Every finding on record at Ferncliff Nursing Home Co Inc

Based on observation, interview and record review during an abbreviated survey (# 2658277), the facility failed to ensure residents were free from physical abuse by a staff member for one (1) of three (3) residents (Resident # 1) reviewed for Abuse. Specifically, on 10/13/2025, Resident #1 who had severe cognitive impairment was slapped in the face by Licensed Practical Nurse #3 after an argument between Resident #1 and Licensed Practical Nurse #3 over a piece of cake. Subsequently, Resident #1 sustained redness and swelling to their right cheek and was crying. Resident #1 was led to their room by Certified Nurse Aide #1 where they consoled them and encouraged the resident to relax. Applying the reasonable person concept, this resulted in psychosocial harm to Resident #1 that was not Immediate Jeopardy. The findings include: The policy titled Resident Abuse Reporting and Investigation last reviewed 08/28/2023, documented to protect residents and ensure freedom from abuse and mistreatment. Resident #1 had the following diagnoses: diabetes mellitus (condition that occurs when blood sugar is too high), major depressive disorder (mental health condition characterized by persistent feeling of sadness or loss of interest in activities), and dementia (condition characterized by progressive or persistent loss of intellectual functioning). The care plan titled Behavior Symptoms initiated 01/29/2022 documented Resident #1 required ongoing redirection, monitoring, and structured activities to alter behavior problems; identify reason and pattern of behavior. The care plan titled Victimization: At Risk Due to Dementia initiated 04/12/2022 documented Resident #1 will not be victimized or harmed by others. Counseling as needed, separate from others as needed, and engage in activity of choice. The 09/12/2025 annual Minimum Data Set (a resident assessment tool) documented Resident #1 had severe cognitive impairment and had no behaviors. The 10/31/2025 Accident and Incident Report documented that at approximately 1:30PM-1:45PM on 10/31/2025, Resident #1 took another resident's cake while in the dining room during lunch. Licensed Practical Nurse #3 got into an argument with the resident about the cake. The resident stood up and spit in Licensed Practical Nurse #3's face and Licensed Practical Nurse #3 slapped Resident #1 on the right cheek. The incident was witnessed by Certified Nurse Aide #1 and Certified Nurse Aide #2 and statements were collected. The Assistant Director of Nursing #1 was notified by Certified Nurse Aide #1. The physician was notified immediately, and Licensed Practical Nurse #3 was removed from the facility. The family was notified as well as law enforcement and the State Department of Health. Nurse Practitioner #8 note, dated 10/31/2025 at 2:50 PM, documented Resident #1's right cheek with mild erythema (redness) and mild swelling. Monitor for pain and change in condition. The Resident may have Tylenol for discomfort, and to be seen by social work for supportive care. The Director of Social Work note, dated 10/31/2025 at 3:09 PM, documented Resident #1 denied any recollection of physical contact or trauma today. No signs of fear, distress, or anxiety noted. Social work provided support and comfort with plan to check up on resident for signs of anxiety, fear and distress. The Nursing note, dated 11/02/2025, documented follow up, no redness to right cheek, redness resolved, resident refused any interventions. Physician #9 note, dated 11/02/2025, documented assessment performed after alleged physical assault by staff, no visible trauma, resident does not recall the event, maintain safety and continue to monitor. Psychiatric Nurse Practitioner #7 note, dated 11/03/2025, documented that Resident #1 was pleasant and had no signs of distress. During an observation on 11/04/2025 at 11:11 AM, Resident #1 was assisting activities staff by adding slices of cucumber to water for the hydration station. Resident #1 smiled, stated their name for the writer and gave a brief explanation of the meaning of their name. Resident #1 appeared happy and content with no redness or swelling to the right side of their face. During an interview on 11/04/2025 at 1:27 PM, Certified Nurse Aide #1 stated that they were present in the dining room during the incident on 10/31/2025. Certified Nurse Aide #1 stated they observed Licensed Practical Nurse #3 slap Resident #1 after Resident #1 spit in their face. Resident #1 started crying and they walked over and escorted them out of the dining room to their room where they consoled them and encouraged them to relax. Certified Nurse Aide #1 stated that Certified Nurse Aide #2 reported the incident to Assistant Director of Nursing #1 and Licensed Practical Nurse #3 was escorted from the unit. During a telephone interview on 11/04/2025 at 1:50 PM, Certified Nurse Aide #2 stated that they witnessed the incident on 10/31/2025 and observed Resident #1 and Licensed Practical Nurse #3 arguing. The staff present tried to get Licensed Practical Nurse #3 to walk away but the argument continued. Resident #1 then spit on Licensed Practical Nurse #3 and Licensed Practical Nurse #3 immediately slapped Resident #1. Licensed Practical Nurse #3 walked away. Certified Nurse Aide #1 removed Resident #1 from the dining room. They reported the incident to Assistant Director of Nursing #1 who came to the unit immediately. Licensed Practical Nurse #3 was escorted off the unit. During a telephone interview on 11/04/2025 at 2:59 PM, Licensed Practical Nurse #3 stated on the day of the incident, Resident #1 took another resident's piece of cake during lunch in the dining room. They tried to take the cake from Resident #1. Resident #1 started yelling using nasty language stood up, and spit at them. Licensed Practical Nurse #3 stated they should have just walked away but were fearful of Resident #1 falling when they stood. Licensed Practical Nurse #3 stated they don't remember slapping the resident, but they did. Licensed Practical Nurse #3 stated they were aware of Resident #1 history of behaviors but never experienced it personally. They apologized to Resident #1 and another staff member took Resident #1 to their room. The Assistant Director of Nursing arrived on the unit, and they were relieved from their assignment, escorted off the unit, and were suspended after providing a statement. During an interview on 11/05/2025 at 9:49 AM, Assistant Director of Nursing #1 stated on the day of the incident, Certified Nurse Aide #2 reported to them that Licensed Practical Nurse #3 slapped Resident #1. They immediately went to the unit with Assistant Director of Nursing #2. They requested relief for Licensed Practical Nurse #3 and escorted Licensed Practical Nurse #3 off the unit. Licensed Practical Nurse #3 stated they knew what they did was wrong and wrote a statement. Licensed Practical Nurse #3 was suspended and escorted out of the facility. Human Resources and law enforcement were contacted. Resident #1's son was notified of the incident. Resident #1 was assessed by Nurse Practitioner #8 and the Director Social Work after the incident. During an interview on 11/05/2025 at 11:35 AM, Psychiatric Nurse Practitioner #7 stated they completed an assessment of Resident #1 on 11/03/2025 via telehealth. They stated Resident #1 has impaired cognition and poor recall, so it was difficult to get information from them about the incident on 10/31/2025. Resident #1 was not exhibiting any signs of distress. Resident #1 was joyful and joking at the time of the assessment. They stated if Resident #1 had shown any signs of feeling threatened by staff approaching them, one may say they were affected by the incident. It is difficult to relate other behaviors to the effects of the incident as Resident #1 also has bi-polar disorder, which causes the resident to exhibit other behaviors.During an interview on 11/05/2025 at 1:18 PM, the Director of Social Work stated after they were notified of the incident on 10/31/2025, they immediately met with Resident #1. The Director of Social Work stated when they asked the resident what happened, they stated people were not being nice in the dining room. Resident #1 stated they felt insulted but could not recall exactly what happened. The Director of Social Work stated Resident #1 was seen after the incident on 10/31/2025 and they observed Resident #1 daily for signs of psychosocial distress. During a follow up telephone interview on 11/14/2025 at 2:45 PM, Psychiatric Nurse Practitioner #7 stated due to Resident #1's cognitive deficit and poor recollection, it is not clear how the incident on 10/31/2025 affected them. When Resident #1 was assessed after the incident they were back to their baseline and showed no signs of distress. However, if an individual with intact cognition went through the same experience, the response and effects would depend on how the individual responds to trauma. If someone is abused by a caregiver, it is possible it will affect them psychologically. The abused person may withdraw and not want to seek assistance from other caregivers. As everyone responds differently to experiences, one cannot generalize but it is possible that an individual may be affected by the incident experienced by Resident #1. 10NYCRR 415.4(b)(1)(i)

Based on observation and interview conducted during the recertification survey from 2/20/25 to 2/27/25, the facility did not ensure specific food items were maintained in accordance with professional standards for food safety and infection control prevention. Specifically, opened and not dated potentially hazardous foods were observed in one of the refrigerators and the dry pantry, and 3 of 4 dietary aides were observed wearing disposable gloves for meal service and did not change gloves after touching other non-meal service objects. The findings are: The facility policy last revised on 1/2025, 'Production, Purchasing, Storage: Food and Supply Storage' included documentation procedure to cover, label and date unused portions and open packages, using Medvantage/Freshdate labeling system. The facility policy last revised on 1/2024 'Sanitation and Infection Prevention/Control: Disposable Glove Use' included documentation procedure disposable gloves must be changed, and hands washed when moving from one task to another. The initial tour of the kitchen was conducted on 2/20/25 at 10:31 AM. The following items were observed: An opened, undated container of thickened milk in the refrigerator. An opened, undated bag of powdered sugar, wrapped with plastic wrap in dry storage. The Food Service Director was interviewed at that time of observation and stated they were unaware the two items were not dated after opening according to facility policy. On 2/21/25 at 11:45 AM Dietary Aide #26 on unit 5A was observed taking temperatures of food on tray line wearing disposable gloves. They held the ink pen and clipboard to write the temperatures while wearing the gloves, placed gloved hand on the wall while waiting for thermometer to register the temperature, and lifted the garbage lid to dispose of paper while wearing disposable gloves. Dietary Aide #26 continued to wear the disposable gloves to begin meal service. On 2/24/25 at 11:43 AM Dietary Aide #27 on unit 3A was observed taking temperatures of food on tray line wearing disposable gloves. They held the ink pen and clipboard to write the temperatures while wearing the gloves, touched door handle to leave the serving area, and then opened the refrigerator door to obtain bread while wearing disposable gloves and then returned to begin meal tray preparation. On 2/25/25 at 12:15 PM during dining observation on unit 5A, Dietary Aide #28 stop plating food for meal service, answered the phone, holding the telephone receiver wearing disposable gloves, and then continued to serve the meal without changing gloves. On 2/27/25 at 1:54 PM during an interview, the Food Service Director stated all dietary staff had been in-serviced on disposable glove use. Staff should have known to change gloves whenever moving from one task to another and when serving food on the resident units per policy on disposable glove use. 10 NYCRR 415.15(h)

Based on observations, record review, and interviews conducted during the recertification and abbreviated (NY00368899) surveys from 2/20/25 to 2/27/25, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) on sixty-nine (69) of ninety-six (96) shifts the facility did not provide the minimum number of staff documented in the facility Minimum Staffing Standard Matrix, and on nine (9) of thirty-two (32) night shifts the facility did not provide the minimum number of staff documented in the general staffing plan in the Facility Assessment, and several staff stated resident's care and resident's meals were delayed when they were short staffed, 2) observations were made of unsupervised residents on the dementia unit and 3) lunch was served late on the 3rd floor. Findings include: The facility Minimum Staffing Standard Matrix levels documented the facility staffing should include 3 certified nurse aides on all units on day shift and evening shifts, and 2 certified nurse aides on all units on night shift. On Sixty-nine (69) of ninety-six (96) shifts reviewed, from 1/19/25 to 2/20/25, the facility did not provide the minimum number of staff documented in the facility Minimum Staffing Standard Matrix. The general staffing plan in the 1/14/2025 Facility Assessment documented the staffing was based on acuity and census. It documented 3-4 certified nurse aides to 66 residents on the neurodegenerative unit on the night shift. On nine (9) of thirty-two (32) night shifts reviewed, from 1/19/25 to 2/20/25, the facility did not provide the minimum number of staff documented in the general staffing plan in the Facility Assessment. On 02/24/25 at 10:50 AM during an interview and review of the facility minimum staffing levels and 30 days of facility staffing from 1/19/25 to 2/20/25 with the Staffing Manager, they stated 2 Certified Nurse Aides should be working on each unit on night shift, and 3 Certified Nurse Aides should be working on each unit on day & evening shift. On 02/24/25 at 4:12 PM during an interview with the facility Administrator, they stated they used the general staffing plan in their 1/14/2025 Facility Assessment for their staffing minimums, which was based on acuity and census. The facility Administrator stated it was not ideal for any unit to drop below 2 Certified Nurse Aides on the night shift. During a review of the actual staffing from 1/19/25 to 2/20/25 with the facility Administrator, nine (9) night shifts were identified when there was only 1 Certified Nurse Aide working on a unit, which included 2/20, 2/18, 2/15, 2/14, 2/9, 2/8, 2/4, 2/3, and 2/2/25. On 02/25/25 at 1:01 PM during an interview, Licensed Practical Nurse #1 stated they worked the night shift. They stated they often were mandated to stay for the day shift against their will. They stated they were not a day person and when they were mandated, they were tired, and it was difficult for them to complete their work. They stated on night shift, at least 4 times per month, they work with only one Certified Nurse Aide although there should be 2 Certified Nurse Aides on the night shift. They stated that working with only one Certified Nurse Aide had a negative impact on the residents. Residents had to wait for assistance, and there were safety concerns depending on the acuity and behaviors of particular residents. They stated they were only able to assist the Certified Nurse Aide sometimes, as it depended on the residents' health and behaviors. They further stated the nursing supervisors did not come up to assist unless they were called for a concern. On 02/25/25 at 6:07 PM during an interview, Certified Nurse Aide #5 stated they work all 3 shifts. They stated they had worked short often lately, they worked alone on the night shift sometimes, and lately worked with only one other Certified Nurse Aide on the evening shift. They stated that short staffing affected the residents on night shift as the staff did not get any residents out of bed when they were working without another Certified Nurse Aide. They stated that more than 10 residents on Unit 2B were dependent on staff for assistance. On 02/25/25 at 6:16 PM during an interview, Certified Nurse Aide #6 stated they work nights. They stated they have been the only Certified Nurse Aide working on the night shift with one nurse a few times in the past month. They stated short staffing affects the residents on night shift because they do not get any residents out of bed when they are the only Certified Nurse Aide working that shift. They stated residents are not assisted with toileting timely when they are the only Certified Nurse Aide working that shift. On 02/25/25 at 06:22 PM during an interview, Certified Nurse Aide #7 stated they worked fulltime evening shift. They stated they had worked with only one other Certified Nurse Aide and one nurse on the evening shift. They stated having only 2 Certified Nurse Aides affected the residents because the residents were not provided assistance with toilet use timely, dinner was delayed, and transferring residents to bed was also delayed. They stated the nurse helped with the dining room but did not assist with resident care. They stated that approximately 14 residents required 2 staff assistance with transfers with mechanical lifts. On 02/25/25 at 06:27 PM during an interview, Certified Nurse Aide #8 stated they were the only Certified Nurse Aide working with one nurse on night shift and the residents were not assisted with toilet use timely and no residents were assisted out of bed. On 02/27/25 at 09:35 during a follow-up interview, the Staffing Manager stated they utilized the Minimum Staffing Standard Matrix for staffing and strived to have 2 Certified Nurse Aides on night shifts. 2) On 02/26/25 from 01:12 PM until 01:32 PM an observation was conducted on Unit 2B (the Dementia Unit). No staff was observed in the day room supervising 20 residents. Residents were observed appearing confused and unable to find seats. On 02/26/25 at 10:05 AM during an interview, Licensed Practical Nurse Unit Manager #9 stated sometimes they only have 2 Certified Nurse Aides on the dementia unit on day shift, and they always needed 3 Certified Nurse Aides. 3) During a lunch observation on 02/25/25 the following was observed: - at 12:46 PM, dietary staff was prepping meal trays for resident rooms on unit 3A and the last lunch tray was observed being delivered to a resident in the 3A dining room. - at 12:49 PM all trays were delivered in the 3B dining room. - at 12:57 PM, Resident #91 was standing in hallway by their room and stated they were hungry. - at 1:17 PM, Certified Nurse Aide #25 delivered a lunch tray to Resident #91. When interviewed on 02/25/25 at 1:21 PM Certified Nurse Aide #25 stated they were unaware Resident #34 took their own tray from the cart and said staff should be delivering the trays. On 02/26/25 at 11:53 AM during an interview, Dietary Aide #22 stated they usually arrived to unit around 11:45 AM to prep the food and put it on the steam table. Nursing staff brought the residents into the dining room and delivered the trays. They stated meals were delayed when nursing was short staffed. On 02/26/25 at 11:56 AM during an interview, Certified Nurse Aide #23 stated meals were delayed when nursing was short staffed or when they had to wait for the nurse to finish giving medications. Certified Nurse Aide #23 stated the Unit Manager was on leave and there was no organization on the unit with the Unit Manager out. 10NYCRR 415.13 (A)(1)(i-iii)

