Every finding on record at Fulton Center for Rehabilitation and Healthcare

Based on observation, interview, and record review during a survey, the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to maintain sanitary bedside care equipment, ensure clean and orderly bedside food storage, safeguard and properly distribute resident-owned personal property, systematically track and investigate missing personal items, and maintain the structural integrity of physical plant walls. Findings were identified across four sampled residents (Resident #17, Resident #25, Resident #26, and Resident #29) and throughout facility-wide areas as detailed below: Findings include: Review of Facility Policies Home Like Environment (Dated 9/19/2022): Documented that residents must be provided with a safe, clean, comfortable, and homelike environment. Staff shall provide person-centered care maximizing characteristics reflecting a personalized setting, explicitly including (a.) cleanliness and order and (e.) pleasant, neutral scents. Personal Property (Revised 12/17/2025): Documented that residents are permitted to retain and use personal possessions and clothing. The facility must inventory personal possessions upon admission and promptly investigate any complaints of misappropriation or mistreatment of resident property. Resident-Specific Findings (Ordered Sequentially by Resident) Resident #17 Resident #17 was admitted with diagnoses including Schizoaffective Disorder (bipolar type), peripheral vascular disease, and dementia. The Minimum Data Set ( an assessment tool) dated 3/26/2026, documented the resident was communicative and cognitively intact. Observations: During an observation on 5/21/2026 at 1:10 AM, Resident #17's bedside commode was observed to be visibly soiled with urine and stool smears. During an observation on 5/28/2026 at 10:39 AM, the bedside commode bucket was observed improperly placed and crooked on its frame. A small amount of urine sat in the bottom, and stool was smeared up the interior side of the bucket. Interviews: During an interview on 5/21/2026 at 1:10 PM, Resident #17 stated they cannot walk to the bathroom and must slide to the commode. They stated Certified Nurse Aides empty it but sometimes take up to an hour to respond, adding, it does get smelly. During an interview on 5/28/2026, at 10:40 AM: Resident #17's roommate stated staff gave [Resident #17] a hard time about emptying the bucket, did not want to clean it, and could be rude to the resident about the task. During an interview on 5/28/2026, at 12:41 PM: Certified Nurse Aide #4 stated they cleaned the commode bucket at the beginning and end of each shift and as needed by spraying and rinsing it. During an interview on 5/28/2026, at 1:23 PM, 5/29/2026, at 11:24 AM, and 5/29/2026, at 11:41 AM, Licensed Practical Nurses #2, #6, and #5 corroborated that commodes must be emptied, wiped down, and sanitized with germicide wipes immediately after every single use. Licensed Practical Nurse #5 emphasized there should be no residual matter left behind. During an interview on 5/29/2026 at 10:49 AM, Licensed Practical Nurse #10 stated each shift must check the commodes, there should never be obvious stool smears, and both Certified Nurse Aides and housekeepers share cleaning responsibilities. Licensed Practical Nurse #10 explicitly stated that uncleaned commodes present an absolute infection control concern and an environmental issue. During an interview on 5/29/2026 at 12:48 PM, Director of Nursing #1 stated commodes must be emptied and rinsed after each use. Director of Nursing #1 acknowledged that dirty commodes were both an infection control concern and homelike environment concern. Resident #25 Resident #25 was admitted with diagnoses including diastolic heart failure, Stage 4 chronic kidney disease, and bipolar disorder with psychotic features. The Minimum Data Set, dated [DATE], documented that the resident was communicative and cognitively intact. Observations (Food Sanitation and Order in room [ROOM NUMBER]-West): On 5/22/2026, 5/26/2026, 5/27/2026, and 5/28/2026 (four consecutive days), multiple covered, unlabeled containers and an open, large bottle of unlabeled orange juice containing an inch of separated, decomposing fluid were allowed to remain on the resident's bedside table alongside old food remnants. Observations (Property Integrity): On 5/22/2026, 5/26/2026, 5/27/2026, 5/28/2026, 5/29/2026, and 6/01/2026, Resident #25's personal property, a bottle of Dove Men's Body Wash clearly labeled with Resident #25's name and room number-was missing from their room and located on another resident's over-the-bed table across the facility. Interviews: During an interview on 5/26/2026 at 10:00 AM, Resident #25 stated family members bring outside food items as an alternative to facility food, and they rely on housekeeping to clear away the dirty dishes. During an interview on 5/28/2026 at 10:40 AM, Director of Housekeeping #1 stated housekeepers were expected to dispose of old food daily. Director of Housekeeping #1 confirmed they were only notified of the decaying items by staff on 5/28/2026, at which point they had to step in and assist with a deep cleaning of room [ROOM NUMBER]-West. During an interview on 5/29/2026 at 10:40 AM, Certified Nurse Aide #2 confirmed all resident food and drink items must be labeled or immediately thrown out, and staff must report resident refusals to the charge nurse. During an interview on 5/29/2026 at 11:30 AM, Licensed Practical Nurse #6 stated they were completely unaware Resident #25's body wash was missing or had been misappropriated. They confirmed a missing items form should have been filled out to replace the item for Resident #25. Resident #26 Resident #26 was admitted with diagnoses including chronic obstructive pulmonary disease (a progressive disease that makes it hard to breathe), heart failure (the heart muscle does not pump blood as well as it should), and Restless Leg Syndrome (a neurological condition that causes an irresistible urge to move your legs). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact and communicative. Record Review: A Resident Property Drop Off Form dated 10/23/2026, documented a 1 red rose 3xL button down sweater cardigan owned by the resident. Review of facility records revealed zero (0) misappropriation or missing items forms were completed by staff for Resident #26 regarding missing clothing. Interviews: During an interview on 5/21/2026, at 12:05 PM, Resident #26 stated laundry goes missing frequently. They reported missing four items, including an oversized sweater, forcing them to purchase a replacement out-of-pocket. They reported this to the Head of Housekeeping, who told them it could not be found. The resident was never reimbursed. During an interview on 5/27/2026, at 12:42 PM,: Director of Social Work #1 stated missing clothing should be logged on a missing item form. During an interview on 5/28/2026, at 12:41 PM and 5/28/2026, at 1:23 PM: Certified Nurse Aide #4 stated they were completely unaware a form existed for missing items. Licensed Practical Nurse #2 stated they usually just leave a note for the unit manager, adding there used to be a form. During an interview on 6/1/2026 at 10:14 AM, Director of Housekeeping #1 acknowledged Resident #26 reported the missing sweater a while ago. Director of Housekeeping #1 admitted they failed to follow up with the resident. Director of Housekeeping #1 further acknowledged that items were only replaced if there was a paper trail, admitting that the facility's lack of documentation directly prevented the resident from receiving reimbursement. During an interview on 6/1/2026 at 12:07 PM, Administrator #1 stated anyone can accept a grievance or misappropriation form, including Housekeeping. They stated a seven-day turnaround investigation is expected. Resident #29 Resident #29 was admitted with diagnoses including necrotizing fasciitis (is a rare but severe bacterial infection that destroys the tissue beneath the skin, including the fascia and muscles) and an open wound of the upper arm requiring assistance with personal care. The Minimum Data Set, dated [DATE], documented that the resident was communicative and cognitively intact. Observations: During an observations on 5/22/2026, 5/26/2026, 5/27/2026, 5/28/2026, 5/29/2026, and 6/1/2026, a bottle of Dove Men's Body Wash clearly labeled with Resident #25's name and room number was observed sitting on Resident #29's over-the-bed table. Interviews: During an interview on 5/26/2026 at 10:30 AM, Resident #29 stated that Certified Nurse Aide #1 personally handed them that specific bottle of labeled body wash when they first arrived at the facility to use for their personal care. During an interview on 5/29/2026 at 11:30 AM, Licensed Practical Nurse #6 stated they were unaware Resident #29 had been given another resident's labeled personal hygiene product instead of facility-provided stock. Facility-Wide Environmental Findings: Physical Plant Maintenance During environmental walkthroughs conducted on 5/21/2026 and 5/22/2026, it was identified that all shared resident bathrooms throughout the facility exhibited a pattern of structural neglect, characterized by cracked, gouged, and water-damaged walls. During an interview on 5/22/2026 at 11:30 am, Director of Maintenance #1 stated that the walls were hard to keep in good condition due to residents using mobility aids, but the facility do try its best and will look into more long lasting solutions to high damage areas. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on record review and interviews during a survey, the facility failed to ensure that residents were free from abuse and or neglect for three (Resident #114, 156, and #181) of seven residents reviewed. Specifically, (a.) Resident #'s 114 and 181 were involved in a resident-to-resident altercation where Resident #181 pushed Resident #114's wheelchair from behind causing the resident to fall from their wheelchair; (b.) Resident #156 was admitted to the hospital with a Discharge summary dated 11/2025 documenting a compression fracture of the lumbar spine level 1. The hospital recommendation were to follow up with Orthopedics because they had recommended a kyphoplasty for the Lumbar 1 compression fracture and Resident #156 should be referred to neurosurgery for the procedure. There was no documentation of orthopedic, or neurosurgery follow up. Furthermore, the Director of Nursing and Administrator were not aware that Resident #156 had a compression fracture. Findings include: The facility's Policy and Procedure titled Abuse Policy,, revised 07/18/2025 documented The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility had designed and implemented processes, which strived to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Neglect was define as f ailure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish or distress. Resident #114 Resident #114 was admitted to the facility with diagnoses of cervical spinal cord injury (damage to the uppermost part of the spine (the neck)), quadriplegia (a condition characterized by the partial or complete loss of motor and sensory faction in all four limbs), and multiple sclerosis (a chronic autoimmune disease that affects the central nervous system (brain, spinal cord, and optic nerves). The Minimum Data Set (an assessment tool) dated 04/14/2026, documented the resident was cognately intact, could be understood, and could understand others. Resident #181 Resident #181 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels), and type two diabetes (an endocrine dysfunction causing unregulated blood glucose levels). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, could be understood, and could usually understand others. A complaint received by the New York State Department of Health on 03/12/2026, documented Resident #114 was seated in their wheelchair at the nurse's station when Resident #181 violently pushed the wheelchair forward causing Resident #114 to fall out of the wheelchair with the wheelchair falling on top of them. Resident #114 suffered from a neck fracture as a result of this. A Psychiatric Consult note dated 9/04/2025, documented Resident #181 had a history of bipolar disorder that was being managed with Lamotrigine and Wellbutrin. Resident #181 was on Seroquel but it was discontinued upon admission to the facility. Resident #181 expressed concern that the Seroquel was discontinued as it had been very helpful in controlling their mania symptoms which tended to include physical aggression and extreme emotional lability with agitation and anger. Resident #181 stated that if they were discharged within a week, they would restart their Seroquel on their own. However, if they were to stay at the facility, Resident #181 would want to restart the medication. The Facility Investigation dated 9/08/2025, documented on the evening of 9/08/2025, Resident #114 was in A wing hallway in their wheelchair speaking to a nurse when Resident #181 came up from behind and made contact with Resident #114's wheelchair causing the resident to fall from the wheelchair. Both residents were immediately separated. A statement written by Resident #114 on 9/08/2025, documented that they were talking