys no longer function to filter the blood of toxins, requiring manual filtration of the blood by a machine), cellulitis of right lower leg (an infection causing redness and irritation), malignant neoplasm of endometrium (cancerous cells formed on the lining of the uterus that has spread to other body areas). The Minimum Data Set assessment (an assessment tool) dated [DATE] documented the resident was able to be understood, understand others, and was minimally cognitively impaired. On [DATE], Resident #1 left the facility around 11:00 AM to go to hemodialysis, returning at approximately at 6:41 PM. When assessed upon their return, Resident #1 was found to be absent of respirations, had no pulse and was pronounced deceased at 6:50 PM. There was no documented evidence that the facility investigated what happened to Resident #1. In a facility provided video dated [DATE] at 12:00 PM, Resident #1 appeared to be exiting the facility in a wheelchair with an oxygen tank on the back of the seat, sitting upright, and communicating with both the facility staff member helping them onto the transport bus and the person driving the transport bus while being placed on the bus. In a facility provided video dated [DATE] at 6:00 PM, Resident #1 appeared to be returning to the facility. Resident #1's friend was visible in the frame, appearing to be waiting for Resident #1 to be unloaded from the transport bus. As Resident #1 was rolled out of the bus and handed off to their friend, it was notable that Resident #1 was slumped over to the left, wrapped in a blanket, wearing a mask. Oxygen tubing could be viewed underneath the mask on Resident #1's face. Resident #1 was not seen interacting with the transport driver, or their friend as they were rolled into the facility. A facility provided statement from Resident #1's friend dated [DATE] at 7:15 PM, documented that 1:20 PM, Resident #1 arrived at the dialysis center at 1:20 PM and was very uncomfortable and crying. Friend #1 wrote that Resident #1 was disoriented but knew their name, knew their address and recognized Friend #1. At 5:30 PM, Friend #1 documented in their note that they arrived at the dialysis center to meet Resident #1 and accompany them back to the facility (Friend #1 drove in their personal vehicle, Resident #1 rode in the facility provided transport bus). Friend #1 documented that Resident #1 appeared to be unconscious, was not moving and did not respond to their friend. The dialysis staff that brought Resident #1 to Friend #1 in the waiting area reportedly said to Friend #1 that Resident #1 was crying and yelling then fell asleep finally while receiving their treatment. Friend #1 further documented that upon arriving to the facility, Friend #1 was alarmed Resident #1 was noted to be limp and drooling. Friend #1 documented that they brought Resident #1 to the nursing station, and they were quickly attended to. A facility provided form titled Dialysis Communication Sheet, dated [DATE], documented that Resident #1 had vital signs taken prior to leaving the facility for dialysis at 11:00 AM. The section of the sheet that was supposed to be filled out by the dialysis center, before the resident returned to the facility, was noted to be blank. This was noted to be true for the previous Dialysis Communication Sheet, dated [DATE] as well. During an interview on [DATE] at 12:37 PM, Certified Nurse Aide #1 stated that when a resident goes to dialysis, they get the residents up, washed and dressed. They might get the oxygen tanks or dialysis book if needed. When asked if they ever write anything in the dialysis book, Certified Nurse Aide #1 stated no. During an interview on [DATE] at 12:38 PM, Licensed Practical Nurse #1 stated that they did not remember Resident #1. Licensed Practical Nurse #1 was observed to have the dialysis sheet for Resident #2 in their hand when approached. Licensed Practical Nurse #1 was asked to review the procedure of getting a resident ready for dialysis and receiving a resident back from dialysis. Licensed Practical Nurse #1 stated that they fill out the top of the sheet (observed to be filled out for [DATE]), and dialysis fills out the bottom of the sheet (sheet noted to be filled out for [DATE]). When asked what Licensed Practical Nurse #1 would do if dialysis did not fill out their portion of the sheet, Licensed Practical Nurse #1 stated that they would call the dialysis center to get the information. When asked what they would do if they were unable to reach anyone at the dialysis center, Licensed Practical Nurse #1 stated they would let the supervisor know so they could continue to try and get the information. During an interview on [DATE] at 1:02 PM, Director of Nursing #1 stated that Resident #1 had only been at the facility for a week. Director of Nursing stated that Resident #1's friend accompanied them to dialysis. When Resident #1 returned, they were unconscious. If the resident had been a full code, the facility would have coded Resident #1 when they arrived at the nurse's station and were seen by facility staff. During an interview on [DATE] at 1:15 PM, Assistant Director of Nursing #1 stated that they saw Resident #1 rolling down the corridor and stated to Friend #1 that they looked sleepy. Friend #1 stated very. About 15 minutes later, a nurse called Assistant Director of Nursing #1 to say they needed to contact the funeral home because Resident #1 had passed. Assistant Director of Nursing #1 called the dialysis center around 6:40 PM and no one answered the phone. Resident #1 had gone to two dialysis treatments since arriving at the facility. The dialysis facility did not fill out their section of the paperwork either time and would not answer the phone when staff called. Assistant Director of Nursing #1 stated they did not know what happened during dialysis. No other residents were currently using the same dialysis facility, so there was no other resident to compare the care to. During an interview on [DATE] at 2:31 PM, Registered Nurse #1 stated that they were on another unit when Licensed Practical Nurse #2 called them to come assess Resident #1. Registered Nurse #1 stated that when they arrived to the unit, Resident #1 was still in the chair, in the common area, and the staff were attempting to get vitals and assessing their condition. Registered Nurse #1 stated that they observed the resident to be mottling in their hands and fingers. Registered Nurse #1 took a statement from Friend #1, checked the dialysis communication book, and noted that the dialysis section was blank. Registered Nurse #1 stated both they and the Assistant Director of Nursing #1 both tried to call the dialysis center and never got an answer. During an interview on [DATE] at 3:24 PM, Licensed Practical Nurse #2 stated that Resident #1 was brought back to the floor by Friend #1. Licensed Practical Nurse #2 stated that they normally did vital signs, and a finger stick upon a resident's return from dialysis. Licensed Practical Nurse #2 stated that they believed Resident #1's fingerstick was within normal limits. Resident #1 was not really responding to Licensed Practical Nurse #2 at the time. Friend #1 stated that Resident #1 had been unresponsive since dialysis. Licensed Practical Nurse #2 stated that the vital sign machine wasn't reading Resident #1's blood pressure and stated they could not recall if they were able to get an oxygen reading. During an interview on [DATE] at 2:16 PM, Director of Transportation #1 stated that they usually just have to make sure that transportation arrangements were made correctly. The transportation bus was part of the local CDTA bus system. The drivers were not medically trained and would not necessarily know what to look for if a resident had a change of condition that wasn't obvious. Typically, dialysis residents have a bag on the back of their chair that has a bagged lunch or breakfast, a blanket and their dialysis book. If they are on oxygen, the facility sends two tanks with the resident to account for any extra wait time, so they don't run out. During an interview on [DATE] at 9:58 AM, Registered Nurse #3 stated that for residents going to dialysis, they typically pack lunch, the dialysis communication book and a blanket in a bag that goes on the back of the chair. When asked about the incident and if a report was filed, Registered Nurse #3 stated that they couldn't say if there was an investigation report done, the Supervisor was there and handled it. Receptionist #1 joined the conversation and stated that an unnamed Social Worker from the dialysis center called to request a copy of Resident #1's Advanced Directives. During an interview on [DATE] at 11:13 AM, Director of Nursing #1 stated that there was no documentation of what gets packed up with the resident, no checklist of items. There was no facility investigation done regarding what happened to Resident #1. If there had been a change of condition on the property, they would have done report, initiated Cardiopulmonary Resuscitation, called the doctor, etc. If there was a change in condition at dialysis, they should have sent Resident #1 to the emergency room and not back to the facility. Resident #1 arrived with no pulse or respirations and was a Do Not Resuscitate, therefore there was nothing to investigate. During an interview on [DATE] at 11:34 AM, Registered Nurse #4 stated that they were doing an admission on the unit when Resident #1 arrived. Licensed Practical Nurse #2 was taking vital signs in the common area, as was common practice for residents returning from dialysis. Licensed Practical Nurse #2 asked Registered Nurse #4 to check Resident #1 for a pulse because they were struggling to find one. Registered Nurse #4 stated that they told Licensed Practical Nurse #1 that Resident #1 was pulseless, and that their lips were blue. Friend #1 told Registered Nurse #2 that Resident #1 had been like that since dialysis brought Resident #1 out. During an interview on [DATE] at 12:21 PM, Administrator #1 stated that the Assistant Director of Nursing #1 had attempted to reach out to the dialysis center but was unable to speak to anyone. Administrator #1 stated that based on what happened, no investigation was done because it was believed that Resident #1 did not pass here, they passed at dialysis and the facility had tried to follow up with dialysis, even though they didn't answer them. When asked what rose to the investigation level, Administrator #1 stated injuries of unknown origin, falls with fracture, abuse concerns, but in hindsight, Administrator #1 stated they should have looked into it harder as they were overall responsible for the residents. 10 New York Code Rules and Regulations 415.4 b (3)

Based on observations, record review, and interviews conducted during the abbreviated survey, the facility did not ensure that each resident received the necessary respiratory care and services that were in accordance with professional standards of practice for 1 (Resident #1) of 3 residents reviewed for oxygen administration. Specifically, Resident #1 did not have a physician's order for oxygen, despite being on oxygen on and off during their admission to the facility. This is evidenced by: A review of the facility's policy and procedure titled Oxygen Therapy - Mask and Nasal Cannula, dated 3/2012, documented that 1. Oxygen administration required a medical order (Medical Doctor, Nurse Practitioner, Physician Assistant), specific to include liter flow, route of administration, as well as frequency. All residents with an order of Oxygen Therapy needs a At Risk for Compromised Respiratory Care Plan initiated and interventions as deemed appropriate; 2. Oxygen was initiated by licensed staff. Only a nurse, Medical Doctor, Nurse Practitioner, or Physician's Assistant may adjust the oxygen liter flow; 3. In an emergency, a nurse may administer oxygen and obtain an order within 24 hours. Resident #1 was admitted to the facility with diagnoses including chronic kidney disease on dialysis (kidneys no longer function to filter the blood of toxins, requiring manual filtration of the blood by a machine), cellulitis of right lower leg (an infection causing redness and irritation), malignant neoplasm of endometrium (cancerous cells formed on the lining of the uterus that has spread to other body areas). The Minimum Data Set assessment (an assessment tool) dated [DATE] documented the resident was able to be understood, understand others, and was minimally cognitively impaired. There was no documented evidence that there was an order for oxygen administration for Resident #1. There was no documented evidence that there was an interventions or associated goals regarding the use of oxygen. A Medication Administration Record dated [DATE] documented pre-dialysis vitals at 11:00 AM, Resident #1 was using 2 liters of oxygen. A Medication Administration Record dated [DATE] documented pre-dialysis at 11:00 AM, Resident #1 was using 2 liters of oxygen. Vital sign records documented Resident #1 was using 2 liters of oxygen on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 1:15 PM, Assistant Director of Nursing #1 stated that they saw Resident #1 coming back from dialysis with Friend #1. Assistant Director of Nursing #1 stated they believed the resident was wearing oxygen from a portable tank. During an interview on [DATE] at 2:31 PM, Registered Nurse #1 stated that they removed oxygen from Resident #1's face when they pronounced Resident #1 deceased . During an interview on [DATE] at 3:24 PM, Licensed Practical Nurse #2 stated that Resident #1 was wearing oxygen when they arrived to the unit from dialysis. During an interview on [DATE] at 11:20 AM, Registered Nurse #2 stated that they typically send two oxygen tanks out with residents when they go out to dialysis trips or longer trips so that resident don't run out of oxygen while waiting for transportation. During an interview on [DATE] at 12:21 PM, Administrator #1 stated that there should have been an order for oxygen. 10 New York Code of Rules and Regulations 415.12(k)(3)(6)

Based on observation, interviews, and record review conducted during the recertification survey from 01/03/2024 to 01/11/2024, the facility did not provide effective housekeeping and maintenance services on five (5) of 5 resident units checked. Specifically, the the facility did not ensure that resident room, resident bathroom, common areas, and closets were clean; and furniture and walls were in good repair. This is evidenced by: The following observations were noted on 01/10/2024 from 10:26 AM through 1:31 PM: Finding #1: Soiled Floors Floors were soiled in corners and next to walls in the following areas: Resident room #s 135, 147, 147, 158, 195, 184, 186, 183, 176, 215, 216, 217, 218, 222, 224, 225, 226, 232, 234, 235, 274, 281, 285, 287, 288, 293, 294, 295, and 296. Bathrooms in resident room #s 111, 113, 116, 117, 118, 123, 124, 127, 128, 131, 133, 134, 135, 142, 144, 145, 147, 156, 158, 162, 163, 164, 165, 166, 175, 182, 184, 187, 214, 215, 216, 217, 218, 222, 224, 225, 226, 228, 231, 232, 234, 235, 272, 275, 281, 283, 285, 286, 287, 288, 291, 294, 295, and 296. One Greenbush Lane closets and doctor office. One Wynantskill Way closets. One Schodack Square closets and shower 2 C Tub Room. Two Schodack Square closets and laundry room. Two Greenbush Lane closets. Finding #2: Cobwebs Cobwebs were found between furniture and between furniture and walls in resident room #s 113, 116, 117, 118, 123, 124, 126, 127, 128, 131, 133, 134, 135, 142, 144, 156, 214, 215, 217, 218, 221, 224, 226, 228, 235, 272, 281, 283, 285, 286, 287, 288, 293, 294, 295, and 296. Finding #3: Soiled Toilets Toilets were soiled behind the seat in resident room #s 113, 116, 118, 123, 124, 126, 127, 128, 131, 133, 134, 142, 145, 152, 158, 162, 163, 164, 165, 166, 181, 183, 215, 218, 221, 222, 224, 225, 226, 228, 231, 234, 235, 275, 283, 286, 287, 288, 294, 295, and 296. Finding #4: Maintenance of Walls, Furniture, and Showers A dark-colored, mold-like substance was found on the walls near the floor in the One Wynantskill Way C Tub Room. The finish on the bed footboards was worn in resident room #s 144 and 195, and the drawers were in disrepair room #s 222 and 228. Walls were scraped or missing paint in resident room #s 195, 186 and 222; the One Wynantskill Way common area; the Two Schodack Square common area; the 109s corridor; and the 240s corridor. Record review of Housekeeping Inservice Training (undated) documented that housekeeping staff were trained to thoroughly clean all resident rooms monthly including dusting and cleaning behind furniture, and were to clean floors along walls and in corners, and to thoroughly clean toilets daily. The document did not include information on reporting furniture, walls, or other areas in disrepair. During an interview on 01/11/2024 at 11:40 AM, The Regional Housekeeping Director stated that the facility was aware that the resident rooms required thorough cleaning, and the facility was actively trying to recruit more housekeeping staff to solve the problem. During an interview on 01/11/2024 at 11:45 AM, the Director of Maintenance stated that the One Wynantskill Way tub room would be cleaned that day, and would be investigated as to whether the substance found was mold. The Director of Maintenance stated that staff had not reported furniture being in disrepair, that wall scrapes were a constant issue, and that the items found would be addressed immediately. During an interview on 01/11/2024 at 11:50 AM, the Administrator stated that the facility would conduct a full house audit for cleanliness, wall scrapes, and the condition of furniture; the results would be reported to the quality assurance committee. To prevent future occurrences, housekeeping recruitment and rounding efforts would be increased, and all current housekeeping staff will be re-educated on cleaning and reporting maintenance issues. 483.10(i)(2); 10 New York Codes, Rules and Regulations 415.5(h)(4)

