Every finding on record at Fordham Nursing and Rehabilitation Center

Based on observation, interviews, and record review conducted during an Abbreviated Survey (2582483), the facility did not ensure a resident received adequate supervision and assistance consistent with the resident's needs to prevent accidents. This was evident for one (1), (Resident #2) out of five (5) residents reviewed and sampled. Specifically, during a review of the facility's surveillance video footage dated from 07/10/2025 at 07:58 PM to 07/12/2025 at 03:29 PM, showed on 07/10/2025 from 08:36 PM to 08:42 PM for six minutes, Resident #2 entered and exited Resident #1's room unsupervised. Three other residents reside in the room with Resident #2 (Resident #3, Resident #4, and Resident #5). No staff were seen on the surveillance redirecting Resident #2 from going into other Residents' rooms.The findings are: The facility's Policy and Procedure entitled Behavior Management Strategies, dated 08/05/2020, documented that it is the policy of the facility to provide the best quality of life and quality of care to residents with behavioral health needs. The purpose of the policy is to manage residents' behavior, direct and motivate residents to change their actions or interactions in certain settings, and guide staff on effective interventions to de-escalate behaviors. Behavioral symptoms which residents may exhibit include but are not limited to wandering into others' rooms/spaces.Resident #2 was admitted to the facility with diagnoses including vascular dementia (decline in mental abilities, such as memory and thinking), alcohol dependence, and adult failure to thrive (a syndrome characterized by weight loss, decreased appetite, reduced physical activity, and decline in overall health in older adults). The Minimum Data Set (a resident assessment tool) dated 07/10/2025, documented that Resident #2 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information), documenting that Resident #2's cognition was severely impaired.A Care Plan for Resident #2 titled elopement risk /wanderer was initiated on 11/4/2021, with a target date 10/14/2025, documented interventions that included hourly check and wander alert. A Behavior Care Plan initiated on 08/04/2022, documented Resident #2 exhibited physical and verbal aggression with interventions to provide a calm structural environment, and to offer diversional activities. A review of the Documentation Survey Report (Certified Nursing Assistant Accountability) dated 07/01/2025 to 07/31/2025 documented Resident #2 was monitored hourly every shift for unsafe wandering/elopement. A review of video footage recorded on 07/10/2025 at 7:58 PM showed that Resident #1(female) was brought from the hospital via stretcher by two attendants. Resident #2 (male) wandered into Resident #1's room at 8:36 PM and exited at 8:42 PM. Resident #2 was in the room for six minutes unsupervised. No staff member redirected Resident #2. Resident #1's three roommates (all cognitively impaired) were in the room at the time. Resident #2 was observed entering approximately one minute on multiple occasions Resident #1's room on 07/11/2025 at 10:45 AM, at 10:51 AM, at 11:07 AM, at 11:20 AM, at 02:11 PM, at 02:58 PM, at 03:09 PM, at 03:14 PM, at 03:39 PM, at 03:44 PM, at 03:50 PM, at 04:12 PM, at 04:39 PM, at 04:43 PM, at 04:50 PM, at 05:01 PM, at 05:06 PM, at 05:10 PM, at 05:15 PM, at 05:25 PM, at 05:29 PM, at 05:37 PM, at 05:43 PM, at 05:48 PM, at 07:48 PM, at 07:55 PM. On 07/12/2025: at 07:21 AM, at 11:51 AM, at 12:16 PM, 12:39 PM, and 12:45 PM. Resident #2 (male) was also observed going in and out of other residents' rooms. During an interview on 08/08/2025 at 2:45 PM, Certified Nursing Assistant #3, who was assigned to Resident #2 on 07/10/2025 and 07/11/2025, 3-11 shift, stated that Resident #2 has wandering behavior and enters other residents' rooms. Certified Nursing Assistant #3 stated that they know Resident #2 goes to their room to look in the window but does not bother anyone. Certified Nursing Assistant #3 stated that Resident #2 starts walking around as soon as they wake up, and they are monitoring them hourly. Certified Nursing Assistant #3 stated that they are responsible for monitoring Resident #2 and preventing them from entering other rooms. Certified Nursing Assistant #3 stated they redirected Resident #2 when they saw them entering another room. During an interview on 08/08/2025 at 04:45 PM, Resident #1's roommate (Resident #3), who had moderately impaired cognition, stated that a man was coming to their room, and looked out the window. Resident #3 stated that the man did not bother them and never touched them. Resident #3 stated that they shouted at the man, and they left the room. Resident #3 stated that the man is good, but they do not want the man to come into their room because they do not know what the man will do. During an interview on 08/08/2025 at 11:15 AM, Registered Nurse #2 stated Resident #2 has a Dementia diagnosis, ambulates independently, and likes to go to other residents' rooms to look in the window. Registered Nurse #2 stated that Resident #2 was on hourly monitoring, and if staff saw Resident #2 go to other rooms, they would redirect them. Registered Nurse #2 stated that all Certified Nursing Assistants on the unit are responsible for monitoring Resident #2's behavior and preventing them from entering other residents' rooms. During an interview on 08/11/2025 at 2:10 PM, Registered Nurse Supervisor #1 stated they are usually assigned Resident #2's unit. Registered Nurse Supervisor #1 stated Resident #2 does wander on the unit, but they have not been involved with any inappropriate behavior on the unit. Registered Nurse Supervisor #1 stated that Certified Nursing Assistants perform hourly rounding during awake hours and every two hours during sleeping hours. Registered Nurse Supervisor #1 stated that since Resident #2 is roaming on the unit, it's easy for the Certified Nursing Assistants to locate Resident #2. During an interview on 08/11/2025 at 12:27 PM, the current Director of Nursing stated that the Resident #2's care plan addressed the behavior of wandering. The Director of Nursing stated that staff were in-serviced on proper monitoring and rounding to ensure residents who wander are safe and redirected appropriately. During the subsequent interview on 08/21/2025 at 1:45 PM, the Director of Nursing stated that all staff on the unit, including Certified Nursing Assistants, recreation staff, and nurses responsible for monitoring residents who wander and preventing them from entering other residents' rooms. The Director of Nursing stated that nurses on the unit and supervisors are responsible for ensuring that staff properly monitor residents through rounding and spot checking. During an interview on 08/08/2025 at 12:30 PM, the Administrator stated that during camera review, they saw Resident #2 entering Resident #1's room, but the resident is harmless and only goes to the room and looks out the window. The Administrator stated that Resident #2, in the past, resided in other units and was not suitable there due to aggressive behavior. 10 NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure infection control practices were followed. This was evident during the Dining Task for 1 of 5 dining rooms. Specifically, 1. The kitchen did not ensure that food items were discarded by the use/expiration date. This was evident for the Kitchen Task. 2. Certified Nursing Assistant #8 did not perform hand hygiene in between residents while assisting multiple residents with hand hygiene prior to lunch being served this was evident for the 5th floor. The findings are: The facility policy titled Standard Precautions for Infection Control that was revised on ,d+[DATE] and reviewed [DATE] documented, It is the policy of the facility to follow and apply standard precautions as infection prevention measure during all resident care regardless of suspected or confirmed infection status of the resident. Standard precautions is based on the principle that all blood, body fluid, secretions, excretions except sweat, regardless of whether they contain visible blood, non-intact skin and mucous membranes may contain transmissible infections agents. Hand hygiene before and after contact with the resident. 1. During observation of the kitchen task on [DATE] from 09:20 AM- 09:54 AM the following was observed: In the emergency food storage area they were 4 boxes of Chefler Foods mayonnaise containing 200 -,d+[DATE]-ounce pouches of mayonnaise with a use by date of 12 [DATE] and 1 box of mayonnaise with expiration date of [DATE]. On [DATE] at 12:20 PM, an interview was conducted with the storeroom person who stated they are in charge of the storeroom and the emergency food room. Last week or prior week they noticed a few expired items that included canned food and enteral feeding and the items were discarded. They saw the mayonnaise in the storage room ,d+[DATE] weeks ago. It was an old delivery, and they are not sure when it was received. They rotated items this month for all food items. The mayonnaise in individual packets are only placed in the storeroom. There should not be any expired food items in the storeroom. They use first in first out and they are in-serviced on it daily. It was a mistake that the expired food item was still there. On [DATE] at 09:18 AM, Food Service Supervisor # 1 was interviewed and stated; I look at items in the storeroom daily and I take expired items and throw them out. Last Friday was the last time I looked at the emergency food storage room and noticed expired items of mayonnaise and threw out on Monday. They stated that on Friday everything was good, and it was on Monday that they found the expired items. We cannot give expired food to the residents, and it will be bad if we give to the residents. They have to make sure food is in good condition. If it is one to two days before expiration date, we throw the food item out. The staff are in-serviced every time we receive items. We put the older items in the back and the dates to use up first. During an interview on [DATE] at 11:21 AM, Food Service Supervisor # 2 was interviewed and stated that they look at the food items daily and at all items for meals. They look at the emergency food daily. No items were expired in the emergency food room that they noticed. They stated they were not informed of the expiration of the mayonnaise. They stated it was curious that they did not notice. The food items needed to be discarded so we won't get risk from expired items and so there is no cross contamination. They stated moving forward they are aware that they need to check more closely for dates of food products. On [DATE] at 11:27 AM, the Dietary Director was interviewed and stated; they look at the storeroom every 6 months and do a thorough check. They stated 1 to 2 times a month they look at food items. They did not notice the items before. We don't want to get anyone sick, and it is something we overlooked and when items come in and when expired. This is something that rarely happens. On [DATE] at 1:05 PM, the Infection Preventionist was interviewed and stated; they inspect the kitchen environment to include the storage room. They look at the expiration date of items in the kitchen storage room. They stated they have not looked at the emergency food. We cannot give expired food which can cause infections and diarrhea. The expiration date is very important. They stated they have not done an in-service on expired items for the kitchen. Mayonnaise if it is expired and not at the correct temperature can give bacteria and cause vomiting among residents. 2. During dining observation on [DATE] between 12:25 PM and 12:31 PM, Certified Nursing Assistant # 5 was observed passing out hand wipes from the dining table on the left side of the room to the right side of the room and assisting residents with hand hygiene by passing out the hand sanitizing wipes in the dining room with bare hands and assisting residents who needed assistance to clean their hands. Certified Nursing Assistant #5 assisted Resident #134 in cleaning their hands with wipes, Certified Nursing Assistant #5 then took additional clean hand wipes from the container and passed the wipes to additional residents who did not require assistance with hand hygiene and then proceeded to assist the following residents to perform hand hygiene with their bare hands, Resident #114's, #176's, 130's and #56. Certified Nursing Assistant #5 did not perform hand hygiene in between residents. On [DATE] at 12:54 PM, Certified Nursing Assistant #5 was interviewed and stated; they are aware that they did not do hand hygiene between residents and there was no reason why it was not done. They further stated that for infection control we don't want to cross germs from one resident to another. Certified Nursing Assistant #5 stated they were supposed to clean their hands in-between residents to prevent the spread of germs from one resident to another. They were supposed to clean their hands for infection control in between residents but they did not do so. On [DATE] at 03:50 PM, Registered Nurse #7 was interviewed and stated; that staff will prepare residents for dining by doing hand hygiene. If staff pick up hand wipes, they are to clean their hands. Residents should be given separate hand wipes. For infection control there are germs, and they can pass from hand to hand, so staff wash their hands before they assist residents. We might get another bacteria or germs from resident to control infection. We make sure we wash hands before touching another resident. We remind staff and staff are re-inserviced. On [DATE] at 03:55 PM, Registered Nurse #8 was interviewed and stated; they are in the dining room during lunch to make sure that the certified nursing assistants wash their hands and kitchen staff washes their hands as well. Certified Nursing Assistants offer hand wipes to each resident in the dining room as well as residents in their rooms before meals. For infection control don't want to spread bacteria from resident to resident and from staff to protect self as well. There has been recent inservice on hand hygiene. On [DATE] at 12:58 PM, the Infection Preventionist was interviewed and stated; they do rounds in the mornings on all floors, they look at personal protective equipment supplies, before lunch and during dining. They observe cleaning of the dining room. They set up and randomly pick a floor for observing the cleaning of residents hands. They stated they have done in-services in relation to hand hygiene as needed. Hand hygiene is for us not to give residents an infection if they have an open site. They do random checks when they do rounds and knock on doors to observe staff are wearing the correct personal protective equipment. 10 NYCRR 415.19(b)(4)