Based on observations, interviews, and record review during the recertification survey from 2/20/25-2/27/25, the facility did not ensure that 1 of 4 residents (Resident #122) reviewed for positioning and limited range of motion, received treatment and care in accordance with professional standards of practice. Specifically, Resident #122 had a history of difficulty swallowing and was not positioned properly while eating. The finding are: The undated facility policy titled Resident Positioning Policy for Therapy and Nursing Staff documented that the purpose of the policy is to establish standardized guidelines for proper positioning to ensure optimal comfort, prevent complications, and promote the overall health and safety of residents. Assistive devices should be used whenever necessary to minimize risk and injury to residents and staff. Resident #122 had diagnoses including Huntington's Disease, Dysphagia (difficulty swallowing), and Gastroesophageal reflux disease (GERD). The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #122 had severely impaired cognition and was dependent on staff for all activities of daily living and mobility. The Comprehensive Care Plan for Activities of Daily Living dated 11/18/24 documented the resident was dependent on staff for eating. There were no interventions regarding positioning while eating. A Speech Therapy evaluation note dated 11/14/24 documented Resident #122 was noted with increased coughing and gagging during meals. The diet was downgraded to pureed consistency with honey thickened liquids and assistance with feeding was recommended. During an observation on 2/21/25 at 12:28 PM, Resident # 122 was eating lunch with assistance from staff. They were sliding down and positioned very low in their chair and coughed intermittently. During an observation on 2/25/25 at 12:42 PM, Resident #122 was low in their chair while a staff member was assisting the resident with feeding. Resident #122 was observed sliding lower in their chair while eating and was not repositioned by staff. During an observation on 2/26/25 at 12:32 PM, Resident #122 was very low in their chair prior to starting lunch. Staff did reposition resident to a more upright position in chair prior to feeding. During an interview with the Registered Nurse Unit Manager #11 on 2/26/25 at 1:32 PM, they stated that staff attempted to feed Resident #122 the best they could, but it could be difficult at times and their intake fluctuated. They stated Resident #122 was on a pureed diet with honey thickened liquids and had not been evaluated by occupational or physical therapy for chair positioning during feeding. They stated Resident #122 should have been sitting upright in their chair and not reclined or sliding down while eating. During an interview with Occupational Therapist #13 on 2/27/25 at 10:18 AM, they stated a recent screen was requested by family and completed for Resident #122 for dexterity. They stated a screen for positioning in their chair while eating had not been requested. They stated they completed regular quarterly screens for residents, and nursing could request a screen if there was a concern. They stated there were devices that could be used to prevent the resident from sliding down in the chair and the resident should have been upright while eating. During a follow-up interview on 2/27/25 at 3:23 PM, Occupational Therapist #13 stated they evaluated Resident #122 during lunch and added a device to help prevent them from sliding down in the chair. 10 NYCRR 415.12

Based on interviews and record reviews conducted during the recertification and abbreviated surveys (NY 00361358) from 2/19/25-2/27/25 it was determined that for one (Resident #400) of two residents reviewed for notification of change, the facility did not notify the resident's representative timely when there was a change in their plan of care. Specifically, Resident #400's Seroquel (antipsychotic medication) and Sertraline (antidepressive medication) were discontinued after a gradual dose reduction, and their representative was not notified of the change in the plan of care. The findings are: The facility policy titled Psychoactive Drugs dated 9/2017, documented the attending physician will monitor and modify the medication regimen in conjunction with the resident and/or representative and other members of the Interdisciplinary Team including psychiatry. A resident or resident representative has the right to be informed about the resident's condition, treatment options, relative risks and benefits of treatment, required monitoring, expected outcomes of the treatment and has the right to refuse care and treatment. Resident #400 was admitted to the facility with diagnoses including dementia, anxiety insomnia and Alzheimer's disease. The 8/15/24 Minimum Data Set Assessment documented the resident's cognition was severely impaired. The resident ate meals with tray set up and walked independently in hallways with a cane. The physician order dated 11/21/23, documented Resident #400 was prescribed Seroquel 50 milligrams one tablet at bedtime by Attending Physician #1. Psychiatric Nurse Practitioner #3's note dated 3/19/24, documented a recommendation to reduce Seroquel to 25 milligrams at bedtime. The physician order dated 3/22/24, documented Resident #400 was prescribed Seroquel 50 milligrams 1/2 tablet (25 milligrams) at bedtime by Attending Physician #1. Psychiatric Nurse Practitioner #3's note dated 4/16/24, documented a recommendation to reduce Seroquel to 12.5 milligrams at bedtime. (There was no corresponding order or documentation as to a reason this was not done.) The physician orders documented on 5/9/24 Seroquel 50 milligrams 1/2 tablet (25 milligrams) at bedtime was discontinued. The physician order dated 5/10/24, documented Resident #400 was prescribed Sertraline 12.5 milligrams daily for depression by Attending Physician #2. The order was discontinued on 8/16/24. There was no documentation in the progress notes reviewed from 3/19/24 -5/9/24 that the resident's representative was notified about the gradual dose reduction for Seroquel on 3/19/24 or when it was discontinued. There was also no documented evidence the resident's representative was notified of the initiation of Sertraline on 5/10/24 and discontinuation on 8/16/24. During an interview with the Assistant Director of Nursing on 2/25/25 at 10:00 AM they stated the resident was admitted to the facility already on Seroquel and was tapered then discontinued. They stated when a resident was on psychotropic medications the family should be notified by the physician and they were not sure what happened in this case. They stated Attending Physician #1 was not good at contacting families and was no longer employed by the facility. During an interview with Attending Physician #2 on 2/25/25 at 12:08 PM, they stated when a report from the Psychiatric Nurse Practitioner comes in, they will go over the report with the Unit Manager and track Psychiatry notes and gradual dose reductions. They will call family or Unit Manager will call to inform the family the gradual dose reduction has been initiated. In this case, they did not recall if they spoke to the family because there was a changeover of attending physicians. Attending Physician #2 could not recall if they notified the resident's representative about the medication changes. During an interview with the Psychiatric Nurse Practitioner #3 on 2/25/25 at 12:28 PM, they stated they saw residents for medication review, loss or deterioration in cognition, and made recommendations. They did not notify families of gradual dose reductions. They stated they were only a consultant and did not know what happened in this case. 10 NYCRR 415.3(e)(1)(a)

Based on observations, record reviews and interviews during the Recertification survey from 2/20/25 through 2/27/25, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 6 residents (Resident #27) reviewed for activities of daily living. Specifically, Resident #27 required staff assistance with personal hygiene was observed on 3 occasions with long and dirty fingernails. Findings include: The policy and procedure titled Clinical, Activities of Daily Living Protocol, Policy and Procedure last revised 11/2022 documented the facility will implement measures to assess the resident's ability to perform Activities of Daily Living and based on the assessment, will implement treatment and services, based on the resident's needs and choices, to maintain/improve and prevent decline due to reversible causes whenever possible. The facility provides services for the following Activities of Daily Living, which included but not limited to hygiene - bathing, dressing, grooming and oral care. The Resident #27 was admitted with diagnoses including rheumatoid arthritis, borderline personality disorder, and bipolar disorder. The 1/31/25 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented the Resident #27 had intact cognition, had impairment on both sides of upper and lower extremities and was dependent with self-care abilities. The 10/3/24 care plan titled Activities of Daily Living documented the resident was dependend ton staff for eating, hygiene, dressing, and bathing. The resident did none of the effort and staff did all the effort. The certified nurse aide was responsible for activities of daily living. The 2/20/25, 2/21/25 and 2/24/25 Certified Nurse Assistant Activity of Daily Living Tasks documented Resident #27 was dependent on staff for ability to maintain personal hygiene. During observation on 2/20/25 at 11:44 AM, Resident #27 was in bed. The resident had finger deformities on their both hands. Some fingers were twisted in an outward direction revealing long fingernails with dark brown matter underneath, other fingers in the middle joint bended inward, toward the palm. The resident stated that they would like to take care of their long fingernails, but they could not, and the staff told them that they were busy. During observations on 2/21/25 at 2:16 PM and 2/24/25 at 10:58 AM, Resident #27 was in bed, revealing long fingernails with dark brown matter underneath. During an interview on 2/26/25 3:58 PM, Certified Nurse Aide #19 stated that shaving and clipping fingernails were included under the personal hygiene care. They said that they documented performance of personal hygiene for residents, but there was no specific task for shaving or fingernail clipping to document. Certified Nurse Aide #19 stated that by observation or asking the resident's preferences the Certified Nurse Aide could perform these tasks. They stated these were Certified Nurse Aide responsibilities. The surveyor went to the resident's room accompanied by Certified Nurse Aide and observed the resident's short fingernails. The resident stated that the nurse clipped their nails yesterday. The Certified Nurse Aide #19 stated when they provided assistance with personal hygiene they did not remember if the nails were long, and did not remember when they were clipped last time. During an interview on 2/26/25 at 4:11 PM Licensed Practical Nurse #18 stated clipping of fingernails and shaving tasks were included under personal hygiene care. They said that they clipped the resident's fingernails on 2/25/25 and noticed how long they were. They stated they did not know when the resident's nails were last clipped and they sometimes clipped them when the certified nurse aides were busy. 10 NYCRR 415.12

51214 Based on observations and interviews during the recertification and abbreviated (NY00368899) surveys from 2/20/25-2/27/25, the facility did not ensure that the environment was maintained in a safe, clean, comfortable and homelike manner. Specifically, 1.) the shower room on the 3A unit had black stains on the shower curtain, the tiles at the base of the toilet had brown discoloration, and the tile grout in the shower stall was discolored with black and orange stains. Furthermore, there was an air conditioner in the window next to the shower stall that caused a cold draft in the room. 2). Dirty linens were observed on the floor next to Resident #27's bed. 3) A broken handrail with a sharp edge was found on the right side of the entrance to the 3A dining room. The findings are: 1) During an interview on 2/20/25 at 11:39 AM, Resident #18 stated that the shower room on 3A was cold and had mildew. During observations of the shower room on the 3A unit on 2/20/25 at 11:59 AM and 2/25/25 at 10:23 AM, shower tiles along the base of the shower stall had black and orange discoloration. Black stains were on the bottom of the shower curtain. The white tiles around the toilet base were discolored brown. There was a cold draft coming from the window next to the shower stall where a window air conditioner unit was in place. During an interview on 2/25/25 at 10:46 AM, the Director of Housekeeping stated housekeeping was responsible for cleaning the shower rooms daily. If shower curtains were soiled, staff should have contacted them for washing or replacement. They stated housekeeping cleaned the tiles, but if the tiles could not be cleaned, maintenance would be contacted for regrouting or repair. They stated they had not received any reports from staff about conditions observed in the shower room on the 3A unit. They stated the tiles needed to be cleaned and the shower curtain should have been replaced. During an interview on 2/25/25 at 4:12 PM, the Director of Maintenance stated they were not aware of any issues in the 3A shower room and acknowledged that the grout in the shower stall was discolored and should be addressed. They stated the air conditioner could be the reason for drafts. 2) During observation of the Resident #27's room on 2/20/25 at 11:44 AM, linens soiled with feces were observed on the floor next to the resident's bed. During an interview on 2/20/25 at 12:02 PM, Certified Nurse Aide #19 picked up the soiled linen from the floor and placed it in a plastic bag. They stated that soiled linens should always be bagged and kept in linen hamper and not on the floor. 3) During an observation on 2/26/25 at 11:52 AM, the handrail on the right side of the dining room entrance was broken and had a sharp edge. When interviewed on 2/26/25 at 11:58 AM, the Maintenance Worker #31 stated they were not aware of the railing being broken in dining room. When interviewed on 2/27/25 at 3:28 PM, the Director of Maintenance stated they added handrails as an item on the to look at when doing rounds. 10 NYCRR 415.5(h)(2)

Based on observations, interviews, and record review during the recertification survey from 2/20-2/27/2025, the facility did not ensure that 1 of 3 residents (Resident # 93) reviewed for nutrition were monitored within acceptable parameters for nutritional status. Specifically, Resident #93's weight loss a 7.5% in three months, and a 13% weight in four months was not addressed. Additionally, the resident's weight was not recorded for the last 2 months. The findings include: Resident #93 had diagnoses that included Huntington's Disease, Dysphagia, and Disturbances in Salivary Secretion. Resident MOLST dated 1/27/2018 documented no limitation on medical interventions and long-term feeding tube if needed. Annual Minimum Data Set, dated dated dated [DATE] documented severely impaired cognition, dependent on assistance for activities of daily living, no swallowing disorder, no significant weight loss, height 65 inches, 134 pounds. The registered dietician's note dated 8/30/24 documented the resident weighed 134.4 pounds, remained within their usual weight range, and was the same as 6 months prior. They were fed by staff, on a puree diet and received Hi Cal and Ensure Plus. The plan was to continue the current plan of care to support weight maintenance. Comprehensive Care Plan for Nutrition updated 8/30/2024 documented the goal for Resident #93 was to maintain weight of 135 +/- 3% Quarterly Minimum Data Set, dated dated dated [DATE] documented severely impaired cognition, dependent on assistance for activities of daily living, no swallowing disorder, no significant weight loss, height 65 inches, 123 pounds. (The MDS did not document the 7.5% weight loss since the Annual MDS on 8/28/24). Review of the resident's record revealed no notes by the Registered Dietician after 8/30/24 and no evidence the weight loss was addressed. Weights for Resident #93 documented a 13.1% loss in 4 months from August to December 2024 and included the following: 8/06/24 134.4 pounds, 9/6/24 128 pounds, 10/4/24 122.8 pounds, 11/6/24 123.6 pounds, and 12/6/24 116.8 pounds. There was no documented evidence of weights for Resident #93 in January or February 2025. Meal Acceptance History for Resident #93 from August 2024 until February 2025 documented intake 0%-100% for meals with the majority documented as 100%. During an observation on 02/21/25 at 8:58 AM, Resident #93 observed in dining room, assisted by staff eating breakfast. Resident #93 needed to be roused to eat and had very poor intake. During an interview on 02/26/25 at 1:54 PM, Registered Nurse Unit Manager #11 reviewed Resident #93's electronic medical record and stated that Resident #93 had a weight loss from September to December 2024. The stated the dietician tracked the weights and was unaware the resident had no recorded weights for the last two months. During an interview on 02/27/25 at 11:36 AM, Registered Dietician #20 confirmed the last weight recorded for Resident #93 was on 12/6/24. No weights were recorded in the electronic medical record for January or February 2025. They stated nursing obtained the weights and they reviewed them and requested reweights as needed. They stated they requested that Resident #93 be reweighed in January and February, but it was not done. They stated they had not documented nutritional notes or put additional interventions in place because they were still waiting for the reweights. 10NYCRR 415.12(i)(1)