with Licensed Practical Nurse #8 about their cell phone being stolen by Resident #181, when Resident #181 grabbed their wheelchair and flipped them out of the chair. Then Resident #181 yelled that was what Resident #114 got for accusing Resident #181 of stealing a cell phone. A statement written by Resident #181 on 09/08/2025, documented that they overheard Resident #114 accusing them of stealing their cell phone at the nurse's station. Resident #114 stated they lost their cool and pushed Resident #114's wheelchair enough to jar the resident, which caused Resident #114 to come to somewhat of a standing position, and then Resident #114 fell down on their right side. Resident #181 further stated that they did not touch Resident #114, only the back of their wheelchair. An Accident/Incident Statement form completed by Licensed Practical Nurse #8 dated 09/08/2025, documented Resident #114 was speaking to them about another resident. Resident #181 came behind Resident #114 and pushed the resident out of the wheelchair onto the floor. They immediately removed Resident #181 from the area and checked on Resident #114. An Initial Event Documentation/Fall Assessment completed for Resident #114, dated 09/08/2025, documented Resident #114 was talking to the nurse on unit when another resident made contact with the resident's wheelchair causing the resident to fall forward out of the wheelchair onto their right side. Resident #114 complained of hip pain. Range of motion was within normal limits with extremities. Skin was intact with no visible injuries. Medical provider was updated and a new order was given for an x-ray of right hip. Residents were separated and room changes expected. Social work was made aware. A Radiology Results Report dated 09/10/2025, documented three views of the pelvis and right hip demonstrated no dislocation or obvious fracture. Moderate bilateral arthritic change was seen of the hips with circumferential collar osteophyte formation. Dorsal lumbosacral orthopedic hardware was appreciated with disc spaces at L4-L5 and L5-S1. The sacroiliac joints and pubic symphysis demonstrated age-appropriate changes. During an interview on 06/01/2026 at 10:48 AM, Resident #114 stated they were attacked by their previous roommate Resident #181 in September 2025. They stated Resident #181 had threatened to kill them at one point. Resident #114 reported it to the unit manager, who told them not to worry about it. Resident #114 stated staff knew Resident #181 was dangerous because they had to have two staff enter the room to deal with them. Resident #114 stated they were at the nurse's station talking about their missing phone, and Resident #181 overheard it. They stated Resident #181 then ran up to the wheelchair and slammed into it, causing Resident #114 to fly 30 feet and landed with the wheelchair on top of them. Resident #114 stated there were multiple witnesses and they insisted that the police were called. There were no charges pressed toward Resident #181. Resident #114 stated there were no restrictions put on Resident #181, but they did move Resident #181 to another room. They stated until Resident #181 was discharged , they still felt threatened. Resident #114 stated they had a noninvasive medical test that uses a strong magnetic field and radio waves to create highly detailed images of internal organs, soft tissues, and bones (MRI) done that showed the previous existing hardware in their neck/back had to be revised because of the attack. Attempted to contact Licensed Practical Nurse #8 on 5/29/2026 and 6/01/2026 was made with no return calls received. During an interview on 05/29/2026 at 11:41 AM, Licensed Practical Nurse #5 stated if they observed or were made aware of a resident-to-resident altercation they would separate the residents, redirect them, and then inform the Assistant Director of Nursing, Director of Nursing, Medical Provider, and Administrator. Licensed Practical Nurse #5 stated they would complete skin checks, obtain an order from the medical provider for behavior monitoring, and call the family. They stated depending on if it were physical or verbal abuse, they would separate the residents into different units. Licensed Practical Nurse #5 stated they would complete an Incident and Accident Report for each resident, get statements from anyone that witnessed the incident, put in notes and then pass it along. Licensed Practical Nurse #5 stated resident-to-resident altercations could be considered abuse depending on the circumstances. They stated if there was injury, it was reportable to the Department of Health. During an interview on 5/29/2026 at 12:35 PM, Director of Nursing #1 stated Resident #114 and Resident #181 were both younger roommates and had a hard time getting along. They stated Resident #114 had a lot of false beliefs. Director of Nursing #1 stated Resident #114 was in their wheelchair, Resident #181 hit the wheelchair, and then Resident #114 went to the floor. Staff intervened immediately and a room change was completed. Director of Nursing #1 stated they were made aware of the altercation immediately. X-rays were performed and Resident #114 was found to have no injuries. Director of Nursing #1 stated they started the investigation right away and spoke to residents and staff. Director of Nursing #1 stated they were not sure if Resident #181 was intentionally trying to hurt Resident #114, but it was considered a resident-to-resident altercation. They stated if someone was intentionally trying to hurt someone, then it would be considered abuse. Director of Nursing #1 stated in their investigation they ruled out abuse, neglect, and mistreatment. During an interview on 06/01/2026 at 12:07 PM, Administrator #1 stated there was an allegation that Resident #181 pushed Resident #114 out of their wheelchair. Resident #114 called the police, but charges were not pressed. Administrator #1 stated the staff separated the residents, and Resident #181 discharged shortly after. Administrator #1 stated the facility completed an investigation but could not recall the outcome. Resident #156 Resident #156 was admitted to the facility with a diagnoses of end stage renal disease (the final, permanent stage of chronic kidney disease, meaning the kidneys can no longer filter waste, toxins, and excess fluids from the blood to stay alive without use of artificial means), bipolar disorder (a lifelong mental health condition that causes extreme emotional highs (mania or hypomania) and lows (depression); and major depressive disorder (a persistent feeling of sadness, emptiness, or loss of interest in once-enjoyable activities). The