Based on interview and record review conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was 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, to the New York State Department of Health. This was evident for 1 (Resident #209) out of 5 residents reviewed for Accidents out of 37 total sampled residents. Specifically, the facility did not report an incident when Resident #209 was found on the floor with laceration on the hand and a head contusion, to the New York State Department of Health. The findings are: The facility's policy and procedure titled, Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/Exploitation and Mistreatment reviewed 10/2022 documented the facility shall ensure that alleged violations involving mistreatment, neglect, or abuse including significant injuries of unknown source are reported immediately to the Administrator of the facility or designee. When required by regulation, the facility shall ensure timely notification to the Department of Health. Resident #209 admitted to the facility with diagnoses of Hypertension, Hyperlipidemia and Non-Alzheimer's Dementia. The Minimum Data Set, dated dated dated [DATE] documented cognition is severely impaired; had short-term memory problem. Resident #209 is dependent on staff assistance to roll left and right, sit to lying and lying to sitting on side of bed, and chair to bed transfer. The Comprehensive Care Plan for Actual Fall revised 9/18/2024 documented Resident #209 had an unwitnessed fall on 9/15/2024 with injuries. The Nursing Note dated 9/15/2024 documented, Resident #209 was found on side of bed on floor, unable to determine cause of fall due to language barrier. Resident was noted with contusion to right posterior head and skin tear to the right hand. Physician was notified and ordered the resident transfered to the hospital. The Physician Order dated 9/15/2024 documented Resident #209 to transfer to hospital for status post fall with injury. The Occurrence Investigation Form completed 9/15/2024 documented on 9/15/2024 at 10 AM, Resident #209 was found on floor by the bed; noted contusion to right posterior head and skin tear to the right hand. It documented that it was an unwitnessed occurrence. Resident #209 did not provide any explanation/statement about the occurrence. The review of Accident Report and Investigation Forms revealed there is no documented evidence that Resident #209 provided a statement about the incident that occurred on 9/15/2024. The Hospital Discharge Summary dated 9/18/2024 documented Resident #209 was admitted following a fall with head trauma at the nursing home. Resident noted with hematoma on right side of scalp and skin tear to right hand. Resident was treated with staples to the scalp and skin tear with Steris strips. The facility's Investigation Summary documented that on 9/15/2024 at 10 AM, Certified Nurse Aid responded to a noise and observed Resident #209 on the floor beside the bed. Resident #209 was unable to provide any information regarding the fall secondary to their cognition. Upon assessment, Resident #209 was noted with a contusion to their scalp and skin tear to the right hand. Resident was transferred to the hospital and was treated with staples applied to the scalp, adhesive strips to the hand. The investigation concluded that resident rolled out of bed sustaining injuries to head and hand due to poor awareness of the bed boundaries. There was no abuse, neglect or mistreatment that occurred to Resident #209. It further documented that as a result of this investigation, this incident will not be reported to Department of Health. The investigation summary with conclusion was signed by Director of Nursing Services and Administrator on 9/18/2024. There was no documented evidence the facility reported Resident #209's unwitnessed fall incident, resulted in injuries, to the New York State Department of Health. On 10/24/2024 at 2:56 PM, Director of Nursing Service stated they will report alleged violations involving mistreatment, neglect, or abuse to New York State Department of Health. Director of Nursing Services stated this incident was not reported to New York State Department of Health because staff responded to a loud noise and saw Resident #209 on the floor in the room. This was an unwitnessed fall resulting in injuries. Director of Nursing Service stated Resident #209 went to the hospital for evaluation and returned to the facility with staples on the head and skin tear treated from the hospital. The investigation concluded that Resident #209 rolled out of the bed resulting in those injuries and that there was no suspicion of resident-to-resident altercation, or staff abuse. On 10/24/2024 at 4:19 PM, Administrator could not recall if they were on duty but stated they were notified about this incident immediately after it occurred on 9/15/2024. Administrator stated the incident was not reported to the New York State Department of Health because resident had a fall incident and ruled out that abuse occurred. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interview conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 of 1 resident observed for tube feeding. Specifically, Enhanced Barrier Precautions were not maintained during tube feeding administration for residents with gastrostomy tubes. (Residents #187) The findings are: The Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum titled Enhanced Barrier Precautions in Nursing Homes, Ref: QSO-24-08-NH dated 03/20/2024 documented that effective 04/01/2024, Centers for Medicare and Medicaid Services is issuing a new guidance for long term care facilities on the use of enhanced barrier precautions to align with nationally accepted standards. Enhanced Barrier Precautions recommendations now include use of enhanced barrier precautions for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. The new guidance related to enhanced barrier precautions is being incorporated into F880 Infection prevention and Control. The facility policy and procedure titled Enhanced Barrier Precautions effective 07/26/2024 documented all personnel which have direct contact with a resident with indwelling medical devices even if the resident is know to be infected or colonized with a multi drug resistant organism will observe Enhanced Barrier Precautions (EBP). Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities which provide opportunities for transfer of MDRO to staff hands and clothing. 1.) Resident #187 was admitted to the facility with diagnoses that include Dysphagia following Cerebral Infarction. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #187 had moderately impaired cognitive skills for daily decision making and had a gastrostomy tube. A Physician's Order dated 07/10/2024, documented enhanced barrier precautions due to presence of feeding tube. 2.) Resident #60 was admitted to the facility with diagnoses that include Non-Alzheimer's Dementia and Dysphagia. The Minimum Data Set assessment dated [DATE] documented that Resident #60 had severely impaired cognitive skills for daily decision making and had a gastrostomy tube. A physician's order dated 04/15/2024 documented enhanced barrier precautions during high contact resident care activities indwelling medical device gastrostomy tube. Order as of 10/16/2024 documented Enteral Feed four times a day, feed flushed 120 cubic centimeters water before and after. Enteral feeding every shift total formula 24 hours (960 ml rate of flow) 240 cubic centimeters four-time day bolus. Enteral feed every shift feed by pump bolus. Order as of 10/18/2024 documented - Four times a day bolus feeding Glucerna 1.5 240 cubic centimeters four times a day at 10 AM, 2PM, 6PM and 10 PM, 120 cubic centimeters before and after. The Nutritional assessment dated [DATE] documented the following goals include the resident will accept and follow Therapeutic/mechanically altered diet through the review date. Resident will accept and follow Supplement/Nourishment plan to aid with intake/healing/abnormal labs through the review date. Resident will tolerate tube feedings with no nausea, vomiting, diarrhea, constipation, aspiration, abdominal distension. Remain free of side effects/complications, through review date. Resident will maintain adequate nutritional and hydration status and stable weight without significant gain/loss, no signs and symptoms of malnutrition or dehydration, through review date. Resident will be provided and consume adequate fluids to maintain hydration, skin turgor and promote bowel regularity through review date. During medication administration observation on 10/24/2024 at 09:59 AM to 10:14 AM, Licensed Practical Nurse #2 was observed performing the administration of enteral feeding to Resident #187 via gastrostomy tube without wearing a gown. At 9:20 AM, Licensed Practical Nurse # 2 was observed taking a gown into resident #187 room, washed their hands in the sink, put gloves on, placing sterile drape to bedside table, 120 ml cup placed on sterile drape field, the 8 ounce carton box of Glucerna 1.5 carton was opened, the cup was filled with water from the sink, resident bed adjusted up toward the Licensed Practical Nurse #2 between knee and hip height. Gloves were removed and Licensed Practical Nurse #2 washed their hands in the sink and new gloves placed on hands, syringe from piston set reassembled 20 cc air placed and abdomen was auscultated. Free water was placed to gravity feed. No gown was worn by the nurse only gloves were worn. Feeding placed to gravity feed, additional feeding from carton placed in syringe to gravity feed. Licensed Practical Nurse #2 asked resident if they are having any pain at this time. The last among of the tube feeding was administered followed by free water for the Resident #187. the resident stomach to assess their bowel sounds, removed gloves and washed hands placed another pair of gloves on, they administered free water via large syringe and tube feeding and then free water flush after. Licensed Practical Nurse #2 did not put on the isolation gown while administering the free water or tube feeding for Resident #187. At the end of the enteral feeding Licensed Practical Nurse # 2 stated that they forgot to put on the isolation gown when doing the free water and tube feeding for Resident #187. The gastrostomy tube cap was replaced, and Resident #187 bed was adjusted down lower. Licensed Practical Nurse # 2 took their gloves off and washed their hands in the resident sink and they took the unused isolation gown with them. On 10/24/2024 at 10:11 AM, Licensed Practical Nurse #2 was interviewed and stated that they brought the isolation gown in the room but they forgot to put it on. The stated the required personal protective equipment includes a gown, gloves and mask for enteral feeding. They should wear the personal protective equipment to protect the resident from anything that they can carry on their uniform since Resident #187 has an opening on their body. Licensed Practical Nurse # 2 stated that their nerves got the best of them. They stated they had training on personal protective equipment 2 months ago and we have personal protective equipment on the unit. The had enhanced barrier training last week. They stated that they wear gloves all the time and wearing the gown slipped their mind and they understand that it is important to wear the personal protective equipment. On 10/24/2024 at 11:30AM, Registered Nurse #8 was interviewed and stated, that they inform staff about hand washing, personal protective equipment before they start working their shift. They let staff know that they need to wear personal protective equipment for residents on enhanced barrier protections. Patients on enhanced barrier protections have their door labeled. Personal protective equipment is adequate on the cart. For enhanced barrier protection staff should be wearing gloves and mask. There are two residents on the unit on enhanced barrier protection. They stated that they make rounds every hour. For infection control don't want to spread bacteria from resident to resident, staff to resident and to protect staff also. Residents on enhanced barrier protection are more prone to infection or bacteria because of open entry ways. On 10/28/2024 at 12:58PM, the Infection Preventionist was interviewed and stated, they do rounds daily in the morning on all floors and also check the personal protective equipment supplies on the unit and do rounds before lunch and before they leave for the day. For enhanced barrier precautions the staff are required to wear the following personal protective equipment (gown, gloves and surgical mask). Personal protective equipment should be used for us not to give resident an infection since they have an open site and no bacterial infection from our scrubs, and we have to protect the residents. They do random checks when they do unit rounds, and they check that staff are wearing the correct personal protective equipment. On 10/03/2024 at 08:29 AM, the Director of Nursing, who was also the Infection Preventionist, was interviewed and stated that enhanced barrier precautions are required when administering medications to residents with gastrostomy tubes. 10 NYCRR 415.19 (a)(1-3)

Based on interview and record review conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility failed to ensure that the physician reviewed the resident's total program of care at each visit. This was evident for 1 (Resident #74) of 1 resident reviewed for an Optometry consult. Specifically, there was no documented evidence that the recommendations by the Optometrist to see the Ophthalmologist was carried out. Additionally, the Optometry consult was dated 04/05/2024 and attending physician reviewed and signed the consult on 09/07/2024 which was 5 months later then the consult date. The findings are: The facility policy titled Medical and dental Consults dated 05/2024 documented it is the policy of the facility to arrange for services of qualified professional personnel to render specific medical services. An order for consultation shall be placed in the electronic medical record (EMR) with the reason for consultation. Consultations shall be completed within 30 days of the initial order. The Licensed Nurse or Registered Nurse Supervisor documents in progress notes that resident was seen by the consultant and any recommendations. The medical provider reviews the recommendations of the consultant and indicates agreement or non-agreement. Resident #74 admitted with diagnoses including Hypertension, Peripheral Vascular Disease (a disorder of the blood vessels outside the heart), Renal Insufficiency, and Age-Related Nuclear Cataract, Bilateral. The Minimum Data Set assessment dated [DATE] documented Resident #74 has intact cognition. The Optometry Consult dated 04/05/2024 documented the diagnosis of Cataract NS (Nuclear Sclerotic) OD (right eye), OS (left eye) Moderate OD OS first study refer for CE (Cataract Extraction) monitor for progression. Referred to Ophthalmologist Cataract Surgery OD. The Optometry Consult dated 04/05/2024 was reviewed and signed by the attending physician on 09/07/2024 which was 5 months later than the consult date. A review of the nursing and physician progress notes dated 03/20/2024 through 04/15/2024 did not reveal documented evidence that Resident #74 's referral to Ophthalmology was carried out and there was no evidence of documentation that Resident #74 refused the recommendation from the Optometrist to consult with the Ophthalmologist. On 10/21/2024 at 2:49 PM, an interview conducted with Resident #74 who stated, they knew they had cataracts prior to admission to the facility and was seen by an eye doctor in the facility but there was no follow up done. On 10/25/2024 at 9:59 AM, an interview conducted with Nurse Practitioner who stated that they were not the one who signed the Optometry consult dated 04/05/2024 but they were aware when the Optometry consultation was made with the recommendation of referral to the Ophthalmologist. Nurse Practitioner stated that they discussed the recommendation with Resident #74, and they (Resident #74) preferred to be followed up from their outside Ophthalmologist. Nurse Practitioner stated they do not have documentation about their discussion with Resident #74. Nurse Practitioner stated that they talked to Resident #74 about the consult now and Resident #74 got an appointment on 11/15/2024 with the Ophthalmologist. On 10/28/2024 at 4:13 PM, an interview conducted with the Attending Physician who stated, they read and reviewed the Optometry consult signed by them. They stated that the consult also usually is reviewed by the Nurse Practitioner in the unit and if there were questions or clarifications with the consult, the Nurse Practitioner would notify them. They further stated that Resident #74 had an Optometry consult made but was not sure if the Nurse Practitioner made a referral to Ophthalmology as what was recommended in the Optometry Consult. They stated they did not speak to Resident #74 regarding the recommendation to see the Ophthalmologist. They stated they do not recall if there is a documentation about the recommendation for the Ophthalmology consult. Consults are usually documented by the Nurse Practitioner. They stated the Optometry Consult was performed on 04/05/2024. They further stated they reviewed and signed this Optometry Consult on 09/07/2024 which was 5 months later. On 10/28/2024 at 4:27 PM, an interview was conducted with the Medical Director who stated, the recommendation by the Optometrist in the Optometry Consult to see the Ophthalmologist should have been carried out. 10 NYCRR 415.15(b)(2)(iii)

Based on record review, and interviews conducted during the Recertification survey from 10/21/2024 through 10/28/2024, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status for 2 ( Resident #170 and #79) residents out of total 38 sampled residents. Specifically, (1) Resident #170 who was not receiving anticoagulant medication was coded as receiving anticoagulant medication. (2) Resident #79 was coded as receiving hospice services after hospice services were ordered disconinued . The findings include are: The facility policy titled MDS Assessment Version 3.0 effective 10/2023 documented the facility will conduct initially and periodically a comprehensive, accurate, standardize reproducible assessment of each resident's functional capacity. The assessment must reflect the status of the resident including resident strengths and needs that must be addressed in an individualized care plan. The Minimum Data Set Assessment Version 3.0 Correction / Modification Policy dated effective 10/2023 documented any errors discovered in a completed Minimum Data Set must be corrected through the appropriate modification process, ensuring the resident clinical status is accurately reflected in the record. Modification request is used to correct an IQIES record containing incorrect Minimum Data Set item values due to transcription errors, data entry errors, software problems errors , item coding errors and /o other error requiring modification. A Minimum Data Set assessment can be modified or corrected if there are errors in the date before submission After submission if an error is found after the assessment is accepted by the State Minimum Data Set data base the facility must complete a Correctio request form to modify the assessment. Complete a significant correctio of a prior full assessment if needed within 14 days of identifying the error. A major cl error occurs when the resident's clinical status is not accurately represented in the Minimum Data Set. The Significant Correction of a Prior Full Assessment is a comprehensive assessment that requires completing the Full Minimum Data Set, Comprehensive Annual Assessment and Comprehensive Annua Assessment Summary. 1) Resident #170 admitted with diagnoses of Hypertension, Peripheral Vascular Disease, Cerebrovascular Accident and Hemiplegia or Hemiparesis. The Order Summary Report as of 08/2024 documented Resident #170 was ordered Clopidogrel Bisulfate Tablet 75 milligram - 1 tablet by mouth one time a day for blood clot prevention. The Medication Review Report dated 08/01/2024 to 08/31/2024, documented that Resident #170 received Clopidogrel Bisulfate Tablet 75 milligram tablets. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented in Section N: Medications under section N0415: coded that Resident #170 was taking anticoagulant medication. The Modification of Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented in Section N: Medications under section N0415: modified that Resident #170 was taking antiplatelet medication. The Modification of Minimum Data Set 3.0 (MDS) assessment under Section X - Correction Request was modified dated 10/22/2024. On 10/24/2024 at 11:00 AM, an interview conducted with the Minimum Data Set Coordinator and stated that Resident #170 was on antiplatelet medication and not an anticoagulant medication. The Minimum Data Set Coordinator stated the Minimum Data Set Assessor is responsible for the accuracy of the assessment. The Minimum Data Set Coordinator stated they are responsible for signing the completeness of the assessment. The Minimum Data Set Coordinator stated that they review the Minimum Data Set, dated dated dated [DATE] on 10/22/2024 and noticed that the medication, Clopidogrel Bisulfate was incorrectly coded, and they modified the assessment on 10/22/2024. The Minimum Data Set Coordinator stated they counselled the Minimum Data Set Assessor and provided with the lists of medications that required to be coded in Minimum Data Set. [NAME], [NAME] 2) Resident #79 diagnoses which include Dementia, Major Depression Disorder Recurrent Unspecified and Insomnia Unspecified. The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the Resident #79 had severely impaired cognition and documented in Section O: (Special Treatments and Programs) that Resident #79 was on hospice services. The Significant Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented Resident #79 had severely impaired cognition and documented in Section O:(Special Treatments and Programs) that Resident #79 was on hospice services. This was done by Minimum Data Set Assessor #2. The Physician Order's Summary for Resident #79 was reviewed and documented orders for Hospice were from 11/29/2023 -05/13/2024. The Dietary Progress note dated 12/29/2023 documented resident #79 remains in hospice care. The Social Work Progress note dated 11/29/2023 documented that they were informed by the Hospice care representative that Resident #79 was admitted into Hospice care with a primary diagnosis of Vascular Dementia secondary to multiple Cerebrovascular accident and the interdisciplinary team was informed and resident care plan updated. The Social Work Progress note dated 2/27/2024 documented the Quarterly Care Plan meeting documented the resident representative and the Hospice social work in attendance, all questions addressed, and no concerns noted. The Medical Progress notes dated 3/6/2024, 4/4/2024 documented that Resident #179 was on hospice services. The Comprehensive Care Plan for Hospice effective 11/29/2023 with interventions assess and monitor resident for signs and symptoms or discomfort, encourage expressions of feelings related to diagnosis and disease progression, engage resident/family in discussion related to goals of care. obtain MD order for Hospice services. On 10/23/2024 at 11:20AM the Minimum Data Set Coordinator was interviewed and stated that they modified the Minimum Data Set for 08/07/2024 and it was modified due to a coding error. They completed Section X (Correction Request) on 10/23/2024. On 10/24/2024 at 11:49 AM, the Minimum Data Set Coordinator was interviewed and stated the last Quarterly Minimum Data Set on 10/07/2024. Resident #79 was not on hospice care at the time of the Minimum Data Set review. While reviewing the chart, they noticed that hospice was checked, and they submitted a correction for the Minimum Data Set. They completed the original Minimum Data Set, and it was incorrectly coded. The assessment should reflect the resident status as of the reference date of the Minimum Data Set. On a regular basis they look at audits of the Minimum Data Sets and the last audit was done for dialysis. They try to take last Minimum Data Sets coded and it is used for internal learning and education and talk to staff to improve in relation to their accuracy. We do it once a quarter, do reviews and look at special triggers (hospice, dialysis and do look backs to make sure it matches. On 10/24/2024 at 04:58 PM, the Minimum Data Set Assessor #1 stated when they complete Section O: Special Treatments and Programs. They go thru progress notes from the previous day of the Assessment Reference Date, consults for the reference and any pertinent information or labs or orders for the residents. They look at the medical provider notes in relation to hospice and nurse's notes if a resident is still under hospice care. We always get in-services or counseling if there are any updates for the section. The Minimum Data Set should be accurately coded to reflect the resident's chart and assessment and it should be accurate. Minimum Data Set Assessments are done in person or offsite. The assessment needs to be accurate so the resident will get the proper care that they need. They stated that they saw a note from the doctor and that's why they may have gotten confused. On 10/24/2024 at 05:04 PM, the Minimum Data Set Assessor #2 stated that they do a 14 day look back period based on the resident's assessment and Section O: Special Treatments and Programs Section O0110: Hospice Care. If the resident is on Hospice, then you have to click hospice on the assessment. You have to capture 14 days from the Assessment Reference Date. They look at the Hospice notes, documents such as physician orders and if the resident is still on hospice the box is checked. They also look at the medical provider notes in the last 30 to 60 days and nurse's notes in the last 14 days. We have to make sure it is accurate, since we are sending it to the Centers for Medicaid and Medicare Services, so they know the residents are on special care. They are provided in-services if there are new updates to the Minimum Data Set and perform webinar trainings also. On 10/24/2024 at 12:21 PM, Registered Nurse # 8 was interviewed and stated Resident #79 was on Hospice when they started working there but they are no longer on Hospice services. On 10/24/2024 at 11:45 AM, the current Attending Provider #1 stated that resident #79 was not on Hospice Services and they took over the resident's care in June 2024 and they used to be assigned to Attending Physician # 2. On 10/25/2024 at 11:22 AM Attending Physician #2 was interviewed and stated, They recall Resident #79 who had Advanced Dementia, and they were also on hospice services. The resident was losing weight and they were admitted to hospice services after a discussion with their family. They stated they communicated with the Hospice nurse in relation to recommendations and plan of care updates for Resident #79. They further stated that the Social Worker will confirm the resident was on hospice and there was an order in the resident's chart and the resident may have a Hospice assistant assigned. If a resident is on hospice they document this diagnosis in the notes. They stated, the unit they worked on changed between January to June 2024. The electronic medical record documents if a resident is on Hospice along with orders for advance directives and Hospice care. On 10/25/2024 at 11:36 PM, The Social Worker #2 was interviewed ant stated that Resident #79 was on Hospice for a period of time. They were referred to hospice services on 11/2/2023 and accepted on 11/29/2023. The reason for the referral was Vascular Dementia due to multiple Cerebrovascular accidents and it was recommended by the interdisciplinary treatment team after discussion and the resident's representative who was in agreement. The attending physician sent the referral to Hospice provider on 11/27/2023 and the order was discontinued on 5/8/2024. They have communicated with the hospice social worker. 10 NYCRR 415.11 (b)