Based on observation, record review, and interview during the Recertification Survey initiated on 2/20/2025 and completed on 2/27/2025 the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible for one (Resident #112) of one resident reviewed for bowel and bladder. Specifically, Resident #112 was not assessed and care planned to improve and restore continence to the extent possible. Findings include: The facility Policy and Procedure, dated 11/1/2026, titled Clinical Bladder Management, documented it is the policy of the facility to assess each resident's bladder continence status on a defined schedule. This assessment will enable the staff to implement a resident-specific re-training, toileting program that addresses the individual's bladder function needs. Resident #112 had diagnoses including fracture of the left patella, cellulitis, and hypertension. The Admission Minimum Data Set (an assessment tool) dated 2/5/25 documented the resident's cognition was intact, they required supervision with eating, and substantial to maximal assist with all other activities of daily living. The resident's bowel and bladder status was documented as frequently incontinent. The Nurse Admission assessment dated [DATE], documented the resident was occasionally incontinent. The Activities of Daily Living documentation revealed the resident was incontinent of bladder on 2/1/25,2/5/25, 2/7/25, 2/9/25, 2/10/25, 2/11/25, 2/13/25, 2/16/25, 2/21/25, and 2/25/25. The Activities of Daily Living Care Plan dated 1/30/25, documented the resident required extensive assistance for toilet hygiene and toilet transfers. The care plan did not include a voiding diary or a toileting program. During an interview on 02/21/25 at 11:39 AM, Resident #112 stated the facility had them wear a pullup, and they did not like to wear a pullup. They stated before they came to the facility, they were able to use the bathroom and had no accidents. They stated they would like to be able to use the bathroom and not wear a pull up. They did not recall being on a toileting schedule or being encouraged to use the bathroom every 2 hours. During an interview on 02/25/25 at 1:25 PM, Registered Nurse #2 stated if a resident had a new onset of incontinence, they would expect to complete an assessment and complete an incontinence care plan. They were unsure why the resident did not have a care plan for incontinence. During an interview on 02/25/25 at 04:45 PM, the Assistant Director of Nursing stated they were unsure why the incontinence care plan or a toileting program was not created for Resident #112. During an interview on 02/26/25 at 1:54 PM, Certified Nurse Aide #33 stated they usually toileted all residents every 2 hours on rounds. Resident #112 knew when they needed to go to the bathroom and rang the bell for assistance. They stated Resident #112 was put on a toileting program yesterday. 10NYCRR-415.12(d)(2)

Based on observation, record review and interview during the Recertification Survey conducted from 2/20/25 through 2/27/25, the facility did not ensure each resident received adequate supervision to prevent accidents and/or the residents' environment remained as free of accident hazards as possible for 2 of 10 residents (Residents #183 and #242) reviewed for accidents. Specifically, 1. Resident #183 was at risk for elopement related to wandering in and out other resident's rooms, roaming, trying to open exit doors and get in the elevator without staff supervision and 2. Resident #242 sustained falls on 11/15/24, 11/27/24, 1/10/25, 1/19/25 and 1/25/25. The findings are: Resident #183 was admitted with diagnoses including but not limited to non-Alzheimer's dementia, traumatic brain dysfunction, and seizure disorder. The 12/6/24 Care Plan titled Risk for Victimization documented encourage resident to attend specific task/activity of interest, separate from others as needed and engage in task/activity of interest, visual checks as indicated per protocol and plan of care, and keep resident at a safe distance from aggravating factors. The 12/16/24 Care Plan titled Dementia/Cognitive loss documented establish a consistent daily routine. The 1/31/25 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #183 had severely impaired cognition, was independent with mobility, and required partial assistance with toileting and personal hygiene. During observation on 2/20/25 at 11:48 AM, without staff supervision Resident #183 ambulated with a walker in the unit hallway and entered Resident #27's room (dependent with self-care abilities) Resident #183 stood in front of the closet located to the left of the room door looking over at Resident #27. Resident #27 screamed get out, get out, get out Resident #183 continued to stand in Resident #27's room, then exited the room and ambulated with a walker down the hallway. At 11:51 AM Resident #183 ambulated with a walker back down the hall and reentered Resident #27's room. Resident #27 yelled get out, get out, please get out. Certified Nurse Aide #19 entered Resident #27's room and redirected Resident #183 to exit Resident #27's room. At 12:03 PM Resident #183 ambulated with the walker down the hallway, without supervision entered Resident #27's room, left Resident #27's room and then proceeded to ambulate unsupervised into aother resident room. During observation on 2/20/25 at 2:30 PM, without staff supervision and without a walker Resident #183 was holding onto Resident #47's wheelchair while pushing Resident #47 who was sitting in the wheelchair down the unit hallway. During observation on 2/20/25 at 2:41 PM, without supervision Resident #183 ambulated with a walker, opened and entered Resident #151's room. During observation on 2/21/25 at 11:34 AM, without supervision Resident #183 ambulated in the hallway with a walker, stopped and attempted to open the stair 2 fire exit door. During an interview on 2/26/25 at 3:43 PM, Certified Nurse Aide #19 stated they always tried to stop and redirect Resident #18 from wandering into other residents' rooms. Certified Nurse Aide #19 stated Resident #183 thought they once worked at the facility. Certified Nurse Aide #19 stated Resident #19 refused to participate in morning activities most of the time. During an interview on 02/27/25 at 10:31 AM, the Recreation and Activities Director stated Resident #183 preferred to participate in afternoon activities. They stated Resident #183 liked social activities, coloring, watching TV, and received a lot of pastoral care. They stated unfortunately Resident #183 had a short attention span and would often leave the room in the middle of activities. During an interview on 02/27/25 at 10:37 AM, Licensed Practical Nurse #183 stated staff kept an eye on Resident #183 as much as they could and tried to engage them in activities. Licensed Practical Nurse #18 stated they were aware Resident #183 entered other resident rooms. They stated it was hard to prevent the resident's wandering due to advanced dementia. They stated if they had more staff, better supervision would be provided. 2. Resident #242 was admitted with the diagnosis of Huntington's Disease. The Comprehensive Care Plan titled Risk for Falls initiated on 10/28/24 documented gait balance problems/neurological disease. Stationary chair removed from room for safety, provide obstacle free environment, refer to rehabilitation as needed, provide assistance when walking to the room after meals. The Annual Minimum Data Set (a resident assessment tool) dated 11/6/24, documented Resident #242 had moderate cognitive impairment, used a walker for ambulation with moderate assistance and required moderate assistance with transfers. The Physician Order dated 12/6/24 documented physical therapy with frequency per rehabilitation. During observation on 2/21/25 at 12:25 PM Resident #242 with an unsteady gait ambulated with a walker, unassisted out of the dining room and into the hallway. During observation on 2/24/25 at 12:54 PM Resident #242 with an unsteady gait ambulated with a walker, and unassisted in the hall to their room after lunch. During interview on 2/25/25 at 12:58 PM Licensed Practical Nurse #10 stated Resident #242 no longer required assistance with ambulation. During interview on 2/26/25 at 5:35 PM the Assistant Director of Nursing stated there was no documentation in the care plan to indicate assistance when walking to the room after meals had been discontinued. The 2/26/25 Progress Note documented Resident #242 had a fall due to an abrupt turn, and loss of balance. During interview on 2/27/25 at 4:35 PM the Director of Nursing stated there should be a note correlating the removal of any intervention from the care plan. During interview on 2/27/25 at 10:19 AM Unit Manager #11 stated Resident #242 was not oriented to the unit at the time of admission and that was why the care plan interventions included staff assistance. Unit Manager #11 stated Resident #242 wandered less now to find their room and the intervention was no longer needed. 10 NYCRR 415.12 51902

Based on observations, interview and record review, during the Recertification Survey from 2/20/25 to 2/27/25 the facility did not ensure that needed services, care and equipment were provided to assure that resident with limited range of motion and mobility to maintain or improve function based on the residents' clinical condition for 1 of 4 residents reviewed for position mobility. Specifically, a resident #36 had limited range of motion in their lower extremities was observed to have right or left foot dangling off the foot pedal of their wheelchair, not appropriately positioned on the foot pedal. The findings are: Resident #36 was admitted to the facility, with diagnoses that included , Diabetes, Cerebral Vascular Accident, and Anxiety Disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident was independent in cognition. The MDS further documented the resident had limited range of motion in bilateral lower extremities. The 2/7/25 Comprehensive Care Plan (CCP) titled Need for restorative Occupational Therapy documented inability to self function as evidenced by decreased muscle strength. There was no documentation occupational therapy evaluated resident's wheelchair for proper positioning. The 2/7/25 Physician's order documented Occupational evaluation and treatment for wheelchair mobility. The 2/7/25 Occupational Therapy evaluation and treatment notes documented Resident #36 was evaluated for wheelchair mobility to increase strength for self-propelling wheelchair. There was no documentation of resident #36 being assessed for proper positioning in wheelchair. There was no documentation of wheelchair being assessed for repairs. On 2/21/25 at 12:18 PM, Observed resident #36 in their wheelchair at dining room table. The resident's right foot was dangling behind foot pedal. Resident was struggling to place it back on the foot pedal started to move foot but never placed it on the foot pedal of the wheelchair. On 2/21/25 at 12:38 PM, Observed resident #36 with right foot hanging off foot pedal of wheelchair. On 2/26/25 at 12:31 PM, Observed resident #36 observed with left foot hanging foot pedal and dangling while sitting in their wheelchair while in the dining room. On 2/26/25 at 4:50 PM, Occupational Therapist #13 stated the resident was asking about a new chair and stated they would be more comfortable in a bariatric broad wheelchair. Occupational Therapist #13 stated instead of downgrading the chair that would make them more dependent they put the resident on program to help get the resident to increase their mobility in the wheelchair and better propel themselves. Observed wheelchair with Occupational Therapist #13 left foot pedal has foot box to prevent foot from dropping because resident #36 had a left foot ankle inversion. The right foot has no inversion, so it didn't have a foot box. Occupational Therapist #13 stated the phalange is not set up the same on both sides and is not working correctly something needs to be fixed. Occupational Therapist #13 stated the phalange will not clip fully allowing foot pedal to swing out to the side and why resident would have trouble keeping foot in place. The left foot box on foot pedal was out of position and needed to be fixed. On 2/27/25 at 12:50 PM, Certified Nurse Aide #14 stated resident #36 never complained they were uncomfortable in the wheelchair. Certified Nurse Aide #14 stated they noticed the residents left foot pedal was swinging out yesterday and not locking. Certified Nurse Aide #14 stated they did not report it to anybody. On 2/27/25 at 1:05 PM Occupational Therapist #13 stated nursing staff usually would verbally report when a wheelchair is in need of repair, but did not receive any report from nursing. Occupational Therapist #13 stated they have no official rounding schedule for assessing wheelchairs and no documented audits. 483.25(c)(2)

