Every finding on record at Fiddlers Green Manor Rehab and Nursing Center

Based on observation, interview, and record review completed during the survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food safety for one (1) of one (1) kitchen. Specifically, on multiple observations, the kitchen ceiling had an active leak along the exhaust hood, onto the front of the stove top, behind the stove, and to the right of the stove, onto the floor. The entire kitchen ceiling was in disrepair, sagging in multiple places, had mixed textures and materials covering the surface, with visible stains and food splatter. The kitchen walls had visible water damage and multiple textures of plaster. Additionally, there were multiple observations of an active leak into an open container under the three (3) bay sink. The findings are:The policy titled Kitchen Operations Sanitization dated October 2008, documented the food service area shall be maintained in a clean and sanitary manner. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.The policy titled Physical Environment, Work Orders, Maintenance, dated April 2010, documented in order to establish a priority of maintenance service, work orders must be filled out and forwarded to the Maintenance Director.During an observation and interview in the kitchen, on 01/27/2026 at 10:25 AM, there was an area of visible water damage on the plaster ceiling approximately three (3) feet in diameter, left of center, as viewed upon entering the room. There was also a ceiling patch made of wood paneling approximately 18 inches by 24 inches to the left of the exhaust hood. There were ceiling patch panels along the front of the exhaust hood that were sagging and ceiling patch panels to the right of the exhaust hood that were sagging. In the kitchen's left ceiling corner, there was an area of water damage that was sagging on the plaster ceiling, approximately one (1) foot in diameter. The plaster archway between the kitchen and the dishwash area had visible water damage on the top and sides, which spanned approximately three (3) feet wide. The Director of Environmental Services stated the ceiling water damage was caused by a previous leak from the shower room above. Continued observation revealed an active leak beneath the three (3) bay sink. The lower half of the wall behind the sink was saturated, and a bin on the floor beneath the sink had collected at least one (1) inch of water. The Director of Environmental Services stated they were aware of the leak and thought they had fixed it the day before.During an interview on 01/27/2026 at 11:46 AM, [NAME] #1 stated they worked in the facility for over 30 years and through that time the ceiling in the kitchen had leaked several times. They stated the most recent leak happened approximately two (2) weeks ago. [NAME] #1 stated if they saw the leak they would call maintenance and they would come fix it. They stated it was not sanitary to have a leaking ceiling in the kitchen. [NAME] #1 stated the container under the sink needed to be emptied daily; they were unsure how long that had been going on.During an interview on 01/28/2026 at 2:34 PM, the Food Service Director stated the last time there was a visible water leak was about a week and a half ago. They stated they did not know exactly what caused the leak but had heard it might be from the shower room above or possibly from the hood vent outside. Maintenance had repaired the ceiling, but they did not know of a plan to replace the ceiling. The Food Service Director stated they attempted to clean the ceiling a while ago, but they were unable to get it clean. They stated the possibility of shower water leaking into the kitchen was gross, and the multiple surfaces made it impossible to properly clean the ceiling. They stated the water leaking from the sink was continuous, they had to empty the container about every other day. They stated having a bucket of standing water in the kitchen was not sanitary and could be an infection control risk.During an observation and interview in the kitchen on 01/29/2026 at 11:58 AM, there was visible water dripping along the outside front, back and sides of the exhaust hood. There were three (3) visible dripping water marks on the front of the hood stretching from the top to the bottom edge. The drip on the front was landing in a metal pan, on the front burner of the stove, with a white towel placed inside. The back drip was creating a puddle on the floor towards the left of the stove; the right-side drip was creating a large puddle on the floor where a towel had been placed. The Food Service Director stated they had never seen it drip that much, that fast. They left to find the Director of Environmental Services.During an observation and interview in the kitchen on 01/29/2026 at 12:07 PM, the Director of Environmental Services observed the active leak. They stated they had never seen it leak that actively before. They stated it was not appropriate to have an active leak in the kitchen, and they would immediately go upstairs to try and find the source.During an interview on 01/29/2026 at 2:45 PM, the Director of Environmental Services stated approximately two (2) to three (3) months ago, they valved off stall #2 in the first-floor shower room, which had leaked into the kitchen below and that remained out of service. It then leaked again into the kitchen about 2 weeks ago. They stated when they saw the leak in the kitchen this afternoon, they were unable to locate the source of the leak.During an observation and interview in the kitchen on 01/30/2026 at 8:50 AM, there was an active drip to the right side of the exhaust hood. The Food Service Director stated it had dripped on and off throughout the morning, causing a puddle that was collected in a towel.During an observation and interview in the kitchen on 01/30/2026 at 9:51 AM, the Administrator stated they were aware there was a leak in the kitchen but did not know it was actively leaking. They observed the dripping from the hood and the water marks along the outside of the hood. They did not know how long it had been going on. They heard maintenance was looking at the shower room above, as the cause. They stated it was gross if shower water was leaking into the kitchen. They were unable to say whether the ceiling could be properly sanitized, but there was definitely work to be done on the ceiling in the kitchen.During an observation and interview on 02/02/2026 8:21 AM, there was an active drip from the right side of the exhaust hood, dripping onto a towel on the floor, and a slower drip to the left/back side of the hood. [NAME] #1 stated the water had been dripping since they got there that day.During an interview on 02/02/2026 at 10:03 AM, Registered Nurse #1, the Infection Preventionist, stated it was unsanitary to have a leak in the kitchen, especially if it was coming from a shower room. They stated the multi-textured, patched ceiling would be difficult to properly sanitize.During an interview on 02/02/2026 at 10:44 AM, the Director of Environmental Services stated they did not have a log for when the kitchen had a leak. Kitchen staff verbally called them when there was an issue. They stated the facility needed to call a plumber to figure out where the water was coming from.During an interview on 02/02/2026 at 10:54 AM, the Administrator stated there should have been a logbook of the maintenance issues in the kitchen. They stated they planned to bring in a plumber to find out what the issue was and fix it.10 NYCRR 415.14 (h)

Based on interview and record review the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility had no evidence that verified six (6) (Certified Nurse Aide #1, Certified Nurse Aide #2, Licensed Practical Nurse #1, Dietary Aide #1, Administration/ Receptionist #1, and Nurse Aide Trainee/ Unit Helper #1) of eight (8) employees reviewed that worked in the facility and were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their first date worked at the facility.The findings are: The policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised November 2025, documented the resident abuse, neglect and exploitation prevention program consisted of a facility-wide commitment and resource allocation to support its objectives. The objectives included developing and implementing policies and protocols to prevent and identify abuse or mistreatment of residents, neglect of residents, and/ or theft, exploitation, or misappropriation of resident property. The facility will conduct employee background checks and not knowingly employ or otherwise engage any individual who has had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. The policy and procedure titled Background Screening Investigations, revised November 2015, documented for any individual applying for a position as a Certified Nursing Assistant, the state nurse aide registry will be contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/ or theft of property have been entered into the applicant's file. For any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board will be contacted to determine if any sanctions have been assessed against the applicant's license. 1a. Review of Certified Nurse Aide #1's personnel file revealed it contained no documented evidence that a New York State Nurse Aide Registry check was completed for Certified Nurse Aide #1, who worked at the facility from 01/08/2025 to 01/22/2025 and 04/24/2025 to 5/16/2025. 1b. Review of Certified Nurse Aide #2's personnel file on 01/29/2026 revealed it contained a New York State Nurse Aide Registry verification sheet that was dated 01/28/2026. Certified Nurse Aide #1 was a current Certified Nurse Aide at the facility who started employment on 11/04/2025. 1c. Review of Licensed Practical Nurse #1's personnel file on 01/29/2026 revealed it contained a New York State Nurse Aide Registry verification sheet that was dated 01/28/2026. Licensed Practical Nurse #1 was a current Licensed Practical Nurse at the facility who started employment on 12/02/2025. 1d. Review of Dietary Aide #1's personnel file revealed it contained no documentation that a New York State Nurse Aide Registry check was performed for Dietary Aide #1, who currently worked at the facility and started employment on 09/30/2025. 1e. Review of Administration/ Receptionist #1's personnel file 01/29/2026 revealed it contained a New York State Nurse Aide Registry verification sheet that was dated 01/28/2026. Administration/ Receptionist #1 worked at this facility from 10/29/2025 to 01/23/2026. 1f. Review of Nurse Aide Trainee/ Unit Helper #1's personnel file revealed it contained no documented evidence that a New York State Nurse Aide Registry check was completed for Nurse Aide Trainee/ Unit Helper #1, who worked at this facility from 01/29/2025 to 03/07/2025. During an interview on 01/29/2026 at 9:24 AM, the Staffing and Payroll Coordinator stated they had been the Staffing and Payroll Coordinator at this facility since March 2025. They stated their procedure included checking the Nurse Aide Registry for each new hire and placing the verification sheet in the personnel file. They stated they performed an audit a few months ago to ensure Nurse Aide Registry check verification sheets were in all personnel files. During the audit, they found a few were missing and made corrections at that time. The Staffing and Payroll Coordinator also stated on 01/28/2026, they pulled all personnel files from staff hired in the last four (4) months to prepare for the survey and to make sure everything was in order. They stated they noticed a few more Nurse Aide Registry check verification sheets were missing and made corrections at that time. During an interview on 01/29/2026 at 1:35 PM, the Director of Nursing stated a check of the Nurse Aide Registry was a part of the facility's background check process that should occur upon hire. During an interview on 01/30/2026 at 12:10 PM, the Administrator stated the Staffing and Payroll Coordinator was responsible to look up all new hires in the New York State Nurse Aide Registry and print the result sheet. The Administrator stated this was done for all new employees upon hire. The Administrator also stated they had completed spot checks of personnel files for Nurse Aide Registry verification sheets, and they found no issues during their spot checks. 10 NYCRR 415.4(b)(1)(ii)(a)(b)

Based on observation, interview, and record review conducted during the survey, the facility did not ensure residents have the right to personal privacy including accommodations for one (1) (Resident #3) of one (1) resident reviewed. Specifically, a privacy curtain in the resident's room did not fully enclose Resident #3's bed. The finding is:The policy titled Resident Rights Guidelines for Nursing Procedures dated October 2010 documented prior to having direct care responsibilities for residents, staff must have appropriate in-service training on resident rights including resident dignity and respect.The policy titled Bedrooms dated May 2017 documented each room was designed to provide full visual privacy for each resident (in the form of ceiling-suspended curtains that extend around the bed) and equipped for adequate nursing care.Resident #3 had diagnoses which included depression, anxiety, and fracture of the left lower leg. The Minimum Data Set (a resident assessment tool) dated 01/03/2026 documented the resident was understood, understands and was cognitively intact.Review of comprehensive care plan revised on 12/30/2026 documented Resident #3 had an activity of daily living self-care performance deficit related to weakness. Interventions included toilet use: total assistance with bedpan and ostomy (artificial connection of the bowel to the skin surface) care.Review of the maintenance logbook located at the nurses' station on 02/02/2026 at 9:10 AM revealed between 12/16/2025 through 02/02/2026 there was no documented evidence that staff notified maintenance of the privacy curtain not going around Resident #3's bed.During an interview on 01/27/2026 at 1:10 PM, Resident #3 stated they felt they did not have any privacy in their room because their roommate would get up and use the bathroom frequently. They stated their roommate would also look around the curtain whenever the nurse was changing their ostomy (artificial connection of the bowel to the skin surface).During an observation and interview on 01/29/2026 at 8:43 AM, Resident #3 was lying in bed. The bathroom door was located near the head of their bed with the privacy curatin between Resident #3's bed and the door. The privacy curtain wrapped approximately halfway around the bed when it was fully pulled closed. Resident #3 stated that the staff closed the curtain, but it does not go all the way around their bed. They stated there were times their roommate would walk past their bed, on their way to the bathroom, and then the roommate would look over and be able to see any care that was being provided.During an interview on 01/30/2026 at 1:31 PM, Certified Nurse Aide #4 stated there were curtains on the unit that do not fully go around the bed of the resident. They stated for Resident #3 they pull the curtain around the foot of the bed and that way only the head of the bed would be exposed. They stated they felt they were still providing privacy to Resident #3, but there could be a privacy problem if the roommate got up to use the bathroom because they would be able to look around the curtain by the head of the bed.During an interview on 01/30/2026 at 3:04 PM, Certified Nurse Aide #5 stated some curtains on the unit did not close all the way and they just did not seem long enough. They stated they did not see it as a privacy concern because they would shut the door or close the curtain of the roommate as well. They stated if one of the roommates wanted to leave or enter the room, they would just have to wait a minute or so until they covered up the resident that they were providing care to.During an observation and interview on 02/02/2026 at 08:57 AM, Licensed Practical Nurse #2 pulled the privacy curtain around Resident #3's former bed. There was a gap between the end of the curtain and the wall. Licensed Practical Nurse #2 stated that there appeared to be a four (4) foot gap between the end of the curtain and the wall and it should not have been like that. They stated that there would be a privacy problem. They stated that the curtain not wrapping around the entire bed should have been entered into the maintenance logbook by anyone who had known it was not wrapping around the bed. During an observation and interview on 02/02/2026 at 9:02 AM Registered Nurse #1 Unit Manager stated Resident #3 had moved to a different bed so the staff could keep a better eye on them. They observed Resident #3's prior room and stated there was a large gap between the end of the privacy curtain and the wall of Resident #3's previous bed. They stated there should not have been a gap that large because it could be a dignity or privacy problem for the resident using that bed. They stated if another resident wanted to either enter or leave the room, they would probably have to wait until care was completed on the resident in that bed. They stated that residents should not have to wait to enter or leave their own room. During an interview on 02/02/2026 at 9:30 AM The Director of Environmental Services stated they were responsible for ensuring the privacy curtains went completely around the beds in the resident rooms. They stated the privacy curtain should have completely enveloped the bed because otherwise it would be a dignity concern.During an interview on 02/02/2026 at 9:41 AM The Director of Nursing stated the privacy curtain should have gone all the way around Resident #3's bed. They stated there should not have been any gaps anywhere for privacy reasons. They stated the certified nurse aides who were aware should have reported the concern to maintenance.During an interview on 02/02/2026 at 10:42 AM, the Administrator stated the privacy curtain should have fully enclosed the bed. They stated not all the privacy curtains were the same length and the correct length depended on where the privacy curtain was being hung. They stated they were unsure how the shorter curtain was hung around Resident #6's bed or for how long it was hung there. They stated it was unknown who had taken it down or who hung up the curtain. It could have been someone from housekeeping who was washing the curtain, or it could have been someone in maintenance. They stated ultimately the Director of Environmental Services was responsible for making sure the correct privacy curtains were hung. They stated the certified nurse aides who were aware that the curtain was too short should have made someone aware and it should have been placed in the maintenance logbook.10 NYCRR 415.3(e)