Based on record review and interview conducted during the Recertification and Abbreviated Survey (NY00354048) from 10/21/2024 to 10/28/2024, the facility did not ensure that it promoted and facilitated resident self-determination through the support of residents choice for 1 (Resident #190) of 2 residents reviewed for Choices out of 38 sampled residents. Specifically, the preferred number of showers per week were not obtained and not provided in accordance with Resident #190's wishes. The findings are: The facility's policy and procedure titled Showers and Bed Bath reviewed 08/2020 documented, It is the policy of the facility that each resident is to have a minimum of two baths/showers each week and all residents shall receive a bath between scheduled showers or tub/whirlpool bath unless otherwise requested by resident. Resident #190 was admitted with diagnoses of Hypertension, Depression and Cervical Disc Disorder with Myelopathy (is a serious condition that occurs when the spinal cord in the neck is compressed, often due to a herniated disc). The Minimum Data Set, dated dated dated [DATE] documented Resident #190 was cognitively intact. Resident #190 required dependent assistance with shower/bathing self. MDS documented that Resident #190 was interviewed for daily preferences and stated that it was very important for them to choose between a tub bath, shower, bed bath, or sponge bath. The New York State Department of Health Complaint Intake (NY00354048) received 09/11/2024 documented that Resident #190's shower was not given as scheduled. On 10/21/2024 at 10:27 AM, an interview conducted with Resident #190 who stated they get showers every couple of days, before, they gave them maybe 3 or 4 times and then no more. Resident #190 stated that staff only washed them in bed and does not remember their shower days. On 10/22/2024 at 10:50 AM, Complainant at Resident #1's bedside (complainant was a Spanish speaking, Resident #190 translated the concern) stated that Resident #190 was not given showers as scheduled. The Comprehensive Care Plan Titled Activities of Daily Living Self- Care Performance Deficit dated 02/10/2024 documented that Resident #190 was dependent with shower/bathing self. The Comprehensive Care Plan Title Resident Preferences dated 02/17/2024 did not document Resident #190's specific preferences for showers/bathing. The Certified Nursing Assistant Documentation Report dated 08/01/2024 to 08/30/2024 documented Resident #190 was showered 4 (08/07/2024, 08/14/2024, 08/21/2024 and 08/24/2024) out of 9 days in August 2024. There was 1 refusal documented and dated 08/03/24. There were 4 occasions that bed bath was provided. The Certified Nursing Assistant Documentation Report dated 09/01/2024 to 09/30/2024 documented Resident #190 was showered 1 (09/28/2024) out of 8 days in September 2024. There was 1 refusal documented dated 09/14/24. There were 6 occasions that a bed bath was provided. A review of behavior and nursing notes dated 08/03/2024 to 09/28/232024 revealed there was no evidence of documentation that Resident #190 refuses showers or prefers bed bath. Documented Resident #190 was calm and cooperative. On 10/23/2024 at 3:05 PM Certified Nursing Assistant #2 was interviewed and stated, they were the regular Certified Nursing Assistant assigned in the evening shift for Resident #190. Certified Nursing Assistant #2 stated that Resident #190 is scheduled 2 shower days in a week, every Wednesday and Saturday. Certified Nursing Assistant #2 stated that sometimes they give showers even if not scheduled because Resident #190 messed with stool and mostly gives bed bath because Resident #190 is stiff. Certified Nursing Assistant #2 stated that Resident #190 does not refuse showers but occasionally they (Resident #190) refused a showers then they give a bed bath. On 10/23/2024 at 3:40 PM Registered Nurse #4 was interviewed and stated, that with regards to showers, Resident #190 is okay and was showered every Wednesday and Saturday. Registered Nurse #4 stated that shower schedule is posted at the nursing station, and they inform the staff which residents are scheduled for showers. Registered Nurse #4 stated that they do not recall Resident #190 refusing a shower because staff did not report to them. Registered Nurse #4 stated they are responsible to monitor and to ensure that staff provided the care as instructed. On 10/25/2024 at 9:25 AM Registered Nurse Supervisor #6 was interviewed and stated, they checked the Certified Nursing Assistant documentation, and it showed that a shower was not given as scheduled to Resident #190. Registered Nurse Supervisor #6 stated that staff should notify the nurse when a resident refuses shower. Resident #190 has no behavior issues of refusing showers. Registered Nurse Supervisor #6 stated that they did not observe any documentation in the medical record that Resident #190 refused showers. Registered Nurse Supervisor #6 stated they plan to give an in-service to staff regarding providing showers, documentation and notifying the nurse regarding residents refusal of care. On 10/25/2024 at 2:16 PM, the Director of Nursing was interviewed and stated, they did not personally hear Resident #190 refuses showers and mostly Resident #190 was given a bed bath. Director of Nursing stated that staff provided bathing but not just in the shower room (while looking at the Certified Nursing Documentation Survey Report dated 9/2024). Director of Nursing stated they were not aware of this reason, normally if resident refused shower the staff informs the nurse. Director of Nursing stated that the nurse in the unit is responsible for monitoring staff to insure care is provided and documented. 10 NYCRR 415.5(b) (1-3)

Based on observation, record review and interviews conducted during Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not provide, based on the comprehensive assessment, interests, and the preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not appropriately assess interests and activity preferences for non-English speaking resident and provide an ongoing program of activities designed to meet their interests for Resident #209. This was evident for 1 (Resident #209) resident reviewed for Activities out of 37 total sampled residents. The findings are: The facility's policy and procedure entitled Activity Recreation Program and Assessment revised 11/2016 documented that facility shall provide for an ongoing program of activities designed to meet the interest and the physical, mental, psychosocial well-being of each resident. Recreation Therapist shall complete a comprehensive assessment and develop a plan of care that reflect the resident's level of leisure and lifestyle satisfaction, response to recreational activity goals which is reviewed on a regular basis. Resident #209 admitted to the facility on [DATE] with diagnoses of Hypertension, Hyperlipidemia and Non-Alzheimer's Dementia. The Minimum Data Set, dated dated dated [DATE] documented Resident #209's preferred language is Mandarin and Resident/Designated Representative were not interviewed for Daily and Activity Preferences because resident is rarely/never understood, and family/significant other was not available. The Minimum Data Set, dated dated dated [DATE] documented Resident #209 has severely impaired cognition and requires substantial/maximal assistance to sit to lying and lying to sitting on side of bed, and chair to bed transfer. On 10/22/2024 at 11:42 AM, Resident #209 was awake, lying in bed with television on, not in their preferred language. The remote control was on the windowsill and not easily accessible for the resident. On 10/23/2024 at 10:18 AM, Resident #209 was awake, lying in bed with television on the same channel, not in their preferred language. There was no list of a channel guide for the resident in the room. On 10/24/2024 at 12:54 PM, Resident #209's family was interviewed who stated they are the designated representative to discuss about Resident #209. Designated representative stated that they have been contacted related to resident's treatment/care needs but never been contacted about resident's daily and activity preferences. Designated representative further stated that they were not aware that there were activity programs for residents in the facility. The Comprehensive Care Plan for Therapeutic Recreation initiated/last revised 6/28/2024 documented to establish/record the resident's prior level of activity involvement and interests by talking with the resident caregivers, and family on admission and as necessary. Invite/encourage the resident's family members to attend activities with resident to support participation. The Therapeutic Recreation Initial assessment dated [DATE] documented Resident #209 is long term, speaks Mandarin. The daily and activity preferences for Resident #209 were checked as no response because resident not able to communicate and family interview could not be completed. It indicated that resident's past/current activities obtained from the chart were inside the home, watching TV/movies, family centered activities, and solitary activities. The Therapeutic Recreation Assessments dated 9/23/2024 documented Resident #209/family member were unable to complete the interview. The daily and activity preferences were checked as no response. It documented staff interview indicated keeping up with the news is important for Resident #209's activity preference. The Therapeutic Recreation Activity Log from 10/1/2024 to 10/23/2024 revealed Resident #209 participated total of 1 activity program: 1 to 1 visit on 10/8/2024. The review of Therapeutic Recreation Notes from 10/1/2024 to 10/23/2024 revealed there was no documented evidence Resident #209 was offered any activities or that they refused the activity program. There was no documented evidence that Resident #209 and/or family member participated in the initial/quarterly assessment process and that ongoing assessment/program of activities that meet the resident's interests and functional capacity were provided for the resident. On 10/24/2024 at 12:04 PM, Certified Nurse Aid #1 stated Resident #209 is dependent for all ADL care and will require Hoyer lift to get out of bed. They further stated Resident #209 is mostly sitting in the bed and watches television. On 10/24/2024 at 11:39 AM, Licensed Practice Nurse #1 stated Resident #209 is assisted out of bed with Hoyer lift and sits in the dining room at times. They further stated they have not seen Resident #209 participating in any activity program with activity staff. On 10/23/2024 at 10:47 AM, Activities Aid stated resident #209 was transferred to this unit about a month ago. Resident #209 can express yes/no or simple terms in English but needs to be prompted for response. Resident #209 was assessed for their activity preferences using hand gestures and resident responded yes if they liked the activity. Activities Aid stated they don't recall calling the family or utilizing the translation service for resident's information because resident understood the simple words/gestures. Activities Aid stated Resident #209 does not really engage in any social activity so Activities Aid will visit resident in the room for 1 to 1 visits. On 10/23/2024 at 9:48 AM, Recreation Director stated activity staff is responsible to introduce the activity programs and interview the resident/family member upon admission to gather information about resident's interests. Activity staff will also introduce different activity programs with the resident to assess their preferences and offer programs that resident can enjoy based on their participation and responses to the program. Recreation Director stated Resident #209's assessment was conducted with assistance of the interpreter hotline; however, the resident was unable to complete the interview due to confusion. Resident #209 did not answer questions as per interpreter, resident repeated the questions instead of answering. 10 NYCRR 415.5(f)(1)

Based on interviews and record review conducted during the Recertification and Complaint survey (NY 567) from 9/7/22 to 9/14/22, the facility did not ensure that in accordance with accepted professional standards and practices, medical records were maintained that were complete and accurately documented for each resident. Specifically, medication administration was not documented for scheduled medication and there was no documented evidence that medication had been refused by the resident. This was evident for 1 of 3 resident reviewed for Pain Management out of 38 sampled residents. (Resident # 361) The finding is: The policy and procedure titled Medication Administration Guidelines effective 6/17 documented medication are given only with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . STAT and as needed (PRN) medications are to be entered on the EMAR/MAR along with the date, dose and time of administration and medication nurse's initials and the reason for the as needed medications. All medication administered are to be signed for in the EMAR. Medications note administered (refused, etc.,) are to be recorded using the code on the EMAR/MAR. And an appropriate explanatory statement is to be entered in the nurse's progress note. Resident # 361 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Aspirin [MEDICATION(S)] coated delayed release 81 mg was not documented on 03/06/2022 at 21:00, 3/15/2022 at 09:00 and 3/17/2022 at 21:00. Acetaminophen 325 mg was not documented on 3/6/2022 at 22:00, 3/11/2022 at 06:00 and 22:00, 3/12/2022 at 06:00, 3/13/2022 at 06:00 and 3/15/2022 at 14:00, 3/16/2022 at 06:00, 3/17/2022 at 22:00 and 3/19/2022 at 06:00. Pain monitoring was not documented on 3/10/2022 and 3/11/2022 on the 11 PM-7 AM shift. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] tablet delayed release 40MG ordered at 06:00 was not documented on 4/6/2022-4/11/2022. Review of the Nurses Progress notes dated 3/5/2022 to 4/5/2022 contained no evidence that resident had refused medication or any documentation related to why ordered medication had not been administered. On 09/14/2022 at 11:28 AM, Registered Nurse (RN) # 3 was interviewed. RN #3 stated that the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/14/2022 at 11:55 AM, the Registered Nurse Supervisor (RNS) #1 was interviewed and stated that they review medication administration in relation to new order, they observe medication pass and perform random checks. RN #1 also stated they audit the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/14/2022 at 1:29 PM, the Director of Nursing (DON) was interviewed and stated the nurses should document medication administered. The DON stated that there was documentation missing for Tylenol for Resident #361 on 3/11/2022, 3/12/2022, 3/13/2022 and 3/19/2022 and documented Resident #361 was given [MEDICATION(S)] on 3/11/2022, 3/16/2022 and 3/19/2022. The DON also stated there was no documentation of the resident refusing any medication including Tylenol and if it was not administered there should have been documentation in either progress notes or on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 415.22(a)(1-4)