Based on record reviews and interviews, conducted during an abbreviated survey (NY00355382 and NY00362103), the facility did not provide adequate supervision/monitoring to prevent accidents for 2 of 3 residents (Resident #1 and #3) reviewed. Specifically, on 9/3/2024 Resident reported they were bumped by the elevator door [NAME] exiting and reported pain 3 out of 10 to their right hip. 2) On 9/30/2024 while exiting the core elevator on the 4th floor, the elevator door closed hitting Resident #1's right hip causing pain and discomfort. 2) On 11/25/2024, Resident #3 was found inside of the facility housekeeping closet on the 4th floor. Facility investigation revealed the housekeeping door was unsecure due to the striker plate being broken. Resident #3 who had a history of wandering behaviors, was able to gain entry to the unit 4A utility closet due to a screw being loose on the striker plate which prevented the door from closing and locking as expected. Findings include: The facility's policy on Accidents and Supervision dated 6/17/2021 documented the resident's environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents. The purpose of this policy is to prevent injury to the resident. Resident #1 had diagnoses that included Alzheimer's Disease, Type 2 Diabetes Mellitus and Hypertensive Heart Disease and a history of Right Hip Surgery. The Minimum Data Set (MDS, an assessment tool) dated 1/2/2025, documented the resident had a Brief Interview for Mental Status assessment (BIMS, used to determine attention, orientation, and ability to recall information) score of 7/15, associated with severe cognitive impairment. Resident #1 was independent with bed mobility and with walking with a rollator/walker and required occasional supervision or touching assistance with transfers, bathing and dressing. Review of Resident #1's Care Plan dated 9/5/2024 documented interventions that included monitor and report pain. Review of the Nurse's Progress note written by Licensed Practical Nurse #3 on 9/5/2024 at 1:53pm documented that at approximately 12:00pm, Resident #1 complained of a pain in their right hip area, which they felt during ambulation. Upon interviewing Resident #1, they stated that the pain was a result of an incident that occurred on 9/3/2024 during the day shift, where the elevator closed into their right hip. Resident #1 has a history of hip replacement in that hip. Review of the Nurse Practitioner Progress Notes written by Nurse Practitioner#1 on 9/5/2024 documented trauma to right hip. Residents #1 reported worsening pain to right hip with trauma from elevator. Resident #1 also reported having hip surgery on the right hip in the past and denied any fall during the elevator incident. No external rotation noted or difference with the length to the right leg. Reported slight discomfort rated 3/10, full range of motion without issues, ambulating well. An order for x-ray of the right hip for further assessment and planning to rule out fracture versus dislocation versus malfunctioning with hardware from possible hip surgery in the past. Review of the X-ray results dated 9/16/2024 revealed no radiographic evidence of acute fracture or dislocation. Review of the Accident/ Incident Report dated 9/5/2024, documented that Resident #1 reported to Licensed Practical Nurse #3 that they were feeling pain of 3/10, to the right hip. Resident #1 stated that they had gotten bumped by the elevator door earlier. No bruising was present. Nursing will monitor and medicate Resident #1 for pain. No evidence of abuse, mistreatment, or neglect. The facility plans to prevent reoccurrence included to remind Resident #1 to report any discomfort to nursing staff. Review of the Accident/Incident Report dated 9/30/2024 documented Resident #1 reported to Licensed Practical Nurse #2 they were attempting to exit the elevator and was bumped by the door on the right hip. Resident #1 has a history of pain to this area and multiple hip replacements. Plan was for elevator sensors to be cleaned, and this was completed on 9/30/2024. Review of the Nurse's Progress note written by Licensed Practical Nurse #2 on 9/30/2024 at 3:20pm, documented that Resident #1 reported to Licensed Practical Nurse #2 that they were riding the core elevator with a large group of people. When the resident needed to exit on the fourth floor, the group of people exited the elevator and Resident #1 was the last to exit. As they exited, the elevator door bumped on their right hip. Resident #1 complained of mild discomfort. All elevator sensors were cleansed by housekeeping. Review of Resident #1's Care Plan dated 9/30/2024 revealed interventions that included an order for Occupational therapy ordered for discomfort following being bumped by elevator door. During an interview conducted on 1/14/2025 at 2:05pm, the Social Services Director stated Resident #1's cognition had declined in the last couple of years. Resident #1 is now using the rollator all around the building. Resident #1 visits other residents and goes to activities. Resident #1 uses the elevator by the coffee shop and does not have a wander guard. The Social Services Director stated they were not aware of the elevator incident that happened September 2024. During an interview conducted on 1/14/2025 at 2:37PM, Resident #1 stated I think my room number is forty something. I have been living here for more than [AGE] years and I have never had to look at the number of my room, I just know where to come back to. Resident #1 stated they walk around the building with their walker and when asked which elevator they used, Resident #1 stated the elevator to the left (pointing to the unit 4B elevator). Resident #1 reported that they had pain to the right hip, and it came from the elevator doors hitting them one of the days when they were exiting the elevator When asked if the elevator doors had closed on them recently, Resident #1 responded no it hasn't happened again, and I am happy with the care I receive from the staff. During an interview with the Director of Support Services was conducted on 1/17/2025 at 3:42pm they stated they were not aware of the two elevator incidents that occurred in September 2024 involving Resident #1. They were only notified of these elevator incidents yesterday (1/16/2025). If they were aware of an issue with an elevator, the process would be to key out or lock the elevator to prevent access and call the company that does repairs and maintenance, so they can come out and fix the problem. This will be documented on the facility service log. The Director of Support Services stated they did not know why they were not informed of these incidents with the elevator. During an interview conducted on 1/17/2025 at 4:26pm, the Director of Nursing was asked why the Director of Support Services was only notified yesterday (1/16/2025) of the elevator incidents that occurred on 9/3/2024 and 9/30/2024. The Director of Nursing stated they were not sure how the incident was not reported to the Director of Support Services. During a follow up telephone interview with the Director of Nursing conducted on 1/22/2025 at 12:15pm they stated the Director of Support Services oversees the Maintenance, Housekeeping and Engineering Departments. When asked if Director of Support Services was the staff that would have been notified of the elevator incidents that happened in September 2024, the Director of Nursing stated yes, they would be the person to be notified. 2)Resident #3 had diagnoses that included, Severe Dementia with agitation, Fracture of the left clavicle and Seizures. The Minimum Data Set (MDS, an assessment tool) dated 11/13/2024, documented a Brief Interview for Mental Status assessment (BIMS, used to determine attention, orientation, and ability to recall information) score of 3/15, associated with severe cognitive impairment. Noted with behaviors present. A review of the discharge Minimum Data Set assessment dated [DATE], documented the resident was dependent with toileting, bathing and dressing and required supervision with transfers and walking. Review of the Medication Administration record for the month of 11/2024, revealed that the order for Wristband Placement, every shift, was ordered on 11/4/2024 and discontinued on 11/20/2024 and the order for Behavior/Intervention Charting, every shift, was ordered on 11/4/2024 and discontinued on 11/20/2024. Review of the Elopement Risk assessment dated [DATE], documented that Resident #3 had a score of 8.00, which translated to high risk for elopement. Resident #3's documented elopement risk factors were: Resident is cognitively impaired or demonstrated impaired decision making, resident verbalized they want to go home and was independently mobile. Review of the Physician's Orders revealed that an order for Wander guard Placement/Function to left wrist, every shift was ordered on 11/26/2024. Review of the Behavior note written by Licensed Practical Nurse #5 dated, 11/8/2024, documented that Resident #3 was removed from another resident's room at approximately 11:00pm. Review of the Behavior note written by the Assistant Director of Nursing, dated, 11/9/2024 documented that Resident #3 was wandering into other residents' rooms, this puts the resident at significant risk for physical illness or injury, this puts other at risk for physical injury and significantly intrude on the privacy or activity of others. Review of the Behavior note written by Licensed Practical Nurse #7 dated, 11/10/2024, documented that Resident #3 displayed behaviors of physical and verbal aggression towards caregivers, peers and visitors, excessive agitation and verbal disruption. This behavior impact on Resident #3 puts the resident at significant risk for physical illness or injury, significantly interferes with the resident's care and significantly interferes with the resident's participation in activities or social interactions. This behavior impact on others: puts others at risk for physical injury, significantly intrude on the privacy or activity of others and significantly disrupt care or living environment. Review of Resident #3's care plan dated, 11/22/2024 was reviewed and interventions included the resident ambulates independently (walking 150 feet) with no assistance from a helper. Resident #3 was noted with behavior symptoms of wandering on the unit and other units and into peers' rooms and interventions included to ensure proper placement and function of ankle alert. Review of the Elopement Risk assessment dated [DATE] documented Resident #3 had a score of 7 indicating the resident was at risk for elopement. Resident #3's elopement risk factors included the Resident exhibited wandering behavior and was independently mobile. Review of Resident #3's care plan dated, 11/23/2024, noted that Resident #3 was at risk for elopement related to wandering and roaming as evidenced by pacing, roaming or wandering in and out of peers' rooms; becoming agitated, oppositional and combative when re-directed; with noted interventions, assess for potential elopement, provide simple, clear directions and to use electronic monitoring devices. Review of the Accident/Investigation form signed statement by Certified Nurse Assistant #2 on 11/25/2024 stated, I was handed the dinner trays. I thought Resident #3 was behind me. I said, come and eat. I heard, no. Yes, I did not look behind me to see. I finished doing the trays and seen the child of Resident #3 come out of the bathroom and asked me where Resident #3 was, then I began to look for Resident #3. Review of the Accident/Investigation statement signed by Certified Nurse Assistant # 3 on 11/25/2024, stated, Around 5pm, the child of Resident #3 came looking around so I ask who they are looking for and I advised them to check the other residents room and they still weren't able to locate so I started check the rooms on unit 4A and 4B, the 3rd, 2nd and 1st floor even the ground floor while calling Resident #3's name and still nothing. So, I called the other aide and asked if they found Resident #3 and the other aide told me that they found Resident #3 in the housekeeping closet. So, I rushed there and saw the other aide re-directing the resident. I assisted Resident #3 to his room, cleaned the resident and put the resident to bed. Then I carried juice and a snack to Resident #3 though the resident was looking sleepy. I apologized to the resident's child and then left the room. Review of the Hospital Discharge Records dated 11/25/2024, revealed that Resident #3 was assessed in the Emergency Department on 11/25/2024 at 7:40pm. the Emergency Department physician documented Work up is not suggesting acute process, no Urinary Tract Infection (UTI), showing only chronic issues. It was decided that resident may return to the facility. Review of the Investigation Summary dated 12/2/2024, documented that on 11/25/2024 at around 5:55pm, Resident #3 who had a history of wandering behaviors, was able to gain entry to the unit 4A utility closet due to a screw being loose on the striker plate which prevented the door from closing and locking as expected. During the investigation, a facility maintenance staff checked the door to the 4th floor utility room to determine how Resident #3 was able to open it and maintenance staff discovered that the striker plate had a loose screw. During an interview with Housekeeper #2 on 1/17/2025, at 12:15pm, stated there are no chemicals kept in the housekeeping closet anymore because a resident was found in this closet a couple of months ago. The chemicals are now stored on the ground floor. During an interview with the Director of Admissions on 1/17/2025, at 1:02pm, they stated If we are admitting a resident with behaviors, we speak to the staff specifically the unit manager, if not, the nurse for that room, even with residents we are re-admitting. During an interview with the Director of Support Services on 1/17/2025 at 3:42pm stated they were notified of Resident #2 been found in the housekeeping closet at 7:00pm on 11/25/2024. It was the 4th floor housekeeping closet. The evening shift maintenance staff discovered that the striker plate was sticking out and it was loose. The Director of Support Services confirmed that all chemicals have now been moved to the ground floor to ensure residents' safety. The striker plate was repaired and the closet remains locked with no chemicals stored. 10NYRCC 415.12(h)(2)

Based on observations, interviews, and record review conducted during the recertification and abbreviated surveys (NY00334054) from 3/13/24 to 3/29/24, it was determined that the facility did not ensure an effective pest control program was maintained to ensure the facility was free of pests and rodents. Specifically, facility staff and residents reported mice sightings. Additionally, there were multiple observations of mice droppings in resident rooms. Findings include: During an interview on 3/13/24 at 4:15 PM Resident #206 stated that there were black mouse traps on the unit and in their room, pointing to their radiator. The trap killed about three mice within the past few weeks. During an observation on 03/14/24 at 09:54 AM in Resident #206 room, small black mouse droppings were noted on the floor around the black mouse trap at the base of the radiator. During an observation on 03/14/24 at 12:47 PM while in Resident # 93's room, a mat against the radiator was pulled back, and a black box mouse trap with black specks was found. During an observation on 3/19/24 at 9:08 AM in Resident #206's room, visible mouse droppings were noted on the floor near the mouse trap and around it. The resident saw this surveyor looking on the floor, and they stated, Mouse. During an observation on 03/19/24 at 09:48 AM while in Resident #93's room, behind the floor mat under the radiator there were black mouse traps with black particles on the floor. During an interview on 3/20/24 at 1:15 PM Staff #41 stated that there were lots of mice droppings in the residents' rooms and dining room and they had seen them about a week ago. The housekeeping manager had the housekeeper assigned to each unit clean each resident room every day, and there were still mice droppings the next day. Review of pest control logs documented on unit 5A dated 11/29/23 to 3/23/24: there were 4 mouse droppings documented and 21 mouse sightings, including on 1/26/24 one documented mouse sighting in Resident #206's room. Review of the pest management company invoice from February to March 2024 documented multiple mouse glue traps disturbed throughout the facility. On 3/4/24, rodent droppings were found on the 4th floor dining area and mouse capture on the same unit in another resident's room. On 3/8/2024, several mice were captured on the 3rd, 4th, and 5th floors. During an interview on 3/21/24 at 10:15 AM, the Director of Support Services stated that mice droppings were a long-standing problem because residents were keeping food in their rooms. There is a unit-based logbook for pest control for new or repeat sightings. They hired a new pest control company that comes twice a week to check and put down glue traps. Housekeeping was to clean the room more frequently if needed. During an interview on 03/28/24 at 12:00 PM Staff #24, who documented in the unit 5A pest control log dated 2/19/24, stated they recall seeing a mouse in the hallway by room [ROOM NUMBER], and put that incident in the binder, and told the supervisor, but did not recall which supervisor. They stated there was a mouse on Unit 2A on the 7 PM-7 AM over the weekend but did not put that information in the pest control log. During an interview on 03/29/24 at 09:21 AM, the Assistance Director of Nursing stated that while they were on the unit in late January or February 2024, Resident 206's family member complained of the resident's messy room and while they were in the resident's room, they saw a mouse run across the room under the tall dresser. They called maintenance; no mouse was found; maintenance removed the empty glue trap box and placed a new box. 10 NYCRR 415.29(j)(5)

Based on interviews and record review conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of the residents. Specifically, 1) multiple residents reported during confidential interviews and the group meeting that the facility was short staffed at times especially at night and there was a lack of timely staff response to call bells, 2) multiple nursing staff members reported a lack of sufficient staffing, 3) a review of one month of facility staffing revealed the facility did not ensure that the minimum staffing levels for certified nurse aides was met on the night shift. Findings include: Review of the facility staffing from 2/13/24-3/13/24 revealed: - on 2/13/24, 7 CNA slots were unstaffed on the night shift, - on 2/15/24, 3 CNA slots were unstaffed on the night shift, - on 2/19/24, 2 CNA slots were unstaffed on the night shift, - on 2/23/24, 2 CNA slots were unstaffed on the night shift, - on 2/27/24, 1 CNA slot was unstaffed on the night shift, - on 2/29/24 1 CNA slot was unstaffed on the evening shift and 1 CNA slot was unstaffed on the night shift, - on 3/2/24, 3 CNA slots were unstaffed on the night shift, - on 3/4/24, 1 CNA slot was unstaffed on the night shift, - on 3/7/24 1 CNA slot was unstaffed on the night shift, - on 3/9/24 3 CNA slots were unstaffed on the night shift, - on 3/10/24 1 CNA slot was unstaffed on the night shift, - on 3/11/24 1 CNA slot was unstaffed on the night shift, - on 3/12/24 1 CNA slot was unstaffed on the night shift, - on 3/13/24 2 CNA slots were unstaffed on the night shift. When interviewed on 03/13/24 at 5:07 PM, Resident #49 stated they had to wait for a long time for the staff to provide personal hygiene for them and take care of their soiled briefs. They stated that was why they had accidents with bowel and urination. When interviewed on 03/13/24 at 4:24 PM, Resident #130 stated there were not enough staff every night. During the Resident Council Meeting on 3/15/24 at 10:37 AM, 10 of 10 residents voiced their concerns that when they rang the call bell they waited a very long time. Some residents stated they wait for 1.5 hours before a response. In addition, the Resident Council Meeting reported that the Administrator stated This is nothing I have not heard before. The residents stated that 90 percent of the concerns that they have brought up had not been resolved and they never heard back from the administration. During an interview on 3/20/24 at 10:09 AM, Staff #31 (Staffing Coordinator) stated all full time and part time nursing staff had a regular schedule, and the per diem staff were booked per facility needs. They stated there was an app called ROBO which was accessed by the facility via text, their staffing needs two weeks in advance. They stated the facility did mandate staff as necessary based on the daily staffing needs. They stated the facility also reached out to staffing agencies on a daily basis, and stated the facility utilized 6 staffing agencies of which 2 were for travelers. During an interview on 3/26/24 at 11:20 AM, Staff #32 (certified nurse aide) stated they were assigned to 11 residents. They stated they had to assist the residents with their activities of daily living, get them up out of bed in the morning, do morning cares, serve the residents their meals as quickly as possible so the food would not get cold, give the residents their food preferences and assist the residents with toileting needs after breakfast. Staff #32 stated they have to do a flexed schedule of 16 hours per week, because they were constantly being mandated to do extra shifts because of the staffing shortage. During an interview on 3/26/24 at 11:25 AM, Staff #33 (certified nurse aide) stated they were assigned 8 residents today. They stated they used to get mandated at least 60 hours a week, but because of their family situation, they volunteered to come in early ,so they did not have to work the overnight shift. Staff #33 stated that when they were working the 7 am-3 pm shift, they did not plan anything for after work hours in case they were mandated. They stated they did not mind getting mandated but stated there was a limit. During an interview on 3/26/24 at 11:35 AM, Staff #11 (Licensed Practical Nurse Unit Manager) stated they sometimes volunteered to come in to cover an extra shift. During an interview on 3/27/24 at 11:02 AM, Staff #34 (Licensed Practical Nurse Unit Manager) stated they have 3 CNAs on this unit at times but when there are 2 CNAs, a CNA would be asked to come in around 8 am or 9 am to make the third CNA. There are mandations approximately 2 times a week for the CNAs, but for the nurses no, they are asked to volunteer. We are here for the residents so they are kept clean, fed, and happy. During an interview on 3/27/24 at 11:12 AM, Staff #17 (certified nurse aide) stated they work 3 days a week x 12 hours. They stated they do not get mandated since they are already working 12 hours. They stated if their replacement calls out sick, I would get mandated to cover another 4 hours. During an interview on 3/27/24 at 11:19 AM, Staff #49 (certified nurse aide) stated they work about 70 hours a week, based on the needs of the facility. During an interview on 3/27/24 at 11:36 AM, Staff #35 (certified nurse aide) stated they work 6 am-2 pm shift because of staffing issues. Staff #35 stated there is a need for improvement in the staffing conditions because they are burning out. During an interview on 3/27/24 at 11:41 AM, the Administrator stated during the pandemic a lot of people left the facility. The Administrator stated they felt the wage should be increased to include sign-on bonus incentives for Registered Nurses, Licensed Practical Nurses, and certified nurse aides which would increased the staffing ratio. The Administrator stated there were not a lot of Licensed Practical Nurses or Registered Nurses in this area. The Administrator stated they had a certified nurse aide training program and hoped the new certified nurse aides would stay on at the facility. The Administrator stated they encouraged the Licensed Practical Nurses to become unit managers. The Administrator stated they could still do better with staffing. The Administrator stated they had been talking with Human Resources Director and Corporate and wanted to create a weekend bonus, so interested staff can pick up extra shifts. The Administrator stated the Human Resources Director recently conducted another wage review for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides which was waiting for approval. The Administrator stated they had to be the most competitive with their rates, and they wanted to eliminate mandatory overtime, and they were also trying to initiate a float pool. 10NYCRR 415.13 (A) (1) (i-iii)