Based on observation, interviews, and record review during the recertification survey from 01/03/2024 to 01/11/2024, the facility did not ensure safe and appropriate labeling and storage of all medications for 3 of 3 units for medication labeling and storage. Specifically, 5 insulin pens were not labeled with expiration dates after opening, and 1 insulin pen was not labeled with the date opened and the expiration date after opening by facility policy. This was evidenced by: The facility Medication Administration Policy, dated 07/28/2023, documented that the expiration date on the medication label must be checked prior to administering. The facility's Diabetic Management Policy, dated 11/2023, documented that upon opening a new vial of insulin, the nurse must date and initial the vial. Insulin vials were to be discarded after 28 days of the date they were opened. During an observation of the team 2 medication cart on 1 Wynantskill Way on 01/08/2024 at 9:45 AM, 1 Degludec insulin Flex pen and one glargine insulin Flex pen were not labeled with the expiration date after opening. During an observation of the team 1 medication cart on 2 Wynantskill Way on 01/08/2024 at 9:55 AM, 1 Victoza insulin Flex pen and 1 Lispro Flex pen were not labeled with an expiration date after opening. During an observation of the team 2 medication cart on 2 Wynantskill Way on 01/08/2024 at 10:05 AM, 1 Basaglar insulin Flex pen was not labeled with the expiration date after opening. During an observation of the team 1 medication cart on 1 Schodack Way 01/08/2024 at 10:15 AM, 1 Humalog insulin Flex pen was not labeled with the date opened and was not labeled with the expiration date after opening. During an interview on 01/08/2024 at 09:31 AM, Licensed Practical Nurse #2 stated that they would determine the expiration date by looking it up on the internet. During an interview on 01/08/2024 at 09:45 AM, Licensed Practical Nurse #3 was not able to identify the expiration date on the Lispro insulin pen. Licensed Practical Nurse #3 stated they were unaware that insulin expiration dates vary. Licensed Practical Nurse #3 stated they did not receive insulin administration training upon hire. During an interview on 01/08/2024 at 10:15 AM, Licensed Practical Nurse #5 stated they overlooked filling in the date the insulin was opened and filling in the date of expiration. During an interview on 01/08/2024 at 12:30 PM, the Nurse Educator stated nurses who were newly hired received medication administration training. The training did not include specific insulin administration training but was included with general medication administration training. During an interview on 01/11/2024 at 10:30 AM, the Director of Nursing stated Licensed Practical Nurse #3 was given additional 1 on 1 training. The Director of Nursing stated the overnight nurse generally cleaned and organized the medication cart. However, it was the responsibility for every nurse to make sure their cart was clean, organized and that medications were labeled according to policy. All expired medications were to be discarded by the nurse. 10 New York Codes, Rules and Regulations 415.18(d)

Based on observation, staff interview, and record review during the recertification and abbreviated survey (Case #NY00324857) from 01/03/2024 to 01/11/2024, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and 11 of 11 kitchenettes checked. Specifically, serving utensils, food preparation area floors, and kitchenettes were not clean; and the main kitchen floor was not in good repair. This is evidenced by: During observations in the main kitchen on 01/03/2024 at 9:32 AM: - In the clean utensil rack, a wire whisk, 5 ladles, and one 4 ounce measuring spoon were soiled with food residue. - The stove, front of the logbook drawer, floor behind cooking equipment, doors to storage areas, and fire extinguisher were soiled with food particles and/or dirt. - Sections of the floor throughout kitchen were missing grout between tiles and were not cleanable. During observations on 01/03/2024 between 10:30 AM and 1:00 PM: - In the 1 Greenbush Lane kitchenette, the refrigerator was soiled with food particles, the wall and front of the drawer were soiled with food drip marks, and the ice machine table was soiled with rust. - In the 1 Wynantskill Way kitchenette, the wall was soiled with food splatters. - In the 1 Wynantskill Way serving kitchenette, the refrigerator, microwave oven, floor behind steamtable, and floor in corners were soiled with food particles. - In the 1 Schodack Square kitchenette, the refrigerator and floor below the refrigerator were soiled with food particles. - In the 1 Schodack Square serving kitchenette, the refrigerator and floor were soiled with food particles. - In the 2 Greenbush Lane Kitchenette, the freezer and floor below refrigerator were soiled with food particles. - In the 2 Greenbush Lane serving kitchenette, the plate warmer and floor below steamtable were soiled with food particles. - In the 2 Wynantskill Way Kitchenette, the floor below the refrigerator was soiled with food particles. - In the 2 Wynantskill Way serving kitchenette, the drawers, wall right of the steamtable, tray rack cart, and dining room wall by kitchenette were soiled with food particles or food splatters. - In the 2 Schodack Square Kitchenette, the refrigerator and drawer were soiled with food particles. - In the 2 Schodack Square serving kitchenette, the floor was soiled with food particles. The undated document titled, Training Checklist documented that dietary staff were trained to clean microwave ovens, refrigerators, plate warmers, and cabinets in the kitchenettes. Additionally, the Training Checklist was an audit tool to check for cleanliness in these areas. During an interview on 01/11/2024 at 12:09 PM, the Regional Manager of Dietary stated that the serving utensils had been cleaned, work had started on cleaning the kitchenettes, and all kitchen employees would be retrained on cleaning utensils thoroughly and cleaning the kitchenettes. The Regional Manager of Dietary stated that a cleaning scheduled would be developed, and the Assistant Food Services Director had received consultation to visually check for cleanliness at various points throughout the workday. During an interview on 01/11/2024 at 12:11 PM, the Administrator stated it was not certain as to why the missing grout in the kitchen floor had not been identified, but the Director of Maintenance would be directed to contact a vendor to re-grout the floor and to notify the quality assurance committee when complete. The Administrator stated that the dietary and housekeeping departments would be directed to clean the unit kitchenettes and serving kitchenettes; and to ensure the serving utensils, kitchen floor, unit kitchenettes, and serving kitchenettes were properly cleaned, more audits would be conducted with the findings reported to the quality assurance committee. 10 New York Codes, Rules and Regulations 415.14(h); Chapter 1 State Sanitary Code Subpart 14

Based on observation and interviews during the recertification and abbreviated survey (Case # NY00315024) from 01/03/2024 to 01/11/2024, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, one hot water heater, the hot water holding tank thermometers, and one shower valve were not maintained in good repair. This is evidenced by: During hot water temperature checks on 01/05/2024 at 1:45 PM, the Two Schodack Square 20s shower hot water temperature was 58-degrees Fahrenheit; and hot water temperatures were between 95 and 113-degrees Fahrenheit on the following resident units: One Greenbush Lane, One Schodack Square, Two Greenbush Lane, Two Schodack Square, and Two Wynantskill Way (3 shower temperatures and 3 resident room sink temperatures taken each unit). During observations on 01/08/2024 at 12:10 PM, the thermometer on hot water holding tank #2 was not functioning, the thermometer on hot holding tank #1 read 105 degrees Fahrenheit, and hot water heater #2 was not functioning. During an interview on 01/08/2024 at 12:15 PM, the Director of Maintenance stated that occasionally the facility would receive complaints about low water temperatures, but due to the size of the building and the design of the hot water system, turning on the water valve would allow hot water to reach the far ends of the hot water loop and resolve the problem. The Director of Maintenance stated that it was not known how long the thermometer on hot water holding tank #2 was not functioning. During an interview on 01/08/2024 at 12:20 PM, the Regional Director of Maintenance stated that the thermometer on holding tank #1 was probably not working since some of the hot water temperatures measured last week were higher than what holding tank #1 thermometer read. During an interview on 01/09/2024 at 10:54 AM, the Administrator stated that the valve in the 2 Schodack Square 20s shower had been repaired, new thermometers would be ordered for the hot water holding tanks, that the Director of Maintenance would be directed to monitor the hot water temperatures in the showers and on hot water tank thermometers, and that the findings would be reported to the quality assurance committee. During an interview on 01/11/2024 at 10:02 AM, the Director of Maintenance stated that the facility would not be replacing hot water heater #2 as the hot water system design was not based on the use of four hot water heaters. 10 New York Codes, Rules and Regulations 415.5(e)(1)(2)

Based on observation, record review, and interviews during the recertification and abbreviated survey (Case #NY00315024 and #NY00324857) from 01/03/2024 to 01/11/2024, the facility did not maintain a pest-free environment and an effective pest control program on three (3) of 6 resident units. Specifically, rodent droppings were found in resident rooms and dining areas, and staff were not familiar with the procedure for reporting pest findings. This is evidenced by: During observations on 01/03/2024 at 11:02 AM, rodent droppings were found in the drawers and along the walls in the One Schodack Square serving kitchenette. During observations on 01/09/2024 at 2:10 PM, rodent droppings were found behind the television in resident room [ROOM NUMBER]. During observations on 01/10/2024 at 1:08 PM, rodent droppings were found behind furniture in resident room [ROOM NUMBER]. The document titled, Evergreen Commons Pest Sightings (the pest sightings logbooks kept on the resident) and dated 11/23/2023 through 01/04/2024 documented the following: - Rodent droppings were found in the cabinet drawers in the One Schodack Square serving kitchenette on 01/03/2024 and in the One Greenbush Lane serving kitchenette on 01/04/2024. - Rodents were sighted in the Two Wynantskill Way dining room on 12/03/2023 and in the Two Wynantskill Way 50s corridor on 11/23/2023. - Rodents were sighted in the Two Schodack Square 10s corridor and in room [ROOM NUMBER] on 12/29/2023. The policy document titled, Evergreen Commons Rehabilitation and Nursing Pest Control and updated 11/2023 documented that staff should report pest sightings and that the maintenance department should ensure proper treatment of any affected areas. This document required that work orders should be completed to address areas that may facilitate pest access or harbor growth. Record revealed no policy or procedure that detailed who was responsible to check for harborage areas if pests were sighted. There was no documented evidence that the facility checked for or sealed harborage areas or entry points for rodents in resident room #s 216 or 296. Record review of pest control document titled, [Vendor] and dated 01/02/2023 through 12/28/2023 documented that the facility was treated for rodents monthly during 2023, and mouse activity on the One Schodack Unit kitchenette was noted on 12/04/2023. During an interview on 01/08/2024 at 11:46 AM, the Director of Maintenance stated that kitchen staff reported mouse droppings on the One Schodack Unit dining room serving kitchenette the week prior. The Director of Maintenance stated that rodent problems were not previously reported, but the pest control vendor would be contacted when an issue with pests was reported. They further stated that as of approximately 6 months ago, pest logs had been kept on the units for staff to record sightings and for the pest control vendor to review twice per month. During an interview on 01/08/24 at 2:59 PM, the Regional Manager of Dietary stated that rodent droppings in the One Schodack Square serving kitchenette had been cleaned. The Regional Manager of Dietary stated that kitchen staff did not know how to report sightings of rodent infestation in the pest sighting logbooks, but the staff would now receive the necessary training. During an interview on 01/09/2024 at 2:10 PM, Resident #25 stated that mice had been sighted in their room but not lately. During an interview on 01/11/2024 at 11:27 AM, the Regional Housekeeping Manager stated that the resident in one room would not let housekeeping staff into their room to clean, but staff would approach the resident again. The Regional Housekeeping Manager stated that not cleaning up the droppings in that room could be due to staffing issues. During an interview on 01/11/2024 at 11:36 AM, the Administrator stated that the pest control vendor would be immediately contacted; the drawers and floor in the One Schodack Square serving kitchenette have been cleaned; the housekeeping department would be directed to clean rooms #s 216 and 296; and all serving kitchenettes and resident rooms would be audited for pest sightings. The Administrator stated that the results of the audits would be reported to the quality assurance committee, staff would be re-educated on how to utilize the pest sighting logbooks, and the facility safety committee would discuss pest control strategies. During an interview on 01/11/2024 at 12:02 PM, the Regional Manager of Dietary stated that a pest entry point in the One Schodack Square serving kitchenette had been identified and sealed. 10 New York Codes, Rules and Regulations 415.29(j)(5)