Based on interviews and record review conducted during the Recertification and Complaint survey (NY 773) from 09/07/2022 to 09/14/2022, the facility did not ensure all alleged violations involving abuse were thoroughly investigated and take appropriate actions to prevent further potential abuse pending an investigation. This was evident for 1 of 9 residents reviewed for Abuse (Resident #45) out of 38 sampled residents. Specifically, the facility did not investigate a resident's allegation of inappropriate touching by a Certified Nursing Assistant (CNA #2) or remove the CNA from the resident's assignment immediately, pending investigation. The findings are: The facility policy titled Reporting and investigation of resident abuse, neglect, misappropriation/exploitation and mistreatment with an effective date of 11/2017 documented that all personnel have the responsibility to report any incident or suspected incident of resident abuse and the facility shall conduct a thorough investigation. The policy also documented that all staff who provide direct resident care are to carefully observe the residents to identify any changes and take note of a resident articulating a problem. Upon identification of such a change, the staff member must report the finding to his/her immediate supervisor to determine if further investigation is warranted. The Administration and Nursing Department will assist in the coordination of the investigation of all allegations of abuse. Resident #45 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly (MDS) assessment dated [DATE] documented the resident's cognitive level was intact. On 09/14/22 at 10:30 AM, an interview was conducted with Resident #45, who stated that they the facility took no action on the complaint until they had filed it with the state and then the CNA #2 was changed from their assignment. Resident#45 also stated that the Director of Nursing (DNS) apologized two days later and then changed CNA #2's assignment. Intake Information for 3/10/21 documented that Resident #45 called the NYS complaint hotline and stated last week a CNA was providing care and cleaning their rectum and they did not like the way the aide was touching their anus and told them to stop several times but they did not. The complaint also documented they complained to management but the CNA continued to be assigned to them until a complaint was made to the supervisor and the resident doubted that an investigation had been conducted. The intake also documented that there were no facility reports at that time. Review of progress notes dated February 2021 to March 2021 did not reveal any documented complaints by Resident #45 regarding care. Review of Accidents/Incidents reports and Grievances for the 3rd Floor for March 2021 and/April 2021 documented no issues for Resident #45. The CNA assignment for March 2021 documented CNA #2 was caring for Resident #45 through the end of the March 2021. There was no documented evidence that the alleged violation was investigated. On 09/14/22 at 10:46 AM an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated that resident complained to them twice about CNA #2. LPN #1 also stated that they reported it to the supervisor who reported it to the DNS. LPN #1 further stated that they could not recall the supervisor this was reported to or whether any documentation or an investigation was done as this incident happened a long time ago. LPN #1 stated the CNA assignment was changed that same day by the DNS. During an interview on 09/14/22 at 02:06 PM, LPN #1 stated Resident #45 stated they did not want CNA #2 assigned to them on the first night, calling the CNA old. The next day, Resident #45 stated CNA #2 was slow. LPN #1 stated after the second night, Resident #45 reported they were not comfortable with the way CNA #2 touched them and felt like CNA #2 was hitting on them. LPN #1 further stated Resident #45 reported CNA #2 tried to stick a finger inside their anus LPN #1 stated they knew it was a problem and took it downstairs, to the DNS. LPN #1 stated they did not write anything down, and they did not know if there was an investigation. Attempts to contact CNA #2 via telephone were unsuccessful. There was no documented evidence LPN #1 reported the allegation of sexual abuse or that CNA #2 was removed from the assignment immediately pending an investigation. The resident called in the complaint on 3/10/21 and indicated the facility had not addressed their complaint for an incident that occurred a week before. In addition, the CNA assignment record indicated CNA #2 continued to be assigned to Resident #45 throughout March 2021. On 09/14/22 at 11:52 AM, an interview was conducted with the Director of Social Services (DSW). The DSW stated they have worked at the facility for 3-4 years and did not recall any concerns for Resident #45. The DSW also stated that if there had been any complaints, there would have been a grievance filed but there was not one for this resident. On 09/14/22 at 03:44 PM an interview was conducted with the Director of Nursing (DNS). The DNS stated that if there is a suspicion of abuse, we do a thorough investigation. We monitor the staff, view the cameras, and interview roommates. After interviewing staff, if we suspect abuse, and we have enough evidence, we report it to the Department of Health (DOH). The DNS also stated they had no knowledge of any reported abuse to Resident #45 and no nurse had reported abuse to them. On 09/14/22 at 03:44 PM, an interview was conducted with the Administrator who stated they could not recall any report of abuse for this resident as it would have been investigated and reported right away and alleged perpetrator would have been removed. 415.4(b)(3)

Based on interviews and record review conducted during the Recertification and Complaint survey (NY 773) from 09/07/2022 to 09/14/2022, the facility did not ensure all alleged violations involving abuse were reported to the State Survey Agency immediately, but not later than 2 hours after the allegations were made. This was evident for 1 of 9 residents reviewed for Abuse (Resident #45) out of 38 sampled residents. Specifically, the facility did not report a resident's allegation of inappropriate touching by a Certified Nursing Assistant (CNA) to the NYS Dept of Health. The findings are: The facility policy titled Reporting and investigation of resident abuse, neglect, misappropriation/exploitation and mistreatment with an effective date of 11/2017 documented that all personnel have the responsibility to report any incident or suspected incident of resident abuse. The policy also documented under Definition that abuse is defined as willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish. All staff who provide direct resident care are to carefully observe the residents to identify any changes and take note of a resident articulating a problem. Upon identification of such a change, the staff member must report the finding to his/her immediate supervisor to determine if further investigation is warranted. The facility shall ensure that alleged violations involving mistreatment, neglect, or abuse are reported immediately to the Administrator of the facility or his/her designee and if applicable, to other officials in accordance with State law. Resident #45 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly (MDS) assessment dated [DATE] documented the resident's cognitive level was intact. Intake Information for 3/10/21 documented that Resident #45 called the NYS complaint hotline and stated last week a CNA was providing care and cleaning their rectum and they did not like the way the aide was touching their anus and told them to stop several times but they did not. The complaint also documented they complained to management but the CNA continued to be assigned to them until a complaint was made to the supervisor and the resident doubted that an investigation had been conducted. The intake also documented that there were no facility reports at that time. Review of progress notes dated February 2021 to March 2021 did not reveal any documented complaints by resident regarding care. Review of Accidents/Incidents reports and Grievances for the 3rd Floor for March 2021 and/April 2021 documented no issues for Resident #45. CNA assignment for March 2021 documented CNA #2 was caring for Resident #45 through the end of the March 2021. There was no documented evidence that the allegation was reported to the administrator of the facility or other officials including the State Survey Agency. On 09/14/22 at 10:30 AM, an interview was conducted with Resident #45, who stated that they the facility took no action on the complaint until they had filed it with the state and then the CNA was changed from their assignment. Resident #45 also stated that the Director of Nursing (DNS) apologized two days later and then changed the CNA assignment. On 09/14/22 at 10:46 AM an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated that resident complained to them twice about CNA #2. LPN #1 also stated that they reported it to the supervisor who reported it to the DNS. LPN #1 further stated that they could not recall the supervisor this was reported to or whether any documentation or an investigation was done as this incident happened a long time ago. LPN #1 stated the CNA assignment was changed that same day by the DNS. During an interview on 09/14/22 at 02:06 PM, LPN #1 stated Resident #45 stated they did not want CNA #2 assigned to them on the first night, calling the CNA old. The next day, Resident #45 stated CNA #2 was slow. LPN #1 stated after the second night, Resident #45 reported they were not comfortable with the way CNA #2 touched them and felt like CNA #2 was hitting on them. LPN #1 further stated Resident #45 reported CNA #2 tried to stick a finger inside their anus LPN #1 stated they knew it was a problem and took it downstairs, to the DNS. LPN #1 stated they did not write anything down, and they did not know if there was an investigation. Attempts to contact CNA #2 via telephone were unsuccessful. On 09/14/22 at 11:52 AM, an interview was conducted with the Director of Social Services (DSW). The DSW stated they have worked at the facility for 3-4 years and did not recall any concerns for Resident #45. The DSW also stated that if there had been any complaints, there would have been a grievance filed but there was not one for this resident. On 09/14/22 at 03:44 PM an interview was conducted with the Director of Nursing (DNS). The DNS stated that if there is a suspicion of abuse, we do a thorough investigation. We monitor the staff, view the cameras, and interview roommates. After interviewing staff, if we suspect abuse, and we have enough evidence, we report it to the Department of Health (DOH). The DNS also stated they had no knowledge of any reported abuse to Resident #45 and no nurse had reported abuse to them. On 09/14/22 at 03:44 PM, an interview was conducted with the Administrator who stated they could not recall any report of abuse for this resident as it would have been investigated and reported right away and alleged perpetrator would have been removed. 415.4(b)(2)