Based on observation, interview, and record review conducted during an Abbreviated Partial Extended survey (Complaint #NY00361768-437980), the facility failed to protect residents from abuse by staff for one (1) (Resident #1) of three (3) residents reviewed for abuse. Specifically, on 11/12/2024 Certified Nurse Aide #5 shared with co-workers, a live photograph (feature on a cell phone that captures a 1.5 to 3 second video with sound that allows a photo to come to life) that was taken on their personal cellphone, of Resident #1 during incontinence care with their buttocks exposed, and without the resident's consent. Using the reasonable person concept, as referenced on the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity guide, it was determined psychosocial harm occurred for Resident #1 that is not -immediate Jeopardy. The finding is: The policy and procedure titled Abuse and Neglect - Clinical Protocol dated 03/2018, documented instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled using technology. The policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 04/2021 documented residents have the right to be free from abuse. This includes but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Establish and maintain a culture of compassion and care for all residents and particularly those with behavioral, cognitive or emotional problems; investigate and report any allegations within timeframes required by federal requirements. Resident #1 had diagnoses including dementia (progressive or persistent loss of intellectual functioning), major depression disorder (condition characterized by persistent feelings of sadness, hopelessness, and loss of interest), and anxiety disorder (mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). The Minimum Data Set (a resident assessment tool) dated 11/06/2024 documented Resident #1 was always understood, usually understands others and was severely cognitively impaired. The Comprehensive Care Plan, revised on 05/17/2021 documented Resident #1 had a mood problem related to diagnosis of bipolar disorder and a history of traumatic events of abuse when they were younger. Documented interventions included to approach in a cheerful manner, monitor, record, report to medical director as needed for mood patterns signs/symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Additionally, it documented Resident #1 had diagnosis of anxiety, had periods of anxiousness, and weepiness. History of accusatory behavior. History of repetitive statement regarding their past. Documented interventions included to attempt to determine triggers that caused behavior. The facility Investigation Summary dated 11/25/2024 documented Resident #1 was found to be grossly incontinent; Certified Nurse Aide #2 went to provide care and became overwhelmed by odor and asked that Certified Nurse Aide #1 assist them. Certified Nurse Aide #2 began to cough and gag in Resident #1's room while Certified Nurse Aide #1 was attempting to assist. Resident #1 was standing with their walker while Certified Nurse Aide #1 was attempting to assist with cleaning Resident #1. Certified Nurse Aide #1 became overwhelmed by odor and began to gag and began telling Certified Nurse Aide #2 I quit, I quit. Certified Nurse Aide #5 whom was down the hallway heard Certified Nurse Aide #1 and went to the room. When Certified Nurse Aide #5 arrived at the room, they observed Certified Nurse Aide #1 and Certified Nurse Aide #2 gagging and laughing at each other while attempting to provide care and took a video/photograph (live photo) of the incident as they thought the staff's reactions were funny. This incident occurred the end of August or the beginning of September 2024. Certified Nurse Aide #5 on 11/12/2024 showed the video/photograph (live photo) to multiple staff, laughing at Certified Nurse Aide #1's reaction. While interviewing staff about the video/photograph (live photo), staff report observing a video which showed Resident #1 unclothed from the waist down, however, did not show Resident #1's face, yet they were certain it was Resident #1. Multiple staff reported the Assistant Director of Nursing was present, so they did not report the incident because they were aware of supervisor knowledge. During an interview on 11/06/2025 at 10:53 AM, Certified Nurse Aide #1 stated they recalled that they were assisting Certified Nurse Aide #2 with Resident #1's care and there was a strong odor in the room because Resident #1 had had a bowel movement. Certified Nurse Aide #1 stated it was overwhelming and there was feces all over Resident #1's buttocks and clothes. They remembered that Certified Nurse Aide #2 began gagging and they placed a clean gown around their face to cover their nose to block the smell. They stated that Certified Nurse Aide #5 had knocked on the door and came in when they heard everyone in the room and that must have been when they took the live photograph. Certified Nurse Aide #1 stated they were not aware that Certified Nurse Aide #5 had taken the live photograph on that day. They stated they found out about the live photograph a lot later but when they saw it, they did not see Resident #1 in the background, they only saw themselves. Certified Nurse Aide #1 stated if Resident #1 was alert and oriented and had found out about the live photograph, they would have felt exposed and could have felt degraded. During an interview on 11/06/2025 at 11:04 AM, Certified Nurse Aide #2 stated they recalled an incident when they were assisting Certified Nurse Aide #1 with providing incontinence care to Resident #1. The smell of the bowel movement was horrible, it caused them to gag. They remembered Certified Nurse Aide #5 knocking on the door and coming in the room with their phone in their hand, but they were unaware that they had taken any video or photograph. They stated just having the cell phone in their hand while in a resident care area was a dignity concern and could lead to a Health Insurance Portability and Accountability Act (HIPAA) violation. Certified Nurse Aide #2 stated they had not seen the video or photograph. They stated if Resident #1 was alert, oriented and had known that a photograph was taken with their buttocks exposed, they would not be very happy and that could be a form of mental abuse. During a telephone interview on 11/06/2025 at 12:44 PM, Licensed Practical Nurse #2 stated in November of 2024 (could not recall exact date) they were standing on the porch of the facility with the Assistant Director of Nursing when Certified Nurse Aide #5 was sharing the live photograph with other staff members. They stated they could not recall everyone that was there, but everyone was talking and laughing. Licensed Practical Nurse #2 stated that Certified Nurse Aide #3 was standing next to them and that Certified Nurse Aide #5 was showing them a live photograph on their phone. Licensed Practical Nurse #2 said when they looked over, they saw Certified Nurse Aide #1 in a resident's room. In the photo Resident #1 was in the background and their buttocks was visible. They stated taking photographs of residents was a form of abuse and would have been very embarrassing for Resident #1. During a telephone interview on 11/06/2025 at 1:00 PM, Resident #1's Responsible Party stated when they received the telephone call from the facility about the incident, they were told that an individual at the facility had taken a video of Resident #1 after Resident #1 had a bowel movement. They stated when Resident #1 was younger, they had experienced similar trauma. If Resident #1 knew about that video, they would have felt embarrassed, upset, degraded and may have relived some of their past trauma. During an interview on 11/06/2025 at 2:37 PM, Certified Nurse Aide #3 stated in November of 2024 (could not recall exact date) they saw a video on Certified Nurse Aide #5's cellphone that showed Certified Nurse Aide #1 and Certified Nurse Aide #2 in Resident #1's room gagging. They stated in the background they could clearly see Resident #1 standing in the bathroom with feces on their buttocks and legs. They stated Certified Nurse Aide #5 kept showing it to staff members who were standing on the porch of the facility at the change of shift. They stated the staff who were on the porch included Certified Nurse Aide #1, Certified Nurse Aide #4, Certified Nurse Aide #7, Licensed Practical Nurse #2, and the Assistant Director of Nursing. Certified Nurse Aide #3 stated it was violation of Resident #1's rights and humiliating for them. During an observation and interview on 11/06/2025 at 2:47 PM, Resident #1 was lying in bed with a blanket pulled up to their face. The resident was noted to be very confused but stated that staff at the facility were friendly. Resident #1 was not able to recall if anyone had taken their photo but stated they would never want a picture taken of them. It would make them feel bad because they have a very big nose. During a telephone interview on 11/06/2025 at 3:24 PM, Certified Nurse Aide #5 stated they had taken a live photograph of Certified Nurse Aide #1 who had a nightgown around their neck. They stated they had thought it was a funny picture and there were no residents in the background. They stated they never should have taken the photograph. During a telephone interview on 11/06/2025 at 3:29 PM, the Assistant Director of Nursing (no longer employed at the facility) denied seeing or having any knowledge of a live photograph/video on Certified Nurse Aide #5's cellphone. During a telephone interview on 11/07/2025 at 8:43 AM, Certified Nurse Aide #4 stated they recalled seeing a live photograph on Certified Nurse Aide #5's cellphone. Certified Nurse Aide #4 stated in the photo they saw two (2) certified nurse aides and Resident #1. Resident #1 was turned around and their bare buttocks was visible. They stated this incident was a violation of Resident #1's privacy and was considered mental abuse. During an interview on 11/07/2025 at 9:15 AM, Resident #2 stated they were aware of the incident that had occurred last year. They were told by staff members that a photograph was taken of a resident who was very confused during incontinence care. They stated since then, they have noticed that there was a lot less cellphone usage by staff at the facility. Resident #2 stated if that was them in the photograph, they would have felt humiliated. During a telephone interview on 11/07/2025 at 9:54 AM, Nurse Practitioner #1 stated they were familiar with Resident #1. They stated the incident that had occurred with the live photograph was a violation of privacy and since Resident #1 had a history of abuse in their past, it could result in psychosocial harm. A telephone interview was attempted with Certified Nurse Aide #7 on 11/07/2025 at 11:30 AM without success. During a telephone interview on 11/07/2025 at 12:11 PM, the Medical Director stated they were made aware of the incident. They stated Resident #1 was incontinent and two (2) certified nurse aides were trying to clean them up. The Medical Director stated the staff were being very dramatic about providing care to Resident #1, another certified nurse aide had gone into the room and started to record the care. The Medical Director stated, Talk about a Health Insurance Portability and Accountability Act (HIPAA) violation!, the whole situation should have never happened. They stated they were made aware that Resident #1's buttocks was visible which was a dignity concern for them. During an interview on 11/10/2025 at 8:47 AM, the Director of Nursing stated they first heard about the incident on Monday, 11/25/2024 when they were talking with the Administrator. An investigation was started immediately. The Director of Nursing stated what Certified Nurse Aide #5 had done was wrong and the investigation showed that abuse had occurred. During an interview on 11/10/2025 at 9:19 AM, the Administrator stated on 11/25/2024, Certified Nurse Aide #3 reported to them that Certified Nurse Aide #5 had taken a live photograph of Certified Nurse Aides #1 and # 2 providing incontinence care to Resident #1. Through their investigation they had determined the resident's exposed buttocks was visible, and that abuse had occurred. During a telephone interview on 11/10/2025 at 2:59 PM, the Director of Quality Assurance stated it was their expectation to never see any staff members on their cellphones in resident care areas. They stated the incident that occurred with Resident #1 was an invasion of privacy and a form of abuse. Based on observation, interview and record review it was determined upon notification of alleged abuse the facility implemented corrective actions to correct the non-compliance as of 11/26/2024 and were as follows: Resident #1 was assessed by nursing staff and social work. Resident #1 was evaluated by the physician. Resident #1 was monitored for any ill effects. Family and police notifications were made. Social Worker #1 interviewed additional residents regarding staff cell phone use and abuse. Staff suspensions pending investigation and education. Certified Nurse Aide #5 was terminated and is no longer employed at the facility. Upon notification the facility immediately initiated training and education to all staff which included abuse, abuse reporting, and the cell phone/social media policy. Additional education was provided on the chain of command, and the location of the corporate compliance number if reporters were uncomfortable with the staff at the facility. Abuse investigation education was made bi-annual. A Quality Assurance Performance Improvement meeting was held 11/26/2024 with all department heads and the Medical Director. The policies for abuse and social media were reviewed at the meeting. The Unit Manager and Assistant Director of Nursing are responsible for being on the units and monitoring cell phone usage. Abuse, neglect, misappropriation, exploitation was reviewed at the next Resident Council meeting. The grievance process was reviewed. Facility conducted audits of their incidents for abuse and potential reportable incidents to ensure there were no further non-compliance issues identified. 10 NYCRR 415.4(b)(1)(i)