Based on observations, record review, and interviews conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure 4 of 6 residents (Residents #432, #218, #48, and #54,) reviewed for pressure ulcers, received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, (1) Resident #432 acquired a stage 4 sacral pressure ulcer at facility and treatments were not completed as ordered. (2) Resident #218 was observed 4 times without a pillow under their right elbow and their right elbow stage 4 pressure ulcer had re-opened, (3) Resident #48 was admitted with moisture associated skin damage to the right sacrum which developed into an deep tissue injury and an unstageable wound, and (4) Resident #54's sacral pressure ulcer increased in size during a time period when 3 of 10 topical wound dressing treatments were not documented as administered. Findings include: The facility's policy, 'Pressure injury care and prevention' last reviewed 12/23 documented to assess and observe all residents for the risk of pressure injury and to have an appropriate interdisciplinary preventative care plan implemented when indicated. Residents with existing pressure injuries will be evaluated and managed in accordance with established clinical practice guidelines. 45478 1. Resident #432 was admitted to facility with diagnoses of Neurogenic bladder, Huntington's Disease, and Multiple Sclerosis. A) Pressure Ulcer Development: The 6/21/23 Braden Scale (tool to determine risk for developing pressure injury) documented a score of 17 (mild risk) -blanchable redness to skin/intact. The 7/19/23 Skin Integrity Care Plan documented resident risk for skin breakdown or pressure ulcer injury. Interventions included certified nurse aide skin inspection daily during care and report, weekly full body skin assessment by nurse; use pressure reducing cushion, Roho (specialized wheelchair seat cushion) when in Broda chair. The 7/29/23 Minimum Data Set (resident assessment tool) documented Resident #432 had moderately impaired cognition, was always incontinent of bowel and bladder, was at risk for pressure ulcers, had no pressure ulcers, had a pressure reducing device for chair and bed, and received applications of medications and ointments other than to feet. The 8/8/23 Behavior Care Plan documented behavior symptoms: non-compliance with turn and position schedule - with new skin finding. There was no documented evidence of interventions to be used related to this noncompliance. The 8/13/23 nursing note documented Resident #432 had a dime sized opening on left buttocks. The area was cleansed with normal saline, barrier cream applied, and a note was placed in the medical book. The 8/28/23 nursing note documented occupational therapy evaluation and treat, and to assess for chair cushion. The 10/4/23 nursing note documented the nurse was made aware the resident had a wound on the coccyx. The wound was 5 inches long and 1 inch wide with bloody drainage, optifoam was applied, and the resident needed a wound consult. The 10/5/23 physician's order documented wound care consult open area to coccyx. Cleanse with normal saline and pat dry, apply skin prep to surrounding skin, apply a thin layer of Triad cream and cover with foam dressing daily on the night shift. The 10/10/23 nursing note documented no abrasions, redness, or ecchymosis. The 10/12/2023 wound care physician's consult note documented the initial visit and the resident had a Stage 4 pressure ulcer on the sacrum that measured 3.5 centimeters x 1.0 centimeters x 0.4 centimeters (length x width x depth). The recommended treatment was honey-based gel, calcium alginate, and foam dressing. The 10/12/23 Impaired Skin Integrity Care Plan documented presence of skin breakdown related to incontinence, non-compliance with offloading, as evidenced by pressure ulcer to sacrum. Interventions included to refer for follow up with the wound care team. Provide pressure relieving devices as appropriate. Apply local treatments as ordered by medical doctor. Back to bed after meals for offloading and an air mattress in bed. The 10/13/23 Physician's orders documented; Air mattress- check functioning every shift, cleanse coccyx wound with skin integrity and sterile gauze, apply Medihoney and opticel dressing to area, cover with optifoam protective dressing to area. The 10/25/23 Minimum Data Set documented Stage 4 pressure ulcer not present upon admission or reentry. When interviewed on 03/27/24 at 01:59 PM, the Wound Care Physician stated the first time they saw the resident was in October 2023 and the wound had progressed to a Stage 4. B) Pressure injury worsening and treatments not provided: The wound care physician's consultation notes and physician orders documented on: - 2/1/24 the wound measured 0.9 x 0.2 x 0.2 centimeters and had increased in size, and the order was Medihoney, calcium alginate, and Optifoam dressing, with Triad to peri wound daily. - 2/8/24 the wound measured 0.8 x 0.2 x 0.2 centimeters, had decreased in size, and the order was changed to cleanse soap and water, apply Triad and Optifoam daily. - 2/15/24 the wound measured 0.6 x 0.4 x 0.2 centimeters, and had increased in size. - 2/22/24 the wound measured 6.0 x 4.0 x undetermined, increased in size and the order was changed to Santyl, calcium alginate and foam to be administered daily. There was no documented evidence the physician was notified when the wound increased in size from 2/15/24 to 2/22/24. The February 2024 Treatment Administration Record (TAR) lacked documented evidence that the treatment was completed on 13 days from 2/1/24 to 2/22/24. The nursing progress note dated 2/27/24 documented the resident was sent to the hospital. The hospital record documented the resident was admitted to the hospital on 2/27/24 with septic shock due to a urinary tract infection and dehydration. Wound culture results on 2/29/24 revealed the Stage 4 pressure ulcer was infected. The Hospital Discharge paperwork dated 3/12/24 documented the resident had an extensive sacral ulcer, did not have acute osteomyelitis but was at high risk for progression given their general debility. The hospital course was complicated by sacral wound. Resident was followed by wound care and underwent surgical wound debridement on 3/8/2024. When interviewed on 3/20/24 at 12:29 PM, Staff #6 (Registered Nurse Unit Manager) stated they were new to the facility and did not know how wounds were monitored or tracked. They stated a wound care physician came in once a week and did rounds. Staff #6 stated none of the unit staff rounded with the physician and they did not have a tracking system. When interviewed on 3/21/24 at 3:50 PM, Staff #3 (Wound Care Registered Nurse) stated they expected nursing call if there were changes in the wounds between visits and did not recall getting any calls. Assistant Director of Nursing #1 stated the Registered Nurse Unit Manager was responsible for reviewing the Treatment Administration Record and making sure treatments were done. C) Wound dressing not as ordered: The physician order dated 3/16/24 documented treatment for the sacral wound included cleanse with Skintegrity (wound cleanser), pat dry, apply Santyl (debriding ointment) , calcium alginate (absorbent wound dressing) and Optifoam (adhesive foam dressing); and apply Triad (wound cream) to periwound twice daily. During a wound observation on 3/19/24 at 12:00 PM, Staff #12 (Licensed Practical Nurse) removed the old dressing which was saturated with tan drainage, cleansed the wound, applied Santyl with a cotton swab to the wound bed, packed the wound with gauze and applied 2 Optifoam dressings. When inteveiwed at 12:30 PM, Staff #12 stated the order was for Santyl, plain gauze and Optifoam and that was what she used. When interviewed on 3/20/24 at 12:29 PM, Staff #6 (Registered Nurse Unit Manager) stated the dressing order was for Santyl, calcium alginate and optifoam; it was not appropriate to substitute plain gauze for calcium alginate. 48847 2.) Resident #218 was admitted to the facility with diagnoses including contractures of right and left hand, dementia, and anxiety disorder. The 02/25/2024 Quarterly Minimum Data Set (resident assessment) documented the resident had severely impaired cognition, required setup with eating, and was dependent with bed mobility, toileting, and transfers. The 12/11/2023 Quarterly Minimum Data Set documented that Resident #218 had an unhealed Stage 4 pressure injury that was not present on admission. The comprehensive care plan titled Resident has a reopened Stage 4 pressure ulcer to right elbow dated 2/25/24 documented interventions including treatments as ordered, staff is to always ensure offloading of elbows. The comprehensive care plan titled Activities of a Daily Living dated 4/17/23 documented interventions including elevating right arm on a pillow to prevent arm from being tucked underneath resident and causing increase in pressure to right elbow wound. Review of the physician's order dated 12/22/23 documented skin integrity review once weekly on Fridays. Review of the Treatment Administration Record dated 3/15/24, 3/22/24, and 3/29/24 had no documented evidence that a skin review was done and signed by the nurse. Review of the physician's order on the Treatment Administration Record dated 02/25/24 documented staff was to always ensure offloading of the elbows with a pillow every shift. Review of the Treatment Administration Record from 2/26/24-3/31/24 revealed no documented evidence that offloading of elbows with a pillow every shift was being done and signed by the nurse. Review of the surgical consult notes written by the wound care physician dated 2/29/24, 3/5/24, 3/16/24, and 3/23/24 documented offloading to include turning per facility protocol. Review of certified nurse aide accountability documentation from 2/25/24-3/26/24 revealed that turning and positioning was not being documented by the certified nurse aides. On 03/13/24 at 01:38 PM, Resident #218 was observed lying in bed on their back. There were no pillows in place under their right elbow. On 03/19/24 at 11:30 AM, Resident #218 was observed in bed lying on their back and no pillows was in place underneath their right elbow. On 03/20/24 at 11:33 AM during a wound care observation with Staff #9, Resident #218 was observed in bed, without a pillow underneath their right elbow that is to be used for offloading. On 03/20/24 at 01:04 PM, Resident #218 observed in bed laying on their left side. There were no pillows in place underneath their right elbow. On 03/19/24 at 11:30 AM during an interview, Staff #9 (Licensed Practical Nurse) stated that the resident was always in pain and did not like to be touched, and that the resident refused wound care and to have a pillow placed underneath their elbow, and that they did report it to the nurse manager. On 03/20/24 at 11:33 AM during an interview, Staff #10 (certified nurse aide) stated that Resident #218 was supposed to have a pillow in place under their right elbow and that they would not allow staff to place the pillow underneath their right arm. Staff #10 stated that they did notify the nurse when the resident refused. On 03/21/24 at 11:50 AM during an interview, Staff #9 (Licensed Practical Nurse) stated that they just did not have time to document in the Treatment Administration Record due to a large assignment and getting caught up with other issues on the unit. On 03/21/24 at 12:19 PM during an interview, Assistant Director of Nursing #1 stated that it was the nurse manager's responsibility for reviewing the surgical consult for the wound care physician's recommendations and instructions, and then transcribing the orders. Furthermore, the Assistant Director of Nursing stated that the unit managers were responsible for monitoring the Treatment Administration Record, and that the missing nurses' initials in the Treatment Administration Record for offloading elbows every shift, indicated that it was not being done. On 03/26/24 at 03:35 PM during an interview, Assistant Director of Nursing #1 stated that instructions for turning and positioning was generated from the resident's care plan and went in certified nurse aide accountability record. On 03/26/24 at 03:59 PM during an interview, Staff #1 stated that the turning and positioning instructions was not in the certified nurse aide accountability record for Resident #218 and that there was no documented evidence that turning and positioning was being done from 2/25/24-3/26/24. Staff #1 stated that the nurses should be documenting in the Treatment Administration Record and writing a progress note for refusals of offloading equipment, and that the skin assessments should be done on Fridays and documented in the Treatment Administration Record, and nurses should be writing a progress note about their findings. On 03/27/24 at 11:05 AM during an interview, Staff #10 (certified nurse aide) stated that they did not have time to document in the turning and positioning section in the certified nurse's aide accountability record. On 03/27/24 at 01:58 PM during an interview, the wound care physician stated that sometimes they cannot examine Resident #218 during wound rounds because Resident #218 has psychiatric issues and screams making it very difficult to perform wound care. On 03/28/24 at 05:43 PM during an interview, the primary care physician stated that stated they were made aware of Resident #218 refusals of wound treatments, and that they assumed it was pain but even before they move them, the resident starts screaming. Therefore, they are trying to get the psychiatrist involved to see if their medications can be optimized and see if anxiety is causing the discomfort to not accept cares. 48849 (3) Resident #48 was admitted with diagnoses including rectal abscess, obstructive uropathy, and early Deep Tissue Injury /Unstageable. The Admission Minimum Data Set (resident assessment tool) dated 1/23/24 documented Resident #48's cognition was intact and the resident was dependent on staff for mobility, transfers, and toilet use. The Minimum Data Set documented the resident was at risk for developing pressure injuries, had an unhealed pressure injury, and unstageable deep tissue injuries present on admission. The admission assessment dated [DATE], documented moisture associated skin damage to the sacrum. The comprehensive care plan dated 1/17/24 the resident was dependent on staff with bed mobility, to roll left and right. The comprehensive care plan dated 1/19/24 documented the resident was at risk for skin breakdown or pressure ulcer/injury. Interventions included to complete pressure ulcer risk assessment (Braden Scale) and review quarterly and when necessary, pressure-reducing mattress, cushion wheelchair, Vander-Lift, roll left and right (dependent); maintaining turn and positioning schedule by registered nurse, use skin barrier when performing perineal care, weekly full-body skin assessment by a registered nurse. The comprehensive care plan updated 1/22/24 documented impaired skin integrity, presence of skin breakdown related to limited mobility as evidenced by pressure ulcer early-deep tissue injury to right buttocks. Interventions included to assess the characteristics of ulcers daily during treatment care and document findings weekly. The wound care physician's notes documented: - On 1/18/24 the right sacral wound was documented as early right buttock deep tissue pressure injury and measured 3.5 centimeters x 3.5 centimeters and was 100% necrosis (dry dead tissue). Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol, and dressing change using Triad and foam. - On 1/25/24 the right sacral wound was documented as unstageable, measuring 2.0 centimeters x 2.0 centimeters x 0.1 centimeters , and decreased in size. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. - On 2/1/24 the right sacral wound was documented as measuring 3.5 centimeters x 0.7 centimeters x 0.1 centimeters. - On 2/8/24 the right sacral wound was documented as measuring 5.0 centimeters x 1.0 centimeters x 0.1 centimeters with 20% granulation and 80 % epithelial tissue and increased in size. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. - On 2/22/24 the right sacral wound was documented as 100% granulation tissue and measured 6.0 centimeters x 2.0 centimeters x 0.1 centimeters, and increased in size. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. - On 2/29/24 the right sacral wound was documented as 7.5 centimeters x 2.3 centimeters x 0.1 cm wound increased in size. 80% granulation 20% epithelial tissue. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. - On 3/5/24 the right sacral wound was documented as unstageable 8. 5 centimeters x 4.0 centimeters increased in size 10% granulation, 70 % epithelial , 20% necrotic tissue. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. - On 3/16/24 the right sacral wound was documented as unstageable 7.5 centimeters x 6.0 centimeters x 0.1- 40% granulation, 60 % epithelial tissue. Interventions included a weekly wound consult, foam dressing, air mattress, turn per facility protocol/policy and dressing change using Triad and foam. The physician order dated 1/22/24 documented a daily wound care treatment order to cleanse the right buttocks and apply a thin layer of Triad and cover with Optifoam. The Treatment Administration Record for January, February, and March 2024 documented a daily wound care treatment order to cleanse the right buttocks, apply a thin layer of Triad and cover with optifoam daily. This treatment lacked documentation of completion on 5 of 14 occasions in January, 21 of 29 occasions in February, and 1 of 16 occasions in March 2024. The skin integrity review every 7 days lacked documentation for all of January and February 2024. The Certified Nurse Aide accountability record from January to March 2024 did not document turning and positioning. During an observation on 03/21/24 at 10:17 AM of wound dressing change for Resident # 48, Staff #14 (Licensed Practical Nurse) removed the dressing revealing bloody drainage and 2 separate wounds on the right buttock measuring 5 centimeters by 2.5 centimeters and 3 centimeters by 5 centimeters. A smaller wound was observed on the left buttock that License Practical Nurse #14 stated was not there before. When interviewed during the observation Staff #14 stated they did the dressing change the previous day and was not expecting to see the 2 open areas on the right side and had Assistant Director of Nursing #2 look at the wound. Staff #14 stated Assistant Director of Nursing #2 measured the 2 areas and determined the wound care physician measured both wounds as one. License Practical Nurse #14 stated no drainage was noted prior to today. The nurse continued the cleanse the wounds and applied Triad to the open areas and covered with Optifoam. Review of the nursing progress notes on 3/22/24 revealed no documentation regarding the new skin impairment on the left buttock and no documentation of Assistant Director of Nursing #2's assessment on 3/20/24. On 03/21/24 at 12:08 PM during an interview, Assistant Director of Nursing #2 stated they observed the wound on 3/20/24 with Staff #14. They measured both wounds and realized the wound care physician was measuring the wounds by clustering as one. The Assistant Director of Nursing #2 stated they were overseeing the unit as the Unit Manager had recently retired. They stated they saw the wound when the resident was admitted and did not go on wound rounds or track the wound. They stated they thought it was bigger, and the top of the wound looked like a Stage 2 but had no drainage. They did not document their assessment and stated the nurse was supposed to document their assessment of the wound daily. Assistant Director of Nursing #2 reviewed the treatment omissions on the Treatment Administration Record and stated missed treatments should have been reported to the physician and the Unit Manager was responsible for reviewing the treatment record but currently there was not a Unit Manager. On 03/26/24 at 4:25 PM during an interview, the Director of Nursing stated the plan of care intervention dated 1/22/24 should have populated to the Certified Nursing Assistant Kardex to turn and position every two hours, but it did not because the Activity of Daily Living category was never initiated by the creator of the care plan; therefore, turning and positioning were not part of the Certified Nursing Assistant Kardex as required care. The Unit Manager was responsible for checking the Certified Nurse Aide documentation and the nursing care plan. On 3/27/24 at 1:57 PM during an interview, the wound care physician stated they measure several areas as one by bridging the wounds for billing purposes because the Minimum Data Set wounds cannot be documented by specific areas such as the upper right buttock, middle right buttock, lateral right buttock, and lower right buttock. Resident #48's skin shifts because of their weight, and it could create various openings affecting the general area and wound dimension and that was why the wound was measured as an area. They stated the wound dressing stayed the same because the treatment worked. It was the facility's responsibility to monitor treatments between wound rounds, monitor if treatment were being done, and report any issues. On 3/28/24 at 4:27 PM during an interview, the Medical Director stated that nurses needed to document wounds at the time of treatment and communicate with the physician if a wound got bigger, signs of infection were observed, if treatments were not working, or if wounds frequently need to be debrided. The Medical Director stated that nurses should be monitored to ensure they are administering treatments correctly. The Medical Director also stated that documentation by the nurses was very important at the time of treatment administration, which should include the color of the wound bed, the color of any drainage, any pain, the size of the wound, and any odor. Nursing was responsible for measuring and documenting any changes between wound rounds and notifying the primary provider with any concerns. 415.12(c)(1)(2) 49364