Based on observation, record review and interviews during an abbreviated survey (NY00297413), the facility did not ensure that a resident was free from physical abuse. This was evident in 1 out of 5 residents sampled for abuse (Resident #2). Specifically, on 06/13/2022 at 8:07 AM, the facility's surveillance video recording showed Certified Nursing Assistant (CNA) #1 roughly slapped Resident #2's hand, grabbed and pushed Resident #2 causing Resident #2 to fall to the floor on their left side. Resident #2's body struck the wall in the dining room. Resident #2 was transferred to the hospital and underwent Percutaneous Pinning (a pin or wire pushed through the skin and into the bone) to the left hip. Resident #2's primary diagnosis was Left femoral Neck Fracture. This resulted in actual harm to Resident #2 that was not Immediate Jeopardy. The findings are: The facility's Policy and Procedure entitled Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/Exploitation and Mistreatment, dated 11/2021 documented Purpose: To ensure that every resident has the right to be free from abuse, neglect, mistreatment, misappropriation of resident property and exploitation. Abuse includes but is not limited to freedom from corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. To provide a safe environment and protect residents from abuse. To ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation or resident property are reported immediately, but not later than 2 hours after the allegations is made, if it involves abuse or result in serious bodily injury, or not later than 24 hours if the allegation do not involve abuse and do not result in serious bodily injury. Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Depression and Psychosis. The Minimum Data Set Assessment (MDS) dated [DATE], documented that Resident #2 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15 associated with intact cognition. Resident #2 required limited assist with ambulation and used a walker. The At Risk for Abuse Care Plan dated 07/08/2019 documented interventions for staff to encourage the resident to seek out staff for assistance if having difficulty with others. Staff to intervene as necessary to ensure safety of resident and provide emotional support as needed. A Situation Background Appearance and Request (SBAR) Nursing Progress Note, by Director of Nursing (DON), dated 06/13/2022 at 10:00 AM, documented that Resident #2 expressed worsening of chronic pain unable to extend left leg due to pain. The summary of observation documented that complete body assessment was done with no visible injury noted. Resident #2 verbalized pain on their left leg and refused to extend the leg. The Medical Doctor (MD) was notified and ordered the resident to be transferred to the hospital for further evaluation. The facility's surveillance video footage dated 06/13/2022 at 8:06 AM, viewed by surveyor, revealed that Resident #2 was sitting in the dining room at approximately 8:07AM. Resident #2 got up from their seat and ambulated with their rolling walker to another table. Resident #2 picked up an item from table in the dining room and ambulated over towards one of the dining room doors with the item in their hand. Resident #2 opened the dining room door. CNA #1 entered the dining room through the other dining room door, picked up a soda can that was sitting on the same table where Resident #2 removed the item. CNA #1 disposed of the soda can and walked over to the dining room door where Resident #2 was standing. The door was slightly opened. Resident #2 had their left hand holding onto their walker and their right hand passing the item to Resident #1 on the opposite side of the door (staff identified the other person as Resident #1). Resident #1's hand could be seen reaching towards Resident #2's through the slightly opened door. Standing behind Resident #2, CNA #1 reached and roughly slapped Resident #2's right hand, grabbed and pushed Resident #2 back towards the wall. Resident #2 and their walker fell and the left side of Resident #2's body hit the floor and wall in the dining room. Another staff (CNA #2) member appeared at the scene after Resident #2 and the walker were both on the floor. The camera recording ended with CNA #1's hand reaching down to touch Resident #2. The facility's Investigation Summary dated 06/13/2022, documented that on 06/13/2022 at approximately 9:40 AM, the Emergency Medical Personnel and Police responded to the facility as summoned by Resident #1, who stated that CNA #1 had physically abused both Resident #1 and Resident #2. Resident #1 stated that CNA #1 pushed them (Resident #1) out of the unit dining room into the wall and that CNA #1 also pushed Resident #2 down to the floor. Both residents were assessed. Resident #1 was without injury and Resident #2 complained of pain. Resident #2 was transferred to the emergency room for further evaluation. CNA #1 was removed from the unit while the investigation was being conducted and was later arrested. Resident #2 returned (3 days later) to the facility with fracture of the left femoral neck The facility investigation arrived at the following set of events. Resident #2 lost their balance and fell . Resident #2 was not pushed as initially thought. CNA #1 tried to prevent Resident #2 from falling. CNA #1 reached out to Resident #2 but grabbed Resident #2's clothing that was draped around Resident #2's shoulder. It appeared that Resident #1 may have pushed the door from the other side causing Resident #2 to be off balance. The facility concluded that there was probable evidence of abuse, neglect, or mistreatment because staff did not follow the plan of care. The Hospital Review Instrument Discharge Summary dated 06/16/2022 documented that Resident #2 was presented after being pushed/fall from standing. Resident #2 was found to have Left Femoral Neck Fracture. Resident #2 was taken to the Operating Room (OR) by Orthopedic on 06/14/2022 for Percutaneous Pinning of the left hip. Diagnosis: Left Femoral Neck Fracture. A Nursing Progress Note, by RN #2, dated 06/16/2022 at 5:51 PM documented that Resident #2 was readmitted to the facility from the hospital with a diagnosis of Left Femoral Neck Fracture following a fall/being pushed. Body assessment revealed that Resident #2 had six staples on left thigh. Five Residents who were in the dining room at the time of the incident were not able to be interviewed due to severely impaired cognition. During an interview on 07/25/2022 at 2:45PM, Resident #2 stated they recalled the incident with CNA #1. Resident #2 stated that Resident #1 was in the dining room and had money left on the dining room table. Resident #2 stated that CNA #1 said Resident #1 could not eat in the dining room and CNA #1 took Resident #1 out of the dining room. Resident #2 stated that they took Resident #1's money off the table in the dining room and went to open the dining room door to give Resident #1 their money. Resident #2 stated that CNA #1 threw me to the floor. Resident #2 stated that CNA #1 was not their assigned caregiver, and they did not have any previous relationship with CNA #1. During a telephone interview on 08/23/2022 at 2:32 PM, Resident #2 stated that CNA #1 pushed them to the floor in the dining room when they attempted to give Resident #1 his/her money. Resident #2 stated that the two CNAs (CNA #1 and CNA #2) assisted them to stand up. Resident #2 stated the CNAs did not call the nurse before they picked them up from the floor. Resident #2 stated that they walked to their room by themselves and that they were in pain and were crying. Resident #2 stated that the nurse (RN #1) came to their room to give them Tylenol for pain. Resident #2 stated that the ambulance came right away and took them to hospital. Resident #2 stated that they are feeling depressed because they cannot walk anymore. Stated at my age you cannot break your hip. Resident #2 stated that they have lost their appetite. Resident #2 stated that they are now using a wheelchair because the hospital told them not to put weight on their foot. During a telephone interview on 08/08/2022 at 11:00AM, CNA #1 stated that he/she saw that Resident #2 was about to stumble and fall and he/she tried to hold onto Resident #2 to prevent the resident from falling. CNA #1 stated as he/she tried to hold onto Resident #2, Resident #2's sweater came off into his/her hand and Resident #2 fell into a sitting position on the dining room floor. CNA #1 stated that Resident #2's head leaned towards the wall. CNA #1 stated that the nurse (RN #1) was called and came over to look at Resident #2. CNA #1 stated that RN #1 asked Resident #2 if they were okay, and Resident #2 said yes. CNA #1 stated that they (CNA #1 and CNA #2) picked up Resident #2 and the resident stood up and walked to their room with their walker. CNA #1 stated at approximately 9:30AM as he/she was about to go on break he/she received a call to come downstairs. CNA #1 stated that he/she went downstairs and was told that a resident made an allegation toward him/her and that the resident called law enforcement officers. CNA # 1 stated that he/she was arrested in the facility by law enforcement officers. CNA #1 stated that he/she was terminated from the facility. CNA #1 stated that after the RN #1 saw Resident #2, CNA #1 and CNA #2 were allowed to pick up Resident #2 from the floor. During a telephone interview on 08/18/2022 at 9:38AM, CNA #2 stated that he/she heard a sound coming from the dining room and went to investigate the sound. Stated that he/she observed Resident #2 on the floor in the dining room. CNA #2 stated that he/she asked Resident #2 what happened, and Resident #2 stated that he/she fell . CNA #2 stated that Resident #2 was trying to get up and he/she asked Resident #2 if the resident was in pain. CNA #2 stated that he/she and CNA #1 picked up Resident #2 and put the resident to sit in a chair. CNA #2 stated that after they picked up Resident #2 from the floor, he/she went and told RN #1. During a telephone interview on 08/17/2022 at 2:44PM, RN #1 stated that initially he/she was not aware that Resident #2 had a fall, and no one notified him/her about the fall. RN #1 stated a CNA (does not remember which CNA) informed him/her that Resident #2 was requesting pain medication. RN #1 stated that he/she took the pain medication to Resident #2's room and asked Resident #2 about the location of the pain. RN #1 stated that Resident #2 reported that he/she fell , and RN #1 stated this is the first time he/she became aware that Resident #2 had a fall. RN #1 stated as he/she was going to get the equipment to take Resident #2's vital signs he/she met Registered Nurse Supervisor (RNS) #1, who was coming to see Resident #2. Resident #2 was assessed by RNS #1. During a telephone interview on 08/17/2022 at 3:46 PM, Registered Nurse Supervisor (RNS) #1 stated that he/she was covering the building for the day and was not aware that Resident #2 had a fall. Stated that he/she became aware of the fall when law enforcement arrived in the building. RNS #1 stated he/she did not get any calls from any of the CNAs or RN #1 that were on the unit. RNS #1 stated when law enforcement informed him/her of the incident he/she went to the unit to see Resident #2. RNS #1 stated that Resident #2 was lying in bed and reported that they had pain to the left foot. RNS #1 stated that Resident #2 reported that they fell in the dining room. RNS #1 stated while he/she was assessing Resident #2, law enforcement came on the unit to see Resident #2 and law enforcement called in their own team (Emergency Medical Team) to assess Resident #2. RNS #1 stated that law enforcement took Resident #2 to the hospital. RNS #1 stated that CNA #1 and CNA #2 were not told to pick up Resident #2 before the resident was assessed. RNS #1 stated when he/she arrived on the unit Resident #2 was already in bed. RNS #1 stated Resident #2 is now using a wheelchair post fall. During a telephone interview on 08/05/2022 at 2:00PM, the DON stated that CNA #1 was the only staff present in the dining room at the time of the incident. The DON stated CNA #2 heard a sound in the dining room and responded and observed Resident #2 lying on the floor. The DON stated CNA #2 asked Resident #2 what happened, and Resident #2 stated that he/she fell on the floor. The DON stated that CNA #1 was removed off the unit and waited in a private room in the lobby for law enforcement. DON stated that law enforcement watched the video recording onsite, and CNA #1 was taken into custody. The DON stated that he/she was not in the building at the time of the incident. The DON stated that RN #1 was on the unit but was not aware that Resident #2 had fallen. The DON stated that CNA #1 and CNA #2 picked Resident #2 up off the floor without notifying the nurse or the supervisor. The DON stated that he/she reviewed the surveillance camera and it revealed that Resident #2's rolling walker was already off the floor and Resident #2 was falling to the left side. It appeared CNA #1 was trying to prevent Resident #2 from falling. During a telephone interview on 08/17/2022 at 4:09PM, Medical Director (MD) #1 stated that he/she received a call from the facility stating that Resident #2 was on their way to the hospital. MD #1 stated that staff usually called and reported whenever something happened at the facility. MD #1 stated that the facility became aware of the incident when law enforcement came to the building. MD #1 stated that when they learned of the incident, they called the onsite Nurse Practitioner (NP) #1 to go and see Resident #2. MD #1 stated NP #1 was not allowed to see Resident #2 because law enforcement was already there attending to Resident #2. MD #1 stated he/she followed up with the hospital and learned that hospital did surgery on Resident #2. Resident #2 is now non-weight bearing; therefore, Resident #2 uses a wheelchair. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review and interviews during an abbreviated and Partial Extended Survey (NY 473), the facility failed to protect resident's rights to be free from sexual abuse and psychosocial harm using the reasonable person concept. The facility did not ensure each resident was free from abuse for 1 out of 6 residents (Resident # 1). Specifically, on 4/18/22 at approximately 11:30 PM, CNA #1 observed LPN #1 in the room of Resident #1 who was diagnosed with dementia and severely impaired cognition. CNA #1 observed LPN #1 naked from the waist down, with pants at the ankles and Resident #1 was observed lying across the bed naked from the waist down, not wearing disposable brief or underwear. Resident #1's buttocks were rested on the edge of the bed and legs elevated in the air. CNA#1 informed the RNS supervisor of the incident. The RNS immediately went to assess Resident #1 who refused physical assessment and denied (through Spanish interpreter) that a man was ever in their room or was assaulted. Resident #1 was transferred to the to the ER (emergency room ). This resulted in Substandard Quality of Care that was Immediate Jeopardy with the likelihood for serious injury and harm using the reasonable person concept for Resident #1. The findings are: The facility's Policy and Procedure entitled Reporting and Investigation of Resident Abuse, Neglect, Mistreatment, Misappropriation/Exploitation dated 11/2021, documented: All personnel have the responsibility to report any incident or suspected incident of resident abuse, including injuries of an unknown source. The facility shall conduct a thorough investigation of all alleged violations involving exploitation, mistreatment, neglect or abuse, and misappropriation of resident property and comply with State reporting regulations. Sexual Abuse was defined as non-consensual sexual contact of any type with a resident. The Facility investigation dated 04/18/2022, documented on 04/18/2022 at approximately 11:30PM, CNA #1 observed Resident #1 lying in bed on their back with their legs up in the air without a disposable brief. LPN #1 was standing in front of Resident #1, 1-2 feet away from Resident #1 with their pants down. LPN #1 immediately pulled up their pants and followed CNA #1 into the hallway as CNA # 1 tried to use the elevator. CNA #1 stated that LPN #1 tried to hinder CNA #1 from reporting what was seen. CNA #1 reported what was witnessed to the Registered Nurse Supervisor (RNS #1). RNS #1 attempted to assess Resident #1, but Resident #1 refused the assessment. Resident #1 was interviewed with an interpreter, and Resident #1 denied seeing a man in their room. The Director of Nursing (DON) was notified and 911 was called. Police Officers arrived at the facility at 12:56 AM, obtained statements from the staff and directed LPN #1 not to leave the facility. Resident #1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 resided on the Dementia Unit. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 05 out of 15, indicating Resident #1 had severely impaired cognition. A Comprehensive Care Plan (CCP), dated 5/26/2021, identified that Resident #1 is at risk to be a victim of abuse, neglect and or mistreatment and documented interventions that are necessary to ensure the safety of Resident #1. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, by Registered Nurse Supervisor (RNS) #1, dated 04/19/2022 at 12:02PM, documented they received a call from CNA #1 regarding inappropriate behavior by a nurse LPN #1 with Resident #1 that was witnessed by CNA #1, while doing rounds on the unit. During an interview on 04/20/2022 at 10:15 AM, CNA #1 stated that he/she was employed at the facility for 2 years and worked with LPN #1 for six months on the Dementia unit on the 11-7 shift. CNA #1 arrived at the facility at 11:19 PM on 04/18/2022, to begin the 11-7 shift and went to the second dementia unit to start making their rounds on the unit. CNA #1 stated, upon arrival at Resident # 1's room, the door was closed, and they opened the door. Upon opening the door, CNA #1 stated they observed LPN #1 standing at the side of Resident #1's bed. Resident #1 was lying across the bed with their nude buttock at the edge of the bed and both legs elevated in the air. CNA # 1 stated that he/she observed LPN #1's pants were down around their ankles. CNA #1 stated that Resident #1 was not making any sounds when they opened the door to the resident's room and LPN #1 bent down to pull up their pants. CNA #1 stated that LPN #1 exited Resident #1's room and spoke to CNA #1, telling CNA #1 not to report what was witnessed. CNA #1 stated they reported what was seen to the RNS #1. During an interview on 4/19/2022 at 2:00 PM, RNS #1 stated that he/she received a call from the security guard at approximately 12:10 AM on 4/19/2022 stating that CNA #1 would like to speak with them. RNS #1 stated that he/she went to Resident #1's unit at 12:30 AM. RNS #1 stated that CNA #1 reported that he/she observed LPN #1 standing in Resident #1's room with their pants down. Resident #1 was observed lying on their back without a disposable brief on with both legs elevated in the air. RNS #1 stated that Resident #1 refused physical assessment. RNS #1 stated the Director of Nursing (DON) was called at 12:37 AM and informed of the incident. The DON advised RNS #1 to call the Police. Police Officers arrived and took LPN #1 into custody. During a follow up interview on 04/20/2022 at 6:00PM, RNS #1 stated that observational rounds were performed on each unit 2-3 times during all tours. RNS #1 reported that spot checks are performed on the unit to ensure that staff members are providing care to the residents. An observational round was performed on the dementia unit at 11:00 PM on 04/18/2022. During an interview on 04/20/2022 at 5:04 PM, the DON stated a call was received from RNS #1 on 04/19/2022 at 12:37 AM to report the allegation involving Resident #1. The DON stated that RNS #1 was instructed to remove LPN #1 from the unit and to call the Police. The DON stated that RNS #1 followed the facility's protocol and protected Resident #1. The DON stated that Resident #1 refused a body assessment and was transferred to the hospital for a rape kit per the Medical Doctor's order. The DON stated that Resident #1's family was notified. The DON stated that RNS #1 is responsible for monitoring resident's care and supervising the staff by conducting rounds on the units three times while on tour and as needed. The RNS #1 did rounds on the Demented Unit at 11:00 PM. On 4/18/2022 there were 2 RNs, 4 LPNs and 13 CNA on duty for the 11:00 PM to 07:00 AM shift. Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified on 04/21/2022 at 7:33 PM. The facility submitted a removal plan that was reviewed and accepted by NYSDOH on 04/21/2022 at 10:10 PM. On 04/22/2022 at 5:40 PM, the survey team determined IJ was removed based on the following corrective actions taken by the facility: 911 was called on 04/19/2022 at 12:42 AM to report the incident from 04/18/2022 and Police Officers arrived at about 12:56 AM. The staff was interviewed. The resident was cognitively impaired and was not able to provide pertinent information. LPN #1 was arrested by the Police Officers on 04/19/2022. The facility terminated the LPN from his/her employment on 04/19/2022. The Facility reported the LPN to the Office of the Professions on 04/20/2022. The Social Services staff interviewed 39 out of 40 residents on Unit 2. There were no findings that would indicate that there are any other residents who had similar concerns or issues. All employee files were reviewed for appropriate background checks, license verifications and other regulatory requirements for employment. The comprehensive care plans of all residents were checked to ensure there is a plan in place to prevent abuse. Nightly audits on the Dementia Unit will be conducted by the RN Supervisor for proper resident monitoring. On 04/22/2022 the facility provided re-in-service on Abuse Prevention and Resident's Rights. The Surveyors reviewed in-service attendance sheet dated 04/22/2022. Listed as follows: Administration/Admission 3/3 = 100%; Maintenance 3/4 = 75%; Directors 8/8 = 100%; Fiscals 2/2 = 100%; MDS 2/2 = 100%; Recreation 4/4 = 100%; Housekeeping 19/20 = 95%; Dietary 23/23 = 100%; Nursing LPN 15/15 = 100%; RNS 28/28 = 100%, CNA 90/90 = 100%, and Security 10/10 = 100%. The Surveyors conducted interviews with the following staff regarding Abuse Prevention and Resident's Rights: 19 CNAs, 4 LPNs, 6 RNs, 4 Housekeepers, 3 Occupational Therapists, 6 Physical Therapists, 1 Speech Therapist, 1 Social Worker, 8 dietary Aides, 1 maintenance workers, 3 Recreation staff, 2 Security Guards, 1 ADON, 1 DON, 1 Administration, 1 IT/Central Supply, and 1 Nursing Liaison. All staff stated they were in-serviced, and staff were knowledgeable on the policy and procedures regarding Abuse Prevention and Resident's Rights. The new policy for resident monitoring will be part of new hires' mandatory in-service for nursing staff. 415.4(b)(1)(i)