Based on interview and record review conducted during an Abbreviated Partial Extended survey (Complaint #NY00361768-437980) the facility did not ensure that all alleged violations involving abuse and mistreatment are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse, to other officials (including the State Survey Agency) for one (1) (Resident #1) of three (3) residents reviewed. Specifically, allegations of resident abuse identified by multiple staff members on 11/12/2024 was not reported to the Administrator until 11/25/2024. The allegation was not reported to the New York State Department of Health within two (2) hours which resulted in psychosocial harm for Resident #1, with the potential to affect all residents in the facility, that was substandard quality of care to resident health and safety that is not Immediate Jeopardy. The finding is: Refer to the additional Statement of Deficiencies (CMS Form-2567) for F 600 Freedom from Abuse and Neglect, scope and severity G. The policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 04/2021 documented all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. If resident abuse, neglect, exploitation is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports their suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying. Immediately is defined as within two (2) hours of an allegation involving abuse. Review of the Internet Quality Improvement and Evaluation System (iQIES) Report: Complaint/Incident/Investigation Report received on 11/25/2024 at 1:51 PM documented Certified Nurse Aide #3 reported to the Administrator that a staff member had a video on their phone involving a resident. Certified Nurse Aide #3 reported observing a video that involved two (2) staff members gagging and laughing while providing incontinence care to a resident. The facility Investigation Summary completed by the Director of Nursing, dated 11/25/2024, documented the alleged abuse was discovered on 11/23/2024, the time the Director of Nursing was notified was blank. The facility investigation documented Certified Nurse Aide #5 had taken a video/photograph of Certified Nurse Aide #1 with Resident #1 in the background. Resident #1 was unclothed from the waist down. The video/photograph was taken at the end of August or beginning of September 2024. On 11/12/2024, Certified Nurse Aide #5 had shown the video/photograph to multiple staff members. Multiple staff reported that the Assistant Director of Nursing was present, so they did not report the incident because they were aware of supervisor knowledge. During an interview on 11/06/2025 at 10:53 AM, Certified Nurse Aide #1 stated they were not aware that Certified Nurse Aide #5 had taken the live photograph (feature on a cell phone that captures 1.5 to 3 second video with sound that allows a photo to come to life) and had found out about the photo a lot later. When they saw the photo, they did not see Resident #1 in the background, they only saw themselves. Certified Nurse Aide #1 stated they did not report the picture because they did not see any residents in it. During an interview on 11/06/2025 at 11:04 AM, Certified Nurse Aide #2 stated they recalled Certified Nurse Aide #5 knocking on the door and coming into the room with their phone in their hand, but they were unaware that they had taken any video or photograph. They also stated that had not viewed the live photo. During a telephone interview on 11/06/2025 at 11:12 AM, Licensed Practical Nurse #1 stated Certified Nurse Aide #3 told them they had viewed a photo/video exposing Resident #1's buttocks. Licensed Practical Nurse #1 stated they never saw the video but had told Certified Nurse Aide #3 to report it to the supervisor, Director of Nursing and Administrator immediately. They stated Certified Nurse Aide #3 had expressed to them that they were intimidated by the Assistant Director of Nursing and were afraid of retaliation from them if they reported it. Licensed Practical Nurse #1 stated they did not report what Certified Nurse Aide #3 told them (about the Assistant Director of Nursing) because they did not think the Director of Nursing or Administrator would follow up on the incident. During a telephone interview on 11/06/2025 at 12:44 PM, Licensed Practical Nurse #2 stated in November of 2024 (could not recall exact date) Certified Nurse Aide #5 was showing a live photograph to Certified Nurse Aide #3 on the porch of the facility. Licensed Practical Nurse #2 stated when they looked over, they saw a video of Certified Nurse Aide #1 in a resident room. In the background they could see Resident #1's buttocks. This was bothersome to them, so they turned around and went back into the facility. They stated it was a form of abuse. Licensed Practical Nurse #2 stated that since the Assistant Director of Nursing was standing next to them, they saw the live photograph as well. They stated they thought that the Assistant Director of Nursing would have been responsible to report it to the Director of Nursing and/or the Administrator. During an interview on 11/06/2025 at 2:37 PM, Certified Nurse Aide #3 stated in November of 2024 (could not recall exact date) they saw a video on Certified Nurse Aide #5's cellphone that showed Certified Nurse Aide #1 and Certified Nurse Aide #2 in Resident #1's room gagging. They stated in the background; they could clearly see Resident #1 standing in the bathroom with feces on their buttocks and legs. They stated Certified Nurse Aide #5 kept showing the photo to the staff members on the porch of the facility at change of shift. They stated the staff who were on the porch included Certified Nurse Aide #1, Certified Nurse Aide #4, Certified Nurse Aide #7, Licensed Practical Nurse #2, and the Assistant Director of Nursing. Certified Nurse Aide #3 stated they wanted to report the video to someone but feared retaliation from the Assistant Director of Nursing because they were close with Certified Nurse Aide #5. They stated the video had bothered them, so they spoke to Licensed Practical Nurse #1 and Registered Nurse #1 about the situation one (1) or two (2) days before contacting the Administrator on 11/23/2024. During a telephone interview on 11/06/2025 at 3:09 PM, Registered Nurse #1 stated Certified Nurse Aide #3 had described the photo/video they had seen and stated they felt it was inappropriate. Registered Nurse #1 stated that Certified Nurse Aide #3 had explained how they were intimidated by the Assistant Director of Nursing and were afraid of reporting the photo/video to the Director of Nursing. Registered Nurse #1 stated they had given Certified Nurse Aide #3 the Administrator's cellphone number and told them to report it immediately. Registered Nurse #1 stated they did not feel they should have reported it to the Administrator because they never saw the photo/video (live photo). During a telephone interview on 11/06/2025 at 3:24 PM, Certified Nurse Aide #5 stated they had taken a live photograph of Certified Nurse Aide #1 who had a nightgown around their neck. They stated they had thought it was a funny picture and there were no residents in the background. They stated they never should have taken the photograph. During a telephone interview on 11/06/2025 at 3:29 PM, the Assistant Director of Nursing (no longer employed at the facility) denied seeing or having any knowledge of a live photograph on Certified Nurse Aide #5's cellphone involving Resident #1. During a telephone interview on 11/07/2025 at 8:43 AM, Certified Nurse Aide #4 stated they had remembered seeing the live photograph on Certified Nurse Aide #5's cellphone. They stated they were able to see Resident #1's bare buttocks. Certified Nurse Aide #4 stated they did not report the video because Certified Nurse Aide #5 was related to the Assistant Director of Nursing and were afraid that the Assistant Director of Nursing would have had them fired. A telephone interview was attempted with Certified Nurse Aide #7 on 11/07/2025 at 11:30 AM without success. During an interview on 11/10/2025 at 8:47 AM, the Director of Nursing stated they first heard about the incident on Monday, 11/25/2024 when they were talking with the Administrator and immediately started interviewing staff regarding the incident. They stated they had reached out to both the Director of Strategic Planning and Development and the Director of Quality Assurance to review the incident. The live photograph should not have been taken and when the staff were shown the live photograph, it should have been reported to the Director of Nursing and/or the Administrator immediately. During an interview on 11/10/2025 at 9:19 AM, the Administrator stated they had received a text message from Certified Nurse Aide #3 on 11/23/2024. The text was not detailed but just stated to call them. They played phone tag for a bit after that and when Certified Nurse Aide #3 had talked to them it sounded like they had seen a video of staff members acting unprofessionally. The Administrator stated they were under the impression that they had a problem that was meant for Human Resources to handle and that there was no resident involvement. During further interview with the Administrator on 11/10/2025 at 12:57 PM, they stated they had interviewed Certified Nurse Aide #3 on 11/25/2024 at 10:00 AM. As soon as they interviewed Certified Nurse Aide #3, they knew right away that there was a potential for abuse and the incident needed to be reported to the New York State Department of Health. During a telephone interview on 11/10/2025 at 2:59 PM, the Director of Quality Assurance stated the incident that occurred with Resident #1 was an invasion of privacy and a form of abuse. It should have been reported immediately by the staff who had seen the live photograph, and the Director of Nursing or Administrator should have reported it to the New York State Department of Health within two (2) hours to ensure a timely follow through and investigation. The Director of Quality Assurance stated if the Administrator was aware there was a potential for abuse once they interviewed the witness on 11/25/2024 at 10:00 AM, then the incident should have been reported prior to 1:51 PM on that day. Based on observations, interviews and record review it was determined upon notification of alleged abuse the facility implemented corrective actions to correct the non-compliance as of 11/26/2024 as follows: Certified Nurse Aide #1, Certified Nurse Aide #5 and the Assistant Director of Nursing were suspended pending an investigation. Certified Nurse Aides #2, #4 and #7 were out on leave of absence. Upon notification, the facility immediately initiated training and education to all staff that included abuse, abuse reporting, and the cell phone/social media policy. Additional education was provided on chain of command and location of the corporate compliance number, if they were uncomfortable with the staff at the facility. Abuse investigation education was made bi-annual. The Administrator and Director of Nursing were provided with education by the Director of Quality Assurance on 11/26/2024 regarding reporting abuse, investigation, retaliation and reporting. A Quality Assurance Performance Improvement meeting was held 11/26/2024 with all department heads and the Medical Director. The policies for abuse and social media were reviewed at the meeting. Facility conducted audit of their incidents for abuse and potential reportable incidents to ensure there was no further non-compliance identified. 10NYCRR 415.4 (b)(1)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00307069) during the Standard survey completed on 4/16/24, the facility did not protect the resident's right to be free from sexual abuse for two (Resident's #22 &53) of three residents reviewed. Specifically, Resident #53 was observed by staff engaged in non-consensual sexual contact with Resident #22. The finding is: The policy and procedure titled Abuse Prevention Program revised 12/16 documented our residents have the right to be free from abuse. This includes but was not limited sexual abuse. As part of the resident abuse prevention, the administration will: protect our residents from abuse from facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The policy and procedure titled Abuse and Neglect-Clinical Protocol revised 3/18 documented that sexual abuse was defined as non-consensual sexual contact of any type with a resident. Resident #53 had diagnoses that included Parkinson's Disease (brain disorder that cause unintended and uncontrollable movements), sleep disorder, and mood disorder. The Minimum Data Set, dated dated dated [DATE], documented Resident #53 was understood, understands, and was cognitively intact. The comprehensive care plan revised 8/22/22 (current at the time of alleged abuse) documented Resident #53 ambulated independently with a rollator walker, and was independent for meeting their emotional, physical, and social needs. Interventions included supervision during activity programs due to prior legal convictions; staff to monitor for any behavior problems related to history of prior convictions and no unsupervised outside appointments. The Kardex (guide used by staff to provide care) with an as of date of 12/16/22 documented Resident #53 was independent with transfers and ambulation using a rolling walker. Resident #22 had diagnoses that included schizophrenia, bipolar, and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 10/10/22, documented Resident #1 was understood, usually understands, and had severe cognitive impairment. The comprehensive care plan dated 8/21/18 documented Resident #22 had impaired thought processes due to dementia. Resident #22 was dependent on staff for meeting emotional, intellectual, physical, and social needs. Review of the nursing progress notes dated 12/15/22 at 5:00 PM, Licensed Practical Nurse #1 documented that Certified Nurse Aide #1 observed Resident #53 with their hands under Resident #22's gown near their chest area. Residents #22 and #53 were immediately separated. Resident #53 denied that they had their hands in Resident #22's gown to Licensed Practical Nurse #1. Review of the investigation summary dated 12/15/22 documented Resident #53 was witnessed by Certified Nurse Aide #1 with their hands under Resident #22's shirt. Resident #22 stated Resident #53 was playing with my breasts. Resident #53 denied touching Resident #22 at the time of the incident and later stated they did touch Resident #22 inappropriately. Review of the Police Report Sex Offense Investigation dated 12/15/22 documented at 6:03 PM a forcible touching incident occurred between Resident's #22 and #53. Certified Nurse Aide #1 witnessed the incident. Resident #22 was moved from the 2nd floor to the 1st floor to keep them away from Resident #53. Certified Nurse Aide #1 stated they went to a common room on the 2nd floor where they saw Resident #53 behind Resident #22 (who was in a wheelchair), reaching into Resident #22's hospital gown up to Resident #53's shoulders with their hands over Resident #22's breast area. Resident #22 was interviewed and had to be brought back continually to the subject matter and relayed they were sexually abused throughout their childhood. Resident #22 stated they did not ask Resident #53 to touch them. Resident #53 squeezed Resident #22's breasts. Resident #53 stated they were giving Resident #22 a massage and may have touched the breast by accident. During an observation and interview on 4/9/24 at 10:22 AM, Resident #22 self-propelled their wheelchair to their room. Resident #22 had no recall of the incident and stated they had no inappropriate contact with other residents at the facility. During observation and interview on 4/10/24 at 11:45 AM, Resident #53 was sitting at the bedside and stated they were never involved with inappropriate contact with other residents. Resident #53 was also observed walking with staff. During a telephone interview on 4/12/24 at 9:37 AM, Licensed Practical Nurse #1 stated Certified Nurse Aide #1 reported they had witnessed Resident #53's hands under Resident #22's hospital gown at 5:00 PM in the resident dining room. There were no other residents in the dining room at the time of the incident. Supper was delivered to resident rooms which left the dining room unattended by staff. Licensed Practical Nurse #1 reported the incident to the Director of Nursing. During a telephone interview on 4/15/24 at 11:23 AM, (the former) Social Worker #2 stated at the time of the incident (12/15/22) Resident #53 ambulated independently with a rollator walker and was cognitively intact. Resident #22 lacked capacity and did not know right from wrong. Resident #22 couldn't consent. Social worker #2 stated, Resident #53 was witnessed to touch Resident #22's breasts and that was considered sexual abuse. During a telephone interview on 4/15/24 at 10:48 AM, Certified Nurse Aide #2 stated Resident #53 was out of their room on 12/15/22 more than usual, however, they did not think much of it at that time. During a telephone interview on 4/15/24 at 12:20 PM, Certified Nurse Aide #1 stated on 12/15/22 between the hours of 2:00 PM - 5:00 PM they noticed Resident #53 was acting strange and was seeking out Resident #22. Certified Nurse Aide #1 stated Resident #53 was out of their room more than usual that day. Certified Nurse Aide #1 stated they came out of another resident's room and noticed Resident #53 pacing back and forth with a smirk on their face. Certified Nurse Aide #1 didn't think anything of it. Certified Nurse Aide #1 stated they saw Resident #53 walk into the dining room. A few minutes later they went to check and that was when they saw Resident #53 standing behind Resident #22 who was seated in wheelchair at the table with their hands through arm holes of Resident #22's gown. Resident #53 was touching Resident #22's chest area. Resident #53 had a weird look on their face as if they knew I saw something that I shouldn't have seen. Certified Nurse Aide #1 intervened and informed Licensed Practical Nurse #1. Certified Nurse Aide #1 stated something was odd and they should have provided more supervision and deterred Resident #53 from entering the dining room sooner but did not. Resident #22 had dementia, could not consent to being touched, therefore was sexual abuse. During an interview on 4/15/24 at 1:44 PM, Certified Nurse Aide #3 stated Resident #53 spent time in their room and attended activities. Increased supervision was provided during activities. When Resident #53 was not attending activities, staff just kept eyes on them. Certified Nurse Aide #3 stated there was no specific monitoring system in place for certified nurse aides to document Resident #53's location. Resident #53 ambulated independently with a rollator walker and could enter other resident rooms on the unit. During an interview on 4/16/24 at 8:53 AM, the (current) Social Worker #1 stated they knew of Resident #53's past legal convictions and would have expected to have been made aware of the sexual abuse history that had occurred between Resident #53 and Resident #22. Social Worker #1 stated Licensed Practical Nurse #4 kept an eye on Resident #53 during the day. In the absence of Licensed Practical Nurse #4, nursing staff monitored Resident #53's where abouts. Social Worker #1 stated they would have expected a more person-centered plan and specific interventions to monitor Resident #53's interactions with other residents more closely. During an interview on 4/16/24 at 9:13 AM, the Director of Nursing stated staff were educated and empowered with awareness on Resident #53's behaviors. The facility had vulnerable residents and was incapable for providing direct supervision for Resident #53. If there was a situation on the unit and staff were attending other residents there was the potential Resident #53, could get into another resident's room without staff's knowledge. The process for monitoring was not good, Resident #22 was moved to another unit. There was no system in place which prevented other vulnerable residents from being at risk. The Director of Nursing stated the facilities investigation into the 12/15/22 incident on between Resident #53 and #22 had concluded sexual abuse occurred. During an interview on 4/16/24 at 10:22 AM, Licensed Practical Nurse #2 stated they redirected Resident #53 when they ambulated in the wrong direction and entered other resident rooms. Staff on the unit were responsible to monitor Resident #53's location. There was no specific system in place for accountability or place to documented Resident 53's whereabouts on a consistent basis. During an interview on 4/16/24 at 10:24 AM, Licensed Practical Nurse #4 Unit Manager stated Resident #53 could potentially enter other resident's rooms, on the unit. Licensed Practical Nurse #4, Unit Manager stated there were no other means of providing increased supervision towards preventing further occurrence other than redirection and there was no documented evidence of ongoing monitoring to prevent reoccurrence. During an interview on 4/16/24 at 10:59 AM, the Administrator stated there was no video surveillance from the incident on 12/15/22. The incident that occurred between Resident #53 and Resident #22 was determined to be sexual abuse. During a telephone interview on 4/16/24 at 12:05 PM, the Medical Director stated Resident # 22 lacked capacity, was unable to consent, therefore the incident on 12/15/22 was sexual abuse. 10 NYCRR 415.3(d)(1)(vii)

Based on observation, interview, and record review conducted during a Standard survey started on 8/4/22 and completed on 8/11/22, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene. Specifically, two (Residents #40 and #4) of two residents reviewed for ADL's had long, jagged, and dirty fingernails. The finding is: The facility policy and procedure (P&P) titled Care of Fingernails/Toenails revised October 2010 documented the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care included daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 1. Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 6/2/22 documented Resident #40 had moderate cognitive impairment, was understood, and understands. In addition, Resident #40 required extensive assistance for personal hygiene. During intermittent observations on 8/4/22 at 9:55 AM, 8/8/22 at 8:04 AM and 1:40 PM, and 8/9/22 at 11:41 AM and 3:30 PM, revealed Resident #40's fingernails on both hands were long (over the tips of the fingers), fingernails on the right hand were dirty with brown debris, and jagged. During an interview on 8/4/22 at 9:55 AM, Resident #40 stated they did not like their nails long and was unable to trim them by themselves. During an interview on 8/9/22 at 3:30 PM, Certified Nurse Aide (CNA) #1 stated Resident #40 required assistance with ADL's (activities of daily living) and nail care would need to be provided to Resident #40. CNA #1 stated nail care was done on shower days or upon resident request by the CNAs, if the resident was not a diabetic. Additionally, during observation of the residents fingernails at this time, CNA #1 stated that Resident #40s fingernails were long, some were soiled and needed to be cut for hygiene purposes, to prevent break in skin, and to prevent infection. During an interview on 8/9/22 at 3:35 PM, Licensed Practical Nurse (LPN) #1 stated Resident #40 was a total assist of one for nailcare and that CNAs perform Resident #40's nailcare, trimming of nails and filing rough edges, usually on shower days. Resident #40 received showers on Tuesday and Friday evenings. Additionally, upon observation at this time, LPN #1 stated resident #40's fingernails were jagged and needed to be cut on the right hand and the left-hand fingernails were long and sharp. 2. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 7/15/22 documented Resident #4 was severely cognitively impaired, was rarely/never understood, and rarely/never understands. In addition, Resident #4 required extensive assistance of two for personal hygiene. Review of the Progress Notes dated 7/10/22 through 8/5/22 for Resident #4 revealed there was no documented evidence nail care was provided or that Resident #4 refused care. Review of the annual history and physical dated 10/21/21 documented staff provided all aspects of care and anticipated Resident #4's needs. During intermittent observation on 8/5/22 at 9:00 AM, 8/8/22 at 8:14 AM, 8:41 AM, 9:23 AM and 1:50 PM, and 8/9/22 at 8:19 AM, 9:56 AM and 3:46 PM revealed Resident #4's fingernails on both hands were long (extended over the tips of the fingers), dirty with dark debris and some with jagged edges. Additionally, Resident #4 was noted to place the fingers of right hand in their mouth and rub the top of their head with right hand fingernails during observations. During an interview on 8/9/22 at 3:53 PM, CNA #2 stated that Resident #4 was completely dependent on staff and has had no refusals of care to their knowledge. Additionally, at 3:58 PM, CNA #2 observed Resident #4's fingernails and stated that they were very long, and dirty. CNA #2 stated that Resident #4 puts their fingers in their mouth a lot and nailcare should be provided so Resident #4 doesn't cut themselves as this could cause concern for infection. During an interview and observation on 8/9/22 at 4:02 PM, LPN #2 stated Resident #4 placed fingers in their mouth when they were hungry. LPN #2 stated Resident #4's right hand middle fingernail was jagged, very long and left-hand fingernails were dirty, long, and sharp. LPN #2 stated Resident #4 usually had their hands by their face and wouldn't want them to put their fingers in their mouth, it was not good hygiene. During an interview on 8/9/22 at 4:10 PM, the Director Of Nursing (DON) stated their expectation is that if resident nails are dirty, staff (CNAs or nurses) were to clean them. On shower days nails should be trimmed and cleaned, this was important for infection control, hygiene, and dignity. The DON stated that if a resident was refusing nail care, the CNA should report it to the nurse, and the refusal of care should be documented. 415.12 (a)(3)