Minimum Data Set, dated [DATE], documented they could understand and be understood by others, and was cognitively intact. Record Review of X-ray dated 11/06/2025 documented the lumbosacral spine had normal alignment with multilevel degenerative disc disease was noted throughout the spine. There was no evidence of acute fracture. There was decreased bony mineralization. Sacrum was grossly intact. Hospital Discharge summary dated [DATE] documented, Discharge Assessment: Message to outpatient provider. Resident was admitted in the setting of respiratory failure with hypoxia secondary to pneumonia. Incidental findings of acute on chronic Lumbosacral 1 (lumbar first level) compression fracture was also noted. Orthopedics recommended kyphoplasty for Lumbosacral 1 compression fracture and resident should be referred to neurosurgery for procedure. Resident diagnosis list in the facility's tracking and documentation database) documented on 12/01/2025 a diagnosis of wedge compression fracture of first lumbar vertebra (spine). Nurse Practitioner #1 progress note dated 03/01/2026 documented resident was admitted to hospital from [DATE] - 11/26/2025 for respiratory failure secondary to pneumonia. They were found to have a chronic Lumbosacral 1 compression fracture. Pain was managed. They improved and returned to facility. They were seen today for routine management. Medical Doctor #1's progress note dated 03/03/2026 documented Assessment: Low back pain with recent history of Lumbosacral 1 fracture managed non-surgically. Plan: The resident's current regimen of oxycodone ten milligrams twice daily appeared to help with their pain. However, the resident would likely benefit from having an additional ten milligrams of oxycodone available to them after their dialysis days. Recommended adding this to the resident's regimen. Record review of Hospital Discharge summary dated [DATE] documented resident admitted with acute hypoxic (low oxygen) respiratory failure and shortness of breath. On presentation, they were found to be hypoxic (low levels of oxygen) with oxygen saturations in the 70's, required six Liters nasal cannula oxygen, and chest imaging revealed multifocal pneumonia. Additional issues managed during admission included moderate malnutrition and ongoing debility related to prior hip fracture and recent coccyx fracture, resulting in wheelchair dependence and need for mechanical lift transfers. Resident #156's Comprehensive Care Plan dated 07/24/2025 documented resident was at risk for falls / has had an actual fall related to deconditioning, history of falls, iImmobility. Alteration in comfort related to (potential/actual) left hip fracture and compression fracture of Lumbosacral one1. Occupational Therapy note dated period of 02/16/2026 - 03/14/2026, documented resident was presenting with increased pain in left lower extremity and lower back this reporting period. Due to pain, resident had declined to participate in toilet transfers. Prior to changes in pain severity level, they were able to complete toilet transfers using rolling walker for support with moderate assistance and 30-35% verbal cues for task initiation, . for proper positioning/ body mechanics, and for safety awareness. Medication Administration Record dated 10/2025 documented : Keppra (levetiracetam) Oral Tablet 500 milligrams Give one tablet by mouth every morning and at bedtime for seizure activity. Medication Administration Record dated 12/2025 documented Keppra (levetiracetam) Oral Tablet 500 milligram Give one tablet by mouth two times a day for seizures. During an interview on 05/21/2026 at 11:10AM, Resident #156 stated they stayed in bed most of the time due to back pain, Resident #156 stated their pain was ten out of ten on a scale of zero to ten, with ten being the worst. Resident #156 stated the facility had been adjusting their pain medication but still had not gotten it correct. Resident #156 stated they had a seizure in the facility and their back broke some months ago As a result, they were sent to the hospital. During an interview on 05/29/2026 at 12:15 PM, Director of Nursing #1 stated Resident #156 did not have fracture of coccyx. The X-ray was of the resident's hip which was healed. They had no knowledge of a fracture of the Lumbosacral spine, and no knowledge of Resident #156 ever falling. During an interview on 05/29/2026 at 12:54 PM, Licensed Practical Nurse #5 stated they had no knowledge of Resident #156 ever falling or having seizure activity. During an interview on 05/29/2026 at 3:28 PM, Resident #156 stated again that they had a seizure, during which used such force to hold them down, Resident #156 broke their back. Resident #156 stated that when they came out of their seizure, they were in a lot of pain and needed to be sent to the hospital. During an interview on 06/01/2026 at 9:53 AM, Administrator #1 stated they had no knowledge that Resident #156 had fractured their Lumbosacral one spine. During an interview on 06/01/2026 at 9:53 AM, Director of Nursing #1 was asked to explain discharge summary findings dated 11/26/2025 and 05/06/2026 both documenting Lumbosacral one and coccyx fractures. Director of Nursing #1 stated they were unaware that resident had any fractures. Director of Nursing #1 stated that when residents returned to the facility from a hospital admission, the unit manager reviewed the discharge summary, and they had no answer regarding why the Lumbosacral one fracture and coccyx fractures were not reported to them. The unit manager for the unit was currently on medical leave. Director of Nursing #1 was unable to provide documentation of recommended follow up with orthopedic for kyphoplasty or the neurosurgery follow up consult. During an interview on 06/01/2026 at 9:56 AM, Administrator #1 stated a documented fracture on the discharge summary should have prompted the facility to conduct an investigation once notified. Unfortunately, this was not done. In addition, documentation did not support that there was follow up on recommendations from the hospital. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i)