Based on observation, staff and resident interviews, and record review conducted during the recertification survey from 01/03/2024 to 01/11/2024, the facility did not ensure that the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental and psychosocial needs for 4 (Residents #'s 539, 25, 69 and 4) of 35 residents reviewed for comprehensive care plans. Specifically, for Resident #'s 539, 25, 69, and 4, the facility did not include interventions specific to the residents' need for oxygen therapy in accordance with professional standards. This is evidenced by: Resident #539: Resident #539 was admitted to the facility on [DATE] with diagnoses including repeated falls, chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems), and unspecified asthma with exacerbation. The Minimum Data Set (an assessment tool) dated 12/12/2023 indicated that the resident could understand and be understood but had some cognitive impairments and required assistance to complete activities of daily living. The Minimum Data Set, dated dated dated [DATE], assessed the resident required oxygen therapy. During observations on 1/03/2024 at 10:54 AM, a portable oxygen tank on the back of the resident's wheelchair was set to deliver 3 liters per minute of oxygen via nasal cannula. The oxygen meter showed the tank was in the red zone, indicating it was empty. During observations on 1/04/2024 at 10:26 AM, the resident's oxygen concentrator was noted to be set at 2.5 liters per minute. The humidifier bottle was noted to be in place and was empty of fluid. During observations on 01/08/2024 at 09:21 AM, the resident's oxygen concentrator was noted to be set to 2.5 liters per minute. No date or time noted was noted on the oxygen tubing or system. The Treatment Administration Record dated 12/6/2023 to 1/10/2024 documented the resident had an active oxygen therapy order for 3 liters per minute via nasal cannula, as well as an active order to check the humidifier bottle every shift. The Comprehensive Care Plan dated 12/6/2023 to 1/10/2024 did not document any oxygen related care plans, interventions, or treatment details regarding the resident's use and need for oxygen therapy. Resident #25: The resident was admitted to the facility initially on 5/29/2018 with diagnoses including chronic diastolic (congestive) heart failure, type 2 Diabetes Mellitus with diabetic neuropathy, and morbid (severe) obesity. The Minimum Data Set (an assessment tool) dated 4/3/2023 documented that the resident could be understood and could understand others, and the resident had the cognition for daily living decisions. During observations on 01/05/2024 at 10:19 AM, the resident's oxygen concentrator was set at five (5) liters per minute. The humidifier bottle was in place and had liquid, and the oxygen tubing was dated 12/24/2023. During observations on 01/08/24 at 10:52 AM, the resident's oxygen concentrator was set to five (5) liters per minute. The humidifier bottle was in place and had liquid, and the oxygen tubing was dated 1/7/2024. During observations on 01/09/24 at 11:33 AM, the resident's oxygen concentrator was noted to be set to five (5) liters per minute. The Treatment Administration Record dated 1/8/2023 documented that the resident had oxygen therapy for four (4) liters per minute nasal cannula as needed. The treatment record documented the resident's oxygen therapy to be as needed. Completion was documented by Licensed Practical Nurse #10. The Treatment Administration Record dated 1/7/2023 documented the resident was to have oxygen tubing and humidifier changed weekly on Sundays during the night shift. Completion documentation was included on the treatment admission report by Licensed Practical Nurse #10. The Medication Administration Records from 1/3/2024 through 1/11/2024 documented that a licensed provider administered no oxygen to the resident during this time frame. The Comprehensive Care Plan dated 12/6/2023 to 1/10/2024 did not document any oxygen-related care plans, interventions, or treatment details regarding the resident's use and need for oxygen therapy. The Comprehensive Care Plan for Compromised Respiratory Status dated 1/10/2024 by the Assistant Director of Nursing documented that the resident had obstructive/central sleep apnea and that their oxygen saturation levels were to be monitored. It also documented that oxygen was to be given per the medical doctor's orders. Resident #69: The resident was admitted on [DATE], with diagnoses of chronic congestive heart failure, acute and chronic respiratory failure, and chronic obstructive pulmonary disease. The Minimum Data Set, dated dated dated [DATE], documented the resident usually understood others and was usually understood, and required some assistance with activities of daily living. The Minimum Data Set, dated dated dated [DATE], assessed the resident to require oxygen therapy. During an observation on 01/04/2024 at 09:42 AM, the resident's oxygen concentrator was noted to be set at 2.5 liters per minute via nasal cannula, no water noted to be in the humidification bottle attached to machine. During an observation on 01/05/2024 at 09:13 AM, the resident's oxygen concentrator was noted to be set at 2 liters per minute via nasal cannula, no water in the humidification bottle attached to machine. Nasal cannula prongs were noted to be both prongs in one nostril on the left side, instead of one prong in each nostril. During an observation on 01/05/2024 at 09:24 AM, the resident's portable oxygen tank was noted to be set at 2 liters per minute via nasal cannula. The Treatment Administration Record dated 12/10/2023 to 1/10/2024 documented the resident had an active oxygen therapy order for two (2) liters per minutes nasal cannula, as well as an active order to check humidifier bottle every shift. The Comprehensive Care Plan dated 3/01/2023 to 1/10/2024, did not document any oxygen related care plans, interventions, or treatment details regarding the resident's use and need for oxygen therapy. Resident #4 The resident was admitted to the facility initially on 3/2/2022, with diagnoses including chronic obstructive pulmonary disease with exacerbation, type 2 Diabetes Mellitus with chronic kidney disease, and unspecified atrial fibrillation. The Minimum Data Set, dated dated dated [DATE] documented that the resident could be understood and could understand others, and the resident had the cognition for daily living decisions. The Comprehensive Care Plan for Compromised Respiratory Status dated 4/9/2023 by the Assistant Director of Nursing documented that the resident had a chronic obstructive pulmonary disease with acute exacerbation, and their oxygen saturation levels were to be monitored. It also documented that oxygen was to be given per the medical doctor's orders. During observations on 01/08/2024 at 10:52 AM, a portable oxygen tank on the armrest of the resident's walker was set to deliver 2 liters per minute of Oxygen via nasal cannula. The oxygen meter showed the tank was in the red zone, indicating it was empty. The Treatment Administration Record dated 1/4/2024 through 1/10/2024 documented that the resident was to have oxygen therapy for two (2) liters per minute nasal cannula. Treatment records document routine checks every day and every shift. They documented completed by Licensed Practical Nurses three (3) times daily. The Medication Administration Records from 1/4/2024 through 1/10/2024 document that a licensed provider administered no oxygen to the resident during this time frame. The Comprehensive Care Plan dated 1/4/2024 to 1/10/2024 did not document any oxygen-related care plans, interventions, or treatment details regarding the resident's use and need for oxygen therapy. During an interview on 1/4/2024 at 2:19 PM, Resident #4 stated that they were on 2 liters of oxygen via nasal cannula because of their chronic obstructive pulmonary disease. They stated that their portable oxygen tanks did not last long and had to be changed regularly. The resident stated that if their bottle was empty, they would notify someone at the front desk area, and someone would get a new bottle for them. They stated that they needed to monitor their oxygen tanks most of the time as the staff did not check to see if the tanks needed to be replaced. They stated that the Certified Nursing Assistants would take the bottles and tanks to the basement, where they could refill them and bring them back to the unit. Interviews: During an interview on 1/9/2024 at 12:01 PM, Licensed Practical Nurse #8 stated they believed Resident #25 was on two (2) to three (3) liters of oxygen per minute but would have to verify in either the medication administration records or the orders. They stated that most fully alert residents with oxygen could self-monitor and turn oxygen on or off, but that those residents should keep the settings the same. If a resident was altered, staff would be more diligent in monitoring the oxygen administration to the resident. During an interview on 1/10/2024 at 2:15 PM, Licensed Practical Nurse #9 stated Resident #'s 25 and 4 were on Oxygen but would have to verify the orders. They stated that the resident was not on oxygen for a specific time, and there was no order to monitor the resident's oxygen level. They further stated that if a resident needed to have their oxygen measured, it would have been conducted by a nurse; residents were not allowed to self-monitor their oxygen or adjust the flow rate. They stated they would refer to the resident's care plan and orders for liter flow, that all residents should have had a care plan for all aspects of their care, and that - if a resident was admitted with oxygen orders - an oxygen care plan should have been in place as soon as they were admitted . Licensed Practical Nurse #9 further stated that they would contact the nursing supervisor to get one in place if one did not exist. During an interview on 1/10/2024 at 10:57 AM, Registered Nurse Educator #1 stated that all staff were educated on oxygen therapy, handling of oxygen concentrators and tanks during orientation, and at least once a year during special focus months. During an interview on 1/10/2024 at 11:20 AM, the Assistant Director of Nursing was asked to show where the care plans for oxygen administration were located on the electronic records system. They stated that they should be in the system's care plan grid and proceeded to pull the grid up on the computer but was unable to locate the proper care plan for oxygen administration. They then looked in the medication administration and treatment administration records but could not find the appropriate care plan. They stated that if a resident was on oxygen, then there would be an order for the oxygen as well as a care plan. They also stated that the care plan could be in another location within the electronic records system, but it would ultimately be within the care plan grid of the electronic records system. During an interview on 1/11/2024 at 10:06 AM, the Director of Nursing stated that when a resident was admitted on oxygen treatment, the admission director would send an email to the admission registered nurse and unit nurse manager to have the resident's care plan set up. They further stated that care plans were reviewed 14 days post admission and 90 days post admission; and that unit managers were responsible for reviewing the care plans for accuracy. 10 New York Codes, Rules and Regulations 483.21(b)(1)

Based on observation, staff interviews, and medical and facility record review conducted during the recertification and abbreviated survey (Case # NY00310589) from 01/03/2024 to 01/11/2024, the facility did not ensure adequate supervision was provided for one (Resident #195) of 7 residents reviewed for accidents. Specifically, on 2/11/2023, the facility did not ensure Resident #195 was provided adequate supervision to prevent an elopement from the facility. This is evidenced by: The facility's Policy and Procedure titled Resident Elopement, revised on 12/17/2018, documented each employee shall be informed of their responsibility in regard to door alarms and response to same, reporting elopements and reporting behavior of residents. The Policy and Procedure also documented precautions including residents at risk for elopement having their picture taken on admission and placed in the electronic medical record and maintained in a notebook by the front door receptionist for identification. Preventions documented in the Policy and Procedure include the receptionist to observe the front doors and redirect an at-risk resident from exiting and notifying the nursing supervisor. The facility's Policy and Procedure titled Wanderguard/Watchmate Bracelet, revised on 12/17/2018, documented a Wanderguard/watchmate bracelet was to be worn by residents identified as a wandering risk or elopement risk by interdisciplinary team assessment and/or history of wandering or elopement behaviors. The Wanderguard/watchmate bracelet was to be checked for proper placement at a minimum of every shift. Resident #195: Resident #195 was admitted to the facility with the diagnoses of alcohol abuse, hypertension, and altered mental status. The Minimum Data Set (an assessment tool) dated 2/16/2023 documented Resident #195 was able to understand others, was able to make self-understood, and had mild cognitive impairment. Resident #195 was able to walk without assistance or supervision with a walker. Resident #195 was observed on their unit during the recertification survey 1/3/2024 through 1/11/2024. The resident did walk around the unit but did not test the doors during multiple observations throughout the survey. The resident was observed wearing a Wanderguard and walking unassisted with a steady gait and a walker. Resident was pleasant but confused. The Elopement assessment dated [DATE] documented Resident #195 was at risk for elopement. The Comprehensive Care Plan dated as initiated on 2/10/2023, documented the resident was at risk for elopement related to verbalizing they wanted to leave the facility, impaired safety awareness and poor impulse control. The Comprehensive Care Plan documented a Wanderguard (a device worn by the resident that will alarm when the resident would try to exit the facility) was applied to the resident's right wrist. The Comprehensive Care Plan also documented that on 2/11/2023, Resident #195 cut the band and removed the Wanderguard with their own pair of scissors then left the facility. The facility's Incident Report dated 2/11/2023 documented the resident returned to the facility without injury. The facility's Investigation Report dated 2/16/2023 documented the resident was an elopement risk. The incident Report documented the resident was last seen before elopement on 2/11/2023 at 3:30 PM. The facility was informed by law enforcement on 2/11/2023 at 4:30 PM that Resident #195 was at a local restaurant. The resident returned to the facility without injury. The facility's Investigation Report included staff statements documenting: - The roam alert system was intact and fully functional on 2/11/2023 - The receptionist on duty did not recognize the resident as an elopement risk and, at the time of the elopement, had been letting visitors gathered by the door out of the facility on 2/11/2023. - The admitting nurse applied a Wanderguard to the left ankle on 2/10/2023 A document titled Daily Walk Through dated 2/11/2023 documented signatures confirming the roam alerts were functioning at the front door. The employee file for Receptionist #2 was reviewed. The employee had received training on Wandering and Elopement as evidenced by the signed in-service sheet and completed post-test with a passing grade. During an interview on 1/9/2024 at 10:50 AM, Receptionist #1 stated there was a binder with a list of residents who were an elopement risk along with their pictures and Wanderguard. The binder was signed by the receptionists every shift to indicate that it had been checked for updates. Receptionist #1 stated that if a resident with a Wanderguard approached the door, an alarm will sound. Then the staff member would redirect the resident away from the door and call the resident's unit. During an interview on 1/9/2024 at 11:17 AM, Licensed Practical Nurse #1 stated the resident had not had any exit seeking behaviors since the incident but did talk about leaving sometimes. The resident had a Wanderguard on as a precaution. The unit was a locked unit that required a code to get onto the unit and an employee badge to unlock the door to leave the unit. During an interview on 1/9/2024 at 12:04 PM, Activities Aide stated they received dementia training and wandering and elopement training when they were hired and annually. During an interview on 1/10/2024 at 12:13 PM, the Registered Dietician stated the facility provided education on wandering and elopement upon hire and annually. The Registered Dietician stated they recalled receiving education on wandering and elopement after the incident. During an interview on 1/10/2024 at 9:06 AM, the Director of Maintenance stated it was the responsibility of the maintenance department to complete daily rounds of the facility, which included checking the roam alerts at exit points to make sure they worked. The duty is signed off on a checklist that is kept in a binder. If a roam alert did not function during rounds, or maintenance is alerted that a roam alert wasn't working, it is fixed immediately. The Director of Maintenance stated they received training on wandering and elopement when they were hired and annually. They stated they did receive additional training on wandering and elopement after the incident. During an interview on 1/10/2024 at 11:05 AM, the Regional Administrator stated the incident was reported per the New York State Department of Health regulation. Receptionist #2 had given their statement at the time of the incident but did not return calls or return to the facility after the incident. The Receptionist #2 was terminated for job abandonment. During an interview on 1/10/2024 at 11:20 AM, the Director of Nursing stated the resident had used their own scissors to remove the Wanderguard. They stated that it was not the policy of the facility to search a resident's belongings without cause, and there had not been any further elopements from this resident or other residents. Based on the following corrective actions, the facility corrected the non-compliance as of 3/2/2023. The facility reached past noncompliance by taking sufficient corrective actions prior to the recertification and abbreviated survey to fully correct the noncompliance before the start of the survey. The facility's corrective actions included the following effective 3/2/2023: - Resident #195 was transferred to a locked memory care unit upon their return. - 100% of staff had been reeducated on elopement and wandering. The education provided included: unsafe wandering/elopement in-service that includes elopement prevention policy and procedure with emphasis on ensuring education to the front desk staff to check the elopement/wandering binder. -Four convex mirrors were installed in the reception/front entrance area to maximize visualization for the receptionist. These mirrors continued to be in place and in good condition during the recertification survey. 10 New York Codes, Rules and Regulations 483.25(d)(1)(2)