Based on interview and record review completed during the Standard survey conducted 8/4/22 through 8/11/22, the facility did not maintain an infection prevention and control program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility had no documented evidence three (Certified Nurse Aides (CNA) #3, 4, 5) of three direct care contract staff, not up to date with their COVID-19 vaccination, were tested for COVID-19 as required. The finding is: The Centers for Medicare and Medicaid Services (CMS) QSO 20-38-NH revised 3/10/22 documented that staff who are not up to date with their COVID-19 vaccinations needed to be tested at minimum twice a week when the COVID-19 community transmission level is at high (red). The QSO documented up to date meant a person had received all recommended COVID-19 vaccines, including any booster doses when eligible. The facility policy and procedure (P&P) titled Coronavirus (COVID-19) revised 6/10/22, documented routine testing of staff, who are not up to date, is conducted based on the extent of the virus in the community. While the level of community transmission is identified as substantial or high, twice weekly testing will be conducted for staff that work four or more days per week. Once weekly testing will be conducted for staff that work less than four days per week. Reports of COVID-19 level of community transmission are available on the CDC (Centers for Disease Control and Prevention) COVID-19 Integrated County View site. The facility should test staff, who are not up to date, at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the past week. Facilities must demonstrate compliance with testing requirements. To do so facilities will do the following: -For routine staff testing, document the date(s) that testing was performed for staff, who are not up to date, and the results of each test. The County Level Timeseries Data for New York report documented [NAME] County had a high level of community transmission of COVID-19 from 7/10/22 through 8/13/22. An undated, untitled facility document identified by the Administrator as the facility COVID-19 vaccine line list did not include contracted staff. During an interview on 8/9/22 at 12:41 PM, the Administrator stated there was no COVID-19 vaccine line list for contracted (agency) staff. The Administrative Assistant (AA) kept track, and gets a copy of agency staff COVID-19 vaccine status/cards and any booster doses upon hire, but if they get any additional doses staff were expected to provide a copy to update their records. The Administrator stated contract staff were expected to test, as required, if their COVID-19 vaccination status was not up to date. Review of facility file folder titled Agency Covid Cards contained documentation of CDC COVID-19 Vaccination Record Cards as follows: -CNA #3 received dose 1 and dose 2 of a brand name COVID-19 vaccine and was eligible to receive their booster. A facility Refusal to Receive Vaccination signed by CNA #3, dated 6/28/22, documented CNA #3 was educated and declined the brand name COVID-19 booster vaccine. -CNA #4 received dose 1 and dose 2 of a brand name COVID-19 vaccine and was eligible to receive their booster. A facility Refusal to Receive Vaccination signed by CNA #4, dated 6/30/22, documented CNA #4 was educated and declined the pneumonia vaccine. There was no documented evidence of education/declination of the COVID-19 booster vaccine. -CNA #5 received dose 1 and dose 2 of a brand name COVID-19 vaccine and was eligible to receive their booster. A facility Refusal to Receive Vaccination signed by CNA #5, dated 4/28/22, documented CNA #5 was educated and declined the brand name COVID-19 booster vaccine. Review of facility Daily Time Cards documented the following: -CNA #3 worked in the facility on 7/12/22, 7/13/22, 7/15/22, 7/16/22, 7/17/22, 7/18/22, 7/19/22, 7/20/22, 7/22/22, 7/25/22, 7/26/22, 7/28/22, 7/29/22, 7/30/22, 7/31/22, 8/1/22, 8/2/22, 8/3/22, 8/4/22, 8/5/22, 8/7/22, and 8/8/22. -CNA #4 worked in the facility on 7/12/22, 7/22/22, 7/23/22, 7/25/22, 7/28/22, and 8/10/22. -CNA #5 worked in the facility on 7/10/22, 7/11/22, 7/12/22, 7/13/22, 7/14/22, 7/17/22, 7/21/22, 7/22/22, 7/25/22, 7/27/22, 7/28/22, 7/29/22, 7/30/22, 8/1/22, 8/4/22, 8/5/22, and 8/8/22. Review of an untitled facility document(s) identified by the Director of Nurses (DON) as the weekly COVID-19 testing sheets dated: -07/10/22 through 7/16/22 -07/17/22 through 7/23/22 -07/24/22 through 7/31/22 -07/31/22 through 8/06/22 -08/07/22 through 8/13/22 had no documented evidence of CNA #3, 4 or 5 COVID-19 testing as required. During an interview on 8/10/22 at 7:37 AM, Registered Nurse (RN) #1 Resident Care Coordinator (RCC) Infection Preventionist (IP) stated if staff, including agency staff, were not COVID-19 boosted, when eligible, or not up to date they had to be COVID-19 tested weekly, as required. RN#1 RCC IP stated the AA kept track of staff that needed to test weekly. The AA and DON track to make sure all staff that were required to be tested , were tested as required. During an interview on 8/10/22 at 11:30 AM, CNA #3 stated they worked at the facility for about a month and a half and declined the COVID-19 booster vaccination. CNA #3 stated they were never told they were required to be COVID-19 tested weekly. CNA #3 stated I had no idea, but would have if they told me I needed to. I saw the self-swabbing, rapid test, table set up, but I thought that was for in house staff. CNA #3 stated they had not received weekly COVID-19 testing through the contracted agency. During interview on 8/10/22 at 11:39 AM, CNA #5 stated they had worked at the facility a couple of months and had declined the COVID-19 booster vaccine. CNA #5 stated they never knew anything about being tested at the facility. CNA #5 stated it was required at the last facility I worked, it was mandated, they kept a record and I made sure I got it done. CNA #5 stated they had not received weekly COVID-19 testing through the contracted agency. During a telephone interview on 8/11/22 at 5:22 AM, CNA #4 stated they had not worked at the facility for that long. CNA #4 stated they had a COVID-19 booster vaccine but was not sure why the facility did not have a record of it. CNA #4 stated I thought the other facility I worked at faxed a copy to the facility. CNA #4 stated they had not been COVID-19 tested at the facility since they worked there, nor through the contracted agency. During an interview on 8/11/22 at 9:49 AM, the DON stated the AA assisted with COVID-19 vaccine record keeping of staff and that the former Assistant Director of Nursing (ADON) and AA worked on it together. The AA kept a line list of all staff and agency/contract staff when they came into the building. They were kept in separate folders and the AA would let the DON know who was not up to date and was required to have weekly testing. Any new agency staff should be added to the line list COVID-19 testing sheet if they were not up to date on their vaccines. The DON stated their corporate staff checked the CDC COVID-19 data tracker and sent it to them, their community transmission level was high and it had been high for a long time. Staff that were not up to date on their vaccines, should be tested , as required, based on community transmission level depending on how many days they worked per week. The DON stated it's a shared responsibility between me, the AA, and the staffing coordinator, who does the payroll. They (CNAs #3, 4, and 5) should be added to the line list of staff that need to be tested . The DON stated they had told staff about the testing requirement and about the self swabbing log book, but if it wasn't recorded, then there is no documentation that they were tested . During an interview on 8/11/22 at 10:16 AM, the AA stated they, the DON and staffing coordinator worked on staff COVID-19 vaccine status and testing together. The AA stated there was no line list of agency staff vaccine status and that it was kept on a separate spread sheet. The AA stated if new staff came in and were not up to date on their COVID-19 vaccinations, they would be told they needed to test 1-2 times per week, as required. The AA stated the prior ADON used to do this when new staff or agency staff were on orientation. The AA stated they made the line list for staff that required COVID-19 testing and the sheet hadn't been updated with the current agency staff who were not up to date on their COVID-19 vaccinations. The AA stated they thought a nurse would be responsible to review the testing book to make sure everyone that was required to test, got tested . During an interview on 8/11/22 at 10:42 AM, the Administrator stated the facility no longer had an ADON and the AA had been out on leave recently. Those were the staff members who tracked staff COVID-19 testing and that was why they may have fallen off on tracking. The ADON used to keep the COVID-19 testing line list updated. There was no line list for vaccine status of contract staff. The expectation would be agency staff keep them updated of their vaccine status or take the booster dose from the facility. The Administrator stated we just assumed that they knew what they should be doing, for testing, if they are not boosted/up to date. 415.19 (a)(5)

Based on interview and record review conducted during the Focused Infection Control COVID-19 survey completed on 2/23/21, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility did not ensure that three of three employees (Certified Nurse Aide (CNA) #1, #2, and Licensed Practical Nurse (LPN) #1) reviewed were screened for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks every 12 hours while on duty. In addition, the facility did not ensure CNA #1 was screened prior to working scheduled shifts. The finding is: 1. The NYS DOH (New York State Department of Health) Commissioner of Health letter to Nursing Home (NH) Administrators, dated 4/29/20, required all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. Review of a CMS (Centers for Medicare and Medicaid Services) memorandum (QSO 20-14-NH) updated 9/28/20 documented facilities should screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, or sore throat. The Centers for Disease Control and Prevention (CDC) guidance, Preparing for COVID-19 in Nursing Homes, updated 11/20/20 documented: Screen all HCP (healthcare personnel) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. Review of a facility policy and procedure (P&P) titled Entrance Screening revised on 11/20/20 documented it is the policy of the facility to comply with the Center for Disease Control (CDC) and State DOH guidelines regarding awareness and prevention of the spread of COVID-19. Everyone in the facility will be screened, including temperature checks, prior to entry into the facility. The facility staff will be re-screened every 12 hours while on duty. Review of an untitled documented identified by the Director of Nursing (DON) as the line list for COVID-19 positive residents, revealed nine residents tested positive for COVID-19 from 1/15/21 through 2/16/21. Review of an untitled document identified by the DON as the line list for COVID-19 positive employees, revealed seven staff members tested positive for COVID-19 from 1/11/21 through 2/17/21. Review of Time Detail (employee timesheets) dated 2/6/21 through 2/23/21 for CNA #1, CNA #2 and LPN #1 revealed: - CNA #1 worked more than 12 hours on 2/10/21, 2/12/21 and 2/17/21, and worked in the facility on the following dates: 2/8/21, 2/11/21, 2/13/21, 2/14/21, 2/16/21, 2/18/21, 2/19/21 and 2/22/21. - CNA #2 worked more than 12 hours on 2/16/21 and 2/22/21. - LPN #1 worked more than 12 hours on 2/8/21, 2/9/21, 2/15/21, 2/16/21 and 2/22/21. Review of the facility's computer-generated kiosk screening reports from 2/6/21 through 2/22/21 revealed CNA #2 and LPN #1 were not re-screened after working 12 hours on the aforementioned dates. In addition, there was no documented evidence CNA #1 was screened prior to working any shifts or after working 12 hours on the aforementioned dates. During an interview on 2/23/21 at 10:08 AM, CNA #1 stated upon entering the facility for the start of their shift, employees use a kiosk (tablet type electronic device) to perform a self-screening questionnaire regarding COVID-19 symptoms or exposure and they take their own temperature. CNA #1 stated she was working a double shift (16 hours) today. She stated she was not required to be rescreened at any point during the 16-hour shift and has worked double shifts pretty often. CNA #1 further stated she worked three double shifts last week. During interview at 2:15 PM, CNA #1 stated she had not been rescreening herself when she worked double shifts. She stated she worked between 2/6/21 through 2/23/21 but forgot to enter the proper code in the kiosk. During an interview on 2/23/21 at 12:59 PM, LPN #1 stated he worked approximately two double shifts a week and had never rescreened himself when working beyond 12 hours because he did not know he had to rescreen himself. During an interview on 2/23/21 at 1:02 PM, CNA #2 stated she had worked double shifts and was aware she was supposed to rescreen herself after working beyond 12 hours. CNA #2 stated she often gets too busy to rescreen herself and didn't recall the last time she rescreened herself when working beyond 12 hours. During an interview on 2/23/21 at 2:45 PM, the DON stated staff are expected to answer screening questions regarding COVID-19 symptoms and take their temperature before the start of their shift. She stated the Activities Director oversees the screening and runs reports from the screening kiosk to make sure staff are screening and answering all the questions prior to entering the building. The DON stated, it was my assumption that she (Activities Director) reviewed them. Additionally, the DON stated she was aware of the directive that employees are screened every 12 hours while on duty. During an interview on 2/23/21 at 2:53 PM, the Activity Department Director stated she did not check if all staff have completed the screening tool. The Activity Director stated she did not check if staff members had been rescreened when working beyond 12 hours and that she was not responsible to ensure staff were being screened. During an interview on 2/23/21 at 2:55 PM, the Administrator stated the DON was responsible for making sure employees were being screened prior to the start of their shift and every 12 hours while on duty. She stated the staff screened themselves at the start of their shift and it was possible staff could come into the facility to start their shift without being screened. The Administrator further stated ultimately, I am the Administrator, so it is my responsibility that screening is being done. 415.19(a)(1); 400.2