Based on observation, interviews and record review conducted during an abbreviated survey (NY00271675) on 08/23/2021 and 08/24/2021, the facility did not ensure that a resident receive adequate supervision to prevent accidents. This was evident in 1 out of 5 residents sampled (Resident #3). Specifically, record review revealed that from 11/25/2020 through 03/05/2021, Resident #3 sustained 27 falls. Eight (8) of the 27-falls resulted in either injury, hospital transfer or complaints of pain. Resident #3 was discharged to another facility on 03/08/2021. The findings are: Review of the facility's policy and procedure entitled Assessment of Patients/Residents at Risk for Falls effective in 08/2013, documented: It is the policy of the facility to identify the residents who are risk for falls upon admission, readmission and quarterly. Following any significant change or following a fall. The interdisciplinary team will develop a care plan that includes interventions to prevent falls or to minimize injury and/or complications if a fall should occur. The nursing staff is responsible for the completion of a fall risk assessment tool upon admission, readmission, and significant change and annually as well as after each fall. Risk scores are identified, and appropriate interventions are recorded in the care plan. The interdisciplinary team is responsible for developing a care plan that reflects the goals and measures to prevent falls based on identified risk factors. After a fall has occurred, the interdisciplinary team will re-evaluate the resident and revise intervention to prevent a recurrence. Resident #3 was initially admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Bipolar Disorder and Schizophrenia. The Minimum Data Set (MDS, a resident assessment tool) dated 02/18/2021 identified Resident #3 with a Brief Interview for Mental Status (BIMS) score of 12/15, associated with moderately impaired cognition. Resident #3 required extensive assistance of 2 staff for transfer and bed mobility. It was documented that walking did not occur. Resident #3 used a wheelchair and required extensive assistance of one person for locomotion on the unit. A Risk for Falls/ Injury care plan initiated on 11/19/2020 documented interventions for staff to anticipate and meet the resident's needs. Keep the call light within reach and encouraged Resident #3 to use the call bell for assistance as needed. There were no interventions for staff to monitor Resident #3. The NSG Morse Fall Scales v3-V1 dated 11/25/2020 documented that Resident #3 scored 40. Per the instructions on the form, Low Risk =0-24, Moderate Risk =25-44 and High Risk =45 and higher. According to the instructions on the form, Resident #3 was identified at moderate risk for falls. Review of the facility's Accident and Incident Reports from 11/2020 through 01/2021, revealed that Resident #3 sustained 8 falls some of which resulted in injuries and hospital transfer. 1) Incident of 11/25/2020 An Accident Report dated 11/25/2020 at 7:35 AM documented that Resident #3 was found sitting on the floor on his/her right side next to his/her closet. Resident #3 was assessed with no visible injury. An Actual Fall care plan initiated 11/25/2020 documented fall, no injury. There were no interventions to monitor Resident #3. An Occurrence Investigative Form dated 11/30/2020 documented that Resident #3 later complained of pain to the lower back and right thumb. The x-ray result, of the right hip, dated 11/26/2020 documented that Resident #3 had mild osteoarthritis of the right hip. Physical Therapy/Occupational Therapy (PT/OT) evaluations were ordered. Resident #3 was reassessed by Rehab and no decline was noted post fall. A Psychiatry Consult dated 01/19/2021 documented Schizoaffective Disorder, Bipolar Disorder. Resident #3's symptoms were described as stress induced daydreams or nightmares. Increase Bupropion to 100 MG daily for Severe Anxiety and continue Sertraline. Please continue to monitor behavioral, mood, sleep, appetite disturbances and follow up as needed. A Social Worker's Progress Note dated 01/26/2021 at 3:04 PM documented that Resident #3's Interdisciplinary Team Meeting was held via teleconference with the resident's family member. The team discussed Resident # 3's treatment goals, Social Worker's interventions, Dietary recommendations and Activities. The resident remained long term placement. 2) Incident of 01/27/2021 An Accident Report dated 01/27/2021 at 7:20 AM documented that Resident #3 was found lying on the floor next to the bed. Resident #3 complained of pain to his/her head, ice pack applied. Resident #3 was transferred to the hospital for further evaluation. The preventive actions documented frequent rounding recommended. An Actual Fall care plan was updated on 01/27/2021 and documented fall, head pain, transferred to hospital. There were no new interventions on how frequently Resident #1 should be monitored. A Nursing Progress Note dated 01/27/2021 at 08.32 AM documented that at 7:20 AM, the writer was notified that Resident #3 was on the floor. Upon assessment, Resident #3 was observed in his/her room sitting up against the wall. Resident #3's legs were stretched out on the floor. No visible injury noted. Resident #3 complained of headache 08/10 on the pain scale. Resident #3 was status post bilateral Deep Brain Stimulator Battery Replacement on 01/25/2021. Resident #3 was not allowed to have physical activity for 2 weeks. Bedrest was reinforced and the Physician was notified. Resident #3 was transferred to the hospital. A Physician's order dated 01/27/2021 documented transfer out to hospital stat for fall. A NSG Morse Fall Scale v3- V1 dated 01/27/2021 at 8:17 AM documented that Resident #3 scored 55. This denoted high risk for falls. A Nursing Progress Note dated 01/28/2021 at 10:08 PM documented that Resident #3 was readmitted to the facility post fall. There were no acute findings in the Computed Tomography (CT) scan and x-rays. A Physician's Orders dated 01/28/2021 documented Seroquel 25 MG 1 tablet orally daily for Schizophrenia, Sertraline HCL 100 MG tablet 1 tablet orally daily for Depression and Bupropion HCL 100 MG tablet 1 tablet orally daily for Depression. Review of the facility's Accident and Incident Reports for February 2021 revealed that Resident #3 sustained 16 falls. Several of the 16 falls resulted in injuries and hospital transfers. 3) Incident of 02/04/2021 An Accident Report dated 02/04/2021 at 10:10 PM documented that Resident #3 was observed on the floor next to his/her bed with lacerations on his/her left back and arm. An Actual Fall Care Plan was updated on 02/04/2021 and documented that Resident #3 had a fall with lacerations. There were no new interventions added to the care plan. A Nursing Progress Note dated 02/04/2021 at 11:14 PM documented that Resident #3 was observed on the floor on 02/04/2021 at 10:10 PM. During assessment, Resident #3 was found with lacerations on his/her left back and left upper arm. No active bleeding noted. Floor mats were placed, and the bed was placed in the lowest position. A Neurology Consult dated 02/05/2021 at 1:00 PM document Resident #3 was status post Deep Brain Stimulator Battery Replacement. Resident #3 had improved tremors but severe gait improvement with freezing of gait. Recommendations for Physical Therapy 3-5 days a week, discontinue bed rest. Continue Sinemet 25/100mg 1 tablet 3 times a day. Continue Seroquel 12.5 mg at night, if hallucinations worsened, Seroquel can be increased to 25 mg at night. 4) Incident of 02/10/2021 An Accident Report and an Occurrence Investigative Form dated 02/10/2021 at 7:45 PM documented that Resident #3 was found on the floor next to the right side of the bed. Resident #3 was noted with a1cm x 0.5cm scalp opening with bleeding from the back of his/her head. Resident #3 was transferred to the hospital and received 2 sutures. The preventative actions documented frequent rounding. An Actual Fall care plan was updated on 02/10/2021 documented that Resident #3 had a fall with skin tear on the back of his/her head. Resident #3 at risk for fall and should be monitored closely was entered on the care plan on 02/11/2021. A Physician's order dated 02/10/2021 documented transfer to the emergency room due to fall and head trauma one time only until 02/10/2021 at 11:59 PM. A Nursing Progress Note dated 02/11/2021 at 9:21 AM documented that Resident #3 returned to the facility at 5:48 AM. CT scan and x-rays were negative. Resident #3 had 2 staples to scalp laceration. 5) Incident of 02/13/2021 An Accident Report dated 02/13/2021 at 11:06 PM documented that Resident #3 was observed on the floor lying on his/her stomach with bleeding above his/her right eye. A 4cm laceration was noted above the right eyebrow. Resident #3 was transferred to the emergency room . the preventative actions documented frequent rounding and several cues as needed. An Actual Fall Care Plan was updated on 02/13/2021 documented that Resident #3 had a fall with a 4cm laceration over his/her right eye. The care plan was updated with intervention to monitor/document/report as needed x 72 hours to the Physician for signs and symptoms: Pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture and agitation. There was no frequency for monitoring Resident #3. A Nursing Progress Note dated 02/14/2021 at 1:09 AM documented Resident #3 had a change in condition due to fall with a 4cm laceration above the right eye on 02/13/2021 at 11:06 PM. The Physician ordered transfer Resident #3 to hospital for Computed Tomography (CT) scan, x-rays, and sutures. A Nursing Progress Note dated 02/14/2021 at 11:39 AM documented that Resident #3 returned from the hospital at approximately 10:30 AM in stable condition. Resident #3 had 6 sutures to the laceration above the right eye. 6) Incident of 02/22/2021 An Accident Report dated 02/22/2021 at 08:45 AM documented that Resident #3 was observed on the floor next to his/her bed. Redness was noted to Resident #3's right mid-back. An Actual Fall Care Plan was updated on 02/22/2021 and documented that Resident #3 had a fall with redness on his/her right mid back. The care plan was updated for Therapy Consult for strength and mobility and check range of motion. There were no documented interventions on how frequently staff should monitor Resident #3 A Nursing Progress Note dated 02/22/2021 at 8:50 AM documented that Resident #3 was observed on the floor on his/her buttocks next to his/bed. On assessment, Resident #3 was noted with redness to his/her right mid back. 7) Incident of 02/23/2021 An Accident Report dated 02/23/2021 at 3:10 PM documented that Resident #3 fell on the floor after he/she got up from his/her wheelchair. No visible injury noted. Resident #3 was transferred to the hospital for evaluation of Hallucinations and Altered Mental Status. An Actual Fall Care Plan was updated on 02/23/2021 and documented that Resident #3 had a fall with no visible injury. The care plan was updated to provide incontinent care every 2 hours and as needed. There were no documented interventions on how frequent staff should monitor Resident #3. A Nursing Progress Note dated 02/23/2021 at 4:19 PM documented that Resident #3 was assessed with no visible injury. Resident #3 was disoriented and mumbling. The Physician was informed and ordered transfer Resident #3 to the hospital. Resident #3's family member was notified. A Nursing Progress Note dated 02/24/2021 at 10:01 AM documented that Resident #3 returned to the facility at 2:54 AM. Resident #3 was alert and in stable condition with no visible injury. Review of the facility's Accident and Incident Reports for March 2021 revealed that Resident #3 sustained 3 falls. Resident #3 also had injuries and hospital transfers. A Nurse Practitioner's Progress Note dated 03/02/2021 at 3:31 PM documented that Resident #3 was seen for fall and sutures removal. It was reported that Resident #3 was observed on the floor in the hallway his/her room. Resident #3 was sitting on his/her buttock at the time and reported to the nurse that he/she fell backwards. A reddened area was noted on Resident' #3's right upper back. Resident #3 denied pain. No limitation of movements noted to the lower extremities motion. Sutures to right eyebrow and staples to occipital scalp removed with no bleeding. 8) Incident of 03/05/2021 A Nurse Practitioner's (NP) Progress Note dated 03/05/2021 at 2:51 PM documented Resident #3 with recent Altered Mental Status and frequent falls was seen today for fall. It was reported that the resident moved from his/her wheelchair in the hallway to pick up something on a table close by him/her and fell face down. The resident has a laceration on his right eyebrow. The resident was bleeding but was alert. Since resident is bleeding, confused with moderate agitation, plan is to send resident to hospital for evaluation. Review of the Actual Fall care plan revealed that the care plan was not updated to reflect Resident #3's fall of 03/05/2021. A Nursing Progress Note dated 03/07/2021 at 2:11 PM documented that Resident #3 was status post fall with sutures above his/her right eye. Resident #3 was alert and oriented. Review of the CNA Documentation Survey Report v2 dated from 11/2020-03/2021 revealed that Resident #3 was being monitored every 2 hours for census monitoring. This was evidenced by staff members initials and Resident #3's locations on the documentation survey report. Review of the CNA Documentation Survey Report v2 dated 02/2021-03/2021 documented bilateral floor mats at all times while resident is in bed. Monitor resident status post fall for new onset of pain, decline in ADL performance, new skin changes, and immediately report abnormal findings to the charge nurse, Physician or NP. There were no instructions on how frequently staff should monitor Resident #3. A Plan of Care Note dated 03/02/2021 at 3:35 PM documented that a significant change in status care plan meeting for decline in Activities of Daily Living (ADL) and frequent falls was held with the interdisciplinary team and Resident #3's family member via phone conference. ADL needs, fall incidence, rehab therapy, nutritional status and consults were discussed. A NSG Morse Fall Scale v3- V1 dated 03/03/2021 at 1:27 AM documented that Resident #3 had a score of 71. This denoted high risk for falls. A Nursing Progress Note dated 03/08/2021 at 3:43 PM documented that the resident was discharged to another nursing and rehabilitation facility at 2:39 PM in stable condition. During an interview on 08/24/2021 at 12:20 PM, the Rehab Director (RD) stated that Resident #3 was admitted from another Long-Term Care Facility. The RD stated that Resident #3 initially had good standing balance. The RD stated that Resident #3 was picked up for therapy after a fall on 12/28/2020 but had declined to limited assistance with ADLs including walking. The RD stated that Resident #3 kept falling and declining further. Resident #3 was kept on therapy from 12/28/2020 to 01/22/2021 and Resident # 3 continued to fall. Resident #3 declined to maximum assistance of 2 persons on 01/07/2021. The facility followed recommendations from the Neurologist. Therapy was put on hold for 2 weeks after Deep Brain Stimulator battery replacement. Resident #3 started rehab again from 02/08/2021 to 03/05/2021. Resident #3 progressed to 1-person moderate assistance. As per family request, Resident #3 was transferred to another Nursing Home. During an interview on 08/24/2021 at 1:20 PM, Certified Nursing Assistant (CNA) #1 stated that he/she was assigned to Resident #3. CNA #1 further stated that Resident #3 would often get up suddenly from his/her wheelchair and bed and fall to the floor. CNA #1 said that Resident #3 was on monitoring and that he/she believed it was every 15 minutes or every 30 minutes. CNA #1 stated that the monitoring was not documented. CNA #1 also said that Resident #3 had a low bed and floor mats. During an interview on 10/13/2021 at 10:13 AM, CNA #2 stated that he/she was assigned to Resident #3 during the evening shift. CNA #3 verbalized that Resident #3 often tried to get out of bed independently. CNA #2 stated that he/she monitored Resident #3 visually every half hour, but the monitoring was not documented. CNA #2 stated that the CNA Accountability record had instructions for Resident #3 to be monitored every 2-3 hours. There were no other monitoring sheets. CNA #2 said that Resident #3 had 2 upper side rails and floor mats at his/her bedside. During an interview on 10/13/2021 at 10:50 AM, Licensed Practical Nurse (LPN) #1 stated that he/she worked on Resident #3's unit during the night shift. LPN #1 stated that Resident #3 was non-compliant with calling for assistance. Resident #3 got up from his/her bed unassisted at times and was observed on the floor. LPN #1 said that Resident #3 had 2 upper siderails and was on every 30 minutes monitoring to prevent falls but it was not documented. During an interview on 10/15/2021 at 11:30 AM, the Assistant Director of Nursing (ADON) stated that he/she was familiar with Resident #3's care. The ADON stated that Resident #3 was being closely monitored by Nursing staff but there was no scheduled monitoring. The ADON verbalized that every time Resident #3 fell , the facility did something. Resident #3 had floor mats, low bed, was referred to Rehab and Psychiatry Consult was done on January 19th, 2021 but none was ordered after January. Resident #3 was also followed by the Neurologist. The ADON stated that the facility did not offer 1:1 monitoring. During an interview on 10/15/2021 at 1:35 PM, LPN #2 stated that Resident #3 had several falls during the evening shift. Resident #3 was non-compliant with staying in the bed. Resident #3 would get out of bed with unsteady gait and at times made it to the doorway. There were times when Resident #3 fell in the morning, then fell again in the evening. LPN #2 said that he/she monitored Resident #3 at the nurse's station. LPN #2 said that he/she assigned a CNA to monitor Resident #3 in the day room when he/she was not at the nurse's station. During interviews on 10/18/2021 at 3:18 PM and 12/08/2021 at 2:00 PM, the Director of Nursing (DON) stated that Resident #3 was initially assessed as at a moderate risk falls but became a high risk for falls afterwards. The DON further stated that he/she investigated Resident #3's falls and the facility attempted different interventions to prevent the falls. The DON verbalized that it was his/her responsibility to see that corrective actions from each fall were entered on Resident #3's care plan. The DON stated that Resident #3 had low bed, room change close to the nurse's station, frequent checks and 1:1 recreation activity. The DON also stated that at one time, the facility had staff sit with Resident #3 for some period, but the facility couldn't continue with it. If Resident #3 was placed on 1:1 monitoring, it would have been only for a short time. Resident #3's falls were discussed in morning meetings with the NP, nursing, rehab and recreation staff. The Nurse Managers are responsible for updating residents care plans, but the facility has had staff turnovers since Resident #3 left the facility. 415.12(h)(2)