Based on record reviews and interviews conducted during the survey, the facility failed to implement a system to consistently and accurately reconcile controlled medications in accordance with professional standards of practice. Specifically, the narcotic count record signature sheet for five of eight units were signed in advanced or incomplete. Findings include: A review of narcotic count record book for Unit A cart 300 documented: On 05/28/2026 at 11:02 AM the 7 AM-3 PM Licensed Practical Nurse #1 signed in advance as the off going nurse at 3 PM A review of narcotic count record book for Unit C cart 500 documented: On 5/28/2026 at 10:30 AM the 7 AM-3 PM Licensed Practical Nurse #2 had not signed as oncoming nurse at 7 AM A review of 05/2026 narcotic count record book for Unit D cart 800 documented: On coming nurse did not sign for 05/01/2026 at 3:00 PM On coming nurse did not sign for 05/09/2026 at 7:00 AM Outgoing nurse did not sign for 05/09/2026 at 3:00 PM On coming nurse did not sign for 05/26/2026 at 3:00 PM On 05/27/2026 at 2:36 PM the 3PM-11 PM Licensed Practical Nurse #3 signed in advance as the off going nurse at 11 PM A review of 05/2026 narcotic count record book for Unit C cart 900 documented: Outgoing nurse did not sign for 05/22/2026 at 3:00 PM On coming nurse did not sign for 05/23/2026 at 7:00 AM Outgoing nurse did not sign for 05/23/2026 at 3:00 PM On coming nurse did not sign for 05/24/2026 at 7:00 AM On coming or Outgoing nurse did not sign for 05/24/2026 at 3:00 PM Outgoing nurse did not sign for 05/24/2026 at 11:00 PM On coming nurse did not sign for 05/26/2026 at 7:00 AM Outgoing nurse did not sign for 05/26/2026 at 3:00 PM On coming nurse did not sign for 05/26/2026 at 7:00 AM A review of 05/2026 narcotic count record book for Unit E cart 100 documented: On coming or Outgoing nurse did not sign for 05/20/2026 at 11:00 PM On coming nurse did not sign for 05/21/2026 at 11:00 PM Outgoing nurse did not sign for 05/22/2026 at 7:00 AM On 05/27/2026 at 2:37 PM the 7AM-3 PM Licensed Practical Nurse #4 signed in advance as the off going nurse at 3 PM During an interview on 5/27/2026 at 2:35 PM, Licensed Practical Nurse #3 stated they had signed the narcotic count book in advance for 05/27/2026 at 11 PM when they would be the outgoing nurse. The narcotic book should be signed when nurses completed the narcotic count and verified the count was correct at the beginning and end of every shift. During an interview on 5/28/2026 at 10:32 AM, Licensed Practical Nurse #2 stated they had not signed the narcotic count book yet because it had been a busy morning. They stated they should have signed when they first came on shift. During an interview on 5/28/2026 at 11:02 AM, Licensed Practical Nurse #1 stated they signed the narcotic count book in advance as the outgoing nurse routinely, so they did not forget. During an interview on 5/28/2026 at 11:05 AM, Licensed Practical Nurse #5 stated the narcotic count book should never be signed in advance, that would be signing for something that was not done. During an interview on 06/01/2026 at 12:45 PM, Director of Nursing #1 stated they had been auditing the narcotic count books and would be increasing the audits due to missing signatures and nurses signing in advance. 10 New York Codes Rules and Regulations 415.22(a)(1-4)

Based on observations and interviews conducted during a survey, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for three (3) (Resident #'s 26, 79, and 116) of five (5) residents reviewed. Specifically, (a.) for Resident #'s 26 and 79, food was not served at an appetizing temperature during a lunch meal on 5/28/2026 and the fries were too crispy to eat; and (b.) Resident #116 was served burnt stuffed shells during a dinner meal that were not palatable. Additionally, 10 anonymous residents during a resident council meeting stated the food was not good, often cold, and was overcooked or undercooked. The findings include: The facility policy titled Food Temperatures revised 5/28/2025, documented food temperatures of cold and hot food items would be recorded on all menu items and substitutions for meal service to maintain a high level of quality assurance and to monitor potentially hazardous food temperatures as per state and federal health regulations thus ensuring that foods were provided in a safe, palatable manner. During a Resident Council interview on 5/22/2026 at 11:00 AM, 10 anonymous residents stated the food was horrible. They stated the food was often overcooked or undercooked. They stated the kitchen did not measure or weigh the food. The residents stated the food was often cold. The chicken tenders were rock hard when served. They stated an egg salad sandwich was just a glop of egg salad in the middle. The bread was often stale or dried out. Some residents stated they had to spend their own money to buy food. During an observation on 5/21/2026 at 1:15 PM, meal trays were delivered to the B unit hall 1. At 1:27 PM, the Licensed Practical Nurse from B unit hall 2 started passing trays. Certified Nurse Aides started passing trays at 1:37 PM. The last meal tray was served at 1:45 PM to room [ROOM NUMBER]. A resident in room [ROOM NUMBER] stated the food was lukewarm, but it was usually cold. Resident #26 Resident #26 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a progressive, long term lung disease that causes restricted airflow and breathing-related difficulties), heart failure (when the heart muscle is too stiff or weak to pump effectively), and restless leg syndrome (uncontrollable, overwhelming urge to move the legs). The Minimum Data Set (an assessment tool), dated 3/03/2026, documented the resident was able to understand others, was able to be understood, and was cognitively intact During an interview on 5/21/2026 at 12:05 PM, Resident #26 stated the food was not the greatest and was often cold. During an observation on 5/28/2026 at 1:36 PM, the meal tray cart arrived to unit B side 1. Kitchen staff stated they were still waiting for an additional 3 meals trays. The last 3 trays arrived on the unit at 1:38 PM. During an observation on 5/28/2026 at 1:40 PM, Resident #26 meal tray was tested in the presence of Certified Nurse Aide #4, and a replacement tray was requested. Food temperatures were measured as follows: soup of the day was 124 degrees Fahrenheit, hot dog was 106 degrees Fahrenheit, waffle fries were 84 degrees Fahrenheit, mixed fruit was 57 degrees Fahrenheit, and apple juice was 57 degrees Fahrenheit. All other food and drinks provided were within normal temperature range. Some of the waffle fries were noted to be too crispy to eat. Resident #79 Resident #79 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), non-pressure chronic ulcer of skin of other sites with fat layer exposed (deep, long-lasting open sore on the skin), morbid (severe) obesity due to excess calories (weighing in excess of 100 pounds of one's ideal weight). The Minimum Data Set, dated [DATE], documented that the resident could be understood, could understand others, and was cognitively intact. During an interview on 5/22/2026 at 10:48 AM, Resident #79 stated the food was not good and they