Based on observations, record review, and interviews conducted during the recertification survey from 1/3/2024 through 1/ 11/2024, the facility did not ensure that each resident received the necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan and the resident's choice for 4 (Resident #'s 539, 25, 69 and 4) of 35 residents reviewed for oxygen administration. Specifically, (a) supplemental oxygen was not provided as ordered by the physician for Resident #'s 539, 25, and 69; (b) portable oxygen tanks ran out of oxygen for Resident #'s 539 and 4; and (c) oxygen delivery was provided by unlicensed personnel for Residents #'s 539, 25, 69 and 4. This is evidenced by: Resident #539 was admitted to the facility on [DATE], with diagnoses including repeated falls, chronic obstructive pulmonary disease, and unspecified asthma with exacerbation. The Minimum Data Set (an assessment tool) dated 12/12/2023, assessed that the resident could understand, be understood, but had some cognitive impairments and required assistance to complete activities of daily living. Resident #25 was admitted to the facility initially on 5/29/2018, with diagnoses including chronic diastolic (congestive) heart failure, type 2 Diabetes Mellitus with diabetic neuropathy, and morbid (severe) obesity. The Minimum Data Set, dated dated dated [DATE], documented that the resident could be understood and could understand others, and the resident had the cognition for daily living decisions. Resident #69 was admitted on [DATE], with diagnoses of chronic congestive heart failure, acute and chronic respiratory failure, and chronic obstructive pulmonary disease. The Minimum Data Set, dated dated dated [DATE], documented the resident usually understood others and was usually understood, and required some assistance with activities of daily living. Resident #4 was admitted to the facility initially on 3/02/2022, with diagnoses including chronic obstructive pulmonary disease with exacerbation, type 2 Diabetes Mellitus with chronic kidney disease, and unspecified atrial fibrillation. The Minimum Data Set, dated dated dated [DATE] documented that the resident could be understood and could understand others; the resident had the cognition for daily living decisions. (a) Supplemental oxygen was not provided as ordered by the physician for Resident #'s 539, 25, and 69: The Treatment Administration Record dated 12/6/2023 to 1/10/2024 documented Resident #539 had an active oxygen therapy order for three (3) liters per minutes nasal cannula, as well as an active order to check humidifier bottle every shift. During observations on 1/04/24 at 10:26 AM, Resident #539's oxygen concentrator was noted to be set at 2.5 liters per minute. The humidifier bottle was noted to be in place and was empty of fluid. During observations on 01/08/24 at 09:21 AM, Resident #539's oxygen concentrator was noted to be set to 2.5 liters per minute, no date or time noted was noted on the tubing or system. During observations on 01/05/2024 at 10:19 AM, Resident #25's oxygen concentrator was set at five (5) liters per minute. The humidifier bottle was in place and had liquid, and the oxygen tubing was dated 12/24/2023. During observations on 01/08/24 at 10:52 AM, Resident #25's oxygen concentrator was set to five (5) liters per minute. The humidifier bottle was in place and had liquid, and the Oxygen tubing was dated 1/7/2024. During observations on 01/09/24 at 11:33 AM, Resident #25's oxygen concentrator was noted to be set to five (5) liters per minute. The Treatment Administration Record dated 1/8/2023 documented that Resident #25's resident had oxygen therapy for four (4) liters per minute nasal cannula as needed. The treatment record documents the resident's oxygen therapy to be as needed. Completion documented by Licensed Practical Nurse #10. The Treatment Administration Record dated 1/7/2023 documented Resident #25's was to have oxygen tubing, and humidifier changed weekly on Sundays during the night shift. Completion documentation was included on the treatment admission report by Licensed Practical Nurse #10. The Comprehensive Care Plan for Compromised Respiratory Status dated 1/10/2024 by the Assistant Director of Nursing documented that Resident # 25 had obstructive/central sleep apnea and that their oxygen saturation levels were to be monitored. It also documented that oxygen was to be given per the medical doctor's orders. During an observation on 01/04/2024 at 09:42 AM, Resident #69's oxygen concentrator was noted to be set at 2.5 liters per minute via nasal cannula, no water noted to be in the humidification bottle attached to machine. During an observation on 01/05/2024 at 09:13 AM, Resident #69's oxygen concentrator was noted to be set at 2 liters per minute via nasal cannula, no water in the humidification bottle attached to machine. Nasal cannula prongs were noted to be both prongs in one nostril on the left side, instead of one prong in each nostril. During an observation on 01/05/2024 at 09:24 AM, Resident #69's portable oxygen tank was noted to be set at 2 liters per minute via nasal cannula. The Minimum Data Set, dated dated dated [DATE], assessed Resident #69 to require oxygen therapy. The Treatment Administration Record dated 12/10/2023 to 1/10/2024 documented Resident #69 had an active oxygen therapy order for two liters per minutes nasal cannula, as well as an active order to check humidifier bottle every shift. The facility policy titled Oxygen Therapy - Mask and Nasal Cannula, dated 12/2023, documents that oxygen is initiated by licensed staff. Only a nurse, doctor, nurse practitioner, or physician's assistant may adjust the oxygen liter flow. Additionally, the policy documented that when humidification is required, change the water bottle weekly. Water bottle change will be documented on the Treatment Administration Record. The Comprehensive Care Plan dated 3/01/2023 to 1/10/2024, did not document any oxygen related care plans, interventions, or treatment details regarding Resident #69's use and need for oxygen therapy. (b) Portable oxygen tanks ran out of oxygen for Resident #'s 539 and 4: During observations on 01/03/2024 at 10:54 AM, a portable oxygen tank on the back of Resident #539's wheelchair was set to deliver 3 liters per minute of oxygen via nasal cannula and the oxygen meter showed the tank was in the red zone, indicating it was empty. During observations on 01/08/2024 at 10:52 AM, a portable oxygen tank on the armrest of Resident #4's walker, was set to deliver 2 liters per minute of Oxygen via nasal cannula. The oxygen meter showed the tank was in the red zone, indicating it was empty. (c) Oxygen delivery was provided by unlicensed personnel for Residents #'s 539, 25, 69 and 4: The facility policy titled, Oxygen Therapy - Mask and Nasal Cannula, dated 2/2023, documented that oxygen was initiated by licensed staff. Only a nurse, doctor, nurse practitioner, or physician's assistant may adjust the oxygen liter flow. Additionally, the policy documented that when humidification is required, change the water bottle weekly. Water bottle change would be documented on the Treatment Administration Record. The Minimum Data Set, dated dated dated [DATE], assessed Resident #539 to require oxygen therapy. The Comprehensive Care Plan dated 12/6/2023 to 1/10/2024 did not document any oxygen related care plans, interventions, or treatment details regarding the resident's use and need for oxygen therapy for Resident #539. The Comprehensive Care Plan dated 12/6/2023 to 1/10/2024 did not document any oxygen-related care plans, interventions, or treatment details regarding Resident # 25's use and need for oxygen therapy. The Medication Administration Records from 1/3/2024 through 1/11/2024 documented that a licensed provider did not administer oxygen to Resident #25 during this time frame. During an observation on 01/09/2024 at 10:26 AM, Certified Nurse Assistant #3 removed Resident #69 from a portable oxygen tank and initiated an oxygen concentrator. Certified nurse assistant #3 asked Registered Nurse #7 how many liters to set the concentrator to and the Registered Nurse replied 2 liters. The Certified Nurse Assistant turned on the oxygen concentrator and placed the nasal cannula on the resident's face. The Treatment Administration Record dated 1/4/2024 through 1/10/2024 documented that Resident #4 was to have oxygen therapy for two (2) liters per minute nasal cannula. Treatment records document routine checks every day and every shift. The documentation was completed by a Licensed Practical Nurse three (3) times daily. During an interview on 1/4/2024 at 2:19 PM, Resident #4 stated that they were on oxygen of 2 liters via nasal cannula because of their chronic obstructive pulmonary disease. They stated that their portable oxygen tanks did not last long and must be changed regularly. The resident stated that if their bottle was empty, they would notify someone at the front desk area, and someone would get a new bottle for them. They stated that they must monitor their oxygen tanks most of the time as the staff does not check to see if the tanks need replacing. They stated that the Certified Nursing Assistants would take the bottles and tanks to the basement, where they could refill them and bring them back to the unit. Interviews: During an interview on 1/09/2024 at 10:42 AM, Certified Nurse Assistant #3 stated that certified nurse assistants were allowed to check tanks and adjust the dials as needed. During an interview on 1/09/2024 at 11:17 AM, Licensed Practical Nurse #7 stated that certified nurse assistants were allowed to adjust oxygen and put residents on oxygen if needed. During an interview on 1/9/2024 at 12:01 PM, Licensed Practical Nurse #8 stated they believed Resident #4 and Resident #25 were on two (2) to three (3) liters of oxygen but would have to verify in the medication administration records or their orders to verify. They stated that most residents with oxygen and fully alert could self-monitor and turn it on or off, but they should keep the settings the same. If a resident was altered, they would be more diligent in administering oxygen to the resident. They stated that Certified Nursing Assistants were not allowed to change or set the oxygen level provided to residents or change residents from their concentrator to portable. Certified Nursing Assistants could take the empty portable canisters to the basement and fill them. They stated that Resident #4 got anxiety a lot and could be on a lower amount or no oxygen at all; the resident was on portable oxygen canisters, and they stated that they know of no issues with the oxygen. During an interview on 1/10/2024 at 10:45 AM, Certified Nursing Assistant # 4 stated that Resident #'s 25 and #4 were on oxygen and had no issues regarding the oxygen or oxygen tubing. They indicated that they had hooked up the residents' oxygen and turned the machine on, setting the liter flow for the resident. During an interview on 1/10/2024 at 10:57 AM with Registered Nurse Educator #1, they stated that all staff were educated on oxygen therapy, handling of oxygen concentrators and tanks during orientation and at least once a year during special focus months. During an interview on 1/10/2024 at 11:45 AM, Certified Nursing Assistant # 6 stated that Resident #4 was on oxygen and had no issues regarding the Oxygen or oxygen tubing. They stated they are not supposed to adjust or set the machines for the residents as they are not licensed providers. They have witnessed Certified Nursing Assistants adjusting and placing residents on Oxygen in the past. During an interview on 1/10/2024 at 2:15 PM, Licensed Practical Nurse #9 stated Resident #4 was on oxygen but would have to verify the orders. If a resident needed to have their Oxygen measured, it would have to be conducted by a nurse. Residents were not allowed to self-monitor their oxygen or adjust it if needed. They stated that Certified Nursing Assistants were not allowed to alter or set the oxygen level provided to residents or change residents from their concentrator to portable. Certified Nursing Assistants could take the empty portable canisters to the basement and fill them. They stated that if the liter flow were wrong on the oxygen delivery device, they would change it to the prescribed ordered amount and notify the Unit Manager. During an interview on 1/11/2024 at 9:30 AM, Registered Nurse Educator #1 stated that all staff were educated on oxygen therapy and handling oxygen concentrators and tanks during orientation and at least once a year during particular focus months. Certified nursing assistants were educated on what they could and could not do for oxygen administration. They stated that the certified nursing assistants could not adjust flow rates, apply oxygen to residents, or monitor oxygen levels. Certified Nursing Assistants could turn on oxygen administration devices and check tubing for kinks. Agency staff individuals were provided the same orientation education as the facility staff. During an interview on 1/11/2024 at 10:06 AM, the Director of Nursing stated registered nurses regulated the oxygen for residents. Certified nurse assistants were not allowed to adjust oxygen, only tell the licensed staff what would be needed for residents. The Director of Nursing further stated that when a resident was admitted on oxygen treatment, the admission director would send an email to the admission registered nurse and unit nurse manager to have the resident's care plan set up. They further stated that care plans were reviewed 14 days post admission and 90 days post admission; and that unit managers were responsible for reviewing the care plans for accuracy. Additionally, it was stated that only licensed staff were allowed to alter, adjust, place, or remove oxygen administration to residents. 10 NYCRR 415.12(k)(6)