Based on observation, record review and staff interviews during the recertification survey the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infections. Specifically, one resident receiving oxygen by a nasal cannula with the oxygen tubing coming from the oxygen concentrator was resting on the floor in the residents room. This was evident for 1 of 1 resident reviewed for oxygen therapy. (Resident #81). The facility policy titled, Oxygen Therapy dated 6/17 documents: General Instructions- 2) The Nursing staff will set up, check and supervise all treatments. Procedure - 6) Oxygen tubing and masks will be changed weekly unless soiled by the 11PM - 7AM staff and as necessary if cleanliness is compromised. On 12/08/19 at 9:53 AM and 12:54 PM, Resident #81 was observed lying in bed. The resident was receiving oxygen via nasal cannula from an oxygen concentrator on the left side of the bed. The oxygen tubing coming from the oxygen concentrator was running along the floor and up the side of the bed to the resident's nasal cannula. Resident #81 had [DIAGNOSES REDACTED]. The Care Plan for Respiratory status dated 9/7/19 documents -Resident is at risk for altered respiratory status. related to a [DIAGNOSES REDACTED]. The resident receives oxygen therapy. Goal- Resident will be free of signs and symptoms of respiratory distress. physician's orders [REDACTED]. 11-7 shift on Sunday. Oxygen - change tubing every week 11-7 shift on Sunday. Oxygen 2 liters/minute via nasal cannula or mask as needed for shortness of breath, humidified. On 12/8 /19 at 9:55AM CNA #1 came into the room while the SA was present and did not observe the oxygen tubing resting on the floor. On 12/08/19 at 12:56 PM, the Registered Nurse (RN #1) was interviewed and acknowledged the tubing on the floor. The RN stated the oxygen tubing should not be lying on the floor. The staff should make sure the excess tubing is attached to the side of the bed and not touching the floor. This is an infection control issue, and she will tell the nurse to replace the tubing. On 12/08/19 at 1:01 PM, the Licensed Practical Nurse (LPN #1) was interviewed and acknowledged the oxygen tubing was on the floor running from the oxygen concentrator to the nasal cannula. LPN #1 stated the tubing should go from the machine to the bed to the resident. I came in the morning at 7AM and I make my rounds. We have to put the oxygen tubing into a plastic bag and the into the drawer so it does not touch the floor. On 12/09/19 10:36 AM, Resident #81 was interviewed and stated, Until yesterday they never educated me about not letting the oxygen tubing lay on the floor. Before yesterday, the staff never placed the oxygen tubing in a plastic bag so as to keep it off the floor. If they would have educated me about the tubing it would not be on the floor. Yesterday, after they attached the plastic bag to the side of my bed, they folded the tubing and put it in the bag so it would not touch the floor. Before yesterday it did not occur to me that the tubing on the floor is a problem. On 12/12/19 at 12:09 PM, the Director of Nursing was interviewed stated, Oxygen tubing should not be lying on the floor. I was not told that the oxygen tubing was coming out of the oxygen concentrator and was lying on the floor as the opposite end of the tubing was running up the side of the bed and into the nasal cannula the resident was wearing. The oxygen tubing should be rolled up in a plastic bag tied to the concentrator or tied to the side rail of the bed. The nursing staff did not follow the protocol to prevent the oxygen tubing from touching the floor. This is an infection control issue. I was told the tubing was immediately changed . As a result of this situation we reeducated the staff. We reeducated all the residents that are on oxygen about the importance of not letting the oxygen tubing touch or lay on the floor. 415.19(b)(1)

Based on observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that a resident received devices to prevent pressure ulcers. Specifically, a resident was observed on multiple occasions without heel booties or diabetic shoes as ordered by the Physician. This was evident for 1 of 2 residents reviewed for Pressure Ulcers. (Resident #37) The findings are: Resident #37 had a [DIAGNOSES REDACTED]. On 12/08/19 at 10:34 AM and 12/10/19 at 10:33 AM, Resident #37 was observed to be laying in bed in her room. Two blue heel booties were observed to be on the resident's bedside table in the far-right corner of the room and no heel booties were observed on the resident's feet. On 12/10/19 at 11:00 AM and 12/11/19 at 11:35 AM, the resident was observed to be dressed, groomed, and out of bed to her wheelchair. The resident was observed to be wearing black regular sneakers. There were no diabetic shoes observed in the resident's room on 12/11/19 at 11:37 AM. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident has severely impaired cognition and is at risk for pressure ulcers. A Comprehensive Care Plan (CCP) initiated on 4/8/19 and related to the resident's potential for skin breakdown due to diabetes documented that nursing staff are responsible for assessing and providing appropriate pressure relieving devices as per physical therapy occupational therapy recommendations. The CCP also documented that nursing staff are to offload pressure areas. The physician's orders [REDACTED]. The Certified Nursing Assistant (CNA) Kardex tasks as of 12/11/19 documented that the resident is to have bilateral cushioned heel booties to be worn in bed with regular skin checks every shift for any discomfort and discoloration. A CCP initiated 4/8/19 and related to the resident's limited physical mobility documented that the CNA is responsible for ensuring that resident has bilateral cushioned heel booties to be worn when in bed with regular skin checks every shift and diabetic shoes to be worn when out of bed with regular skin checks. A CCP initiated 4/11/19 and related to the resident's risk for pressure ulcer development documented that the resident has a history of pressure ulcers. The licensed nurse is responsible for following the skin integrity protocol and offloading pressure areas. A Skin/Wound Note dated 5/7/19 documented that the resident was evaluated by the vascular doctor for friction blisters to bilateral lower extremities. The Medical Doctor (MD) recommended to offload resident's bilateral heels. The resident's CCP related to pressure ulcer development was updated on 4/11/19 to reflect this recommendation by the MD. The CNA Documentation Survey Report, the Treatment Administration Record, and the Medication Administration Record [REDACTED]. A MD Note dated 5/2/19 documented that the resident had a bilateral heel tissue injury and heel booties are to be applied to bilateral heels while in bed. The CCP related to the resident's limited physical mobility was updated on 5/3/19 to reflect the MD recommendation for resident to have heel booties applied while in bed. The CCP was updated on 11/8/19 to reflect the order of diabetic shoes. A Rehab Intervention Note dated 11/8/19 documented that the resident was evaluated by a certified Pedorthist on 11/7/19 and recommended to have diabetic shoes. Diabetic shoes are to be worn when the resident is out of bed and nursing was informed. The CCP related to limited physical mobility was updated to reflect that the resident is to wear diabetic shoes while out of bed. An interview was conducted with CNA #2, the CNA assigned to Resident #37, on 12/12/19 at 9:53 AM. CNA #2 stated that she has been working with the resident since 12/1/9. She believes the resident wears regular sneakers and crocs style shoes. CNA #2 is aware what a diabetic shoe looks like but Resident #37 has never had this type of shoe in her closet or her room since CNA #2 has started working with her. The only special type of shoes that are provided to the resident by the facility are the heel booties that the resident wears while she is in bed to protect her feet from getting pressure ulcers. The resident is not currently wearing the booties even though she is still in bed. CNA #2 does not believe that the booties are in the resident's room because the resident was not wearing the booties when the CNA came in this morning and the CNA did not observe the heel booties anywhere in the room. Usually, CNA #2 removes them when she comes in at 7 AM to start her shift. She then provides the resident with breakfast, washes her, and takes her out of bed by 11 AM. At 9:59 AM heel booties were observed in the resident's closet, the CNA was present during this observation. CNA #2 stated that it is not a regular occurrence for the resident to be without her heel booties and she has observed this approximately 2-3 times since she began working with the resident on 12/1/19. She is unsure whether the CNA Kardex Tasks includes documentation of the order for the resident to wear heel booties while in bed and is only aware of this resident having heel booties because she physically saw them in the room. When the Physical Therapy Department recommends a device for a resident, they communicate it to the nurse and the nurse gives the CNAs instruction on how and when to use it by giving a verbal instruction. The Nurse did not communicate anything special to CNA #2 about how to use the heel booties for Resident #37. On 12/12/19 at 10:12 AM, an interview was conducted with the charge nurse, Registered Nurse (RN) #2. RN #2 stated that she is familiar with the resident and that Resident #37 has an MD order for heel booties to be worn while she is in bed. This is communicated to the assigned CNA via the CNA Kardex Tasks. The CNA must sign off on the Kardex Tasks each day indicating that they are providing the resident with the heel booties. RN #2 stated that the resident was not wearing them this morning because the aide is preparing the resident to come out of bed. She made rounds this morning between 7:30 AM and 8AM to visually check whether each resident is wearing their appropriate devices and is pretty certain that Resident #37 was wearing her heel booties while in bed. RN #2 is unaware of an order for [REDACTED]. of diabetic shoes while out of bed. After RN #2 checked the resident's medical record, and acknowledge the physician's orders [REDACTED]. She checked the At resident's room and was unable to find the diabetic shoes. She stated that a few weeks ago, there were several residents that received diabetic shoes, but the residents are usually in bed when she conducts her rounds. RN #2 stated that the shoes would be labeled with the resident's name and she is going to inform the Physical Therapy Department that they are missing. On 12/12/19 at 10:48 AM, an interview was conducted with the Physical Therapist (PT) that had worked with Resident #37. The PT stated that she recommended for the resident to have heel booties while in bed and that is highly recommended that the resident wear the heel booties the entire time that she is in bed. The PT Department comes to the unit and provides the device to the nursing staff. They inservice them on how to use the device. It is then expected that the nursing staff will ensure that the resident receives the device as ordered. The diabetic shoes were ordered for the resident after a specialist came into the facility in (MONTH) of 2019. The PT Director would know more about that order. The PT stated that she is responsible for updating the resident's care plan with to include devices that have been ordered for her but does not know how the CNA Kardex Tasks are updated to reflect this information. The CNA Kardex had been updated to reflect that the resident was to have heel booties applied while in bed; however, the CNA Kardex did not document that the resident is to wear diabetic shoes out of bed. The PT stated that the SA would need to speak with her Director regarding the documentation related to the diabetic shoes. An interview was conducted with the Director of the PT Department (DPT) on 12/12/19 at 11:03 AM. The DPT stated that there was a specialist that came in and evaluated Resident #37 in (MONTH) of 2019 and ordered for her to have diabetic shoes. The nursing staff was provided with a list of those residents who received diabetic shoes and the resident's CCP was updated to reflect this information. The heel booties order is included on the CNA Kardex Task but not the order for diabetic shoes. The DPT was unaware of how to include this on the Kardex since this option is not available on pre-populated drop-down list available on the Electronic Medical Record (EMR). The DPT then began to look at the options available on the EMR and was able to find a way to manually input this information onto the Kardex in order for the CNA to be aware that the resident has an order for [REDACTED]. 415.12(c)(1)

Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, staff did not identify and address a resident's abrasions/injuries during skin assessments. This was evident for 1 of 2 residents reviewed for Skin Conditions. (Resident #22) The findings are: A facility policy and procedure related to Skin Inspection Treatment dated 4/16 documented that a thorough inspection of the resident's skin surface, particularly all areas over bony prominence, on each shift by the assigned Certified Nursing Assistant (CNA) and weekly by the licensed nurse. The CNA reports all changes to the licensed nurse. The licensed nurse documents weekly observation in the medical record. Resident #22 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] documented that the resident is severely cognitively impaired, did not have any skin conditions, and did not have any falls since the previous assessment was completed. On 12/08/19 at 09:28 AM Resident #22 was observed to be sitting up on his bed in his room. The resident had a short-sleeved shirt on, was alert, and displayed some confusion. The Surveyor observed a linear scab of about 4 inches in length on the bottom portion of the resident's right forearm. The scab was dry and a deep red color. There was no active bleeding observed from the site. The resident stated that he fell but was unable to provide any further information. Resident #22 then raised his left arm and showed the surveyor that he had round quarter-sized scab to the bottom of his left forearm, approximately 2 inches from his elbow. The scab was brown in color and dry with no oozing or active bleeding observed. The surrounding area of the scab appeared slightly inflamed and red. Physician order [REDACTED]. The Nursing Skin Inspection forms dated 12/10/19, 12/2/19, 11/20/19, and 11/12/19 documented that the resident did not have any rashes, excoriated areas, bruises, open [MEDICAL CONDITION], cuts, laceration or skin tears. The Certified Nursing Assistant (CNA) Kardex Task form dated 12/10/19 documented that the CNA should monitor the resident's skin condition each shift. Medical Doctor (MD) notes from 9/1/19 through 12/09/19 did not document that Resident #22 had any skin conditions to his bilateral forearms. Nursing Notes from 9/1/19 to 12/9/19 did not document that the resident had any skin conditions to his bilateral forearms. The Treatment Administration Record (TAR) for (MONTH) 2019 did not document that that any treatment was provided to the resident's bilateral forearms prior to 12/11/19. A (MONTH) 2019 Documentation Survey Report that is used to document the daily tasks and observations performed by the CNA documented that skin observations were made every shift (three times daily). The record documented that no skin conditions were observed on any of the three shifts from 12/1/19 through 12/9/19. A Comprehensive Care Plan (CCP) related to Falls was initiated on 6/26/17 and documented that the resident had stepped on his shoe string on 6/25/17 and had a bruise to the right knee on 1/1/18. There was no documented evidence that the resident sustained [REDACTED]. A CCP related to Activity of Daily Living (ADL) self-care performance deficit initiated on 12/27/2016 documented that the resident the CNA and Nursing Staff are to inspect the resident's skin for redness, open areas, scratches, cuts, bruises and repot changes to the nurse. An interview was conducted with CNA #4 on 12/10/19 at 02:47 PM. CNA #4 has been working with Resident #22 intermittently since (MONTH) 2019 and is currently assigned to care for him. She assists the resident with changing, choosing his clothes, showering, and observing his skin during care. CNA #4 makes her skin observations while assisting the resident in changing his clothes and/or when she provides him with a shower. She had observed the resident's skin today while changing his clothes in the morning and she did not observe any cuts, bruises rashes, or skin conditions of any sort. She did not observe any scabs to the resident's bilateral forearms. After SA brought the CNA to the resident's room, CNA #4 observed the resident's forearms and stated that she did not notice the scabs to his bilateral arms. If she did observe any skin conditions, she would have reported it to the nurse. The nurse did not report to the CNA that the nursing staff was aware that the resident had scabs on his bilateral arms during the morning meeting on the resident's unit. On 12/10/19 at 2:55 PM, an interview was conducted with the Registered Nurse (RN) #3, the RN assigned to the resident's unit. He has been working on this unit for approximately 8 months and is familiar with Resident #22. Skin assessments of residents are done by the CNAs during shower days. The CNA assesses the resident's skin and then reports any issues to the Licensed Practical Nurse (LPN) or RN. The RN or LPN then documents the CNA's findings on the skin assessment form. If there is any issue found with the resident's skin, the RN must assess the skin condition for particulars, complete a wound care referral form, and communicate it to the interdisciplinary team. The MD is also made aware of the resident's skin condition since the MD may want to give an order for [REDACTED]. He is not aware of any skin conditions for Resident #22. After going to the resident's room with the SA, RN #3 observed the resident's bilateral forearms. RN #3 stated that he has never observed these scabs or skin conditions on the resident's bilateral forearms before. This has not been reported to him and he was unaware of any prior injury. He will need to look into this. Each shift is responsible for verbally communicating any incidents that have occurred, writing a progress note, and documenting the incident on the 24-Hour Nurse Report. There are no nursing notes related to this skin condition and nothing was verbally communicated to him. Now that this has come to his attention, the RN stated that he will contact the MD. On 12/11/19 at 9:37 AM, an interview was conducted with the Director of Nursing (DON). The DNS stated that no incidents or skin conditions have been reported to nursing administrations in relation to Resident #22. The DON first became aware that the resident had scabs on his bilateral forearms on the evening of 12/10/19. As soon as the DON became aware, an investigation was initiated. The DON stated that the resident's roommate reported that he observed the resident sliding from his bed in the evening between 12/9 and 12/10. When she was made aware that the resident was observed with this skin condition on 12/8/19, the DON stated that she would need to expand her investigation. The DON stated that the injuries are consistent with the resident sliding from his bed and then using his elbows to lift himself back up and is likely the result of a fall. Although Resident #22 is confused, he did report that he fell . The question is the timeframe of when this occurred. The CNA is responsible for conducting a skin observation of the resident and then documenting accordingly. The CNA informs the nurse who then performs a skin assessment, writes a progress note, and then informs the resident's designated representative and the MD. A follow up interview was conducted with the DON on 12/12/19 at 12:55 PM. The DON stated that the resident is sometimes guarded about having staff complete a skin assessment and sometimes wears long-sleeved shirts. Skin monitoring should be done by CNAs daily to report any irritation or breakdown. CNAs should attempt to check the resident's entire body unless the resident refuses. If the resident refuses, the nurse should be made aware. If there is anything irregular on the skin, the CNA must let the nurse know. The nurse then assesses the resident's skin and lets the MD or wound care nurse know. If it is a skin tear, bruising, or an injury then an Accident/Incident investigation is initiated, and the DON is made aware. The nurse is required to assess the resident's skin independently and should not rely only upon the CNA's report. Licensed Practical Nurses (LPN) conduct a body check once weekly. Nursing notes are written, and the CNA accountability is updated. A Skin Assessment form is then filled out after the LPN visually observes the resident's skin. The DON stated that she does not believe that a skin assessment was done thoroughly for Resident #22. The DON believes that the staff may have done a cursory check of the resident's skin but not enough to see the injuries to his bilateral forearms. On 12/11/19 at 10:19 AM, an interview was conducted with CNA #3, the resident's regularly assigned CN[NAME] CNA #3 stated that she has been assigned to the resident daily since 12/1/19. She assists him with taking showers, choosing his clothes, and getting him dressed. She also assists with applying A&D ointment to his skin to protect against dryness and observing the resident's skin for any conditions or injuries. The resident has never refused showers or having his skin checked by CNA #3. She has not noticed anything unusual with his skin and did not notice any scrapes that he has on his forearm. CNA #3 stated that if she observed that any resident had scrapes or bruises on him, then she would report it to the nurse. 415.12