had been served burnt food before. They stated sometimes a hot dog was served on a hamburger bun. During an observation on 5/28/2026 at 12:52 PM, Resident #79's meal tray was tested, and a replacement tray was requested. Food temperatures were measured as follows: cottage cheese was 58.3 degrees Fahrenheit, waffle fries were 110 degrees Fahrenheit and some were too hard to eat. All other food provided was within normal temperature range. Resident #116 Resident #116 was admitted to the facility with diagnoses of chronic respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide), heart failure (a chronic, progressive condition where the heart muscle is too weak or stiff to efficiently pump enough oxygen rich blood ot meet the body's needs), and depression (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life). The Minimum Data Set, dated [DATE], documented the resident was cognately intact, could be understood, and could understand others. During an observation on 5/28/2026 at 5:58 PM, Resident #116's meal tray was tested, and a replacement tray was requested. The meal included stuffed shells, pudding, and milk and the temperatures were within normal limits. The stuffed shells were observed to be burnt and tough on top. During an interview on 5/28/2026 at 6:00 PM, Resident #116 stated dinner trays were always late. Resident #116 demonstrated difficulty cutting the burned stuffed shells and pointed out that they did not have teeth. Staff were made aware and ordered a new tray. During an interview on 6/01/2026 at 11:00 AM, Diet Tech #1 stated it was unacceptable for burnt food to leave the kitchen let alone make it to the residents. During an interview on 6/01/2026 at 11:48 AM, Food Service Director #1 stated they cooked to a minimum of 165 degrees Fahrenheit, then food was placed on a steam table in smaller batches due to the large size of the facility, then they have a pellet base that gets heat and a plate went on top. They stated they took temperatures and used a temp log so food was cooked to proper temperature. Food Service Director #1 stated they did not have insulated carts. They stated they started serving lunch around 11:30 AM and were usually done by 1:30 PM. They stated some meals took a little longer to put together. Food Service Director #1 stated corporate put together the menu and they just started the new spring/summer menu, which was an adjustment for the staff. They menu follows a 4 week cycle. After the first 4 weeks of the new menu, they could request changes or make suggestions to corporate. Food Service Director #1 stated they were looking to replace waffle fries on the menu. They stated they did attend the monthly food committee meeting and would identify and address resident concerns with the food. They stated they did not have chefs, they had cooks and they really were trying. During an interview on 06/01/2026 at 1:00 PM, Administrator #1 stated they had been completing audits on meal accuracy and were working with corporate to upgrade meal carts. They stated they were unaware of meals reaching residents burnt, and they would not expect burnt food to leave the kitchen. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure residents could safely self-administer medication when clinically appropriate for one (1) (Resident #108) of one (1) resident reviewed for medication administration. Specifically, Resident #108 had an inhaler observed in their room that was not listed in the resident's orders, they reported using the medication, and they were not assessed for their ability to self-administer medication. Findings include: The facility policy titled Medication Self-Administration reviewed 7/2019, documented the resident may request to keep medications at bedside for self-administration in accordance with resident rights. The staff and practitioner would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate for the resident upon request. In addition to a general evaluation of decision-making capacity, the nurse would perform a more specific skill assessment. It would be determined if the resident was able to safely store and self-administer their medication, self-administer their medication with assistance from the nurse by storing the medication in the med-cart, or was unable to safely self-administer medication. Staff should identify and give the Charge Nurse any medication found at the bedside that were not authorized for self-administration, for return to the family or responsible party. The electronic medical record and medication administration record must identify meds that were self-administered. The staff and practitioner would periodically reevaluate a residents' ability to continue to self-administer medications. Resident #108 Resident #108 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease ((a group of lung diseases that block airflow and make it difficult to breathe), asthma with acute exacerbation (a sudden, progressive worsening of asthma symptoms and a decrease in lung function), and obesity (a chronic disease characterized by excessive body fat that increased the risk of severe health problems). The Minimum Data Set (an assessment tool) dated 3/17/2026, documented the resident was cognitively intact, could be understood, and could understand others. During an observation on 05/22/2026 at 10:02 AM, there was a blue inhaler observed on Resident #108's tray table at bedside. During an interview on 5/22/2026 at 10:02 AM, Resident #108 stated the order for their inhaler was discontinued so their partner brought in their inhaler from home. They stated they needed the inhaler on occasion. Resident #108 further stated the facility discontinued the order for their inhaler because they did not use it often. A review of Resident #108's Physician Orders did not include orders for an albuterol inhaler. A review of Resident #108's medical record did not include documentation that the resident was assessed for their ability to self-administer their medications. A review of Resident #108's medical record did not include documentation from the resident's physician that the resident could self-administer their medications. A review of Resident #108's care plan did not include documentation the resident could self-administer their medications During an interview on 5/29/2026 at 10:37 AM, Resident #108 stated that the facility tried to take away their inhaler, but they told them they would slap them from here to the other side of the building if they touched it. They further stated that Director of Nursing #1 told them to hide it. Resident #108 stated it was hidden inside the tissue box observed on