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 320) completed on 10/7/19, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown origin source, are reported immediately, but not later than two hours later after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and the Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures. Four (Residents #6, 20, 22, and 33) of four residents reviewed for reporting of alleged violations of abuse were involved in incidents not reported timely to the New York State Department of Health (NYSDOH) as required. Specifically, resident to resident altercations. The finding is: A facility policy titled Residents Rights to Freedom from Abuse, Neglect, and Exploitation dated (YEAR) documented residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation. This includes, but is not limited to, freedom from corpal punishment, involuntary seclusion, and any. In response to allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported in the proper timeframe. Report the results of all investigations to the Administrator and to other officials in accordance with the State law, including to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. A facility policy titled Resident-to-Resident Altercations dated 2007 documented all altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. Report incidents, findings, and corrective measures to appropriate agencies as outlined the facility's abuse reporting policy. 1. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 6/23/19 documented the resident had severe cognitive impairments and required limited assistance of one staff member for ambulation. The MDS further documented verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). The CCP dated 9/30/19 documented Behavioral Problem related to TBI. The following plan included attempt to determine underlying cause and document potential causes, move to a less stimulating environment: Provide activities of interest; engage in conversation; anticipate needs; intervene before agitation escalates; guide away from source of distress, and approach later. The CCP further documented altercations' involving other residents. The undated certified nurse aide (CNA) care guide documented to keep distant from Resident #33, provide increased supervision when around Resident #6 and provide increased supervision when in group activities with Resident's #33 and 22. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had intact cognition and required supervision for transfers and ambulation. The Comprehensive Care Plan (CCP) dated 10/7/17 documented a history of altercations involving other residents. The undated CNA care guide (a guide used by staff to provide care) documented instructions to intervene before agitation escalates, guide away from source of distress, re-approach and keep away from Resident #20. Review of the Facility Investigation Summary dated 1/7/19 documented at 9:30 PM Resident #20 was found on the floor. Resident #20 attempted to maneuver Resident #6's television. Resident #6 walked toward Resident #20 pushed foot out, causing Resident #6 to fall onto the floor. The Director of Nurses (DON) was notified on 1/7/19 at 10:00 PM. A complete and thorough investigation was conducted, and residents were immediately separated, and a room change implemented for Resident #20. Review of the Health Electronic Response Data System Nursing Home Incident Form dated 1/10/19 the incident was reported to the NYSDOH on 1/10/19 at 5:47 PM. Further review of the Nursing Home Incident Form documented there was no reasonable cause to believe that abuse, neglect or mistreatment occurred. 2. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented intact cognition and transferred with staff supervision. The CCP dated 8/27/19 documented Behavior Problem- argumentative with other residents. Interventions included to intervene as necessary to protect the rights and safety of others; determine cause of underlying behavior; keep distant from resident #20. The CCP further documented potential to be verbally aggressive and history of altercation involving Resident #20. Review of the Facility Investigation Summary dated 5/6/19 documented at 8:00 AM staff over heard a verbal altercation between Residents #22 and 20. Resident #20 hit Resident #22 in his left shoulder. The DON was notified of the incident at 8:30 AM. An investigation was conducted. Review of the Health Electronic Response Data System Nursing Home Incident Form dated 5/11/19 the incident was reported to the NYSDOH on 5/11/19 at 12:00 AM. Further review of the Nursing Home Incident Form documented there was reasonable cause to believe that abuse, neglect or mistreatment occurred. 3. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented intact cognition and transferred with limited assistance of one staff member. The CCP dated 8/13/19 documented Resident #33 had the potential to be physically aggressive. Interventions included to move to a less stimulating environment, intervene before agitation escalates and guide away from source of distress. The CCP further documented an alteration in Safety related to an altercation with Resident #20. The plan involved to provide increased supervision during group activities with Resident #20. Review of the Investigation Summary dated 6/25/19 documented at 3:52 PM a resident to resident physical altercation between Resident #20 and Resident #33 after Resident #20 called Resident #33 a racial slur. Resident #33 then stood up out of the chair and began striking Resident #20. Resident #20 proceeded to stand up to strike Resident #33 and Resident #20 fell to the ground. The CNA intervened immediately and separated the two residents. Further review of the Investigation Summary documented the DON was notified at 4:05 PM. An investigation was conducted. Review of the Health Electronic Response Data System Nursing Home Incident Form dated 6/26/19 the incident was reported to the NYSDOH on 6/26/19 at 1:50 PM. Further review of the Nursing Home Incident Form documented there was no reasonable cause to believe that abuse, neglect or mistreatment occurred. During an interview on 10/1/019 at 10:05 AM, Resident #22 stated, a resident here calls me the 'N' word and I'm sick of it. I was helping a lady into the dining room and he threw a punch at me. During an interview on 10/7/19 at 9:45 AM, the DON stated the Nursing Home Reporting Incident Manual was followed for reporting guidelines. Then stated it was her responsibility to report to the NYSDOH within 2 hours if there was serious bodily injury and within 24 hours for all other allegations. During interview on 10/7/19 at 10:19 AM the Administrator stated the Nursing staff are expected to contact her immediately and start an investigation. The Administrator then stated, If it rises to mistreatment and abuse, that is different from neglect and if there was any doubt would call the NYSDOH. 415.4 (b)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 10/7/19, it was determined that the facility did not ensure that a resident who was unable to carry out activities of daily living receives the necessary services to maintain good grooming, and personal hygiene. Specifically, one (Resident #37) of three residents reviewed for activities of daily living had issues with multiple approximately one- inch long whiskers on her chin. The finding is: The facility policy and procedure titled Shaving the Resident dated (MONTH) 2010 documented the purpose of shaving was to promote cleanliness and to provide skin care. 1. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documented the resident is an extensive assist of one person for personal hygiene which includes shaving. During an observation and interview on 10/1/19 at 2:01 PM, the resident had multiple approximately one- inch long chin hairs. When asked if she wanted them shaved the resident stated shave repeatedly while rubbing the whiskers on her chin. During an observation and interview on 10/2/19 at 7:47 AM, the resident had the same whiskers on her chin. When asked if she wanted them to be shaved, she stated yes. When asked if she told anyone she wanted them shaved she nodded her head yes. During an observation and interview on 10/3/19 at 8:00 AM, the resident still had the same whiskers on her chin. When asked if they shaved her this morning, she shook her head no. The resident's Comprehensive Care Plan (CCP) dated 11/21/16 (identified as current) documented the resident was an extensive assist of one person for personal hygiene. An undated Certified Nurse Aide (CNA) Bedside Kardex Report (guide used by staff to provide care) documented the resident was an extensive assist of one person for personal hygiene. A review of the Point of Care (P[NAME]) Legend Report dated 9/5/19 to 10/3/19 revealed that staff documented that the resident received personal hygiene care on those dates. A review of the facility CNA assignment sheet revealed the resident was a 10:00 PM to 6:00 AM daily get up out of bed. On the bottom of the assignment sheet it stated 10 - 6 residents should be washed, dressed, shaved, and ready for the day. During an interview on 10/3/19 at 8:21 AM, CNA #1 stated that CNA's are supposed to shave a resident's chin especially if they request it. She also stated the resident needed to be shaved and that we will go shave her right now. During an interview on 10/3/19 at 8:24 AM, Registered Nurse (RN) Unit Manager #1 stated that she expected her staff to shave a resident if they want to be shaved. During an interview on 10/7/19 at 9:56 AM, the Director of Nursing (DON) stated that she expected her staff to shave a resident as long as the resident was agreeable to shaving. 415.12 (a)(3)

Based on interview and record review conducted during the Standard survey completed on 9/21/18, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries. Specifically, three (Resident #47, 49, 62) of three residents reviewed for beneficiary protection notification, the facility did not provide residents with a Notice of Medicare Non-Coverage (NOMNC) (#47, 49, 62) or a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) (#49, 62) at the termination of Medicare Part A benefits. The findings are: Review of an undated document entitled Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS- (2018), provided by the facility stated Medicare requires SNFs to issue the SNF ABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or considered custodial. 1. Resident #47 was admitted to the facility on [DATE] under Medicare Part A services with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 9/7/18 revealed the resident was cognitively intact, understands and was understood. Review of the facility Clinical Census revealed Medicare A was the Primary Payer for Resident #47 from 7/13/18 through 9/17/18. The resident was discharged from the facility on 9/17/18. There was no evidence that the Notice of Medicare Non-Coverage (NOMNC) was given to the resident. 2. Resident #49 was admitted to the facility on [DATE] under Medicare Part A services with the [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was severely cognitively impaired, understands and was understood. Review of the facility Clinical Census revealed Medicare A was the Primary Payer for Resident #49 from 7/16/18 through 9/14/18, and the resident remained in the facility. There was no evidence the SNF ABN (SNF ABN - a letter given to residents who are terminated from Medicare coverage and remain in the facility) or the NOMNC was given to the resident. 3. Resident #62 was admitted to the facility on [DATE] under Medicare Part A services with the [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was moderately cognitively impaired, understands and was understood. Review of the facility Clinical Census revealed Medicare A was the Primary Payer for Resident #62 from 9/19/18 through 8/18/18 and the resident remained in the facility. There was no evidence the SNF ABN, nor the Notice of Medicare Non-Coverage (NOMNC) was given to the resident. During an interview on 9/21/18 at 12:37 PM, the Administrative Officer #1 stated, when residents come in on Medicare and are on therapy, if therapy gets cut before their days run out I go to the nursing department and see if there is anything skilled that would keep their services. If not, we would issue the NOMNC and give it 48 hours prior to the resident leaving. I've been to the corporate in-services where we received spread sheets and different tools to keep on our desktop to reference the different letters within the past year. The resident would receive a SNF ABN notice if they remained in the facility. The Administrative Officer stated that all three residents had benefit days remaining. Additionally, the Administrative Officer stated there was no documentation in the name of computer program, regarding the notices provided, and they will start to scan the notices into the computer system. During an interview on 9/21/18 at 12:57 PM, the Administrator, stated the Administrative Officer #1 had the guidelines of what forms were to be used. When issuing letters, she should be ensuring that she was using the right forms. 415.3(g)(2)(i)

Based on observation and interview during the Standard survey completed 5/9/17, the facility did not assure that all essential mechanical, electrical and patient care equipment was in safe operating condition. One (Third Floor) of three resident use floors observed for the maintenance of equipment had issues involving plumbing that lacked a vacuum breaker (a device that prevents contaminated or waste water from being siphoned backward into the public drinking water system) to ensure that waste water would not be siphoned backward into the building's potable water supply. The findings are: 1. Observation of the Third Floor on 5/3/17 at approximately 11:06 AM revealed the hose for the hopper sink, located in the soiled utility room, was submerged approximately two inches below the surface of the water located inside of the hopper. Further observation at this time revealed the rinse water hose/wand for the soiled hopper, was directly plumbed into the clean water supply pipe, located below the hand washing sink. Continued observation at this time revealed the hose/wand and water pipe did not have vacuum breakers installed on them. An interview with the Maintenance Supervisor, at the time of the observation, revealed the hopper's hose and the water line it was connected to did not have vacuum breakers installed on them to prevent wastewater from backflowing into the potable water supply for the facility. Further interview with the Maintenance Supervisor, at this same time, revealed he was not aware that the hose had been connected to the water supply line without a vacuum breaker and he had only been working at the facility for approximately three weeks. 415.29(d)

Based on observations and interview conducted during the Standard survey completed on 5/9/17, the facility did not store, prepare, distribute, and serve food under sanitary conditions. Issues included: ready for use pots, pans, scoops, tongs, spoons, whisks, pitchers, and bowls that were stacked or stored together wet and soiled with greasy white and brown colored substances, and aluminum foil that was adhered to the pans. The shelving, where clean ready-to-use pots and pans were stored, was soiled with black, brown, tan, and white colored food debris and crumbs. The wall behind the oven was deteriorated, was not made of a non-porous material and was not an easily cleanable surface. The floor below the wall was soiled with pieces of gypsum board and dust. This affected one of one First Floor Main Kitchen. The findings are: 1. Observation on the First Floor, in the Main Kitchen, on 5/3/17 at approximately 9:32 AM revealed the following: - 17 pots and pans were stacked together wet on the clean pot and pan rack and water was observed dripping from the pans when the surveyor pulled the pans apart. Seven of the pots and pans were soiled with brown, tan, and white colored greasy substances and two pans still had pieces of aluminum foil attached to them. - Four of the shelves on the clean pot and pan rack, were covered with sheets of aluminum foil that was soiled with black, brown, tan, and white colored food debris and crumbs. - Two slotted spoons, hung from a rack, were greasy to the touch and soiled with a greasy white colored substance. - Two ladles, hung from a rack, were soiled with crusty white and tan colored substances. - Two whisks, hung from a rack, were soiled with a crusty green colored substance. - Two pairs of tongs, hung from a rack, were greasy to the touch and soiled with a greasy tan colored substance. - Seven maroon colored bowls, were stacked together wet on a shelf. Two of the seven bowls were soiled with a wet white colored substance. The bowls were stored on the shelf with at least eight other clean, dry bowls. - Four, cleaned and sanitized pitchers, were stored upright on a shelf, with their lids on and not able to air dry after being sanitized. Each pitcher had greater than one quarter of an inch of water in them. - One approximate 12 inch wide frying pan was soiled with a crusty brown substance. The frying pan was stored stacked on top of three other clean fry pans. - Seven scoops were stored in a drawer, still wet. Four of the seven scoops were soiled with greasy wet, brown and tan colored substances. The seven scoops were stored in the same drawer with at least ten other cleaned and dry scoops. - Two slotted spoons were stored in a drawer, still wet, with clean, dry, metal and plastic spatulas and other clean dry slotted spoons. - An approximated four foot long, by two foot wide, area of the wall behind the oven was deteriorated and missing gypsum board and ceramic tiles. Wooden wall support studs in the wall were exposed due to the missing gypsum board and tiles. The wooden studs were also deteriorated. An approximate two foot long, by two inch wide area of the floor behind the oven was soiled with pieces of the deteriorated gypsum board and dust, that had fallen off of the deteriorated wall. - Interview with the Cook at the time of the above observations, revealed the pots, pans, scoops, tongs, spoons, whisks, pitchers, and bowls were ready for use. - Interview with the Food Service Director on 5/4/17 at approximately 8:40 AM revealed the aluminum foil was put on the shelves of the clean pot and pan rack during the beginning of April 2017 because the metal shelves were not in good condition and she did not want to store the clean pots and pans directly on the deteriorated shelves. Further interview with the Food Service Director at this time revealed the wall behind the stove started deteriorating a couple of months ago. 415.14(h) New York State Sanitary Code Subpart 14-1 14-1.110(b) 14-1.110(d) 14-1.110(e) 14-1.116 14-1.171(a) 14-1.171(b)

Based on interview and record review during the Standard survey completed on 5/9/17, the facility did not ensure that the State nurse aide registry was checked for new employees to identify potential findings concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. One of five employees hired in the last four months lacked verification with the New York State Nurse Aide Registry prior to employment. The finding is: 1. Review of the employee file for Employee #1, a Housekeeping Aide, revealed the employee was hired on 1/5/17 and the file did not contain a Nurse Aide Registry Verification Report for the employee. Review of weekly Supervisory Tracking for Temporary Employees forms for Employee #1 on 5/4/17 revealed the employee had worked at the facility from the week of 1/9/17 through 5/4/17. Interview with the Business Office Manager (Authorized Person) on 5/4/17 at approximately 11:23 AM revealed Employee #1 was currently employed by the facility as a Housekeeping Aide. The interview revealed the Business Office Manager conducted a Nurse Aide Registry Verification Report for Employee #1 prior to the employee being hired but had mistakenly pressed the wrong print tab on her computer screen resulting in two blank sheets of paper being printed instead of a Nurse Aide Registry Verification Report. Review of the two pieces of paper from Employee #1's file dated 12/30/16 revealed they contained no information about Employee #1. Further interview with the Business Office Manager at this time revealed the facility did not have a detailed policy and procedure for how Nurse Aide Registry Verification Reports shall be conducted for employees and that she conducts Nurse Aide Registry Verification Reports for the employees prior to their employment. Continued interview revealed that all Housekeeping Aides work throughout the facility. Review of a New Hire Notice on 5/5/17 revealed Employee #1's hire date was 1/5/17. Review of Time Detail logs on 5/5/17 revealed Employee #1 worked at the facility for 79 days between 1/9/17 and 5/4/17. Review of an undated Employment Policy and Procedure revealed the Nurse Aide Registry Verification Report is to be completed prior to any applicant interview. 415.4(b)(1)(ii)(b)