Based on observation, interview, and record review during an abbreviated survey (Case #NY00307197), the facility did not ensure acceptable parameters of nutrition were maintained for 3 (Residents #'s 1, 5, and #6) of 5 residents reviewed for nutrition. Specifically, for Resident #'s 1, 5 and #6, the facility did not ensure the residents' weights and meal intakes were documented and monitored in accordance with professional standards of practice. This is evidenced by: The Policy & Procedure (P&P) titled Supervision of Resident's Nutrition dated 4/2022, documented each resident shall receive proper nutrition in accordance with the resident's assessment, care plan, and physician's order. Food and fluid intake must be observed by nursing personnel at each meal. The amount eaten must be recorded in the electronic medical record (EMR). The P&P titled Height & Weight dated 4/20/2022, documented upon admission and/or readmission, all resident's heights and weight were to be obtained by nursing personnel within 24 hours. The data would be recorded on the initial admission assessment on the computer and would be transcribed onto the resident's monthly weight record. For new admissions or re-admissions, the resident would be weighed weekly for 4 weeks. If a resident's monthly weight resulted in a 5-pound loss or gain from the previously recorded weight, a reweigh would occur. A reweigh would be obtained within 24 hours after the previous weight was obtained. Resident #1: Resident #1 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, chronic kidney disease, and hyperlipidemia. The Minimum Data Set (MDS - an assessment tool) dated 11/21/2022 documented the resident's cognition was not assessed but the resident was usually able to understand others and was usually able to make themselves understood. The Comprehensive Care Plan for Nutrition dated 11/16/2022 documented to monitor weight per MD (physician) orders: Weekly. Physician orders did not include documentation of an order to weigh the resident. Weight Record (in pounds) from 11/15/2022 to 12/10/2022 documented: 11/15/2022- refused admission weight 11/23/2022- 120.8 lbs. The medical record did not include a weight after 11/23/2022. Meal Intake Record from 11/16/2022 to 12/10/2022: -Breakfast: 13 out of 25 opportunities were not documented. -Lunch: 18 out of 25 opportunities were not documented. -Dinner: 17 out of 25 opportunities were not documented. Nutrition Progress Notes documented: -11/30/2022: Weekly weight pending. The resident's intake at meals was 75%. -12/7/2022: Weight pending. The resident's intake at meals was 75%. Resident #5: Resident #5 was admitted to the facility with diagnoses of cancer, diabetes, and depression. The Minimum Data Set (MDS - an assessment tool) dated 2/21/2023 documented the resident had moderately impaired cognition, was able to understand others and was able to make themselves understood. The resident census documented Resident #5 was readmitted to the facility on [DATE]. The Comprehensive Care Plan for Nutrition dated 2/9/2023 documented to monitor weight per MD (physician) orders: Weekly. Physician orders did not include an order to weigh the resident. Weight Record (in pounds) documented from 2/8/2023 to 3/22/2023: -2/8/2023- Unable: Need Hoyer (full mechanical lift) Weight -2/16/2023- 229.6 -3/1/2023- 205.1 The medical record did not include a weight after 3/1/2023, did not include weekly weights for 4 weeks after the resident was readmitted to the facility on [DATE], and did not include a reweigh when there was 24.5-pound weight loss from 2/16/2023 to 3/1/2023. Meal Intake Record from 3/1/2023 to 3/22/2023: -Breakfast: 10 out of 22 opportunities were not documented. -Lunch: 13 out of 22 opportunities were not documented. -Dinner: 13 out of 22 opportunities were not documented. Nutrition Progress Notes documented: -3/8/2023: The resident's intake at meals was 76-100%. The resident weighed 205.1 on 3/1/2023 with a reweigh pending. The resident's weight was showing a 24-pound loss from 2/16/2023. The note documented ? wt on 2-16: of 229.6#. -3/15/2023: The resident's intake at meals was 76-100%, and a weekly weight was pending. Resident #6: Resident #6 was admitted to the facility with diagnoses of cerebrovascular accident, diabetes, and depression. The Minimum Data Set (MDS - an assessment tool) dated 2/18/2023 documented the resident was cognitively impaired, was usually able to understand others and was usually able to make themselves understood. The resident census documented Resident #6 was readmitted to the facility on [DATE]. The Comprehensive Care Plan for Nutrition dated 1/17/2023 documented to monitor weight per MD (physician) orders: Weekly. Physician orders did not include an order to weigh the resident. Weight Record (in pounds) documented from 1/7/2023 to 3/22/2023: -1/17/2023: 182.2 -2/8/2023: 169.2 -2/27/2023: 161.4 -3/8/2023: 168.0 The medical record did not include weekly weights after the resident was readmitted on [DATE] and did not include a reweigh when there was a 13-pound weight loss from 1/17/2023 to 2/8/2023, when there was a 7.8-pound weight loss from 2/8/2023 to 2/27/2023, and when there was a 6.6-pound weight gain from 2/27/2023 to 3/8/2023. Meal Intake Record from 3/1/2023 to 3/22/2023: -Breakfast: 14 out of 22 opportunities were not documented. -Lunch: 7 out of 22 opportunities were not documented. -Dinner: 19 out of 22 opportunities were not documented. Nutrition Progress notes documented: -2/10/2023: The resident's intake at meals was 75% and intake varied. On 1/17/2023, the resident weighed 182.2 and now weighed 169.2 on 2/8/2023. The note documented ? accurate wt. Reweigh requested. Do ? 182.2# on 1-17. -2/16/2023: The resident's intake at meals was 75% and intake varied. Weekly weight pending. Resident had varying weights since admission. -2/24/2023: The resident's intake at meals was 75% and intake varied. Weekly weight and reweigh pending. Resident had varying weights since admission. Interviews: During an interview on 3/23/2023 at 10:00 AM, Certified Nursing Assistant (CNA) #3 stated all residents were supposed to be weighed monthly, by the 10th of every month, unless they were on weekly weights. If they were on weekly weights, they would be weighed during the week their weight was due. The CNA stated the Registered Dietitians (RDs) gave the unit weight sheets that told the staff which residents needed to be weighed monthly and weekly, and who needed a reweight. After a resident's weight was obtained, the CNAs would cross the resident's name off the sheet and the CNA or nurse would document the resident's weight in the computer. During an interview on 3/23/2023 at 11:45 AM, CNA #4 stated monthly weights were obtained for all residents anywhere from the 1st to the 10th of each month, and if a resident needed a weekly weight dietary would let the staff know which residents needed to be weighed weekly. The CNA stated if a resident needed a reweigh, dietary would let them know that too. The CNAs were provided with lists of the residents that needed to be weighed. The CNA stated the CNAs documented the weights in the computer. During an interview on 3/23/2023 at 1:35 PM, the RD stated new admissions or readmissions were weighed weekly for 4 weeks or until they were stable. Reweighs were obtained when a resident weighed above or below 5 pounds from their previous weight, or when there was a significant weight loss. A reweigh should be obtained within 24 hours. The RD stated if a weight was not obtained, the RD would initially document in their progress note that the weekly weight, or re-reweight, was pending, and then go to the unit and let the staff know the weight was needed. The weight did not get skipped just because it had been documented by the RD that it was pending. A follow up note would be written when the weight was obtained. The RD stated they would get an alert in the computer when a reweigh was needed and would let the staff know. The CNAs and the nurses obtained the residents' weights on the unit and the CNAs or nurses documented the weights on weekly weight sheets that were posted on the unit and they would also enter the weight into the computer. The RD stated the RDs could also enter the weight into the computer from what was written on the weight sheet. The RD stated the units were provided with weight sheets for residents who needed to be weighed monthly and weekly, and those who needed to be reweighed. The RD stated even if there was not a physician order to a weigh the resident, the protocol was to weigh weekly upon admission or readmission. The RD reviewed Resident #1's medical record and stated the resident had a right to refuse to be weighed but the admission weight should have been attempted the next morning after the resident's admission and documented if they had refused. The RD stated it looked like Resident #1 did not have any more weights obtained after 11/23/2022 and would not be able to say if the resident had lost or gained weight while in the facility. The RD stated Resident #5 was on the list to be reweighed and stated they did not know why the resident had not been reweighed. The RD stated Resident #5 would be a full weight loss trigger and a 3 day calorie count would need to be put in place. The RD stated Resident #6 was still on weekly weights and Resident #6 was on their weekly weight list that they sent out every morning to the interdisciplinary team. During an interview on 3/23/2023 at 1:50 PM, the Assistant Administrator stated they were aware that there were residents who needed to be weighed and the RD kept in close contact with everyone. The Assistant Administrator stated there was a lack of documentation when a resident refused to have their weight obtained. The CNAs should be making the Unit Managers aware of any refusals and the residents should be reapproached to have their weights done. The Assistant Administrator stated when they received the weight email from the RD, they would bring it up in morning report and would tell the Unit Managers the weights needed to be done. During an interview on 3/24/2023 at 9:20 AM, CNA #5 stated the CNAs documented meal intakes in the medical record. It was the responsibility of the CNAs to document how much a resident ate at breakfast, lunch, and dinner. If a resident refused, the CNA would document the refusal in the computer and report it to the nurse. The Unit Managers oversaw that the CNAs completed their documentation. The CNA stated the staff were very busy and they tried to document after each meal but it might not always get done. During an interview on 3/24/2023 at 9:30 AM, Registered Nurse (RN) #1 stated it was the responsibility of the CNAs to document meal intakes for all residents. The RN stated as a Unit Manager they would print out the CNA documentation that was not completed at the end of each shift and let the CNAs know what documentation was missed and would ask them to document. The Unit Managers were responsible for ensuring documentation was completed. The RN stated the RDs would also say in morning report when there were meal intakes missing and would say the intakes needed to be documented. The RN stated the staff were very busy and documentation was not always done. During a subsequent interview on 3/24/2023 at 10:30 AM, the RD stated every morning before morning report they emailed a list of residents who needed to be weighed and a list of residents who were missing meal intake documentation to Administration and the Unit Managers and then the list was also discussed in morning report. There was a facility computer system (Real-Time) that provided a Nutritional Alerts Summary that alerted the RD when more than 20% of a resident's meal intakes were not documented. When the RD got this alert, they would send it to Administration and the Unit Managers. The RD stated the meal intake percentage documented in the RD notes was the average of the meal intakes that were documented in the medical record for that week. When there was missing documentation for meal intakes, the RDs still monitored the resident's intake by reviewing nursing notes, conducting staff interviews, and making their own observations of the resident. The RD stated there needed to be better documentation for meal intakes and stated it was the Unit Managers' responsibility to oversee that CNA documentation was completed. During an interview on 3/24/2023 at 11:15 AM, the Administrator stated RDs gave weight lists to the units and made staff aware which residents needed to be weighed. The staff attempted to obtain admission weights and reweighs as soon as possible within 24 hours, and if a resident refused, the nurse on the unit should be made aware and it should be documented. The Administrator stated there was an email thread that the RDs sent out to administration and the Unit Managers regarding weights and the RDs also reported in morning report when weights needed to be obtained. It was the responsibility of the Unit Managers to bring that information back to the staff on the unit. The RDs also made rounds on the units to assist with obtaining weights and it was an all-hands-on deck approach to get the weights completed. The Administrator stated the RDs were responsible for monitoring the residents' meal intakes and weights and in the event a weight was not obtained, the RD would write a generalized note that the weight was not collected yet, but the resident was still eating and would follow up. The resident's nutritional status was still monitored through the intake, appearance, and activity of daily living status even though a weight may not have been obtained. The Administrator stated the CNAs were responsible for documenting meal intakes. The facility's computer system (Real-Time) and 24-hour report were reviewed for alerts regarding resident meal intakes and there would follow up with the staff and residents as necessary based on those alerts. The Unit Managers should be running the reports and monitoring that the CNAs were documenting the meal intakes. The Administrator stated the care plan should be implemented regarding the frequency a resident was to be weighed. The care plan drove the physician orders, and if there was not a physician order for weights, the care plan would be followed. 10NYCRR 415.12(i)(1)

Based on record review and interviews during an abbreviated survey (Case #NY 767), the facility did not ensure each resident was free from abuse for 1 (Resident #1) of 5 residents reviewed. Specifically, for Resident #1 who was care planned for being a potential victim of abuse due to cognitive disabilities, the facility did not ensure the resident was free from abuse by a Certified Nurse Aide (CNA). This was evidenced by: The Policy and Procedure (P&P) titled Freedom from Abuse, Neglect, and Exploitation last reviewed 11/2021, documented it was the policy of the facility to assure that all staff were familiar with the Freedom from Abuse, Neglect, and Exploitation Program. The P&P documented abuse was the willful infliction of injury that resulted in physical harm, pain, or mental anguish. The facility Abuse, Neglect, Mistreatment and Misappropriation of Resident's Property Addendum revised on 6/19/2020, documented physical abuse included hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 4/7/2022, documented the resident had severe cognitive impairment. The Comprehensive Care Plan (CCP) for Cognitive Loss/Dementia last reviewed on 4/4/2022, documented Resident #1 would make daily choices in care. Staff were to address the resident in a slow quiet manner, maintain a calm environment, and provide positive reinforcement. The CCP for Potential Victim of Abuse last updated on 4/23/2022, documented Resident #1 was vulnerable due to cognitive disabilities. The resident was to be protected from being a victim of abuse. On 4/23/2022, the CCP update documented a skin assessment, and an abuse assessment were completed. A Statement of Record dated 4/23/2022 at 12:15 PM by CNA #2, documented CNA #2 and CNA #1 were bringing residents into the dining room for lunch. As CNA #2 was about to walk out of the dining room, they heard CNA #1 tell Resident #1 to uncross their feet. Resident #1 told CNA #1 no, because the table was too high for them. As Resident #1 told CNA #1 no, Resident #1 pushed back (in their chair) with their feet and that was when CNA #2 saw CNA #1 smack Resident #1 on top of their head. CNA #2 immediately told the supervisor. A written statement dated 4/23/2022 by the Director of Investigations (DOI), documented the DOI was operating in the capacity of the supervisor on 4/23/2022, when CNA #2 came into the office visibly upset. CNA #2 informed the DOI that they had just witnessed CNA #1 pushing Resident #1 who was in their wheelchair into the dining room and the resident kept putting their feet down and stopping CNA #1 from pushing. CNA #2 stated that CNA #1 slapped Resident #1 on top of their head and told them to stop it and that there was a red mark on top of their forehead. The DOI immediately went down to the unit and observed a quarter size red mark on the top of Resident #1's forehead. The DOI asked the resident if anything had happened and the resident stated, Yes. That girl with the brown hair slapped me on my head and I'm pissed. The DOI then called CNA #1 into the office and asked them what had happened with Resident #1 and if they did slap the resident in the head. CNA #1 reported that Resident #1 told CNA #1 that something was on their head and CNA #1 was brushing it off. CNA #1 was then escorted out of the building. A Nurse's Note dated 4/23/2022 by the DOI, documented they were notified of an incident with Resident #1. Resident #1 had a quarter size red mark on the top of their head. A full body assessment was completed with no other bruises or redness noted. A Social Worker Progress Note dated 4/23/2022, documented that they met with Resident #1 for follow-up after being notified of a red mark on the resident's head. Resident #1 engaged with SW #2 and spoke about the alleged incident. The facility Investigation Report for an event dated 4/23/2022 at 12:30 PM, documented by the DOI, that they were working in the capacity of a Registered Nurse Supervisor (RNS) and was approached by CNA #2 who was visibly upset and reported that they had witnessed abuse. CNA #2 stated that their training required them to report any abuse they witnessed and then stated that they observed CNA #1 transport Resident #1, who was in the wheelchair, into the dining room. CNA #2 reported that the resident kept putting their feet down to stop CNA #1 and CNA #1 tapped the resident on top of their head and yelled stop it at the resident. CNA #2 reported that the resident had a quarter size red mark to the top of the forehead, which was later confirmed by the DOI through an assessment of the resident. The DOI asked Resident #1 if anything had happened and the resident replied, Yeah. (CNA #1) hit me on the top of my head and I was pissed. During an interview on 4/27/2022 at 10:23 AM, Resident #1 stated that they got smacked on top of their head for unknown reasons. The resident then stated that it was not the first time that it happened, and addedd that they could not say if it was the same person. The resident stated that it was painful when they were struck by CNA #1. During an interview on 4/28/2022 at 2:52 PM, CNA #2 stated that, while they and CNA #1 were bringing the residents to the dining room, they heard CNA #1 yelling at Resident #1. Res #1 said No, that table is too high, I don't want to sit there. CNA #1 then said to the resident, I said uncross your feet, CNA #1 then smacked Resident #1 right on top of their head. CNA #2 was CNA #1 hit the resident with a hard smack, you could literally see the handprint on their head. CNA #2 said they immediately went to the DOI who was also the supervisor that day and told them what they witnessed, and Resident #1 told the DOI that they, got wacked on the head. During an interview on 4/28/2022 at 3:26 PM, the DOI stated that they were supervising on the date of the incident, and CNA #2 came into the office and was visibly upset. CNA #2 stated they saw CNA #1 pushing Resident #1 in their wheelchair and the resident put their feet down so that CNA #1 could not move them. The DOI asked the resident what happened, and the resident stated, That (staff member) with the brown hair hit me on my head and I'm pissed. The The DOI assessed the resident and identified a quarter sized red mark, and that the red mark was gone about 15 minutes later. The DOI questioned CNA #1 and CNA #1 stated that the resident had something on their head, and they were brushing it off. During an interview on 5/6/2022 at 12:00 PM, the Administrator stated 89.5 % of staff were educated on abuse following the incident. Daily abuse audits were being done on all shifts with all disciplines, and they were randomly asking staff to name three forms of abuse, what they would do if they witnessed abuse, and who was responsible for reporting abuse/neglect. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: -On 4/23/2022, the alleged perpetrator, Certified Nurse Aide (CNA) #1, was immediately suspended and escorted out of the building pending investigation results. -On 4/23/2022, Resident #1 was immediately assessed by the Registered Nurse (RN) and was interviewed about the allegation of abuse. -On 4/23/2022, the facility notified the local police department following the incident. -On 4/23/2022, the incident was reported to the New York State Department of Health (NYSDOH) vis HERDS. -On 4/23/2022, facility-wide abuse education was initiated for all staff. At the time of the survey, 89.5 % of all staff were educated. -RN completed head-to-toe assessments on all other residents on CNA #1's assignment on the date of incident, 4/23/2022. No areas of concern were noted. -The Social Worker assessed all other residents on CNA #1's assignment on the date of incident, 4/23/2022. No residents showed signs of emotional or mental distress. -Abuse, Neglect, Mistreatment & Misappropriation Competency Audit initiated on 4/25/2022 and would be completed on various staff members at random. -CMS CE Pathway for Abuse was initiated by the Director of Investigations (DOI). -On 4/25/2022, Interdisciplinary Team (IDT) discussion to review the incident and discuss abuse and reporting. -On 4/25/2022, CNA #1 neglected to show for an in-person interview, was interviewed by the Administrator via phone and was terminated. CNA #1 was removed from CHRC on 4/25/2022. 10 NYCRR 415.4(b)(1)(i)