Based on observation, interview, and record review conducted during the Recertification Survey completed from 3/13/24 through 3/29/24, the facility did not ensure each resident received drinks, including health shakes and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 17 (Residents #1, 6, 11, 34, 53, 63, 65, 84, 85, 145, 177, 204, 216, 237, 250, 258, and 278) of 36 residents reviewed. Specifically, Residents #1, 6, 11, 34, 53, 63, 65, 84, 85, 145, 177, 204, 216, 237, 250, 258, and 278 did not receive coffee or tea, and health shakes as per meal ticket. Findings include: The undated facility policy titled Resident Meal Service, documented beverages were to be provided as listed on ticket or per resident preference. On 03/13/24 from 12:21 PM-01:05 PM, during the dining room lunch observation, Residents #1, 11, 84, 177, 237, 250, 258, and 278's meal tickets all documented 6 ounces of a hot beverage (tea, coffee, and decaffeinated tea or coffee). None of the residents received the hot beverages listed on their meal tickets and none were provided an alternate 6 ounce beverage in place of the hot beverage. During the same meal observation, Residents #6, 34, 53, 63, 65, 84, 85, 145, 204, 216, 250's meal tickets all documented 4 ounces of Health Shake on their meal tickets and none of the resident were provided with the Health Shakes. During an interview on 03/13/24 at 01:00 PM, Staff #56 (dietary aide) stated that the residents did not receive coffee, tea, and the health shakes because nursing staff was responsible for putting the items on the residents' trays. During an interview on 03/20/24 at 09:42 AM, the Registered Dietician stated that both the food service worker and nursing staff were responsible for making sure all items on the meal tickets were provided to the residents before the tray was taken away from the resident. They stated the health shakes should be brought up from the kitchen by the dietary aide for every meal and has had issues in past and was not able to provide health shakes due to supply chain issues. The Registered Dietician stated that coffee and tea was on the resident tickets and was needed for hydration and should have been provided to resident when the trays was served. During an interview on 03/20/24 at 01:09 PM, Staff #10(certified nurse aide) stated that the health shakes was supposed to be put on tray by dietary and that the nursing staff was only responsible for serving the coffee tea, ginger ale, juices, and milk. During an interview on 03/21/24 at 10:18 AM, Staff #30 stated that they were not aware the health shakes were not distributed to the residents, and that dietary was responsible for bringing the health shakes on the unit. 10NYCRR415.14(d)(4)

Based on observation, interview, and record review conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1. Portable food storage bins used for storing bulk dry foods were not maintained in a sanitary condition, 2. A cooling log was not used to monitor cooling of potentially hazardous cooked food (poultry), 3. Storage racks used to store cleaned and sanitized food preparation equipment were not maintained in a sanitary condition and the floor under the storage racks was not maintained in a sanitary condition, 4. Eight (8) food transport trucks used for transport of foods to the resident units were not maintained in a sanitary condition, and 6. A formica countertop located directly in front of 1 of 8 kitchenette hot food holding areas was in poor repair and presented a risk for food contamination and potential injury to residents. The findings are: During a follow up tour of the main kitchen on 3/19/2024 between 9:04 AM and 10:59AM the following were observed: 1) On 3/19/24 at 9:22 AM, three (3) portable bins used for storing bulk dry foods (rice, flour, and food thickener) were observed with black-ish colored grime and orange-ish colored soiling on both the exterior and interior rims of each of the 3 bins. During an interview at that time, the Food Service Director stated that each bin holds about forty (40) pounds of rice, flour, or food thickener, stated that their master cleaning schedule lists the portable storage container was to be scheduled for weekly cleaning, and stated that they did not have a weekly log to document the cleaning of the portable bins. When asked when the bins had last been cleaned, the Food Service Director stated that the bins had not been cleaned often enough, the utility man was responsible to clean the bins, but they did not have a utility man scheduled on a lot of days as they are short staffed. 2) On 3/19/24 at 9:45 AM, the general walk-in refrigerator was observed and found to contain sixteen (16) cooked 1/2 turkey breasts which had been cooked and held for service. The turkey breasts were dated 3/18/2024 and a use by date of 3/21/1024. Surveyor requested to see the cooling log for the turkey breasts. The Food Service Director produced the main kitchen/cooks' log for 3/18/2024 which did not document cooling temperatures for the 1/2 turkey breasts cooked on 3/18/2024. The Food Service Director stated that they do not having a cooling log for the 1/2 turkey breasts as they thought that the cooling of smaller pieces of turkey did not have to be recorded on a cooking log. 3) On 3/19/24 at 10:32 AM, three (3) racks with four (4) metal shelves each were observed in the pot washing area. The racks and shelves were soiled with greasy, sticky, and dried food debris, dust, and rust. The shelves each held cleaned and sanitized food preparation and service equipment including several dozen standard hotel pans, more than a dozen 1/2 hotel pans, greater than twenty (20) sheet pans, and various other pots, pans, and mixing bowls. The floor under the three metal racks were soiled with an accumulation of grime and food debris. In an interview on 3/19/24 at 10:42 AM, the Food Service Director stated that the cleaning schedule for the storage racks is scheduled weekly and the pot room floor cleaning is scheduled daily. The Food Service Director stated that, if they had close to the amount of staff they needed, the cleaning could be managed. 4) On 3/19/24 at 10:57 AM, the interiors of the eight (8) portable food transport trucks (used to transport hot and cold foods to each resident unit) were observed to contain sheet pans soiled with dried food debris, and the walls and pan sleeves were heavily soiled with grease, dried food debris, and grime. In an interview on 3/19/24 at 10:59 AM, the food service aide stated that the process was that the sheet pans would be given to the dishwasher after the meal was completed and the carts would be returned to the kitchen. The food service aide stated that the food transport trucks would be cleaned by the worker on the unit or by the utility worker. In an interview at that time, the Food Service Director stated the food transport trucks are to be cleaned daily and stated that they were not being cleaned consistently. 5) On 3/19/24 at 12:15PM Surveyor observation of the unit 4A kitchenette revealed a broken formica countertop located directly in front of foods held on the steam table. In an observation and interview on 3/19/24 at 12:31 PM, the Maintenance Supervisor stated the countertop was 1/16-inch formica, and they were not aware that the formica countertop had cracked and a piece was missing. When asked if it the condition of the formica countertop was safe for food service, the Maintenance Supervisor stated that the broken formica could get into the food and a resident could swallow it or break a tooth. The Maintenance Supervisor stated that staff could report equipment in need of repair by calling them, paging them, or submitting a work order. The Maintenance Supervisor stated they conduct environmental rounds, and they did not recall when they had last conducted environmental rounds on unit 4A. 10 NYCRR 415.14 (h)

Based on observations, record review, and interviews conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure 4 of 5 residents (Residents #114, 161, 216 and 258), reviewed for abuse, had the right to be free from abuse. Specifically, Resident #258 was observed on multiple occasions exhibiting physical and verbal aggression towards other residents including Residents #114, #161 and #216, and the facility did not ensure interventions were implemented to prevent abuse. Findings include: The facility policy titled Clinical, Resident Abuse Reporting and Investigation Protocol, Policy and Procedure dated 1/11/20 and last revised on 8/28/23 documented to protect residents' and ensure freedom from abuse, mistreatment, neglect, misappropriation of property, exploitation corporal punishment and involuntary seclusion. The facility takes all witnessed and/or suspicion of resident/patient abuse, mistreatment, neglect, misappropriation of funds and/or exploitation by anyone including facility staff, other residents, consultants, volunteers, staff of other agencies, family members, legal guardian's, friends, or individuals. The facility will adhere to the federal and state requirements that mandate the reporting of alleged violations of verbal , sexual, physical, or mental abuse. Resident #258 was admitted to the facility with diagnoses including Alzheimer's Disease, major depressive disorder, and metabolic encephalopathy. The At Risk for Victimization Comprehensive Care Plan dated 9/19/23 documented interventions that included separating from others as needed and engaging in task/activity of interest. The Behavior Symptoms Comprehensive Care Plan dated 10/16/23 documented interventions that included identifying the reason for behavior and identifying the pattern of behavior. The Behavior Notes documented: - On 3/6/24 the resident threw objects, hitting staff on the head and physically hit staff twice in the process of verbally redirecting her to a quiet area for her to calm down. - On 3/7/24 the resident was very agitated, upset and crying at start of shift, getting into other residents' personal space, yelling and threw an object at staff when trying to redirect her. - On 3/11/24 the resident was agitated and intrusive in other residents and staff space. - On 3/11/24, the resident was very disruptive during dinner, yelling at staff and residents. Getting in others faces and cursing. Attempts to redirect were unsuccessful. The 3/13/24 nursing progress notes documented the resident was noted with increased pacing and verbal agitation in the morning; and the resident was noted with increased verbal agitation. On 03/13/24 at 10:37 AM, Resident #258 was observed in the hallway near the nurses station calling Resident #161 derogatory names, and stated, I'm going to smack you in the face and proceeded to raise their hand at Resident #161. The charge nurse was nearby and overheard Resident #258 yelling and verbally attempted to move Resident #258 away from Resident #161. On 03/13/24 at 10:40 AM, Resident #258 was observed in the hallway at the nurses station agitated and anxious while yelling at multiple residents. On 03/13/24 at 10:52 AM, Resident #258 was observed in the unsupervised day room in front of Resident #114, touching their face and rubbing their hand, and the resident requested not to be touched. Resident #258 snatched a straw from Resident #114 hand, smacked their hand, then stated I would like to punch you in the throat, and then proceeded to pinch Resident #114's lips and began smacking them with the straw in their face. The surveyor had to summon Staff #50 (Certified Nurse Aide) to the unsupervised dayroom for assistance with the incident. On 03/13/24 at 11:01 AM, Resident #258 was observed walking up to Resident #216 while the resident was sitting in their wheelchair near the nursing station. Resident #258 began to yell at Resident #216, then grabbed their right hand and squeezed it tightly and bent their finger back. Resident #216 was screaming let me go you're hurting me. On 03/13/24 at 11:03 AM, Staff #50 was walking by, and surveyor summoned them to assist with separating Resident #258 and Resident #216. Staff #50, attempted to redirect Resident #258 and as they were walking towards the dayroom, Resident #258 walked towards Resident #114 who was sitting in the nursing station, and stated this the one I really want and proceeded to smack them. On 03/13/23 at 11:05 AM, Staff #50 was observed telling Staff #1(Licensed Practical Nurse) that something needed to be done because Resident #258 was going around smacking people. On 03/13/24 at 11:20 AM, Resident #258 was observed in the hallway near the nursing station and walked up to Resident #216, and told Resident #216 to move out of their way. During an interview on 03/13/24 at 10:40, Staff #1 (l Licensed Practical Nurse) stated Resident #258 was always on edge and that yelling and being agitated was their normal behavior. During an interview on 03/13/24 at 10:46 AM, Staff #1 stated that the residents, even those with behaviors could be alone in the dayroom. During an interview on 03/13/24 at 11:21 AM, Resident #34 stated that Resident #258 was always hitting people and staff did nothing about it. During an interview on 03/13/24 at 12:37 PM, Staff #7 (Certified Nurse Aide) stated that the resident got sent to hospital because she was attacking people. During an interview on 03/14/24 at 11:16 AM, the Director of Nursing stated that when they did rounds on 3/13/24 at 9:30 AM, Resident #258 was pacing and being verbally disruptive, and stated it was their normal behavior. The Director of Nursing stated that they were unaware that Resident #258 lashed out against residents and was only aware that the resident lashed out at staff. The Director of Nursing stated that Staff #1 notified them that Resident #258 was having problems with agitation and increased aggression and stated that they observed resident with increased behaviors and started an investigation. During an interview on 03/14/24 at 11:20 AM, Staff #1 stated that Staff #50 did not report any resident to resident altercation. Review of the Accident/Incidence/Occurrence worksheet for Resident #258 dated 3/14/24 documented it was reported that Resident #258 was in the dayroom standing near Resident #114 and was agitated and tapping resident on the forehead with a straw. Resident was at high risk for behaviors due to dementia with behaviors, and poor judgement. The resident had noticeable change in physical and/or verbal aggression towards others. The resident was noted with increased aggression and agitation towards staff and fell ow residents and was sent to the hospital for further evaluation. During an interview on 03/15/24 at 01:24 PM, Staff #50 stated that on 3/13/24 they heard Resident #258 yelling in the dayroom and did not react stating they did not feel it was any different from another day and stated that physically and verbally aggressive behaviors was Resident #258 normal behavior, and when incidents happened in the past, they reported it to the nurse manager. Staff #50 stated that their memory was bad and they did not recall the incident when Resident #258 was physically aggressive towards other residents on 3/13/24. Staff #50 stated that they were unaware of interventions and was not trained on how to approach Resident #258 when exhibiting verbally and/or physically aggressive behaviors, and that they just redirected the resident when there was a behavior. During an interview on 03/28/24 at 06:52 PM, the primary care physician stated they were familiar with the Resident #258's physical and verbal behaviors towards residents and staff and stated the resident was very impulsive. The primary care physician said stated that Resident #258 could be very calm one minute and then physically/verbally aggressive the next minute. The physician stated the resident could become agitated at the smallest things and stated the resident could sometimes be redirected if able to get them out of an aggressive mindsight but sometimes could not. The primary care physician stated Resident #258 was recently physically aggressive to another resident and had to be sent out to the hospital, and then physically aggressive with another resident when they returned from the hospital. The primary care physician stated the behaviors were unavoidable and they could not anticipate when a rage was going to happen. They stated when the behaviors could not be managed the in the facility, the resident was sent out to the hospital. 10NYCRR 415.4(b)

Based on observation, interview, and record review conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure residents had a right to a dignified existence in an environment that promotes maintenance or enhancement of their quality of life. Specifically, Resident #133 was observed on multiple occasions, not shaved with a large amount of facial hair, and hair on the head was disheveled. The findings are: Resident # 133 was admitted to the facility with diagnoses including Alzheimer's disease, diabetes mellitus, and history of traumatic brain injury. The 02/17/24 Quarterly Minimum Data Set ( an assessment tool ) documented Resident #133 had severely impaired cognition, required partial assistance with personal hygiene, and had no behavioral symptoms and no rejection of care. The comprehensive care plan titled impaired activities of daily living, dated 1/18/22, documented Resident #133 would remain clean, neat, dressed appropriately for the season and free of body odor. Interventions included Resident #133 would be provided privacy, and dignity was to be always preserved especially during care. On 03/13/24 at 10:47 AM, Resident #133 was observed sitting in dayroom not shaved with a full whitish grayish beard and goatee, and disheveled hair. On 03/14/24 at 12:55 PM, Resident #133 was observed sitting in the dining room eating lunch with disheveled hair, and unshaved with a full whitish grayish beard and goatee. During an interview on 03/20/24 at 01:13 PM, Staff #10 (certified nurse aide) stated that Resident #133 was supposed to be shaved on shower days and as needed, and that Resident #133 used to be temperamental but had gotten better over the years. Staff #10 stated Resident #133 did allow staff to shave them and that it was not acceptable for them have a full beard. During an interview on 03/20/24 at 01:24 PM, Assistant Director of Nursing #1 stated that Resident #133 could either be shaved by the beauty parlor or certified nurse aides, and that there was no reason that Resident #133 should have any hair on their face unless it was their preference, and that they were unaware of Resident #133 refusing to be shaved. 10 NYCRR 415.5(a)