Based on observation, record review and interview conducted during a Standard survey completed on 5/9/17, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Two (Units 1, 2) of two units observed for environment had issues with unlabeled urinals in shared bathrooms, a labeled urinal dated 12/29 that did not belong to any of the residents in a shared bathroom, graduated urine measuring cylinders on the floor next to the toilet that contained urine, unlabeled compression stockings hung on toilet grab bars in a shared bathroom, and paint peeling on a resident's wall. The findings are: 1. Intermittent observations on 5/3/17 between 10:00 AM to12:00 PM revealed the following: Room #110 - area of peeling paint approximately one square foot above the resident's night stand. Room #112 - two pairs of unlabeled compression stockings hanging on toilet grab bars in a shared connected bathroom that is shared by four people. Room #213 - unlabeled urinal hanging on a toilet bar in a shared connected bathroom. Room #214 - unlabeled urinal hanging on the toilet grab bar and another urinal labeled with the initials NV with a date of 12/29 on it in a shared connected bathroom. None of the residents in room #214 or room #212 have those initials. Intermittent observations on 5/4/17 between 9:00 AM and 10:00 AM revealed the following: Room #115 - two graduated urine measuring cylinders on the floor next to the toilet in a shared connected bathroom. Intermittent observations on 5/5/17 between 6:00 AM and 10:00 AM revealed the following: Room #110 - area of peeling paint approximately one square foot above the resident's night stand. Room #112 - two pairs of unlabeled compression stockings hanging on toilet grab bars in a shared connected bathroom that is shared by four people. Room #115 - one graduated urine measuring cylinder on the floor next to the toilet in a shared connected bathroom with a scant amount of urine in it. Room #213 - unlabeled urinal hanging on a toilet bar in a shared connected bathroom. Room #214 - unlabeled urinal hanging on the toilet grab bar and another urinal labeled with the initials NV with a date of 12/29 on it in a shared connected bathroom. None of the residents in room #214 or room #212 have those initials. During an interview on 5/3/17 at approximately 10:35 AM, Resident A revealed that the the peeling paint has been there for a while and it looks kind of ugly. When asked on 5/5/17 at approximately 6:45 AM if the peeling paint bothered Resident A the resident stated, Yes, and it doesn't look good. During an interview on 5/5/17 at approximately 9:50 AM, Resident B did not know who the stockings belonged to in the bathroom and stated they might be mine but I'm not sure. Interview with Registered Nurse (RN) #1 on 5/5/17 at approximately 10:10 AM revealed that the aides are responsible for labeling, cleaning, and storing the resident's equipment. RN #1 stated that if there is a problem he expects his staff to fix it if they are able and to report any repairs that need to be done to the Maintenance department. He stated that there is a Maintenance Log that Maintenance checks. RN #1 stated that he will put the room issues in the Maintenance Log and get them to repair it. Interview with the Maintenance Director on 5/5/17 at approximately 10:30 AM revealed that environmental rounds are done once a month and he was not aware of the issues in Room #110. He stated he will address the issue with the room as soon as possible. Interview with RN #2 on 5/5/17 at approximately 11:10 AM revealed that she expects her staff to label and store the urinals properly and to throw out any resident equipment if the resident is no longer there. RN #2 stated that she expects her staff to throw out the unlabeled resident care equipment in a shared bathroom because that's disgusting. During an interview on 5/5/17 at approximately 11:15 AM, the CNA revealed he was trained that after you measure the urine in the urinal, you dump it out in toilet, rinse it and place it in night stand. In addition, it should be labeled with name of the resident. Review of the facility policy entitled Storage of Items in Resident Rooms dated 1/1999 revealed that no items will be stored on floors in the resident rooms and that graduated cylinders shall be clean and placed on the bottom shelf of the bedside stand. 415.5(h)(2)

Based on interview and record review during the Standard survey completed on 4/5/16, the facility did not implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Two of five employees hired in the last four months lacked verification with the New York State Nurse Aide Registry prior to employment. The finding are: 1. a.) Review of the employee file for Employee #4, a Dietary Aide, on 4/1/16, revealed the employee was hired on 2/15/16 and a Nurse Aide Registry Verification Report had not been conducted for the employee until 4/1/16. Further review of the employee's file revealed Employee #4 was hired on 2/15/16. Review of employee time sheets for Employee #1 revealed the employee worked at the facility for at least 30 days between 2/18/16 and 3/30/16. Interview with the Business Office Manager (Authorized Person) on 4/1/16 at approximately 9:49 AM revealed she was not in charge of conducting Nurse Aide Registry Verification Reports on potential employees when Employee #1 was hired. Further interview with the Business Office Manager revealed she was not sure why the verification report was not conducted. The Business Office Manager stated that she conducted a Nurse Aide Registry Verification Report for Employee #1 on 4/1/16 after she reviewed the employee's file and noticed that it did not contain a Verification Report. b.) Review of the employee file for Employee #6, a Certified Nurse Aide (CNA), on 4/1/16, revealed the employee was hired on 1/27/16 and a Nurse Aide Registry Verification Report had not been conducted for the employee as of 4/1/16 at approximately 10:24 AM. Review of employee time sheets for the employee on 4/1/16 revealed the employee worked at the facility for at least 40 days between 2/4/16 and 3/31/16. Interview with the Business Office Manager on 4/1/16 at approximately 10:24 AM revealed she was not in charge of conducting Nurse Aide Registry Verification Reports on potential employees when Employee #6 was hired and she was not sure why the report was not conducted. 415.4(b)(1)(ii)(b)

Based on observation, interview, and record review during the Standard survey completed on 4/5/16, the facility did not ensure that residents were allowed to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care. Three (Residents #3, 21, 70) of four residents reviewed for choices were not given a choice regarding the frequency of showers and/or type of bathing options each week. The findings are: 1. Resident #21 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/18/15 revealed the resident is cognitively intact, usually understands, and is usually understood. Review of the Annual MDS dated [DATE] revealed that it was determined that it is somewhat important for the resident to be able to choose between a tub bath, shower, bed bath, or sponge bath. Review of the current undated Kardex (guide used by staff to deliver care) revealed the resident receives a shower and requires limited assistance. The Kardex documented that the nurse is to sign the shower list if the resident refuses. Review of the Resident Care Plan dated 7/9/15 (identified by the Licensed Practical Nurse (LPN #2) Charge Nurse as current) revealed the resident requires assistance with washing and hygiene related to [MEDICAL CONDITION] arthritis, chronic pain, and often refuses showers. Approaches include to re-approach the resident if she refuses. a.) During an interview on 3/30/16 at 12:50 PM, the resident stated that she'd rather have a bath than a shower. I always took a bath at home but they (the facility) do not have a tub. I do not like the water to run on my face it scares me. I am offered a shower twice a week and I would prefer to have a bath three times a week. No one ever asked me. During an interview on 4/4/16 at 8:00 AM, a Certified Nurse Aide (CNA #3) stated she has worked at the facility for about two years and has never seen the tub work. Observation on 4/4/16 at 8:36 AM revealed the bath tub on the Second Floor was able to be filled with water; both the hot and cold facets worked as well as shower wand. The hydraulic lift chair attached to the tub did not move up or down when the pedals were activated. During an interview at the time of the observation, the LPN (#4) Charge Nurse stated that she has been here for years and has never seen the tub used. During an interview on 4/4/16 at 1:00 PM, the Building Superintendent stated that the bath tub on the Second Floor works, the power is off because it has not been used in so long. Observation of the bath tub, at the time of the interview, revealed the Superintendent unscrewed a panel on the left side of the tub and flipped a switch. When the foot pedals were activated, the hydraulic lift chair attached to the tub was able to move up and down. The Superintendent stated that the bath tub on the First Floor is the tub that does not function, and they are unable to get replacement parts. During an interview on 4/5/16 at 8:46 AM, the LPN (#2) Charge Nurse stated that she believes the bath tub on the Second Floor has not functioned in years and to her knowledge there has not been a resident that requested a tub bath in some time. The LPN Charge Nurse stated that at times, Resident #21 will refuse her shower. The LPN Charge Nurse stated The resident gives us a lot of different reasons; one being she does not like to get her hair wet, or its cold. The LPN Charge Nurse stated that the residents are offered two showers a week and that the shower schedule is predetermined by room number. If a resident wanted something different, the resident would have to ask. b.) Review of the Second Floor Shower List dated 3/31/15 revealed that Resident #21's showers are scheduled for Tuesdays and Fridays. During an interview on 4/4/16 at 12:31, the LPN (#4) Charge Nurse stated that the shower schedule is determined by the resident's room number. During an interview on 4/5/16 at 8:39 AM, the Social Worker stated that Activities determines the residents' preferences in regards to bathing because they ask the resident those questions on the MDS. The Social Worker stated that she believes that resident preferences are reviewed at least quarterly at the Care Plan meetings. The Social Worker stated that Resident #21's Care Plan meeting was due in February and she believed that Resident #21's Care Plan was not reviewed as it was supposed to be. 2. Resident #70 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident has severe cognitive impairment, rarely understands, and is rarely understood. Additional review of the MDS revealed that the resident's preferences regarding bathing were not elicited from the responsible party and the staff assessment of preferences revealed the resident receives a shower. The MDS Nurse who completed the 12/2/15 assessment was no longer employed at the facility and not available for interview. During an interview on 3/31/16 at approximately 11:30 AM, the resident's responsible party stated that he does not know how many showers the resident receives; staff never asked for the resident's preferences. Review of the First Floor Shower List Sheets dated 3/1/16 to 4/5/16 revealed the resident was planned to receive a shower on Wednesday and Saturday nights and did not receive showers on 3/5/16, 3/9/16, 3/12/16, 3/16/16, 3/19/16, 3/26/16, and 4/2/16. During an interview on 4/5/16 at approximately 10:00 AM, the LPN (#3) Medication Nurse stated that the showers for Unit 1 are scheduled according to room assignments, each resident is scheduled for two showers per week. The LPN stated that the facility does not have a working tub so nobody gets a tub bath. During an interview on 4/5/16 at approximately 10:10 AM, the LPN (#1) Charge Nurse stated that bath schedules are made by room assignments, two per week. The LPN Charge Nurse stated that residents are informed of the unit process of two showers per week and if the resident requests a different schedule or more, they will honor that request. The LPN Charge Nurse stated he has never asked a responsible party about bath preferences if the resident is unable to speak for themselves. 3. Resident #38 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident is cognitively intact, usually understands, and is usually understood. The MDS documented that it is somewhat important for the resident to choose between a tub bath, shower, bed bath, and sponge bath. During an interview on 3/30/16 at approximately 2:00 PM, the resident stated that she is supposed to get a shower twice a week; however, many times she only gets one per week. In addition, the resident stated she would rather have a soak in the tub with bubble bath; however the facility does not have a tub. Review of the First Floor Shower List sheets dated 3/1/16 to 4/5/16 revealed the resident is planned to receive a shower on Wednesdays and Saturdays during the day shift and the resident did not receive a shower on 3/5/16, 3/12/16, and 3/26/16. 415.5(b)(1,3)

Based on observation and interview conducted during a Complaint investigation (Complaint #NY 546) during the Standard survey completed on 4/5/16, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Two (Units 1, 2) of two units observed for residnt room environment had issues with used urinals and urine leg bag not labelled or properly stored in shared bathrooms; used urine measuring hat left behind a toilet in a shared bathroom; multiple walls and floors in disrepair; toilet paper dispensers in disrepair; floor molding missing or in disrepair; a toilet bowl with a brown stain inside of it; wall heat register covers missing paint and in disrepair; and toilet grab bars that were loose. The findings are: 1. Observations of resident rooms on 3/30/16 between 10:00 AM and 2:00 PM revealed the following: -Room #201 - a brown ring inside the toilet bowl, one tile with a yellow stain approximately 8 inches () by (x) 1 under toilet, approximately 1 grey stain in diameter on tile next to the toilet, black circular stain on tile approximately 1 in diameter underneath the sink. -Room #213 - two tiles underneath the toilet stained green and brown. -Room #214 - a used urinal not labeled on the grab bar next to the toilet, the metal toilet paper dispenser would not close completely, a tile underneath the toilet stained brownish black. -Room #216- railings on both sides of toilet loose, four tiles under toilet stained with yellow stain approximately 3 x 5 and four tiles stained with black squiggly line approximately 12 x 4. -Room #101- floor tile missing approximately 2 piece, three cracked wall tiles along floor and metal toilet paper dispenser does not close properly. -Room #103 - metal toilet paper dispenser does not close properly, approximately 12 x 6 area wall in bathroom not sanded or painted, a wall behind the toilet cracked approximately 3 feet (') x 3' area that is spackled and not sanded or painted, two floor tiles under toilet with yellow stains approximately 6 x 4 and another approximately 1 in diameter. -Room #105 - approximately 12 floor molding piece was on the back of the toilet, approximately 12 piece of floor molding not attached to the wall behind the toilet, and drywall crumbling in those areas. -Room #107 - four tiles missing underneath toilet, two chipped tiles in front of toilet, two crack tiles near bathroom door, wall gouges approximately 12 long next to bed and underneath headboard. -Room #110 - four tiles cracked in bathroom, black stained floor tiles around toilet, missing paint on wall heater registers. -Room #113 - two used urinals on floor not labeled or stored properly, urine measuring hat on floor behind toilet, metal toilet paper dispenser does not close properly, wall heater register in bathroom cover falling off at one end. 2. Observations of resident rooms on 3/31/16 between 2:15 PM and 3:30 PM revealed the following: -Room #213 - two tiles underneath the toilet stained green and brown. -Room #216- railings on both sides of toilet loose, four tiles under toilet stained with yellow stain approximately 3 x 5 and four tiles stained with black squiggly line approximately 12 x 4. -Room #101- floor tile missing 2 piece, three cracked wall tiles along floor, and metal toilet paper dispenser does not close properly. -Room #103 - metal toilet paper dispenser does not close properly, approximately 12 x 6 area not sanded or painted wall in bathroom, a wall behind the toilet cracked approximately 3' x 3' area that is spackled and not sanded or painted, two floor tiles under toilet with yellow stains approximately 6 x 4 and another one approximately 1 in diameter. -Room #105 - approximately 12 floor molding piece was on the back of the toilet, approximately 12 piece of floor molding not attached to the wall behind the toilet, and drywall crumbling in those areas. -Room #107 - four tiles missing underneath toilet, two chipped tiles in front of toilet, two crack tiles near bathroom door, wall gouges approximately 12 long next to bed and underneath headboard. -Room #110 - four tiles cracked in bathroom, black stained floor tiles around toilet, missing paint on wall heater registers. -Room #113 - two used urinals on floor not labeled or stored properly, urine measuring hat on floor behind toilet, metal toilet paper dispenser does not close properly, wall heater register in bathroom cover falling off at one end. 3. Observations of resident rooms on 4/1/16 between 8:00 AM and 9:00 AM revealed the following: -Room #201 - a brown ring inside the toilet bowl, one tile with a yellow stain approximately 8 x 1 under toilet, approximately 1 grey stain in diameter on tile next to the toilet, black circular stain on tile approximately 1 in diameter underneath the sink. -Room #214 - a used urinal not labeled on the grab bar next to the toilet, a used unlabeled urine collection leg bag on top of the toilet pipe, the metal toilet paper dispenser would not close completely, and a tile underneath the toilet stained brownish black. Interview on 4/5/16 at approximately 8:40 AM with Licensed Practical Nurse (LPN) #1 revealed that anyone on the staff can write items that need to be repaired or looked in the Maintenance Log and it is addressed by maintenance. LPN #1 also stated that resident care items such as urinals should be cleaned, labeled with the resident's name and stored in the resident's nightstand. LPN #1 also stated that urine measuring hats should be thrown away after it is used. During an interview 4/5/16 at approximately 9:00 AM the Building Superintendent stated that he expects staff to log items that need to be repaired into the Maintenance Log. He then stated that they do environmental rounds monthly and check and fix things. He also stated that he was not aware of all the maintenance issues. Interview on 4/5/16 at approximately 9:20 AM with LPN #2 revealed that she expects the staff to label and store resident care equipment in a wash basin and placed in the resident's nightstand. She also stated that if there was unlabeled resident equipment it should be thrown out. Interview on 4/5/16 at approximately 9:30 AM with a Housekeeping Aide revealed that they are supposed to clean the resident rooms once a day and use bleach on the stains in the toilet. She also stated that they try to clean the rooms and bathrooms as best as they can. During an interview on 4/5/16 at approximately 10:00 AM the Director of Housekeeping and Laundry stated that they are trying to find products that will help remove the stains from the tiles. She also stated that the rooms with the stains on the floor aren't homelike and are unacceptable. 415.5(h)(2)