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Food time/temperature controlled for safety (TCS foods), is to be cooled to 41 degrees Fahrenheit (F) within 6 hours provided the food is cooled from 135F to 70F within the first two hours of cooling, automatic dishwashing machines are to operate in accordance with manufacturer specifications, and food and non-food contact surfaces are to be kept clean. Specifically, TCS foods were not cooled properly, the automatic dish washing machine was not rinsing at the specified water pressure, and floors and equipment were not clean in the main kitchen and 6 of 6 kitchenettes. This is evidenced as follows. The main kitchen and kitchenettes were inspected on 08/26/2021 at 9:09 AM. Internal temperature of 6 corned beef roasts, approximately 10 pounds each located in the walk-in cooler that were prepared on 08/25/2021 at 4:00 PM, had an internal temperature of 48.6 degrees Fahrenheit (F) when checked. The automatic dish washing machine (dish machine) in the main kitchen final rinse was 17 pounds per square inch (psi); the data plate instructions on this machine state that the final rinse water flow pressure is to be at a minimum of 20 psi. Five cutting boards were soiled with a black substance and the oven, stovetop, fryer, walls in the three-bay sink area, and floors in the 6 kitchenettes were covered in food debris. The Director of Food Service stated in an interview on 08/26/2021 at 10:00 AM that the corned beef roasts were cooked on 08/25/2021 at 4:00 PM, then placed in the walk-in cooler, but were too large to cool to 41 F within 6 hours, the low pressure on the dish machine will be reported to the maintenance department, and there is an area for improvement with cleaning the kitchenettes and main kitchen. The Administrator stated on 08/26/2021 at 2:45 PM, that the Food Service Director will re-educate kitchen staff on proper cooling and cleaning procedures, and the maintenance staff will repair the dish machine. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.40(a) 14-1.110, 14-1.113

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor and surrounding area was not maintained in a sanitary condition. This is evidenced as follows. The trash compactor was inspected on 08/26/2021 at 9:30 AM. The sides of the trash compactor were covered in an oily black substance, and the concrete pad below the compactor was covered in food debris. The Director of Food Services stated in an interview on 08/26/2021 at 1:31 PM, that the trash compactor, and the concrete pad will be cleaned. The Administrator stated in an interview on 08/26/2021 at 3:15 PM, that the facility will pressure wash the trash compactor and concrete pad, and the food debris will be cleaned. 10 NYCRR 415.14(h)

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, floors were not clean in resident rooms. This is evidenced as follows. The floors in resident rooms were spot checked on 08/26/2021 at 2:30 PM, 08/30/2021 at 12:30 PM, and on 08/31/2021 at 2:30 PM. The floors in resident rooms #'s 114, 131, 183, 184, 185, 186, 191, 193, 194, 196, 197, 214, 273, 274, and #281 were soiled with dirt and brownish build-up. The Director of Maintenance stated in an interview on 08/30/2021 at 2:30 PM, that the facility will make sure that the floors are cleaned in the resident rooms. The Administrator stated in an interview on 08/31/2021 at 3:05 PM, that the facility will audit the floors in resident rooms to ensure that they are clean. 483.10(i)(2)

Based on observation, interview and record review during the COVID-19 Focused Infection Control Survey conducted on 7/29/2021, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on 2 (1 Greenbush and 1 Schodack) of 6 units reviewed. Specifically, the facility did not ensure staff members performed proper hand hygiene after glove removal and prior to touching a clean area, and on 1 of 6 units staff did not contaminate a resident's bedside table with blood filled vials obtained from another resident and the resident's bed with a multi resident use laboratory bag. This is evidenced By: The findings are: The policy and procedure titled, Handwashing, with a last reviewed date of 3/12/20, documented that hands are to be washed after removing gloves. On 7/29/2021, the Hospital Electronic Response Data System (HERDS) report listed the following information; facility census is 238 and two residents are COVID-19 positive. During an interview on 7/29/2021 at 10:21 AM, the Administrator stated the facility currently had two COVID-19 positive residents that were residing on 1 Greenbush. The remainder of the residents residing on 1 Greenbush were under observation for COVID-19. The New York State Department of Health guidance, titled Health Advisory: COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and revised 7/10/20, provides that when there are confirmed COVID-19 positive cases in a nursing home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e., do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The Center for Disease Control (CDC) guidance titled Using Personal Protective Equipment (PPE), updated on 8/19/20, provided: PPE was needed for a patient with confirmed or possible COVID-19 and healthcare personnel should adhere to standard and transmission-based precautions when caring for patients with COVID-19 infection. This guidance further documents that before exiting a patient's room, gloves and gown shall be removed (doffed) and the gown discarded in a trash receptacle, the facemask or respirator removed and discarded, and hand hygiene performed thereafter. Likewise, the CDC diagram guidance regarding PPE Sequencing, How to Safely Remove Personal Protective Equipment (PPE) document ID CS 2-E (undated), provides: discard [gloves, disposable face shield, gown, and mask or respirator] in a waste container before performing hand hygiene. 1 Schodack During an observation on 07/29/21 at at 11:01 AM, Phlebotomist #1 entered Resident #5 and 6's room, with gloves on, placed a multi-resident use laboratory bag on the end of Resident #5's bed and removed laboratory vials and a tourniquet (a device that is used to apply pressure to a limb or extremity in order to limit - but not stop - the flow of blood). Phlebotomist #1 walked to Resident #6's bed, placed the tourniquet on the resident's right arm, performed venipuncture and filled 3 laboratory vials with blood. Phlebotomist #1 placed a gauze on the resident's arm where the venipuncture was performed and removed the tourniquet. Phlebotomist #1 walked to Resident #5's bedside, placed the three blood filled laboratory vials on Resident #5's bedside table and removed papers from the laboratory bag. Phlebotomist #1, placed blood vials in a plastic bag, removed her gloves, exited the residents' room and walked to an elevator in a common area and pushed the up button. Phlebotomist #1 did not perform hand hygiene, cleanse the multi resident use laboratory bag or cleanse Resident #5's bedside table after placing the blood vials obtained from Resident #6 on it. During an interview on 7/29/2021 at 11:08 AM, Phlebotomist #1 stated she worked for an agency that contracted with this facility. She stated she performed hand hygiene after every two residents. She stated she should not have placed her multi-resident use laboratory bag on a resident's bed, and she should not have placed Resident #6's blood filled vials onto Resident #5's bedside table. She stated she had been educated on the importance of hand hygiene after each glove removal, however she had to much work to complete to perform hand hygiene as expected. During an interview on 7/29/2021 at 11:32 AM, Registered Nurse Unit Manager (RNUM) #3 stated she had been employed at the facility for approximately four months and was not sure who was responsible to supervise contract staff. RNUM #3 stated she would expect hand hygiene to be performed after each glove removal. 1 Greenbush During an observation on 7/29/2021 at 12:41 PM, Housekeeper (HK) #1 removed a filled garbage from Resident #7 and #8 's room from the bathroom, placed the filled garbage in a large bin in a multi-resident use housekeeping cart and removed gloves. Donned gloves from a box on top of the housekeeping cart, and removed a roll of unused garbage bags from the top of the multi-resident use housekeeping cart, removed three garbage bags and re-entered Residents #7 & #8's room. HK #1 was observed wiping the resident's sink and toilet with a gloved hand and cloth. HK #1 exited Resident #7 & #8;s room, placed a spray bottle inside of the housekeeping cart and doffed gloves, donned gloves from a box on-top of the housekeeping cart and removed the mop from the side of the cart. HK #1 mopped the floor, closed the door, doffed gloves and performed hand hygiene. HK #1 donned gloves from the glove box on top of the housekeeping cart, removed a cloth and spray bottle from inside the cart and entered Resident #9 & #10's room. HK #1 sprayed the sink and toilet in the resident bathroom and wiped the sink with a cloth. HK #1 exited Resident #9 & #10's room, placed the cloth in a bag hanging from the cart, placed a spray bottle inside the cart, doffed gloves and placed them in the garbage receptacle in the cart. HK #1 removed gloves from the box on top of the cart and a cloth from the cart, entered the residents' room and wiped the toilet. HK #1 exited the residents' room, placed the cloth in a bag hanging on the side of the cart and doffed gloves. HK #1 removed gloves from the box on top of the cart and removed the mop from the cart. HK #1 did not perform hand hygiene after each glove removal and prior to entering a multi-resident use housekeeping cart. During an interview on 7/29/2021 at 12:48 PM, HK #1 stated all residents on the unit were on contact and droplet precautions. HK #1 stated the expectation was to perform hand hygiene after cleaning each room. HK #1 stated she was not expected to perform hand hygiene after each glove removal or prior to entering the multi-resident use housekeeping cart. During an interview on 7/29/2021 at 2:24 PM, the Infection Control Preventionist (ICP) #1 stated the expectation was that all staff would perform hand hygiene prior to entering and after exiting a resident's room, before donning gloves and after doffing gloves, before touching a multi-resident use cart or a clean area. ICP #1 stated the phlebotomist was expected to place the multi-resident use bag to be left outside of the resident area and not be placed on a resident's bed. ICP #1 stated she would expect staff to not place a used laboratory vial on another resident's bedside table. ICP #1 stated it was the expectation of all facility staff including the RNUM to oversee the care and services contract staff provide to residents. 10NYCRR415.19(a)(1-3),(b)(4)

Based on record review and interviews during an abbreviated survey (Case #NY 711), the facility did not ensure an allegation of abuse was reported to the New York State Department of Health (NYSDOH) within 2 hours of becoming aware of the allegation for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, the facility did not ensure an allegation of abuse involving Resident #1 was reported within 2 hours of becoming aware of the allegation on 4/13/2021 at 6:00 PM. This is evidenced by: Resident #1 was admitted to the facility with [CONDITION(S)], debility and emotional stress. The Minimum Data Set (MDS-an assessment tool) dated 4/4/2021 documented the resident had mildly impaired cognition and could usually make him/herself understood and could understand others. The facility's policy and procedure (P&P) dated 3/15/2003, and last reviewed 6/19/2020 documented sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The Nursing Supervisor or designee must complete a Resident Incident/Accident Report and written statements from staff would be obtained. Any case in which sexual abuse has been identified via the investigation, or a conclusion cannot be drawn, will be reported promptly the NYSDOH. The undated facility investigation documented that on 4/13/2021 the facility became aware of an allegation that Resident #1 had been sexually abused. The NYSDOH Complaint Intake form dated 4/16/2021 documented the allegation that Resident #1 was sexually abused was reported by the hospital case worker. After the onsite survey on 4/16/2021, the facility reported the allegation to NYSDOH on 4/21/2021. During an interview on 4/16/2021 at 1:00 PM the Director of Social Work (DSW) #1 stated that on 4/13/2021 the resident's son informed her that the resident made an allegation of sexual abuse against a staff person at the facility. She notified the Director of Nursing, the Director of Investigations and the Administrator, and an investigation was started. During an interview on 4/16/2021 at 1:10 PM the Administrator (ADM) stated she became aware of the allegation of sexual abuse on 4/13/2021 at 6:00 PM when DSW #1 called to inform her. The ADM stated she did not report the allegation of abuse to the NYSDOH. 10 NYCRR 415.4 (b)