Based on observation and staff interviews during the recertification survey from 3/13/24 to 3/29/24, the facility did not maintain a homelike environment for 4 of 8 rooms observed on unit 5B. Specifically, for Residents #154, #210, #135 and #131, observations were made of ripped and peeled protective padding in bathrooms, particles of food and other debris on the floor, dirty adult briefs on the floor, and a toilet paper dispenser with fecal remains dried on over a period of 6 days. Findings include: On 3/13/24 at 11:16 AM, Resident #210's bathroom, located on unit 5B, was observed with an adult brief soiled with urine and feces lying on the floor. Feces were observed on the toilet and the toilet paper dispenser. A soiled gown was observed on the floor. A heavy urine odor was noted in the room. The resident's bed headboard was observed with protective padding that was ripped, peeling and damaged. On 3/13/23 at 3:33 PM, Resident #210's bathroom was observed with the soiled adult brief still on the floor. The feces were still on the toilet and the toilet paper dispenser and a soiled gown was observed still lying on the floor. On 3/19/24 at 9:52 AM, Resident #210 room and bathroom was observed with dried stains on the floor, food and other particles on the floor, and the room had a strong odor of urine. The bathroom was observed with feces still caked on toilet paper dispenser and had a heavy urine odor. When interviewed during the observation, the resident was asked if the room was cleaned, and they stated no. On 3/13/24 at 11:20 AM, Resident #135's bathroom, located Unit 5B, was observed with protective padding on sink that was ripped and peeling. On 3/19/24 at 9:50 AM, Resident #131's bathroom, located on Unit 5B, was observed with protective rail padding that was peeling, and particles from the peeling were observed on top of the toilet paper dispenser. On 3/19/24 at 11:04 AM, Resident #154's bedroom, located on Unit 5B was observed to have food and other particles on the floor. On 3/19/24 at 11:08 AM, the Director of Housekeeping observed the aforementioned rooms with the surveyor and stated they were not sure why the floors were not cleaned but stated it could have happened after the housekeeper was there and particles could have been dropped on the floor after they had already cleaned. The Director of Housekeeping stated they were aware of the peeling padding and stated it was an infection control issue, because the exposed fabric inside cannot be cleaned since it is porous. The Director of Housekeeping stated they were aware of Resident #210's behavior and the staff tried to clean the room as best they could. The Director of Housekeeping stated the resident refused to let them clean the floor, but stated they were aware they should make an effort to clean the room despite their behaviors. The Director of Housekeeping stated Resident #210's bathroom should have been cleaned and no soiled adult briefs should have been left on the floor. The Director of Housekeeping stated they would tell the housekeeper about the soiled toilet paper dispenser and tell them to clean all of the observed rooms. 415.5(h)(2)

Based on staff interviews and record reviews the facility medical director failed to implement and coordinate resident care polices at the facility in regards to procedures/protocol for ordering, and monitoring of resident receiving [MEDICATION NAME] (a blood thinner) that was consistent with current standards of practice. Specifically, the medical director failed to provide oversight for resident #1 who continued to receive daily [MEDICATION NAME] from [DATE] to [DATE], without having PT/INR testing as ordered. Resident was hospitalized on [DATE] for change in mental status and hematuria and expired at the hospital. This resulted in actual harm to Resident #1 that is Immediate Jeopardy and the potential for serious harm to resident health and safety for 32 residents receiving [MEDICATION NAME] therapy. Complaint # NY 443 Findings are: During and abbreviated survey deficiency ' s for Professional Standards of Practice (F 281),Quality of Care (F309), Physician Services (F 386), Drug regime Review (F 428), were cited at an Immediate Jeopardy level. The Medical Director was interviewed on [DATE] at 10:10AM and asked what type of policy and procedure he had in place for resident ' s that receive [MEDICATION NAME] therapy. He states that each Physician, Physician ' s Assistant, and Nurse Practitioner are given a lap top which has the policy and procedures with clinical protocols and medical procedures for anticoagulation therapy. He further states that whatever happens in a month with the resident should be included in the monthly progress note and that includes review of all labs. Review of the policy and procedures used by the Physicians, Physician ' s Assistants, and Nurse Practitioners documents the recommended frequency of testing when initiating or altering [MEDICATION NAME] therapy is to be followed: PT/INR results should be maintained in a flow sheet to assist the prescriber in following the results and effect of dosage changes more easily. It further states that the resident is stable on [MEDICATION NAME] should have a weekly INR. Those residents whose INR are fluctuating should have bi-weekly INR. 415.15(a)

Based on staff interviews and medical record review the facility failed to provide care and services in accordance with the standards of professional nursing practice. Specifically, the nursing staff failed to document the physician's order [REDACTED]. Resident #1 continued to receive daily [MEDICATION NAME] (a medication to thin the blood and prevent blood clots) from [DATE] through [DATE] and did not have the weekly PT/INR (therapeutic blood testing) completed as ordered by the physician. The resident developed hematuria (blood in the urine) and a change in mental status which required transfer to an acute care hospital on [DATE], where the resident expired. This resulted in actual harm to Resident #1 that is Immediate Jeopardy and the potential for serious harm to resident health and safety for 32 residents receiving [MEDICATION NAME] therapy. Complaint ID Number: NY 443 The findings are: Resident #1 is a [AGE] year old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) (a resident assessment tool) dated [DATE] documented the resident as being oriented to year, month and day, usually makes self understood, sometimes understands others. A [DATE] Medical Note entered by a nurse practitioner (NP) documented that on [DATE] the resident's PT was 49.9 (normal range is 10.4 -11.9) and INR was 4.56 (normal range is 2.00 - 3.00). The NP ordered [MEDICATION NAME] 7 milligrams (mg.) to be held on [DATE] and to resume the medication at a decreased dose of 6 mg. on [DATE]. The NP further ordered that the lab test be repeated in one week. The [DATE], [DATE], and [DATE] Physician order [REDACTED]. by mouth daily, and PT/INR lab tests were ordered to be done weekly on Mondays. Review of the resident ' s plan of care dated [DATE]; documented that the resident was on anticoagulant therapy of [MEDICATION NAME]. Interventions included monitoring laboratory work (PT/INR) as ordered and evaluate medication based on laboratory reports. There was no documented evidence in nurse ' s notes, treatment records or evaluation of care plan that PT/INR laboratory testing was obtained or monitored from [DATE] through [DATE]. On [DATE], the resident ' s lab results documented PT of 39.4 (high) and INR was 3.59 (high). There is no documented evidence that nursing reported this result to the physician. A review of the laboratory section of the resident's chart, residents Treat Administration Record (TAR) (a record that nurses initial when treatment is performed and completed) and [MEDICATION NAME] flow sheet revealed there was no PT/INR drawn from [DATE] until [DATE]. (9 weeks) A review of the unit lab book did not include documentation that a requisition for the weekly PT/INR labs had been completed by nursing staff for Resident #1 from [DATE] through [DATE]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. of [MEDICATION NAME] was given from [DATE] through [DATE] without monitoring the residents PT/INR labs. A nursing note on [DATE] at 2:15 p.m. states, " Resident noted with hematuria. Reported to Dr. and orders were noted to hold [MEDICATION NAME] and PT/INR to be done tomorrow. Resident ' s [MEDICATION NAME] on hold this evening." A nursing note that same day at 9:50 p.m. states that a moderate amount of hematuria was noted in the resident's incontinence brief and [MEDICATION NAME] was placed on hold that evening. The [DATE] nursing note at 6:44 a.m. states that the resident is noted to have large ecchymosed areas to the left arm, left breast area and upper buttock. Also noted was frank hematuria without any complaints of burning or discomfort. The supervisor was made aware. On [DATE] at 3:41 p.m. a medical progress note by NP documents that staff reported a temperature of 100.1 and painless hematuria. It further noted that during her physical exam of the resident, resident was moving all extremities, had several bruises to left posterior elbow, lower arm and upper arm, lethargic but responsive, with clear speech. The note goes on to document that the resident's INR was 7.03 (high anemic), encourage fluids, continue to monitor, [MEDICATION NAME] was discontinued and she ordered Vitamin K (interferes with blood thinning effects of [MEDICATION NAME]) to be given. The nurse's note dated [DATE] at 6:12 a.m. documents that the supervisor was called to the unit at 5:50 a.m. due to a change in the resident ' s mental status and a large amount of hematuria in the urine. The resident was not responding to verbal or tactile stimuli. The supervisor called the NP and orders were issued to transfer the resident to the hospital due to a change in mental status and hematuria. Review of the facility ' s nursing policy and procedure for transcription of Physician Orders, dated May, 2008, documented that that nurses complete requisitions for labs, and then place it into the lab book under the correct date, document the type of lab ordered on the TAR, including the date it was ordered. When the lab is done, document the date on the TAR. An interview was conducted with Licensed Practical Nurse (LPN #1) on [DATE] at 12:15 p.m. She stated that on [DATE] she picked up the order for the PT/INR lab test. She further stated that she remembers only making out one lab slip and was not aware at that time that she had to make 3 or 4 lab requests for the month. She stated that she was not aware she had to transcribe the order to the Treatment Administration Record (TAR) and did not know that it was the facility policy to place that PT/INR order in the TAR. The Director of Nursing was interviewed on [DATE] at 1:00 p.m. She stated that the schedule for ordering lab tests for Resident #1 every week on Mondays, beginning on [DATE], was not established with lab slips, or entered into the lab requisition book. She stated that nursing was responsible for building a schedule in the Electronic Medical Record (EMR) when picking up physician orders. She stated building a schedule in the EMR would automatically set up the treatment in the TAR for nurses to sign off. She also stated that they have been recently auditing all residents on [MEDICATION NAME] and reviewing and revising the policy for [MEDICATION NAME] monitoring. In an interview with the In-Service Director (RN #3) on [DATE] at: 9:00 a.m. she stated that nurses are not responsible for building a schedule in the EMR for labs to be drawn. She stated that she was not aware of the ,[DATE] nursing policy and procedure in which nurses are to document the type of lab ordered on the TAR, including the date it was ordered and received. Interviews were conducted on [DATE] and [DATE], and 12 of 14 residents stated that they were not aware of the facility nursing policy and procedure requiring that lab orders are to be transcribed onto the TAR with dates ordered and completed. Twelve (12) nurses stated it was not the responsibility of the nursing staff to create a schedule of lab tests in the facility's electronic medical records. Seven (7) nurses interviewed stated that they would create 4 lab requisition slips for a request that weekly labs to be drawn; Five (5) nurses stated they would make 3 lab requisition slips for weekly labs to be drawn; and one nurse said she would only do one lab requisition slip for that particular week. 415.11(c)(3)(i)

Based on interviews and record reviews conducted during an abbreviated survey, it was determined that the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility Administrator failed to ensure that residents on Anticoagulant therapy ([MEDICATION NAME]) attained the necessary labatory testing (PT/INR) to monitor the effectiveness of the medication. Resident #1 continued to receive daily ([MEDICATION NAME]) from [DATE] to [DATE] without having PT/INR testing as ordered. The resident was hospitalized on [DATE] for change in mental status and hematuria and expired at the hospital. This resulted in actual harm to Resident #1 that is Immediate Jeopardy and the potential for serious harm to resident health and safety for 32 residents receiving [MEDICATION NAME] therapy. Complaint # NY 443 Findings are: During and abbreviated survey deficiency ' s for Professional Standards of Practice (F 281),Quality of Care (F309), Physician Services (F 386), Drug regime Review (F 428) and Medical Director (F 501), were cited at an Immediate Jeopardy level. The Administrator was interviewed on [DATE] at 1:00 pm he stated that he became aware of the problem of monitoring, and follow- up with PT/INR laboratory tests at the facility after the Resident was sent to the hospital. He stated that the thought nursing was responsible for building a schedule in the Electronic Medical Record (EMR) when picking up physician orders, and writing out laboratory slips so laboratory tests are completed.He further stated that he was not aware that the medical staff did not note the absence of PT/INR laboratory test from [DATE] through [DATE] during their monthly progress notes. Review of the facility ' s nursing policy and procedure for transcription of Physician Orders, dated May, 2008, documented that that nurses complete requisitions for labs, and then place it into the lab book under the correct date, document the type of lab ordered on the Treament Adminstration Record (TAR) , including the date it was ordered. When the lab is done, document the date on the TAR. 415.26