their tray table. During an interview on 5/29/2026 at 10:59 AM, Licensed Practical Nurse #10 stated Resident #108 had an order for an advair diskus inhaler twice daily and previously had an order for an as needed albuterol inhaler that was discontinued on 5/06/2026. They stated the order was most likely discontinued because it was not use for an extended period of time. Licensed Practical nurse #10 stated there were probably risks with Resident #108 having the inhaler if they were not using it appropriately. They stated risks could include heart racing, jitteriness, and that it was potentially a risk to others, although Resident #108 did not leave their room often. Licensed Practical Nurse #10 stated they would follow up with the resident. During an interview on 5/29/2026 at 12:53 PM, Director of Nursing #1 stated they did not believe Resident #108 was able to self-administer medication. They stated they were not aware of any residents that could self-administer medication. Director of Nursing #1 stated they completed assessments for residents to self-administer medication as needed or per request. They stated the nurse would complete the assessment with the resident, the resident had to be able to lock the medication in their bedside stand, and there needed to be a physician order. Director of Nursing #1 stated a resident could suffer from respiratory complications if an inhaler was overused. 10 New York Codes, Rules, and Regulations: 415.3(f)(1)(vi)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure residents were able to exercise the right to self-determination, including making choices regarding daily routines and preferences, for two (Resident #4 and #79) of two residents reviewed for choices. Specifically, (a.) Resident #4 was not permitted to go outside as they preferred; (b.) Resident #79 had not been able to have a shower since they were admitted to the facility. Findings include: The facility's policy, Resident Rights, revised 05/28/2024, indicated residents have the right to self-determination and are to be supported by the facility in exercising their rights. Residents have the right to communicate with and access to people and services both inside and outside the facility. The facility's policy, Out on Pass/Therapeutic Leave, revised 05/27/2026, indicated residents may leave the facility with or without an escort following an assessment of the resident's ability to do so. The policy further indicated the Out on Pass/Therapeutic Leave process should not be utilized when a resident wishes to sit outside while remaining on facility property. Resident #4 Resident #4 was admitted to the facility with diagnoses including quadriplegia (inability to actively move arms and legs), atrial fibrillation (an irregular heart rhythm), and major depressive disorder. The most recent comprehensive Minimum Data Set (a, dated 01/23/2026, indicated the resident was able to understand others and able to be understood. Their preferences included going outside and getting fresh air when the weather was nice, as very important to the resident. The care plan dated 01/28/2026 indicated the resident was able to make recreation and leisure preferences known. Documented interests included football and use of cell phone. The care plan included interventions to assist the resident in identifying activities of interest, provide a monthly activity calendar, and provide independent leisure opportunities. During an interview on 05/22/2026 at 11:06 AM, Resident #4 stated the only activity the resident wanted to participate in was to go outside especially when their friends and family came to visit. They were frequently denied because of the facility rule which had denied residents access unless activities staff was present. The resident stated there had been many nice days when family visited and they had requested to go outside and were denied access. During an interview on 05/28/2026 at 11:40 AM, Licensed Practical Nurse #9 stated the door to the outdoor patio area remained locked and residents could not go outside unless activities staff were present. Many residents desired to go out, however there was no access when activity staff were not present. Licensed Practical Nurse #9 stated residents should be able to have the choice. Independence and autonomy were very important, especially given the young population at the facility. During an interview on 05/28/2026 at 12:27 PM, Director of Recreation #1 stated residents were only allowed to go outside when activities staff were available to unlock the patio door. Director of Recreation #1 stated the door always remained locked and when activities staff were unavailable residents could not access the patio. The Activities Director acknowledged the practice limited resident access to the patio and stated many residents did not like the limitation of access. During an interview on 05/28/2026 at 2:03 PM, Administrator #1 stated residents could go outside at any time. There was no limitation on access to the patio and indicated all nursing supervisors had the key and could provide access to the patio upon request. Administrator #1acknowledged this was their home and the ability to access the nice weather was very important. They further stated the resident would need to be evaluated for safety prior to allowing them to be out side but they should be given access if safety had been accessed. During an interview on 05/28/2026 at 4:36 PM, Registered Nurse Supervisor #2 stated that if a resident wanted to go outside, the resident would have to wait until someone from activities was available to unlock the door. Registered Nurse Supervisor #2 stated the patio door remained locked unless activities staff were present and reported that administration had not provided a key or informed them that access could be provided independently of activities staff. Registered Nurse Supervisor #2 stated residents who wished to go outside should be able to do so as this is their home. Resident #79 Resident #79 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), non-pressure chronic ulcer of skin of other sites with fat layer exposed (deep, long-lasting open sore on the skin), morbid (severe) obesity due to excess calories (weighing in excess of 100 pounds of one's ideal weight). The Minimum Data Set, dated [DATE], documented that the resident could be understood, could understand others, and was cognitively intact. Record Review: Facility work order dated 05/18/2026 documented the facility's stretcher shower had a broken frame. Interviews: During an interview on 05/22/2026 at 9:45 AM, Resident #79 stated they had not been able to