Based on interview and record review conducted during the Standard survey completed 4/5/16, the facility did not conduct a quarterly re-assessment using the Resident Assessment Instrument (RAI) specified by the State within three months of the last assessment. Five (Residents #5, 21, 37, 57, 70) of twenty one resident's reviewed for Quarterly Review Assessments did not have quarterly assessments completed as required. The findings include but are not limited to: 1. Resident #21 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/18/15 revealed the resident is cognitively intact, usually understands, and is usually understood. Review of the medical record Face Sheet (demographics form) revealed the resident was admitted to the facility on [DATE]. Additional review of the medical record revealed the most recent complete resident quarterly (MDS) assessment was completed on 12/18/15. The resident's quarterly re-assessment due on 3/18/16 was documented as in progress. During an interview on 4/1/16 at 9:20 AM, the Director of Nursing (DON) stated she would expect that all MDS assessments be completed in the required time frames. 2. Resident #57 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, usually understands, and is usually understood. Review of the medical record Face Sheet revealed the resident was readmitted to the facility on [DATE]. Additional review of the medical record revealed the most recent complete resident (MDS) assessment was completed on 12/4/15. The resident's quarterly re-assessment due on 3/4/16 was documented as in progress. 3. Resident #5 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands, and is understood. Review of the medical record Face Sheet revealed the resident was admitted to the facility on [DATE]. Additional review of the medical record revealed the most recent complete MDS was the resident admission assessment completed on 12/21/15. Review of a quarterly MDS dated [DATE] revealed that as of 4/4/16, the assessment was initiated, however all sections of the MDS were incomplete. The resident quarterly MDS assessment due on 3/18/16 was documented as in progress. 415.11(a)(4)

Based on observation, record review and staff interview, the facility did not provide each resident the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #126) of one resident observed with a pressure ulcer had issues involving the lack of a timely and comprehensive assessment of bilateral heel ulcers, including measurement of size, by a registered professional nurse (from 8/31/12 to 9/13/12); a delay initiating treatment to the heel ulcers; and pressure relief that was not provided as planned and/or recommended by the Podiatrist. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #126 has [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident is cognitively intact, usually understands, is usually understood, and was identified at risk for developing pressure ulcers and did not have a pressure, venous or arterial ulcer present. Review of a hospital Adult Patient/ Resident Discharge form dated 8/11/12 revealed the resident had a stasis ulcer (wounds that occur due to the improper functioning of venous valves, usually in the legs) on the right ankle. Review of an Admission assessment dated [DATE] revealed the resident was admitted with scabbed areas on the right ankle and toes, a "bump" on the right shin and no open areas. Review of a Norton Plus Pressure Ulcer Scale (assessment tool used to determine potential skin breakdown) dated 8/11/12 revealed the resident's score was 15, indicating that the resident was at moderate risk for developing a pressure ulcer. Review of the Kardex (Certified Nurse Care Plan) dated 8/11/12 revealed no documented evidence of a plan to provide any pressure relieving devices. Review of the Resident Care Plan dated 8/20/12 revealed the resident had a history of [REDACTED]. Review of an MDS Nurse's Note, written by a licensed practical nurse (LPN), dated 8/29/12 at 12:00 PM revealed the resident's left foot was swollen and painful to touch. The MDS Nurse's Note documented that the right foot had scabbed areas; there was petichiae (red or purple spots on the body, caused by broken capillary blood vessels) on both feet; and there were "no open areas". The Nurse's Note documented that a new order was obtained for the Podiatrist see the resident. Review of a Report of Consultation dated 8/31/12 revealed the Podiatrist examined the resident and documented that the resident had bilateral heel ulcers with recommendations for bilateral heel cushions. Additional review of the 8/11/12 Kardex and the 8/20/12 Resident Care Plan revealed there was no documentation regarding the resident's bilateral heel ulcers or of a plan to provide pressure relief and/or bilateral heel cushions. Review of Nurses' Notes dated 9/1/12 to 9/8/12 revealed the following: - On 9/1/12 (6:00 AM to 10:00 PM shift), LPN #1 documented areas of concern were noted on both heels and heel protectors are to be on while in bed. - On 9/1/12 (6:00 AM to 10:00 PM shift), LPN #1 documented "podiatrist recommendations found and implemented", and were faxed to the physician with a copy given to PT (Physical Therapy). - On 9/3/12 at 3:00 AM, LPN #2 documented "Blister intact on heels. Booties in place". - On 9/8/12 (2:00 PM to 10:00 PM shift), RN #1 documented the resident had a 3 centimeter (cm) diameter open area on the left heel and Allevyn (absorbent dressing) was applied to the site. There was no other description of the left heel wound and no assessment of the right heel. During an interview on 10/3/12 at 12:15 PM, the Assistant Director of Nursing (ADON) stated that scabbed areas were noted on the resident's right ankle upon admission on 8/11/12. The ADON stated that weekly skin checks are documented in the Treatment Record (Medication Record) and are initialed by the nurses when completed. Review of the Medication Record, used to document treatments, dated 9/12 revealed a weekly skin/ body check was documented as done on 9/6/12, however there was no documentation that open areas were identified. During the interview on 10/3/12 at 12:15 PM, the ADON was asked to review the Podiatry Consultation dated 8/31/12. The ADON stated the Podiatrist documented that the resident had bilateral heel ulcers and that the resident needed heel cushions. The ADON confirmed there was no RN assessment of the resident's heels when the resident returned from the Podiatrist on 8/31/12 and there was no plan to provide pressure relief to the resident's heels. The ADON stated that heel booties were applied on 9/1/12 and review of a physician's orders [REDACTED]. The note said that the resident had "something on her heels". The ADON stated that the first time she looked at the resident's heels was on 9/6/12 and she should have charted the assessment on 9/6/12 but did not. The ADON stated she thinks the left heel was pinkish; the right heel was the "black one"; and she thought this was an old issue. During the interview, the ADON stated the left heel opened on 9/8/12 and that was when the Allevyn dressing was ordered. The ADON stated her first documented measurements of the resident's heels were on 9/13/12. The ADON stated she staged the heels by looking at a picture and stated they looked "very dark". The ADON stated she documented the wound tissue as granulation on her assessment form (Pressure, Stasis, and Other Ulcer Flowsheet) but noted it was eschar in the Nurse's Note dated 9/13/12. The ADON stated her lack of expertise contributed to this. The ADON stated that "the heel booties did not do anything (in terms of pressure relief) and there was still pressure on the resident's heels". She stated she was not aware there were pressure relief boots available that remove pressure from the heels. The ADON stated that the facility did not have any boots that off-load pressure from the heels. During an interview on 10/3/12 at 2:33 PM, the ADON stated the 8/31/12 Podiatry recommendation for pressure relief meant heel booties and elevation and that heel booties are a nursing treatment. Review of Pressure, Stasis and Other Ulcer Flowsheets and Nurses' Notes dated 8/31/12 to 9/12/12 revealed no documented evidence of a comprehensive RN assessment, including the assessment of size, of the bilateral heel ulcers following the 8/31/12 Podiatry appointment. Review of physician's orders [REDACTED]. Review of a Physician's Telephone Order dated 9/8/12 revealed an order to apply Allevyn to "left heel open area, change q (every) 3 days prn (as needed). There was no treatment order for the right heel ulcer. Review of a Nurse's Note, written by the RN ADON dated 9/13/12 at 3:00 PM revealed the Physician was updated regarding the resident's bilateral heel ulcers. The ADON documented that there was eschar (black or brown dead tissue) on the right heel measuring 5 cm by 4 cm and an open blister on the left heel measuring 4 cm in diameter. The ADON documented "Allevyn intact, no drainage noted" and that the right heel had a foul odor. A new order was received for a consult with the podiatrist. Review of a Pressure, Stasis, and Other Ulcer Flowsheet for the left heel dated 9/13/12 to 9/28/12 revealed the following: - 9/13/12 - A Stage III "diabetic" ulcer of the left heel measured 4 cm long (L) x 4 cm wide (W), with no depth and no drainage. The tissue was described as "subq" (subcutaneous - beneath the skin) and treatment was an Allevyn dressing. - 9/20/12 - The left heel Stage III ulcer measured 4 cm L by 3.9 cm W with no depth and no drainage. The tissue was described as "subq" and the treatment was [MEDICATION NAME] (treatment cream that prevents infection). - 9/28/12 - The left heel Stage III ulcer measured 4 cm L by 4.25 cm W with no depth and no drainage. The tissue was described as "subq" and the treatment was Santyl chemical debridement (sterile ointment to remove dead tissue). Review of a Pressure, Stasis, and Other Ulcer Flowsheet for the right heel dated 9/13/12 to 9/28/12 revealed the following: - 9/13/12 - A Stage III diabetic ulcer on the right heel measured 5 cm L by 4 cm Width with no depth and no drainage. The tissue was described as granulation (formation of tissue in the process of healing) tissue and the treatment was an Allevyn dressing. - 9/20/12 - The right heel Stage III ulcer measured 5 cm L by 4 cm W with no depth and no drainage. The tissue was described as eschar and treatment was [MEDICATION NAME]. - 9/28/12 - The right heel Stage III ulcer measured 5 cm L by 4.5 cm W with no depth and no drainage. The tissue was described as eschar and the treatment was Santyl chemical debridement. Review of an undated Physician's Telephone Order signed by the physician on 9/25/12 revealed an order for [REDACTED]. Observation of the resident on 10/1/12 at 2:40 PM revealed the resident was sitting in a wheelchair in her room. The resident had slipper socks on both of her feet and her feet were resting directly on the foot pedals of the wheelchair. The resident was not wearing heel cushions or heel protection and there were no heel pressure relieving devices in place. During an interview on 10/1/12 at 3:30 PM, the day shift Certified Nurse Aide (CNA) assigned to the resident stated that Resident #126 requires the assistance of two for transfers. The CNA explained that the CNAs put heel booties on the resident's feet when in bed and "maybe a pillow under her legs if she wants one to keep them up a little". The CNA stated there is a treatment provided to the resident's foot but that the nurses monitor it. Observation of the resident's heels on 10/3/12 at 9:00 AM revealed the eschar on the right heel was black in color and the posterior edges of the blackened area were pulling away from the heel. The irregularly shaped blackened area on the right heel measured approximately 5 cm. The resident's left heel was observed to have blackened eschar measuring approximately 4 cm in diameter (round in shape). The edges of the black eschar on the left heel were peeling away from the heel. During an interview on 10/3/12 at 2:06 PM, an evening shift CNA stated she has taken care of the resident since the resident was admitted . The CNA stated that she bathes the resident at night and noticed that the resident had round, reddened areas on the left heel a couple of weeks ago. The CNA stated she reported it to a nurse but does not remember who. The CNA stated did not see the resident's heels again because they were wrapped up. Observation on 10/3/12 at 2:10 PM revealed Resident #126 was sitting in a wheelchair in her room with socks covering only her toes and dressings on both heels were intact. Both feet were resting directly on the wheelchair pedals and there was no pressure relief device in place. When interviewed again on 10/3/12 at 2:26 PM, the evening shift CNA stated there were no special instructions (regarding the provision of pressure relief) for the resident's feet or legs when out of bed. The CNA stated there was nothing on the CNA Kardex about pressure relief for the resident's heels when out of bed and there was no care plan for putting the resident's blue booties on. The CNA stated she put the booties on the resident when she was in bed because the booties are in the room. The CNA stated she does not elevate the resident's legs when in bed. The CNA stated she might have been told to elevate the resident legs in bed, "but it might have slipped my mind". When interviewed on 10/3/12 at 2:55 PM, the Physician stated Resident #126 has an open area on her heel but doesn't remember if the area is on one heel or both heels. The Physician stated she became aware of the heel ulcers at the end of August and they put heel booties in place. The Physician stated that facility staff told her there was a lot of eschar on the heels but she did know what they looked like now. The Physician explained that the resident has vascular issues in her legs and feet and she saw a specialist earlier this summer. When asked if she thought that the areas on the resident's heels are pressure related, the Physician stated considering the resident's venous issues, the pressure on her heels when she has "her feet on the wheelchair pedals doesn't help". When asked if pressure was a contributing factor to the resident's heel ulcers, the Physician replied "yes". During an interview on 10/3/12 at approximately 4:00 PM, the Administrator, DON and ADON were asked if any additional information was available. At 5:00 PM on 10/3/12, the Administrator provided a manilla folder containing faxed Podiatry notes. Review of a typewritten Podiatry Visit Note dated 8/31/12, (faxed to the facility on [DATE] at 4:54 PM) revealed the resident had Type 2 diabetes for years and currently had a 1 cm diameter right ankle ulceration. The Podiatrist documented that the resident had a 4.0 cm by 2.0 cm by 2 mm (millimeter) ulcer on the heels and that the "ulcerations are superficial pressure ulcerations". The Podiatrist documented "patient needs to have off-loading heel pads". Review of a typewritten Podiatry Visit Note dated 9/18/12 (faxed to the facility on [DATE] at 4:54 PM) revealed the resident had bilateral heel ulcerations and the right leg venous ulcer was healed. The Podiatrist documented that the resident had Allevyn type dressings on both heels and was "not wearing heel off-loading boots as was recommended at last visit. The bandages have a slight odor to them". The Podiatrist's exam revealed that the right heel ulcer measured 3.0 cm by 3.0 cm by 5 mm and was draining; had an escharotic base, was malodorous and was weeping. The ulcer on the left heel measured 3.0 cm by 3.0 cm by 5 mm and was draining, had a granular base, was malodorous, and weeping. The Podiatrist documented that the resident "needs to have off-loading heels boots to be worn at all times. This was discussed with the aide present at last visit who said he would be sure this would be done and obviously hasn't happened". 415.12