Based on staff interviews and record review during an abbreviated survey (NY 727), the facility did not ensure that Office of the State Long Term Care Ombudsman was notified of the transfer/discharge of each discharged resident. This was evident in 6 out of 6 sampled residents, (Resident #1, #2, #3, #4, #5 & #6). Specifically, the facility initiated transfer/discharges for Resident #1, #2, #3, #4, #5 but did not send a copy of the transfer/discharge notice to the Office of the State Long Term Care (LTC) Ombudsman. A Facility Policy and Procedure titled, Discharge/Transfers Rights and Regulations, dated 03/2017 states, it is the responsibility of the Social Worker (SW) to complete the Discharge/Transfer Notice and provide a copy to the resident and representative. Documentation in the medical record, by the Social Worker, should indicate the date the Notice was given and to whom the notice was given, as well as the date and Notice was mailed to the designated representative and the Ombudsman and appropriate information is communicated to the receiving health care institution. The Social Worker will send a copy of the Notice to the Representative/Guardian and the Office of the State Long Term Care Ombudsman via First Class Mail or another communication method as requested. A copy of the notice will be maintained in the medical record. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool)) on 01/23/2018, indicated a BIMS (Brief Interview for Mental Status) cognitively intact. A Transfer /Discharge Notice dated 02/01/2018 documented Resident #1 was given a notice that the facility will discharge him on 02/01/2018 to the hospital with the following reason: This transfer/discharge notice is being issued for your welfare as your needs cannot currently be met by the services available at hospital. The notice documented left hip surgical site possible infection, as a statement of fact that supports the determination to discharge or transfer the resident. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool) on 01/19/2018, indicated a BIMS (Brief Interview for Mental Status) score of 15/15, cognitively intact. A Transfer /Discharge Notice dated 01/16/2018 documented Resident #2 was given a notice that the facility will discharge him on 01/18/2018 to a shelter. The notice did not indicate the reason of why the transfer/discharge notice is being issued. A MD Discharge Summary with an effective date of 01/17/2018, documented the resident was discharged to the community on 01/18/2018. The reason for transfer/discharge indicated the resident's health has improved significantly so the resident no longer needs the services provided by the facility. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool) on 12/12/2017, indicated a BIMS (Brief Interview for Mental Status) score of 15/15, cognitively intact. A Transfer /Discharge Notice dated 12/05/2017 documented Resident #3 was given a notice that the facility will discharge the him on 12/11/2017 to a shelter. The reason for transfer/discharge indicated the resident's health has improved significantly so the resident no longer needs the services provided by the facility. A review of the MD Discharge Summary with an effective date of 12/11/2017, documented the resident was discharged to the community on 12/11/2017. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool) on 03/20/2018, indicated a BIMS (Brief Interview for Mental Status) score 15/15, cognitively intact. A review of the Transfer /Discharge Notice dated 03/16/2018 documented Resident #4 was given a notice that the facility will discharge her on 03/20/2018 to a shelter. The reason for transfer/discharge indicated the resident's health has improved significantly so the resident no longer needs the services provided by the facility. A review of the MD Discharge Summary with an effective date of 03/19/2018, documented the resident was discharged to the community on 03/20/2018. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS resident assessment tool) on 01/26/2018, indicated a BIMS (Brief Interview for Mental Status) score of 13/15, cognitively intact. A review of the Transfer /Discharge Notice dated 01/29/2018 documented Resident #5 was given a notice that the facility will discharge him on 02/02/2018 to an address mentioned on the form. The reason for transfer/discharge indicated the resident's health has improved significantly so the resident no longer needs the services provided by the facility. A review of the Social Work Discharge Plan dated 02/02/2018 documented Resident #5's discharge destination is resident's own home. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool) on 12/07/2017, indicated a BIMS (Brief Interview for Mental Status) score of 13/15, cognitively intact. A review of the Transfer /Discharge Notice dated 01/04/2017 documented Resident #6 was given a notice that the facility will discharge her on 01/08/2017 to (an address mentioned on the form). The reason for transfer/discharge indicated the resident's health has improved significantly so the resident no longer needs the services provided by the facility. A review of the Social Work Discharge Plan dated 01/08/2018 documented Resident #6's discharge destination is resident's own home. There was no documented evidence that the facility sent a copy of the Notices of transfer/discharge to the Office of the State Long Term Care Ombudsman. The SW was interviewed on 03/21/2018 at 11:15 AM, and stated that a copy of the Notice given to Resident #1, was not sent to the Ombudsman because it was not a 30-day notice of transfer/discharge. The Director of Social Service (DSS) was interviewed on 04/27/2018 at 9:10 AM via telephone. She stated that a copy of transfer/discharge notice for all mentioned residents was not sent to the Office of the State Long Term Care Ombudsman because the discharges were not involuntary and they were not 30-day notices. 415.3(h)(1)(i)(iii)(a-c)

Based on interviews and record review during an abbreviated survey (NY 727), the facility did not ensure that a resident received the necessary care and services to maintain the highest practicable well-being in a timely manner for 1 out of 6 residents sampled (Resident #1). Specifically, Resident #1 was assessed on 01/31/2018 with redness, swollenness and tenderness to the left hip surgical site and the Nurse Practitioner (NP) was made aware. Record review revealed that no interventions were implemented on 01/31/2018. Resident #1's primary physician was informed on 02/01/2018 at 9:40 AM and ordered Antibiotic treatment. Subsequently, Resident #1 was transferred to the hospital on [DATE] at 11:30 AM and was given a dose of Intravenous Antibiotics in the Emergency Department (ED) for the [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) on 01/23/2018, indicated a Brief Interview for Mental Status (BIMS - used to determine attention, orientation and ability to recall information) score of 15/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment & 12-15 cognitively intact). A Nurse's Progress Note, (by Registered Nurse #1) RN #1, dated 01/31/2018 at 5:32 PM documented that Resident #1's left hip incision site was noted with [DIAGNOSES REDACTED] and tenderness to the distal part of the incision site. The site was intact and without any drainage. The Nurse Practitioner (NP) was notified regarding the surgical incision status. There was no documentation of interventions implemented. A Rehab Progress Note by the Physical Therapist (PT), dated 01/31/2018 at 08:21 PM, documented that on observation, Resident 1's left hip surgical site appeared swollen, red, tender and warm to touch. The Nurse Manager and the Social Worker (SW) were informed. A Nurse's Progress Note, (by RN #1), dated 02/01/2018 at 09:40 AM documented that she spoke with the physician regarding Resident #1's left hip surgical incision site. The physician ordered Keflex 500 milligrams (mg) twice a day for 7 days. An Order Summary Report dated 02/01/2018 - 02/28/2018 documented, Keflex Capsule 500mg, give 500mg by mouth two times a day for [MEDICATION NAME], for left hip surgical wound for 7 days. A Situation, Background, Appearance, Request or Recommendation (SBAR) tool dated 02/01/2018 at 10:58 AM, (by RN #2), documented that Resident #1 had infection to his left hip surgical site which started on 02/01/2018 at 10:00 AM. The tool also documented that Resident #1 was started on Keflex. At 10:00 AM, the physician recommended to transfer Resident #1 to ED. A Medication Administration Record [REDACTED]. A Nurse's Progress Note, (by RN #2), dated 02/01/2018 at 3:26 PM documented that Resident #1 was transferred to the hospital on [DATE] at 11:30 AM with the [DIAGNOSES REDACTED]. A hospital document dated 02/01/2018 documented that Resident #1's chief complaint by Emergency Medical Services (EMS) was infection to left hip surgical site. The Emergency Department (ED) physician's note dated 02/01/2018 documented no discharge or palpable abscess along incision. [MEDICAL CONDITION] approximately 10 cm diameter spanning the inferior aspect of incision. Resident #1 received a dose of Intravenous Antibiotic and labs were ordered. Resident #1 was discharged from the hospital with the [DIAGNOSES REDACTED]. A prescription was given for oral [MEDICATION NAME]-Clavulanate and Bactrim DS and Resident #1 to follow up with Ortho Surgeon. The PT was interviewed on 03/21/2018 and 05/08/2018, and stated that on 01/31/2018, the resident complained that his left hip was red and swollen. She also stated that the resident showed her the left hip surgical site on 01/31/2018 at approximately 2:00 PM and she notified the nurse and Rehab Director. RN#1 was interviewed on 03/22/2018 at 11:43 AM via telephone and stated that she notified the NP on 01/31/2018 (does not remember time) after she observed Resident #1's left hip surgical site with redness and swollenness. She also stated that she notified the physician on 02/01/2018 regarding redness on Resident#1's left hip surgical site and an order for [REDACTED]. The NP was interviewed on 05/04/2018 at 11:25 AM via telephone, and stated he reviewed Resident #1's medical record and does not recall Resident #1 and does not recall speaking with the RN. He further stated that if he did, he would have documented his interventions in the resident's medical record. RN #2 was interviewed on 03/21/2018 at 12:07 PM, and stated that she assessed Resident #1's left hip surgical site on 02/01/2018 and that it was swollen and red. She stated that the physician ordered for the resident to be transferred to the hospital for further evaluation. Resident #1's primary physician was interviewed on 03/22/2018 and 04/26/2018 via telephone. He stated that on 02/01/2018, a nurse called him regarding Resident #1's complaint of pain and [DIAGNOSES REDACTED] at the surgical site. The physician further stated that the site had signs of possible infection and that he gave an order for [REDACTED]. The Director of Nursing Services (DNS) was interviewed via telephone on 05/08/2018 at 11:15 AM, and stated that she was not aware that RN#1 spoke with the NP on 01/31/2018 regarding [DIAGNOSES REDACTED] and swollenness to Resident 1's left hip surgical site. She also stated that she was not aware that there were no interventions implemented after the NP was notified. 415.12

Based on staff interviews and record review during an abbreviated survey (NY 727), the facility did not ensure that a resident's physician documented information about the basis for hospital transfer or discharge. This was evident for 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 was transfer/discharge to the hospital on [DATE]. The physician did not document in Resident #1's medical record the reason, specific needs the facility could not meet, the facility efforts to meet those needs and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. A Facility Policy and Procedure titled, Discharge/Transfers Rights and Regulations, dated 03/2017 states that the documentation required must be completed by a physician /Nurse Practitioner (NP) when a transfer or discharge is necessary due to resident's welfare and the resident's needs cannot be met in the facility. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a resident assessment tool) on 01/23/2018, indicated a BIMS (Brief Interview for Mental Status) score of 15/15, cognitively contact. A Nurse's Progress Note, (by Registered Nurse #1) RN #1, dated 01/31/2018 at 5:32 PM documented that Resident #1's left hip incision noted with [DIAGNOSES REDACTED] and tenderness on distal part of the incision and that Resident #1 complained pain. The site was intact and without any drainage. The Nurse Practitioner (NP) was notified regarding the surgical incision status. No further documentation noted on 01/31/2018 regarding the left hip surgical site. A Nurse's Progress Note, (by RN #1), dated 02/01/2018 at 09:40 AM documented that she spoke with the physician regarding Resident #1's left hip surgical incision. The physician ordered Keflex 500 milligrams (mg) twice a day for 7 days. An Order Summary Report dated 02/01/2018 - 02/28/2018 documented Keflex Capsule 500mg give 500mg by mouth two times a day for [MEDICATION NAME] for left hip surgical wound for 7 days. A Medication Administration Record [REDACTED]. A Situation, Background, Assessment, Recommendation (SBAR) form dated 02/01/2018 at 10:58 AM, (RN #2), under title Situation documented that Resident #1 had infection on left hip surgical site started on 02/01/2018 at 10:00 AM. The form also documented that Resident #1 was started on Keflex. Resident #1's vital signs documented as Temperature 98 degrees Fahrenheit, Pulse 68, Respiration 18 and Blood Pressure 133/85. Primary physician's recommendation at 10:00 AM to transfer the resident to Emergency Department (ED). An Order Summary Report dated from 02/01/2018 - 02/28/2018 revealed no doctor's order to transfer Resident #1 to the hospital. A Nurse's Progress Note, (by RN #2), dated 02/01/2018 at 3:26 PM documented that Resident #1 was transferred to the hospital on [DATE] at 11:30 AM with [DIAGNOSES REDACTED]. A Transfer /Discharge Notice dated 02/01/2018 documented Resident #1 was given a notice that the facility will discharge Resident #1 (mentioned by name on form) on 02/01/2018 to the hospital. The appropriate reason (checked mark) this transfer/discharge notice is being issued for your welfare as your needs cannot currently be met by the services available at facility, left hip surgical site possible infection. A hospital document dated 02/01/2018 documented that Resident #1 chief complaint by Emergency Medical Services (EMS) was infection to left hip surgical site. The Emergency Department (ED) physician's note dated 02/01/2018 documented no discharge or palpable abscess along incision. [MEDICAL CONDITION] approximately 10cm diameter spanning the inferior aspect of incision. Physician's plan included dose of Intravenous Antibiotic, labs and discharged back to facility with oral antibiotics for two weeks and follow-up with ortho surgeon. Resident #1 was discharged from hospital with [DIAGNOSES REDACTED]. A prescription was given for oral [MEDICATION NAME]-clavulanate and Bactrim DS. A Nurse's Progress Note, (by RN#3), dated 02/02/2018 at 7:00 AM documented that a follow-up disposition call was made to the hospital and was informed by ER nurse that Resident #1 was discharged to the community. A review of the Physician's Progress Notes did not reveal any documented evidence of Resident #1's transfer/discharge. The last entry made by physician was 01/26/2018. In addition, there was no documentation from the NP who was informed on 01/31/2018 regarding Resident #1's surgical site with redness and complaints of pain. RN #2 was interviewed on 03/21/2018 at 12:07 PM, and stated that she assessed Resident #1's left hip surgical site that was swollen and red. She stated that the physician ordered for the resident to be transferred to the hospital for further evaluation. Resident #1's primary physician was interviewed on 03/22/2018 and 04/26/2018 via telephone. He stated that a nurse called him regarding Resident #1's complaint of pain and [DIAGNOSES REDACTED] at the surgical site. The physician further stated that the site had signs of possible infection and that he gave an order for [REDACTED]. He stated that that he did not document because Resident #1 was not discharged and that he gave an order to send the resident to the hospital for an evaluation of the wound infection. The Director of Nursing was interviewed on 04/18/2018 at 3:50 PM via telephone. She stated that the order was documented as a telephone order. The DNS responded to a question regarding physician documentation of a resident transfer/discharge. She stated there was no documentation in the physician's progress notes regarding the resident's basis for transfer. She added that if the physician is in the building during the time of the transfer, then he will write a note, otherwise it will be a telephone order. She further added that the resident's transfer to the hospital was documented by the nurse on the SBAR form. 415.3(h)(1)(ii)(a-c)