Based on record review and staff interview during complaint investigation (NY 343), the facility did not ensure that the resident environment remains as free of accident hazards as is possible and that the residents recevied adequate supervision to prevent accidents. Specifically, Resident #99, who was identified as a fall risk, had an indiviualized care plan to be gotten "out of bed first on the 7:00 am - 3:00 pm shift." On 4/9/14, the facility did not ensure that the resident was the first resident assisted from bed on the 7:00 am - 3:00 pm shift and subsequently was found with her call bell activated and on the floor outside of her room in the corridor at 7:23 am. As a result of Resident #99's fall, the resident sustained [REDACTED]. This resulted in actual harm that is not immediate jeporady. This is evidenced by: Resident #99 was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident with severe cognitive impairment. The Comprehensive Care Plan for Falls with a start date of 4/12/12 documented Resident #99 was at risk for falls with approaches noted. On 11/7/13 an approach documented "first get up on 7-3." The CNA Task List Assignments documented "1st OOB on assignment" on the day shift each day. This task is documented with a start date of 11/7/13. The Assignment Sheet for Resident #99's Unit for 4/9/14 documented that CNA #1 and #2 were assigned to Assignment #2 (a sepcified group of residents), for the 7:00 am - 3:00 pm shift. The assignment sheet documented Resident #99's name with a notation "1ST Get up". No other resident on the unit or on assignment 2 had a notation "1ST Get up." An Incident Report dated 4/9/14 at 7:23 am documented Resident #99 was found on the floor in the corridor complaining of pain in her right wrist and right hip. The report documented that the charge nurse was notified, notified the supervisor, the resident was assessed and orders were obtained from the physician to send the resident to the hospital for evaluation and treatment. The report further documented that the resident was trying to transfer herself out of bed to get up for the day. A nurse's note dated 4/9/14 at 8:20 am documented that a CNA was noted to hear a call bell going off, she went into the hall to go answer it and she found Resident #99 on the floor. The resident was alert and was compalining of her right wrist and right hip hurting. The Charge Nurse was notified and he then notified supervisor. Supervisor completed assessment and called physician who decided to send resident out for evaluation. Pain 9/10 in both right wrist and hip, decreased range of motion in both wrist and hip were noted. Resident trying to transfer herself out of bed to get up for the day. Resident transferred to the emergency room . A nurse's note dated 4/9/14 at 2:31 pm documented that Resident #99 returned from the hospital. A Medical Progress Note dated 4/9/14 at 8:23 pm signed by the Nurse Practitioner documented "Resident fell now with fracture pelvis and wrist: pubic rami fracture and right distall radius fracture." In a statement prepared for the facility investigation signed and dated 4/9/14, the charge nurse, Licensed Practical Nurse #1 (LPN), documented "To Whom It May Concern: At the beginning of the shift CNA #1 was made aware that Resident #99 was a "1ST Morning Get Up" by LPN and it was also stated on the assignment sheet." The Resident statement signed by the Director of Nursing (DON) documented "Resident reports "I was trying to get myself up for the day" A Witness Statement signed by the DON on 4/9/14 documented that CNA #1 was contacted via phone for a statement at 3:15 pm and reported that the last time he had seen the resident was on the night shift because he was doing a double shift (11-7am and 7am - 3pm.) The witness statement documented CNA #1 was asked if he had any idea how this could have happened, to which he responded, "I was helping my partner get her patients out of bed." and added "I should have got my own patients up first." Investigation Summary Conclusion signed by the DON dated 4/9/14 documented that on 4/9/14, Resident #99 got herself out of bed and was going to "get herself going for the day". She made it to the corridor where she fell . The conculsion further documented that the Certified Nurses Assistant was suspended pending investigation. Also documented was "It appears that abuse, neglect or mistreatment did not occur as CNA did not start assignment due to the fact another CNA needed assistance and resident removed herself from her bed. Investigation Summary follow-up action documented on 4/9/14, CNA suspended investigation and documented on 4/11/14 CNA returned to work with full day of re-orientation with lead CNA. Witness Statement signed by the DON and CNA #2 on 5/1/14 documented CNA #2 was asked if she had any idea how this could have happened, to which she responded, that she was in a residents room getting ready to do care alone and went into the hallway and found CNA #1. CNA #2 documented that CNA #1 came into the room and assisted with the lift. CNA #2 documented after providing care to her resident, she entered the hallway and observed CNA #1 coming out of a different resident's room. CNA #2 doucmented that CNA #1 asked her if she would take one of his other residents from his assignement. CNA #2 documented "I recognized that Resident #99 needed to be done, so I told him to go do her and he said "It was too late, she already fell on the floor." During an interview on 4/22/14 at 12:00 pm, Registered Nurse #1 stated that she was the Unit Manager for Resident #99's unit until recently. The RN reviewed Resident #99's comprehensive care plan entitled falls, "first get up on 7-3" started on 11/7/13, and stated that she had implemented the intervention as a result of a fall. RN #1 stated that the resident would attempt to get up first thing in the morning, she was most at risk for falling in the morning and therefore to avoid another fall, she initiated the intevention to assist the resident out of bed before she attempted to get out of bed on her own. During an interview on 4/22/14 at 1:40 pm, CNA #2 stated that she was fairly new to the facility and she was still working with CNA #1 but they had kind of split the assignment. CNA #2 stated that she started with another resident on the assignment, came out of the resident's room and found CNA #1 who assisted her in transferring another resident. CNA #2 stated that the transfer was routine in nature. CNA #2 stated that she provided care to her resident and then found out that Resident #99 was found on the floor. CNA #2 stated that she had not been spoken to by administration nor had she been disciplined. During an interview on 4/22/14 at 2:45 pm, the DON stated that she was the supervisor in the building the morning of Resident #99's fall. The DON stated that she was called to the unit by LPN #1 to assess the Resident #99. The DON stated that LPN #1 immediately reported "I told CNA #1 that he needed to get Resident #99 up first." The DON stated after assessing the resident and getting the order to transport her to the hospital, she reviewed the assignment sheet for the day, which documented in type, "1ST get up" next to the resident's name. Then the DON reviewed Resident #99's CNA task list, that the CNA utilize to provide necessary care to residents, and confirmed that it included the direction to "1st OOB on assignment." The DON stated that she immediately suspended CNA #1 for violation of the care plan, and stated "it was right there, she should have been taken out of bed first." The DON stated that when the Administrator came in he told her that there was no care plan violation because technically, he didn't start his assignment yet and instructed her to return CNA #1 to work with one day of orientation. During an interview on 4/22/14 at 3:20 pm, the Administrator stated that he was aware of Resident #99's fall and susequent fractures and stated that "we talked about it, and believed there was something with the care plan but we didn't believe that there was a care plan violation." The Administrator stated that he thought the residents care plan said something about "1st get up on the floor" and that "someone was very thorough" in writing it but he was unclear of all of the circumstances of that day. The Administrator stated that the CNA received two days of orientation with a seasoned aide on the entire roll of a CNA, including the resident task lists. The Administrator was asked if the incident was reported to the Department of Health and the Adminstrator stated "no, not unless something was wrong, we don't have to report every fracture." During an interview on 5/13/14 at 10:15 am, CNA #1 stated that he was assigned to Resident #99 on the morning of 4/9/14. CNA #1 stated he usually works on the 11:00 pm - 7:00 am shift but that day he was doing a double and staying on for the 7:00 am - 3:00 pm shift. CNA #99 stated that he had not really worked with Resident #99 in the past because he works the night shift, but that LPN #1 did inform him that she needed to get up first. CNA #1 stated he did not get Resident #99 up first, instead he assisted his coworker in getting another resident up first and then went on to assist another resident. CNA #1 was asked if he was responding to the two other residents due to an emergency or a critical incident and the CNA stated "no, I know, I should have gotten Resident #99 up first." CNA #1 was asked if he violated the care plan by not getting Resident #99 up first and CNA #1 stated "no, they told me that technically, I didn't violate the care plan because I didn't start my assignment yet." During a follow-up interview on 5/13/14 at 1:30 pm, the Administrator was asked to identify the root cause of the resident's fall and the Administrator stated that he would be unable to answer that until he reviewed the file, and stated that he would have to get back to the surveyor. During an interview on 5/13/14 at 3:35 pm, the Medical Director stated that the Administrator had requested that he respond to the DOH surveyor regarding root cause of Resident #99's fall. The Medical Director stated that the resident was on antibotic therapy which may have caused her to be a little more unsteady and anxious. The DOH surveyor asked if his suspected increase in unsteadiness and anxiousness to Resident #99 with the addition of medication would further support the need to get the resident up per the care plan, the medical director stated, "well, yes, so maybe we should have reworded the care plan." 10NYCRR415.12(h)(1)