Based on observation, record review and staff interview, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility utilizes multiple methods to identify residents' resuscitation status and failed to consistently identify the correct status for three (Residents #1, 4, 8) of 21 residents. Nursing and non-nursing personnel were not knowledgeable and had conflicting information regarding the facility's procedures on how to identify residents' resuscitation status and how to respond to a medical emergency. In addition, the facility policy for DNR (Do Not Resuscitate - to withhold CPR if an individual stops breathing and/or their heart stops) identification did not reflect the procedures that staff were currently following to identify residents' resuscitation status. Resident #1 had a physician's orders [REDACTED]. List. Resident #4 had a physician's orders [REDACTED]. In addition, there were incorrect identifiers in the resident's chart and room, indicating the resident was a Full Code (requiring CPR). Resident #8 had an order for [REDACTED]. This was a pattern of no actual harm that is IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed on [DATE], prior to the completion of the survey. The findings are: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the medical record Face Sheet revealed the resident was admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognition was severely impaired. Review of physician's orders [REDACTED]. Review of the current, undated Care Kardex, used by certified nurse aides (CNAs) to provide care, revealed Resident #1 was identified as a Full Code (provide CPR). Review of a facility policy and procedure (P&P) entitled DNR (Do Not Resuscitate) Identification dated ,[DATE] revealed the following: - Residents are identified as a Full Code by placing a green sticker on the binder (spine) of their chart - Residents are identified as a DNR by placing a red sticker on the binder of the chart - A weekly, updated Census Sheet, containing residents names and room numbers, will have a heart printed next to the name of each resident who is a Full Code. The Census Sheet will be distributed to each department to identify residents' resuscitation status when they are off of the nursing units (Physical Therapy, Occupational Therapy, Activities, etc.). Interview with the Medical Records Clerk on [DATE] at 10:40 AM revealed the Medical Records department is responsible for updating the weekly Census Sheet. Review of the current Second Floor Census Sheet dated [DATE], on [DATE] at 6:10 PM, revealed that Resident #1's name was on the list and there was no heart next to the resident's name. The Census Sheet was kept on a clipboard that was located on the Second Floor Nurse's Desk. Review of previous weekly Census Sheets dated [DATE], [DATE], [DATE] and [DATE] revealed Resident #1 was listed on the sheets and did not have a heart symbol next to her name indicating that she is to be resuscitated. Review of Physical Therapy and Occupational Therapy Modality Spreadsheets dated [DATE] to [DATE] revealed Resident #1 attended Restorative Therapy five times per week. Interview with the Physical Therapist on [DATE] at 3:55 PM revealed he did not have a Resident Census List available to him in the Physical Therapy (PT) department (located in the basement) that day. The Physical Therapist explained that residents' DNR status is written on the binder of the chart and before he takes a resident to physical therapy, he checks the status. The Physical Therapist stated that he knew the residents' charts were color coded but was not sure what the colors meant. The Physical Therapist stated that if any resident became unresponsive in the PT department, he would call Code Blue (the announcement of a medical emergency) overhead for a medical emergency. Interview with a Certified Occupational Therapy Aide (COTA) on [DATE] at 4:00 PM revealed she did not have a Resident Census List available to her in the Occupational Therapy (OT) department (located in the basement) that day. The COTA stated that she knew residents' name bands and charts were color coded but she did know what the colors meant. The COTA stated that if a resident became unresponsive in the OT department, Code Blue is called overhead for medical emergencies. Interview with the Activities Director on [DATE] at 4:10 PM revealed there is a Resident Census List sent out weekly to program directors that identifies residents' code status. The Activities Director stated she had a list dated [DATE] that was the most current list available. The Activities Director explained that residents with a heart next to their name on the list were Full Codes. The Activities Director stated she would call overhead for a nurse "stat" (immediate) to the activities department, if she had a medical emergency. Interview with the Assistant Director of Nursing (ADON) (Registered Nurse (RN) #2) on [DATE] at 9:30 AM revealed she was not aware there was a facility Census List that identified residents' resuscitation status. Interview with the RN Evening Supervisor (RN #1) on [DATE] at 4:33 PM revealed she was not aware there was a Census List that documented Full Code and DNR status. Observations on [DATE] at 11:30 AM and 4:15 PM revealed Resident #1 was wearing a white name band on her right wrist with a green dot on it identifying that she wished to be resuscitated. Observation of the resident's room revealed there was no identifier over the bed to indicate the resident's resuscitation status. During an interview on [DATE] at 9:30 AM, the Director of Nursing (DON) was asked if she was aware that there were discrepancies regarding the identification of residents resuscitation status and that there were procedures being followed by staff that were not documented in the facility's DNR Identification policy. The DON replied "no". The DON was asked to explain the facility's process on how to identify and communicate a resident's code status. The DON stated that the Social Worker is responsible to send an e-mail to the Medical Records department identifying whether the resident is a Full Code or a DNR. Medical Records staff then place the correct color sticker on the resident's name band, on the wall above the back of the bed, on the spine of the medical record and on the Face Sheet. Medical Records staff also update the Census Sheet. The DON explained that a green sticker identifies a Full Code and a red sticker identifies DNR. When asked if the facility audited the implementation of the DNR policy or conducted any Code drills, the DON replied "no". Further interview with the DON revealed that she had provided training to nursing staff in ,[DATE] entitled "Resident Rights, DNR, CPR". When the DON was asked what was specifically covered in the education, she stated "Census Sheet Updates; the use of name bands with green and red dots; and green and red dots on the wall behind the resident's bed and on the spine of the chart and on the face sheet". The DON stated she also reviewed the fact that the facility has a code team and that staff should call Code Blue to summon help in a medical emergency. During the interview, it was learned that the DON did not know that the procedures that were taught to staff in ,[DATE] were not included in the facility P&P for DNR Identification. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Nonhospital order Not to Resuscitate (DNR Order form) signed by the Physician on [DATE] revealed Resident #4 was a DNR. Review of a physician's orders [REDACTED]. Observation on [DATE] at 1:30 PM revealed there was a sign on the wall over the resident's bed that had a green dot on it. Interviews with a Second Floor Licensed Practical Nurse (LPN #4) on [DATE] at 1:15 PM and 1:30 PM revealed the facility policy to determine a resident's resuscitation status included a green dot indicating the resident is a Full Code and a red dot indicating DNR. LPN #4 explained that the facility uses the dot system on the spine of a resident's chart, in the chart, on the name band and over the head of the bed. The LPN stated that Resident #4 has a green dot over his bed which means he is a Full Code and if the resident went into [MEDICAL CONDITION] (absence of a heart beat and blood pressure), "staff would yell Code Blue and begin resuscitation measures". Observations on [DATE] at 12:50 PM, 12:55 PM and 1:30 PM revealed that Resident #4 was wearing a white name band on his left wrist that did not identify the resident's resuscitation status. Observation of the resident's chart on [DATE] at 12:50 PM revealed the chart had a red dot (indicating DNR) on the spine of the binder and a green dot (indicating Full Code) on the Face Sheet. During interviews on [DATE] at 4:35 PM and 6:20 PM and on [DATE] at 7:55 AM, the LPN Nurse Manager (LPN #6) stated that Resident #4 should have a red dot above his bed and not a green one and that Resident #4's face sheet was also incorrect. The LPN Nurse Manager stated that several residents did not have signs above their beds (about 10) and they have now all been replaced. During an interview on [DATE] at 9:30 AM, the Registered Nurse (RN) Assistant Director of Nursing (ADON) stated that she was not aware of any list (Census List) that identified residents' DNR/CPR wishes. During an interview on [DATE] at 6:10 PM, LPN #7 who works on the Second Floor stated if a resident was found unresponsive, she would yell for help. Interview with CNA #4 who works on the Second Floor on [DATE] at 7:15 PM revealed if she found a resident unresponsive she would yell Code Blue or Code Red, but she wasn't sure which one. Review of the facility DNR P&Ps revealed an untitled, undated paper documented that "Code Blue" is used for a medical emergency and "Code Red" is for a fire. 3. Resident #8 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident has severely impaired cognition, short and long term memory impairment, and an altered level of consciousness. Review of a Nonhospital Order Not to Resuscitate (DNR Order) form signed by a physician dated [DATE] and physician's orders [REDACTED]. Observation on [DATE] at approximately 11:30 AM revealed there was a green sticker on the wall above the resident's bed. Interview with CNA #1 at the time of the observation revealed the green sticker on the wall indicated that the resident is a Full Code and wants CPR. The CNA said she was surprised that the green sticker above Resident #8's bed was incorrect. The CNA explained that a red sticker on the wall above a resident's bed would indicate the resident is a DNR and does not want to be resuscitated. Observation of the resident's wrists revealed there was no name band. The CNA stated that the resident should have a name band on with a red sticker. CNAs #1 and #2, who work on the First Floor were interviewed on [DATE] at 1:30 PM and 2:50 PM. When asked what they would do if they came upon an unresponsive resident, CNA #1 stated he would put the call light on and yell "Code Red". CNA #2 stated she would yell for the nurse and say "Code Red". During an interview on [DATE] at 3:40 PM, LPN #1 who works on the First Floor stated that if a CNA comes across an unresponsive resident whose chest is not moving, they are expected to put the call light on, get the nurse and yell "Code Red". Further review of the facility's DNR P&P revealed an untitled, undated paper documented that "Code Red" is used for a fire. Further observations on [DATE] at 6:36 PM and [DATE] at 8:25 AM revealed Resident #8 did not have a name band on and continued to have a green sticker on the wall above his bed. Interview with the Administrator on [DATE] at approximately 3:15 PM revealed the stickers on the wall above the resident's bed and on the resident's name band should be green when a resident wants to be resuscitated, and should be red when a resident does not want resuscitation. The Administrator stated that he should be aware if there are problems with identifying residents' resuscitation status, but he was not aware there was a problem since no concerns had been brought to the attention of the Continuous Quality Improvement (CQI) Committee. Interview with the Social Worker on [DATE] at approximately 4:30 PM revealed it is her responsibility to review residents' advance directive status and to assure the residents' status are current and correct. The Social Worker stated that review of residents' advance directive follow the Minimum Data Set (MDS) schedule; residents are reviewed every 90 days or when there is a significant change in the resident's condition. The Social Worker stated she has not identified any problems with the identification of residents' advance directive status. Review of the facility "DNR Identification" P&P dated ,[DATE] revealed the P&P did not reflect the identification process that was actually being followed by facility staff. The P&P did not document that stickers on the bedroom wall and name bands were a method to identify residents' resuscitation status. 4. During an interview on [DATE] at 12:10 PM, the Administrator stated actions were taken to remove the Immediate Jeopardy situation in the facility. a). Review of a letter to the New York State Department of Health, signed by the Administrator, dated [DATE] revealed the following: - Each resident in the facility was reviewed for accurate identification of their resuscitation status in accordance with the facility coding system. Green (Full Code) or Red (DNR) dots were placed on the spine of the charts, Face Sheets, over the head of the bed and on residents' name bands. - In-house staff education for all three shifts was completed regarding code status identification and proper announcement of emergencies. - Policies and procedures were revised to reflect the changes to the advance directive protocol within the facility. - The new Medical Records Clerk was retrained regarding the revised policies and procedures. - Signs were posted on all floors to remind staff of appropriate emergency announcements. b). Review of the revised DNR Identification P&P dated [DATE] revealed specific steps the facility will take to assure a consisted pattern is followed by staff in identifying residents' CPR/DNA status. This includes the job responsibilities of specific staff, as well as back-up personnel. c). Review of facility Inservice Record Sheets dated [DATE] through [DATE] confirmed that staff education for personnel on all three shifts was completed. Provisions were made for education and training to continue on an on-going basis. Training consisted of code status identification, proper coding utilized within the facility, proper announcement of emergencies, and use of the facility internal Census Sheet. d). Observations on [DATE] revealed the following: - Medical Emergencies Call Posters were placed throughout the facility to assist staff in identifying Full Code (CPR), DNR CODE, and the Fire Emergency Code. - At approximately 8:00 AM, Resident #1 had a green sticker over her bed. The revised Census List dated [DATE] documented that the resident was a Full Code. - At approximately 9:00 AM, Resident #4 had a red dot on his name band and on the wall over his bed. - At approximately 5:00 PM, Resident #8 had a red dot on his name band and a red dot on the wall over his bed. 415.12

Based on observation, record review and resident and staff interview, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. One (Resident #3) of one resident reviewed for indwelling urinary catheters ( Foley catheter - tube inserted into the bladder to drain urine) had issues involving lack of evidence that a trial without the catheter was attempted prior to hospitalization [DATE]. In addition there was no documented evidence that the resident was educated about the risks of continued use of a Foley catheter. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #3 has [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] indicated the resident was cognitively intact and had occasional bladder incontinence. On 9/6/11 at 1:20 PM, the resident was observed sitting in a wheelchair near her bed. During an interview at the same time she stated "I just got back from the hospital". "I got an infection in my bladder and kidneys. They said I had the catheter in too long". At this time the resident was not observed to have a Foley catheter. She went on to say that it (Foley catheter) was put in last December because she was having problems but that they never tried to take it out despite her asking the staff if they were going to take the Foley catheter out and she got an infection. The resident added that since the hospital took it (the Foley catheter) out she has been okay but is occasionally incontinent. Review of the medical record revealed: - Nurses Notes from 12/12/10 to 12/19/10 indicated that the resident was having increased urinary frequency and was very demanding, requesting the bed pan frequently. Further review of the same Nurse's Notes revealed that a new medication, [MEDICATION NAME] (a medication to decrease bladder spasms), was ordered for the resident with some improvement noted with the resident's frequency of urination. - A physician progress notes [REDACTED]. - A physician progress notes [REDACTED]. - Unsigned Physician Telephone Orders dated 12/19/10 revealed an order for [REDACTED]. - A Nurses Note dated 12/19/10 revealed a Foley catheter was inserted for urinary frequency per Physician orders [REDACTED]. There is no documented evidence that the 250 ml of urine was a post void residual or that the resident was consulted or educated about the long term use of a Foley catheter or was involved in the care decision. - A Urology Report of Consultation dated 1/3/11 indicated the consult was to rule out a bladder cyst secondary to frequency and incontinence. A [DIAGNOSES REDACTED]. - A Urology Report of Consultation dated 2/15/11 reported that the cystoscopy (procedure that [MEDICATION NAME] the inside of the bladder) was done which indicated bladder function was normal and no tumors were seen. The consult also indicated that the resident had a [DIAGNOSES REDACTED]. There was no documented evidence that the resident had a [DIAGNOSES REDACTED]. - A physician progress notes [REDACTED]. The Nurse Practitioner added that the resident was being followed by the urologist for urinary incontinence due to frequent UTIs. There is no further documentation by medical personnel including the urologist regarding the Foley catheter until the resident's hospital admission on 8/28/11. - Physician order [REDACTED]. - Nursing Treatment records indicated the Foley was changed monthly from 12/19/10 until discharge to the hospital on [DATE]. Review of initial untimed Nurse's Notes dated 8/28/11 written by the Registered Nurse (RN) revealed the resident was very confused and disoriented with tremors noted in both upper extremities. The Foley output was observed to be dark and concentrated. Abnormal VS (vital signs) included a BP (blood pressure) of 215/104 and P (pulse) of 100, both above normal. Further review of Nurse's Notes written at 4:45 PM on 8/28/11 revealed the Physician was notified and the resident was transferred to the hospital at 5:00 PM. Nurse's Notes written by the RN on 8/28/11 at 8:00 PM revealed the resident was admitted to the hospital with [REDACTED]. Review of a hospital Discharge Summary dated 8/31/11 revealed that the resident was admitted to the hospital on [DATE] and diagnosed with [REDACTED]. The Discharge Summary also documented that at first the family was resistant to removing the Foley catheter due to the resident's past skin issues but the catheter was discontinued once the family was informed of the infection risk if the Foley catheter was left in. The Foley catheter was removed and recommendations at that time included toileting every 2 hours and possible anti-spasm medication. In an interview with the Licensed Practical Nurse (LPN) Nurse Manager (NM) on 9/8/11 at 7:50 AM and again on 9/9/11 at 7:30 AM she stated that Resident #3 had a lot of urine infections and some retention and she thought that the family wanted the catheter to stay in. She added that a Foley catheter removal was never attempted as far as she knows and it was never discussed in care plan meetings because Resident #3 has not had a care plan meeting since 11/10 which was before the resident had the Foley catheter. The NM further stated that she was not aware of any resident or family education regarding the risks of keeping the Foley catheter in long term. When interviewed on 9/9/11 at 12:05 PM the Physician stated that the Foley was left in because of urine retention. He did not recall any attempt to remove the Foley and could not recall if any education was done with the resident/family regarding the risks of long term use. The Physician added that he is aware of the risk of infection with long term catheter use but that a lot of people have Foley catheters for retention. The Physician added that the hospital took the catheter out due to an infection and the facility has not replaced it because the resident was voiding on her own. During an interview with the Director of Nursing (DON) on 9/9/11 at 2:30 PM the DON stated that a trial of removing the Foley catheter was never attempted because nurses could not remove the Foley catheter without a Physician order. The DON went on to say that they discussed the continued use of the resident's catheter in Quality Assurance meetings and it was thought to be ok to leave the catheter in because there was a [DIAGNOSES REDACTED]. 415.12(d)(1)