Based on medical record review and staff interview, it was determined that the facility failed to have a system in place to complete laboratory testing as ordered and report results to the physician. Specifically, the facility ' s medical team (physician, nurse practitioner, physician 's assistant, pharmacy consultant and nursing staff) did not thoroughly review a resident on [MEDICATION NAME] (a blood thinner) for physician ordered PT/INR (An elevated PT/INR may increase the risk for bleeding or hemorrhage manifested by, but not limited to, bruises, hematuria, and increased temperature). The resident developed hematuria (blood in the urine) and a change in mental status which required transfer to an acute care hospital on [DATE], where the resident expired. This resulted in actual harm to Resident #1 and the potential for serious harm to the health and safety of 32 residents currently on [MEDICATION NAME] therapy that is Immediate Jeopardy. Complaint ID Number: NY 443 The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) (resident assessment tool) of [DATE] assessed the resident as being oriented to year, month, and day, usually makes herself understood, and sometimes understands others. The residents medical record states she was transferred to the emergency roiagnom on [DATE] for evaluation with change in mental status, where she was diagnosed with [REDACTED]. Resident expired at the hospital. On [DATE] a Medical Note entered by nurse practitioner (NP) documented the residents [DATE] PT as 49.9 (normal limit 10XXX,[DATE].9 sec.) and INR 4.56 (normal limit 2XXX,[DATE].00), the NP then ordered [MEDICATION NAME] 7 milligrams (mg.) to be held on [DATE] and resume [MEDICATION NAME] at a decreased dose of 6 mg. on [DATE] Then repeat the INR in one week. Physician orders [REDACTED]. A laboratory report dated [DATE] documented the residents PT results as 39.4 (high) and INR of 3.59 (high). There was no documented evidence found in the medical record that this irregular lab was monitored or addressed by any of the facility ' s medical staff from [DATE] through [DATE]. A review of the laboratory section of the resident's chart, residents Treat Administration Record (TAR) (a record that nurses initial when treatment is performed and completed) and [MEDICATION NAME] flow sheet revealed there was no PT/INR drawn from [DATE] until [DATE]. (9 weeks) The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the Medical procedures dated 2011 issued to physicians, physician assistants and nurse practitioners from the medical director documents the recommended frequency of testing when initiating or altering [MEDICATION NAME] therapy is to be followed: PT/INR results should be maintained in a flow sheet to assist the prescriber in following results and effect of dosage changes more easily. It further states that residents who are stable on [MEDICATION NAME] should have a weekly INR. Those residents whose INR are fluctuating should have bi-weekly labs. Review of the physician monthly progress note documents: - [DATE] by nurse practitioner, " [MEDICATION NAME] anticoagulation given for history of [MEDICAL CONDITION] Fibrillation (AFIB), AFIB rate is controlled. [MEDICATION NAME] therapy will continue PT/INR monitoring, therapeutic range 2XXX,[DATE].0 " . [MEDICAL CONDITION] in [DATE], [MEDICATION NAME] therapy continues for [MEDICATION NAME] " . - [DATE] by resident ' s attending physician documents, " resident was on [MEDICATION NAME], AFIB rate is controlled [MEDICATION NAME] therapy will continue PT/INR monitoring, [MEDICAL CONDITION] history of recent [MEDICAL CONDITION] in [DATE], [MEDICATION NAME] therapy continues for [MEDICATION NAME] " . - [DATE] by resident ' s physician assistant documents, " [MEDICATION NAME] anticoagulation given for history of AFIB. AFIB rate is controlled. [MEDICATION NAME] therapy will continue PT/INR monitoring. therapeutic range 2XXX,[DATE].0. [MEDICAL CONDITION] history of recent [MEDICAL CONDITION], [MEDICATION NAME] therapy continues for [MEDICATION NAME] " . - [DATE] by resident ' s attending physician documents, " resident was on [MEDICATION NAME], AFIB rate is controlled [MEDICATION NAME] therapy will continue PT/INR monitoring, [MEDICAL CONDITION] history of recent [MEDICAL CONDITION] in [DATE], [MEDICATION NAME] therapy continues for [MEDICATION NAME] " . - [DATE] by nurse practitioner documents, " AFIB rate is controlled [MEDICATION NAME] therapy will continue PT/INR monitoring, therapeutic range 2XXX,[DATE].0, [MEDICAL CONDITION] history of recent [MEDICAL CONDITION] in [DATE], [MEDICATION NAME] therapy continues for [MEDICATION NAME] " . Review of the physicians monthly progress notes from [DATE] through [DATE] did not include documentation regarding resident #1 current medical status. Review of the facility ' s nursing policy and procedure for transcription of Physician Orders, dated May, 2008, documented that nurses complete requisitions for labs, and then place it into the lab book under correct date. Document the type of lab ordered on the Treatment Administration Record (TAR), including the date it was ordered. When the lab is done document the date on the TAR. A review of the Resident #1TAR from [DATE] through [DATE] did not contain documentation that the physician orders [REDACTED]. An interview was conducted with Licensed Practical Nurse (LPN #1) on [DATE] at 12:15 p.m. She stated that on [DATE] she picked up the order for the PT/INR lab test. She further stated that she remembers only making out one lab slip and was not aware at that time that she had to make 3 or 4 lab requests for the month. She stated that she was not aware she had to transcribe the order to the TAR and did not know that it was the facility policy to place that PT/INR order in the TAR. The Director of Nursing was interviewed on [DATE] at 1:00 p.m. She stated that the schedule for ordering lab tests for Resident #1 every week on Mondays, beginning on [DATE], was not established with lab slips, or entered into the lab requisition book. She stated that nursing was responsible for building a schedule in the EMR when picking up physician orders. She stated building a schedule in the EMR would automatically set up the treatment in the TAR for nurses to sign off. She also stated that they have been recently auditing all residents on [MEDICATION NAME] and reviewing and revising the policy for [MEDICATION NAME] monitoring. In an interview with the In-Service Director (RN #3) on [DATE] at: 9:00 a.m. she states that nurses are not responsible for building a schedule in the electronic medical record for labs to be drawn. RN #3 also stated that she was not aware of the ,[DATE] nursing policy and procedure in which nurses are to document the type of lab ordered on the TAR, including the date it was ordered and received. Twelve nurses interviewed between [DATE] and [DATE] stated that they were not aware of the facility nursing policy and procedure requiring that lab orders are to be transcribed onto the TAR with dates ordered and completed. Twelve nurses stated that it was not the responsibility of the nursing staff to create a schedule of lab tests in the facility's EMR. Seven nurses interviewed stated that they would create 4 lab requisition slips for a request that weekly labs are to be drawn; Five nurses stated they would make 3 lab requisition slips for weekly labs to be drawn; and one nurse said she would only do one lab requisition slip for that particular week. A review of the policy and procedure from Long Term Solutions (a pharmacist consultant company hired by facility to conduct Medical Record Review (MRR) documents that the consultant pharmacist performs comprehensive MRR ' s monthly that includes but is not limited to reviewing and or evaluating the laboratory results, diagnostic studies or other medication therapy measurements obtained by staff/physician, monitoring of residents for adverse consequences when there is an addition or deletion of a medication or change in dose. The prescriber and/or medical director is notified if needed of any irregularities. The pharmacist was interviewed on [DATE] at 9:30 a.m. concerning monthly pharmacy reviews for this resident which she completed on [DATE], and [DATE] and documented no irregularities and PT/INR monitored. She states her review includes a review of medications the resident is receiving, physician orders [REDACTED]. The pharmacist returned for an interview at 7:30 pm and stated that she was aware of the physician order [REDACTED]. The attending physician was interviewed at 10:02 am on [DATE] who stated that he was aware that the resident had a high INR reading in February that is why he wrote an order for [REDACTED]. He then stated that he must have told the nurses verbally to get a stat order for INR. The Medical Director was interviewed at 10:10 am on [DATE] and asked what type of policy and procedure he had in place for resident ' s that receive [MEDICATION NAME] therapy. He states that each physician, physician assistant and nurse practitioner are given a lap top which has the medical policy and procedures with clinical protocols and medical procedures for anticoagulation therapy. He further states that whatever happens in a month with the resident should be included in the monthly progress note and that includes review of all labs. 415.12

Based on medical record review and staff interviews, the facility failed to adequately monitor and assess residents on Anticoagulant Therapy/[MEDICATION NAME] (a blood thinner) failed to complete critical laboratory tests used to monitor its effectiveness. Specifically, a physician order [REDACTED]. This resulted in actual harm to Resident #1 that is Immediate Jeopardy and the potential for serious harm to resident health and safety for 32 residents receiving [MEDICATION NAME] therapy. Complaint ID Number: NY 443 The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) (resident assessment tool) of [DATE] assessed the resident as being oriented to year, month, and day, usually makes self understood, and sometimes understands others. Resident ' s medical record states that resident was transferred to the emergency room ( ER) on [DATE] at 6:10am for evaluation due to change in mental status and hematuria (blood in the urine). At the ER resident was diagnosed with [REDACTED]. Resident expired at the hospital. On [DATE] a Medical Note entered by nurse practitioner (NP) documented the residents [DATE] PT as 49.9 (normal limit 10XXX,[DATE].9 sec.) and INR 4.56 (normal limit 2XXX,[DATE].00), the NP then ordered [MEDICATION NAME] 7 milligrams (mg.) to be held on [DATE], resume [MEDICATION NAME] at a decreased dose of 6 mg. on [DATE] Then repeat the INR in one week. On [DATE] lab results documented residents PT results were 39.4 High (normal limit 10XXX,[DATE].9 sec) INR of 3.59 High (normal limit 2XXX,[DATE].00). Physician orders [REDACTED]. Review of the physician monthly progress note documentation is as follows: [DATE] by nurse practitioner documents, " [MEDICATION NAME] anticoagulation given for history of [MEDICAL CONDITION] Fibrillation (AFIB), AFIB rate is controlled [MEDICATION NAME] therapy will continue PT/INR monitoring, therapeutic range 2XXX,[DATE].0. [MEDICAL CONDITION] in [DATE], [MEDICATION NAME] therapy continues for [MEDICATION NAME]. " [DATE] by resident 's attending physician documents, " resident was on [MEDICATION NAME], AFIB rate is controlled [MEDICATION NAME] therapy will continue PT/INR monitoring, [MEDICAL CONDITION] history of recent [MEDICAL CONDITION] in [DATE], [MEDICATION NAME] therapy continues for [MEDICATION NAME]. " [DATE] by resident's physician assistant documents, " [MEDICATION NAME] anticoagulation given for history of AFIB. AFIB rate is controlled. [MEDICATION NAME] therapy will continued PT/INR monitoring. therapeutic range 2XXX,[DATE].0. [MEDICAL CONDITION] history of recent [MEDICAL CONDITION], [MEDICATION NAME] therapy continues for [MEDICATION NAME]. " [DATE] by resident ' s attending physician documents, " resident was on [MEDICATION NAME], AFIB rate is controlled [MEDICATION NAME] therapy will continue PT/INR monitoring, [MEDICAL CONDITION] history of recent [MEDICAL CONDITION] in [DATE], [MEDICATION NAME] therapy continues for [MEDICATION NAME]. " [DATE] by nurse practitioner documents, " AFIB rate is controlled [MEDICATION NAME] therapy will continue PT/INR monitoring, therapeutic range 2XXX,[DATE].0, [MEDICAL CONDITION] history of recent [MEDICAL CONDITION] in [DATE], [MEDICATION NAME] therapy continues for [MEDICATION NAME] " . A review of the February, March, and [DATE] treatment record ( a log which nurses sign when treatment is completed) did not include documentation for the completion for the weekly (Monday) laboratory work for the PT/INR labs that were ordered by physician on [DATE]/2011, [DATE], and [DATE]. A review of the unit lab book did not include documentation that requisitions for the weekly PT/INR labs had been completed by nursing staff from [DATE] through [DATE]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] at 3:41 pm a medical progress note by NP#1 documents that staff reported a temperature of 100.1, and painless hematuria ( blood in the urine). The NP physical exam documents, " resident was moving all extremities, had several bruises to left posterior elbow, lower arm and upper arm, lethargic, but responsive, speech clear. INR 7.03 High, Anemic, encourage fluids, continue to monitor, [MEDICATION NAME] discontinued. " The [DATE] progress note by the on call physician documents, " Licensed practical nurse called to inform me that resident presented with an episode of painless hematuria. Noted resident is receiving [MEDICATION NAME] for history of [MEDICAL CONDITION]. Ordered to hold [MEDICATION NAME]. Check PT/INR, complete blood count tomorrow, vital signs with parameters every 4 hours. " Review of the policy and procedures used by physicians, physician assistants and nurse practitioners documents the recommended frequency of testing when initiating or altering [MEDICATION NAME] therapy is to be followed: PT/INR results should be maintained in a flow sheet to assist the prescriber in following results and effect of dosage changes more easily. It further states that residents who are stable on [MEDICATION NAME] should have weekly INR. Those residents whose INR ' s are fluctuating should have bi-weekly tests. On [DATE] a review of residents flow sheet did not have documentation of the physician ordered weekly (Monday) laboratory work for 9 weeks between the dates [DATE] and [DATE]. The Nurse Practitioner stated in interview on [DATE] at 2:00pm that she reviews and acknowledges consults, labs, and other reports to do a monthly progress note. When asked how she would check to see that a lab was completed she states that she checks the " Bio Reference Reports " , but she would not be able to see if a lab was ordered here they only have completed lab reports. She states she does not utilize a flow sheet to monitor the results. When she was asked about residents PT/INR she stated that for [MEDICAL CONDITION] a resident should have routine weekly monitoring, and she follows the geriatric guidelines for AFIB and [MEDICAL CONDITION] from her policy and procedure which is in her lap top computer. She stated that resident#1 has had steady results with no fluctuation up or down and only remembers one high INR reading of 49.9 on [DATE]. She stated she held the [MEDICATION NAME] for 2 days and decreased her dose from 7 mg. to 6 mg. daily, but did not remember seeing a lab after that. She stated she must not have reviewed the PT/INR results if they are not done, and admitted to documenting to continue to monitor and ordering weekly PT/INR labs to be conducted on Mondays. The Physician Assistant was interviewed at 2:42pm on [DATE] who stated that she saw the resident in [DATE] and completed the [DATE] monthly progress note because the Nurse Practitioner was away on vacation. She further stated that if she did not list the lab in the monthly progress note she did not review it. She further stated that she personally makes a mental note and knows when her patients are to be checked because everyone is done on Mondays, then she will check the results in the " Bio Reference " lab reports. The attending physician was interviewed at 10:02 am on [DATE] who stated that he was aware that the resident had a high INR reading in February that is why he wrote an order for [REDACTED]. He then stated that he must have told the nurses verbally to get a stat order for INR. The Medical Director was interviewed at 10:10 am on [DATE] and asked what type of policy and procedure he had in place for resident ' s that receive [MEDICATION NAME] therapy. He states that each physician, physician assistant and nurse practitioner are given a lap top which has the medical policy and procedures with clinical protocols and medical procedures for anticoagulation therapy. He further states that whatever happens in a month with the resident should be included in the monthly progress note and that includes review of all labs. 415.15(b)(2)(ii)

Based on medical record review and staff interviews, the facility failed to adequately review and/or revise the drug regime of resident completed by the pharmacist. Specifically, the consultant pharmacist failed to detect during comprehensive monthly medication regime reviews (MMR) that physician ordered weekly critical laboratory tests for resident #1 on daily Coumadin (a blood thinner) were not completed from [DATE] through [DATE] in order to ensure therapeutic levels of the medication were maintained while receiving Coumadin medication. Resident #1 was hospitalized on [DATE] for change in mental status and hematuria and expired at the hospital. This resulted in actual harm to Resident #1 that is Immediate Jeopardy and the potential for serious harm to resident health and safety for 32 residents receiving Coumadin therapy. The findings are: Complaint Intake #NY 3 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) (resident assessment tool) of [DATE] assessed the resident as being oriented to year, month, and day, usually makes self understood, and sometimes understands others. Resident ' s medical record states that resident was transferred to the emergency room ( ER) on [DATE] at 6:10am for evaluation due to change in mental status and hematuria (blood in the urine). At the ER resident was diagnosed with [REDACTED]. Resident expired at the hospital. A [DATE] Medical Note entered by nurse practitioner (NP) documented the residents [DATE] PT as 49.9 (10XXX,[DATE].9 sec. normal limit and INR 4.56 (2XXX,[DATE].00 normal limit ), the NP then ordered residents Coumadin 7 milligrams (mg.) to be held on [DATE] and resume at a decreased dose of Coumadin 6 mg. on [DATE]. Repeat the INR in one week. The [DATE], [DATE], and [DATE] Physician order [REDACTED]. by mouth daily, and PT/INR lab was ordered to be done weekly on Mondays. A laboratory report dated [DATE] documented residents PT results were 39.4 (high) and INR of 3.59 (high). The medical record review on [DATE] and [DATE] revealed that there were no further (PT/INR) lab reports documented in the resident's record from [DATE] through [DATE] (9 missed weeks). A review of the monthly MRR written by the pharmacist consultant on [DATE] documented, " no irregularities " . Then again on [DATE] the MRR by same consultant documented, " no irregularities, consultant pharmacist plan of care, PT/INR monitored with Coumadin usage " . The pharmacy review did not include specific information regarding the change in resident dosage of Coumadin or the PT/INR results for resident #1. On [DATE] a review of the policy and procedure (not dated) from Long Term Solutions (a pharmacist consultant company hired by facility to conduct MRR) documented that the consultant pharmacist performs comprehensive MRR ' s monthly. The comprehensive MRR includes: - Evaluating resident ' s response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication. - Reviewing and or evaluating the laboratory results, diagnostic studies or other medication therapy measurements obtained by staff/physician. - Monitor for adverse consequences when there is an addition or deletion of a medication or change in dose. - Notifying the prescriber and or medical director if needed, of any irregularities. The pharmacist was interviewed on [DATE] at 9:30 a.m. concerning monthly pharmacy reviews conducted for resident #1 on [DATE], and [DATE]. Both reviews documented " no irregularities and PT/INR monitored " . The pharmacist stated that when conducting a pharmacy review all the medications the resident is receiving are looked at as well as physician orders [REDACTED]. The pharmacist stated that she is aware of the policy and procedure for reviewing labs and medication changes and the day that she reviewed the chart she did not believe there was a problem. She stated she recalled the irregularities with the February findings but thought that monitoring was in place. She states any irregularities are documented in the monthly report and are placed in the chart for physician review, but if she had noted that they were not there she would have spoke to the nurse or physician herself. At 7:30 pm the pharmacist retuned for an interview and stated she was aware of the physician order [REDACTED]. In an interview with resident #1 attending physician on [DATE]@ 10:00 am he stated that he did not receive notice from the pharmacist that the labs for resident had not been completed. In a meeting at 10:30 am on [DATE] with the Administrator, Director of Nursing and the Medical Director (via telephone) all stated that they had not received any notice from the pharmacist consultant that there were irregularities or missed PT/INR labs for resident #1. 415.18(c)(2)