Based on record review, resident and staff interview during an abbreviated survey (NY 846) the facility did not ensure that a resident without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable for one resident (# 1) of three residents reviewed. Specifically, a resident with the [DIAGNOSES REDACTED]. The resident returned to the facility with an immobilizer in place to her left lower leg and subsequently sustained an unstageable pressure sore beneath the immobilizer. This was actual harm for the resident that is not immediate jeopardy. This is evidenced by the following: Policy and Procedure (P&P) entitled Pressure Ulcer Prevention and Management and dated as revised 11/22/2010 documented it is the policy of the facility to maintain the highest degree of skin integrity at all times. However, there are resident conditions that may contribute to breaks in a resident's skin integrity. It is the responsibility of the facility staff via the interdisciplinary team to recognize any resident who is at risk for pressure ulcer development and initiate appropriate preventive measures. The prevention and treatment of [REDACTED]. Preventive measures will be implemented by the interdisciplinary team to address the areas identified as risks. A weekly skin check of all residents will be conducted by the Licensed Practical Nurse (LPN) during the first shower of the week, as well as by the Registered Nurse (RN) during weekly general observations and findings will be documented in the EMR (electronic medical record). The facility's interdisciplinary team will conduct ongoing monitoring of the facility's skin integrity program to ensure that appropriate preventive interventions are in place for "at-risk" residents and residents with actual pressure ulcers will have a plan of care implemented to promote healing of the ulcer as quickly as possible. Procedures included, the RN will conduct a pressure ulcer risk assessment upon admission/readmission and weekly for four weeks, quarterly, annually and upon significant change in status. A comprehensive care plan will be developed for residents "at-risk" to prevent pressure ulcers from developing. The preventive plan should address all assessed risk factors. When a pressure ulcer is identified, the RN will notify the physician, document assessment in the skin and wound module and on the 24 hour report, notify the unit manager/supervisor, update the CNA directives, assess/reassess for pain and initiate documentation of pain in the EMR, and send a rehab screen-notifying the rehab of the pressure ulcer. The resident will be discussed at morning report, including a description of the pressure sore. Resident # 1: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident is alert and oriented with a BIMS score of 15 according to the Minimum Data Set ((MDS) dated [DATE]. Resident required extensive assistance of two staff members for bed mobility, required total assistance of two staff members for transfers and toileting, does not ambulate, and required extensive assistance of one staff member for personal hygiene and dressing. Resident # 1 returned from the hospital on [DATE] with the history of flaccid [MEDICAL CONDITION] and [MEDICAL CONDITION] with a new [DIAGNOSES REDACTED]. The treatment kardex documented that Resident had an immobilizer and ace wrap to left lower extremity per Orthopedic three times per day and this treatment was discontinued on 11/8/12. There was no further treatment or monitoring of the left leg or immobilizer documented on the treatment kardex from 11/8/12 through 12/5/12 at which time an unstageable pressure sore was noted. Resident was followed by the Wound Care Center and subsequently had a left lower extremity, above the knee amputation done on 1/10/13. Comprehensive Care Plan (CCP) dated 10/29/12 and printed on 12/5/12 entitled Resident at risk for fractures, positive fracture proximal tibia. Interventions included left leg immobilizer in place as ordered (there were no instructions regarding release for skin care). Observe for pain, redness and swelling. Provide resident with assistance-supervision with ADL's ( activity of daily living) as indicated by plan of care. Therapy screen as indicated. CCP dated 4/19/10 and printed on 12/5/12, entitled at risk skin as related to: bruising, skin tears, pressure ulcers and [MEDICAL CONDITION]. There were no interventions documented to address the left leg immobilizer and skin checks to the leg. CCP dated 4/19/10 and printed on 12/5/12, entitled Resident is dependent on staff in meeting ADL needs. Interventions were dated with start dates of 4/19/10, and one dated 9/20/10. There were no interventions documented to address the left leg immobilizer and skin checks to the leg. Incident report dated 10/24/12 documented the resident fell from chair at 2:30 pm. It documented CNA was present in room, turned around, resident took off shirt as always, she witnessed her fall and could not get there in time. It was described "minor injury, documented as a bruise to her forehead." Physician note dated 10/28/12 at 7:03 am documented, asked to see resident regarding bruise to the left shin with warmth. Resident has no feeling in her lower extremities. History of MS and [MEDICAL CONDITION]. Recent fall out of wheel chair. At 7:17 am, comment added to note by physician included resident also complains of left hip hurting. Bilateral foot drop and [MEDICAL CONDITION] to lower extremities. No palpable cords in the calf. She does not move the lower extremities. Has limited range of motion (ROM) of left knee, passive ROM performed to left leg without complaint yet it is hard to know what she feels. Will order x-ray and doppler of left leg as well as x-ray left hip. Nurse note written by LPN dated 10/28/12 at 3:20 pm documented results of x-ray, fracture proximal tibia. Supervisor aware, daughter aware, resident left via stretcher with ambulance to hospital. The hospital emergency department (ED) report dated 10/28/12 documented X-rays of the lower extremity were obtained, there was no evidence of femur fracture, however, there does appear to be a fracture through the proximal tibia, as well as fibula. There does appear to be extension of the fracture into the knee joint space, consistent with a tibial plateau fracture on both the medial and lateral tibial plateaus. A consult was obtained with the Orthopedic Physician by telephone. He did review the x-rays and feels that ace wrap and knee immobilization is appropriate. The patient is non-weight bearing and goes from bed to chair. This treatment will need to be continued 4-6 weeks. He will follow her up in the office. She is discharged via ambulance back to the nursing home with knee immobilizer and ace wrap on the left knee and extending down the ankle. There was no instruction in regards to care of the immobilizer or the opening or removal of the immobilizer for care. Nursing progress note written by LPN dated 10/28/12 at 9:46 pm documented new orders received, primary physician (MD) notified, via phone conversation, change in condition-returned from Emergency Department (ED). Resident returned with ace wrap and knee immobilizer on, physician notified. There was no documentation in regards to care of the immobilizer or immobilized leg. physician's orders [REDACTED]. There was no documentation in regards to care of the immobilizer or immobilized leg to prevent complications. physician progress notes [REDACTED]. Resident has limited feeling in lower extremities due to MS, resident is incontinent. Assessment and plan documented MS, [MEDICAL CONDITIONS] joint disease (DJD), left tibial fracture, new prescription for Foley due to incontinence and knee immobilizer, resident at risk for skin breakdown-has had pressure ulcer in past. New treatments f/u with orthopedics as needed. There was no mention of steps to be taken to prevent complications related to the immobilizer. The October 2012 electronic treatment administration record (ETAR), (the report that serves as a legal record of the treatments administered to a resident) documented treatment to be done: ace wrap and knee immobilizer to LLE for six weeks, three times per day, during the Day, Evening and Night shift. The treatment is initialed as completed for October 29, 30, and 31 for the day, evening and night shifts indicating it was completed. The ETAR did not instruct to open or remove immobilizer for prevention of complications. The October 2012 ETAR documented treatment to be done: skin checks one time per day every Tuesday during the day shift (weekly skin checks). The treatment is initialed on 10/30/12 by LPN # 1, indicating it was completed for that week. A dictated Orthopedic physician consult dated 11/7/12 documented the patient is insensate (lacking physical sensation) in the left lower extremity and is nonambulatory. Assessment/Plan documented, I have filled out a consult sheet recommending continued knee immobilizer for the next six weeks. May take it off for bathing and to check the skin. The written Orthopedic physician consult dated 11/7/12 documented knee immobilizer times five more weeks, and discontinue ace wrap to the left calf. The November 2012 ETAR documented treatment to be done: ace wrap and knee immobilizer to LLE for six weeks, three times per day, during the Day, Evening and Night shift. The treatment is initialed as completed for November 1st through November 8th indicating it was completed. This treatment was discontinued after 11/8/12. There is no further evidence on the ETAR that the left leg or the immobilizer was monitored after 11/8/13. In error the LPN discontinued the ace wrap and included the immobilizer, which had not been ordered by the physician. The November 2012 ETAR documented skin checks one time per day every Tuesday during the day shift (weekly skin checks). The treatment is initialed on 11/6/12, and 11/13/12 by LPN # 2, both with the notation NA (indicating not administered), and 11/20/12, and 11/27/12 by LPN # 1, indicating it was completed for that week. General Nurse Observation assessment dated [DATE] and completed by the Registered Nurse Manager (RNM), documented immobilizer remains in place to left leg for tibia fracture. Friction areas noted to posterior of left lower leg from immobilizer so abd pads placed. Interdisciplinary progress notes dated 11/16/13 and completed by RNM, documented immobilizer remains in place to left leg for tibia fracture, friction areas noted to posterior of left lower leg from immobilizer so abd pads placed. The twenty four hour Supervisor report sheets from 11/16/12 through 12/5/12 had no documentation of a friction area to the posterior left lower leg from the immobilizer. There was no treatment or instruction added to the ETAR in regards to monitoring the friction area or to place abd pads for protection. The December 2012 ETAR had no documentation in regards to the left leg fracture or immobilizer, prior to the discovery of the stage three pressure area on 12/5/13. Treatment initiated on 12/6/12 [MEDICATION NAME](foam designed to protect skin from splints, casts and prostheses) to immobilizer on each side of area, three times per day for left lower leg ulcer. The December 2012 ETAR documented skin checks one time per day every Tuesday during the day shift. The treatment is initialed with the notation of NA (indicating not administered), on 12/4/12 by LPN # 1. Nurse Practitioner progress note dated 12/5/12 documented resident seen this am, staff noted new area on left lower leg. Resident with immobilizer on left knee. Tibia fibula fracture left lower leg, pressure ulcer, new prescription-santyl with [MEDICATION NAME] dressing. Discovery Memo for Pressure Ulcer development dated 12/5/12 documented unstageable area to left posterior lower leg. Skin Condition/Wound Progression note dated 12/5/12, signed by the Assistant Director of Nursing (ADON) documented a new (1st recording), wound present on the left middle calf is a pressure ulcer. Unable to accurately stage-suspected deep tissue injury (SDTI) in evolution, length 7 centimeters (cm), width 4 cm, no odor is apparent, moderate drainage is present, color is red-tinged. Area unstageable caused by immobilizer. Wound base is visible, eschar tissue type 100%, surrounding tissue is reddened. The Wound Care Clinic note dated 12/12/12 documented pressure ulcers left calf times two and debrided. Treatment included to elevate, offload, will check x-ray, PVR and ultrasound. Report of the Mobile Imaging, venous ultrasound of the left lower extremity dated 12/12/12 documented unremarkable study with no evidence of left lower extremity [MEDICAL CONDITION]. Report of the Mobile Imaging, PVR study (is a test that measures blood flow in the leg arteries) to the lower extremities dated 12/13/12, documented bilateral severe Peripheral Vascular Obstructive Disease. The Wound Care Clinic note dated 12/20/12 documented the patient is here for two stage three pressure ulcers of the left calf. The patient has no sensation in the lower extremities, she has no pain or discomfort. This [AGE] year old female with a history of [MEDICAL CONDITION] who has lower extremity [MEDICAL CONDITION]. We have encouraged leg elevation, complete offloading, use of nutritional supplements and good nutritional intake. The Wound Care Clinic note dated 12/27/12 documented the patient is here for pressure ulcers of the left calf, the patient did not know she had a problem with the left heel. Documented there is an ulcer on the left calf proximally, on the left calf distally and the left heel has an area of darkened skin, intact and not distinct eschar at this point. Wound Care Clinic note dated 1/4/13 documented the the left heel blistered area from last week is now solid eschar with a very small rim of surrounding [DIAGNOSES REDACTED]. The left posterior calf ulcer is filled with very necrotic, slough, nonviable tissue. Documented under Treatment Plan, I think the patient needs urgent evaluation at this point, not only for vascular evaluation but for consideration for possible amputation of the left lower extremity. The patient is aware that her ulcer areas have worsened, is in agreement with being evaluated by the emergency room and Vascular Surgery. Report of the hospital PVR study dated 1/4/13, documented marked decrease in blood flow to both lower extremities, more severe distally. Report of hospital CT scan dated 1/4/13, documented left superficial femoral artery with multiple moderate stenosis. Hospital Discharge Summary dated 1/15/13 documented hospital admission date of [DATE] with [DIAGNOSES REDACTED]. During an interview on 5/6/13 at 12:15 pm, the Resident stated she was seen by another physician for her [MEDICAL CONDITION] and had no feelings in her legs prior to coming into the facility. Resident stated it has been years and she can't feel anything in her legs. Resident stated when she fell and broke her leg they put an immobilizer on. Resident has no memory of anyone taking the immobilizer off before they found her wound. Resident did not feel anything and did not know when the wound occurred. During an interview on 5/6/13 at 2:40 pm, the Nurse Practitioner (NP) stated the Resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Resident has a history of pressure ulcer of her sacrum and could be resistive to turning and positioning. On 12/5/13 she had seen the pressure area after being told about it by the 11:00 pm to 7:00 am (night shift) and the facility had the Physical Medicine Physician look at it as well. NP stated that the Resident did have PVR studies and was found to have severe [MEDICAL CONDITION] and that she would have developed a wound on her leg at some point due to her circulation. NP stated that the facility is now checking all residents with immobilizers and braces and there are no further issues. During an interview on 5/6/13 at 4:00 pm, the Medical Director stated that the nursing staff should have been looking at the skin and that the facility certainly needs to look into their protocol. The Medical Director stated the facility often finds pressure areas related to appliances, and that an appliance such as an immobilizer would increase the risk for skin breakdown. The Medical Director stated that if we had known of the friction area that was documented by the RNM on 11/16/12 that we could have done something; possibly seen by Vascular or even had the appliance redone to avoid the pressure and friction. The Medical Director stated that the Resident would have developed something to her lower extremities given her poor circulation, although it would probably have been more distal. During an interview on 5/7/13 at 11:25 am, CNA # 1 stated there were no special CNA instructions in caring for the Resident with her immobilizer. CNA stated that prior to the wound she had never seen a nurse open or remove the immobilizer. During an interview on 5/7/13 at 11:30 am, LPN # 1 stated that she is not aware of any protocol in caring for the immobilizer. Stated the consulting paperwork should list any removal of the immobilizer and it would be ordered. LPN stated the Treatment kardex documented the ace wrap and immobilizer to be checked every shift, and she would check only to see it was on. LPN # 1 stated she never took the immobilizer off even on weekly skin check day, LPN # 1's initials were entered into the box on the ETAR for the weekly skin checks on 12/4/12. There were no instructions to open or remove splint. LPN had no recollection of the immobilizer being opened or removed. During an interview on 5/7/13 at 12:00 pm the Director of Nursing (DON) stated she had not been working at the facility during the time of this residents wound discovery. The ETAR was reviewed with the DON . The DON stated it looks like there were no instructions after 11/8/12 to look at the immobilizer. DON stated she had recognized a problem with documentation and has plans to improve on it. She also stated 24 hour report sheets will also need to be changed to improve on communication. During an interview on 5/7/13 at 1:10 pm, CNA # 2 stated that the Resident was a Hoyer lift, and a set-up for bath in which the Resident did her upper body and the CNA did the lower body. CNA stated never saw anyone open or take the splint off, stated the Resident had bed baths when the immobilizer was on and a nurse never came in and checked the skin. CNA stated there was no special instruction or training for the Resident with the immobilizer. During an interview on 5/7/13 at 1:30 pm, the Physical Therapist (PT) stated they do a screen on a resident who is readmitted to the facility following a hospitalization . A resident who goes to the emergency room and returns the same day would not have a screen. The PT stated the Resident came back with an immobilizer, but she was a total lift and there was no change in the plan of care. Therapy department does educate staff when their department issues a new splint and monitors it for a time. Therapy department does not educate and monitor the staff when a resident comes in from the outside with a splint or cast. During an interview on 5/7/13 at 2:00 pm, the RN Educator stated the facility had no policy and procedure in how to care for residents with immobilizers or casts. She stated she was aware of the fracture but had not been requested to inservice staff in regards to the immobilizer. She stated that after the discovery of the wound she was asked to meet with, and re-educate the RNM # 1 in regards to finding the friction area on 11/16/12 and not reporting it or following through on making sure it was monitored. She also met with the LPN on the unit who had been made aware of the friction area by the RNM to review reporting and caring for new pressure sores. During an interview on 5/7/13 at 2:45 pm, the Assistant Director of Nursing (ADON) stated that there were two nurses that made the error that led to the pressure sore, that the discovery on 11/16/12 of the friction area should have been reported by the RNM and/or LPN who were aware of it. ADON stated that the immobilizer should have been removed during the weekly skin checks when the bath was given, to assess the skin. The ADON stated that the RNM did the weekly skin observations on this Resident. ADON was not aware that the order for checking the immobilizer daily had been discontinued on 11/8/12 and that the immobilizer was not being monitored daily. The ADON stated that the immobilizer should have been removed for care and skin checks by the LPNs. During the conference prior to the DOH investigator leaving the facility on 5/7/13 at 3:00 pm, the Administrator, DON, ADON and Medical Director were present. In conversation with the Administrator, he stated that the Resident's skin was being monitored during the weekly skin checks, and that the immobilizer was being removed. The Administrator stated that the pressure area was the fault of the RNM only. Stated that the facility was not at fault for the pressure area. The Administrator stated the RNM responsible was terminated from employment at the facility. The Medical Director stated that the Resident did have decrease sensation to her lower legs and he felt that weekly skin checks were sufficient for this Resident, given that there were no problems. Stated the friction area of 11/16/12 should have been reported and something could have been done. During an interview on 5/8/13 at 2:00 pm, LPN # 2 stated there were no special instructions or inservice given on caring for the Resident's immobilizer. LPN stated the immobilizer and ace wrap that was documented in the ETAR from 10/29/12 through 11/8/12 was for the nurses to make sure it was in place, not to be opened or removed. LPN # 2 stated that when she did the weekly skin checks that the immobilizer was not opened or removed. LPN # 2's initials were entered into the box on the ETAR for the weekly skin checks on 10/30/12, 11/6/12, 11/13/12, 11/20/12 and 11/27/12. LPN stated that on the 11/7/12 follow-up appointment with Orthopedic the Resident returned with an order to discontinue the ace-wrap and that she discontinued the immobilizer and ace-wrap in the ETAR and did not start another treatment. LPN was not sure why she did not start a treatment without the ace-wrap. LPN was aware of the friction area that the RNM found on 11/16/13 and she did place an abd pad on the area. LPN stated she did not open the immobilizer to do this, she would push the abd pad down into the immobilizer from the top metal part. She stated she did this because the RNM told her to, but that it was not placed on the ETAR for others to do as well. During an interview on 5/8/13 at 2:30 pm, LPN # 3 stated that there was no treatment ordered to open the immobilizer, the ETAR documented only to make sure the immobilizer was on. The LPN stated she never opened the immobilizer herself and was not aware of any other nurse opening or removing it. During an interview on 5/29/13 at 3:30 pm, the RNM (who no longer works at the facility) stated when the Resident was sent to the emergency room for the fracture that she returned on the evening shift. The RNM stated there were no special instructions in regards to caring for the Resident's immobilizer. RNM stated that all residents were scheduled for weekly skin checks and the LPNs signed for them, and she was not aware that the nurses were not removing the immobilizer for the skin checks. RNM stated there was no team discussion about this Resident having paraparesis and having an immobilizer and there were no special interventions put into place. She stated the nurses should have been checking the skin under the Resident's immobilizer. RNM stated that on 11/16/12 she did observe an area to the posterior leg that was pink but there was no skin breakdown. She stated she did not feel it was an area that required a skin alert form to be completed. The RNM stated that she padded the area with a pad and instructed the LPN to do the same. This was not placed in the treatment kardex, and was not sure why. She did not place this on report because she felt there was no open area. 10 NYCRR 415.12 (c)(1)(2)