have a shower since being admitted to the facility. They stated there was one shower bed for the facility and it needed repair since their arrival at the facility. They had been given bed baths routinely; however, they would feel better if they could get in the shower. They have multiple health conditions that cause the shower chair to be uncomfortable and intolerable to use. They have asked staff about the shower bed often and they were always told it was still broken. During a subsequent interview on 05/26/2026 at 10:20 AM, they stated a staff member had told them over the weekend they finally sent the shower bed for repair. During an interview on 05/27/2026 at 9:37 AM, Licensed Practical Nurse #6 stated the shower bed had been out for about 1-2 weeks for repair. The residents would be offered bed baths until the shower bed was fixed. During an interview on 05/27/2026 at 9:42 AM, Certified Nurse Aide #3 stated the shower bed was out for repair as of last week. They were familiar with Resident #79 and knew they would prefer a shower and would offer them one once shower bed was fixed. During an interview on 05/27/2026 at 12:04 PM Resident #79 had not had a shower in over one (1) year. During an interview on 06/01/2026 at 12:45 PM, Director of Nursing #1 stated if residents would prefer a shower they should be receiving a shower. They would be auditing the shower records in the facility. During an interview on 06/01/2026 at 1:00 PM, Administrator #1 stated they were made aware of the shower bed needing replacement last week, they had since ordered a new shower bed that had a weight capacity of 600 pounds to fit the needs of the facility. They stated that they were unaware of Resident #79 not getting their choice of a shower instead of a bed bath over the past year. 10 New York Codes, Rules, and Regulations: 415.3(b)(1)

Based on observation, interview, and record review conducted during a survey, the facility failed to report all alleged violations involving abuse, neglect, and injuries of unknown source immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury, to the State Agency for three (Resident #'s 114, 181, and 191) of three residents reviewed. Specifically, the following incidents were not reported to the New York State Department of Health: (a.) Resident #191 had a fall with a significant injury of unknown origin; (b.) Resident #'s 114 and 181 were involved in a resident-to-resident altercation on 9/08/2025 where Resident #181 pushed Resident #114's wheelchair from behind causing the resident to fall. Staff witnessed this and police were called. Based on observation, interview, and record review conducted during a survey, the facility failed to report all alleged violations involving abuse, neglect, and injuries of unknown source immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury, to the State Agency for three (Resident #'s 114, 181, and 191) of three residents reviewed. Specifically, the following incidents were not reported to the New York State Department of Health: (a.) Resident #191 had a fall with a significant injury of unknown origin; (b.) Resident #'s 114 and 181 were involved in a resident-to-resident altercation on 9/08/2025 where Resident #181 pushed Resident #114's wheelchair from behind causing the resident to fall. Staff witnessed this and police were called. The findings include: The policy titled Accidents-Incidents reviewed 06/01/2024 documented: Any unwitnessed incident or accident or incident must be investigated for potential abuse. Determine if it is of known or unknown or known. If injury of known or unknown origin, Document the location and type of injury; Accurately document the resident's ability to explain the injury; Include documentation of a resident examination conducted by a physician or nurse practitioner, as required. If an unknown origin injury, ensure that statements from staff / parties involved include preceding shifts and days, if necessary, to assist in ruling out abuse, neglect, mistreatment or exploitation; Director of Nursing and Administrator are responsible to review Incident / Investigation and Conclusion to determine if incident requires reporting to outside agencies such as; Department of Health, Office of Inspector General, Centers for Medicare and Medicaid Services, etc The policy titled Abuse revised 07/18/2025 documented: The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. Notify the local law enforcement and appropriate State Agency(s) immediately (no later than 2 hours after allegation / identification of allegation) by Agency's designated process after identification of alleged/suspected incident. Initiate process according to the Elder Justice Act and State- specific regulations. (a.) Resident #191 Resident #191 was admitted to the facility with diagnoses of unspecified dementia, unspecified severity (cognitive decline severe enough to interfere with daily life), chronic kidney disease stage 3A (when your kidneys have mild to moderate damage), unspecified abnormalities of gait and mobility (walking pattern deviates from normal). The Minimum Data Set, dated [DATE], documented that the resident could usually be understood, could usually understand others, and was severely cognitively impaired. A Nursing Progress note by Licensed Practical Nurse #7 dated 3/31/2026 at 7:30 AM, documented the resident was found on the floor by a staff member. The resident could not verbalize what happened. Resident #191 was noted to have a bruise on their mid-forehead, their eyes widened with staring glare and not focusing, and they could not follow simple directions. Registered Nurse #1 and Director of Nursing #1 were notified. A Registered Nurse Assessment by Registered Nurse #1 on 3/31/2026 at 7:24 AM, documented they were notified by a staff member Resident #191 was found on the floor. The resident could not verbalize what had happened. Resident #191 was noted to have a bruise on their mid-forehead, eyes widened with staring glare and not focusing, they could not follow simple directions. They placed the resident in sitting position, then assisted them to bed. The provider was notified by Licensed Practical Nurse #7, they obtained an order to send Resident #191 to the emergency room for evaluation and treatment. Review of Accident / Incident Statement form dated 3/31/2026, documented Licensed Practical Nurse #7 was notified by Licensed Practical Nurse #8 of an incident for Resident #191. Staff involved in the care for the Resident was Licensed Practical Nurse #8 and Certified Nurse Aide #1. There were no documented witnesses to the event. One statement was attached by Licensed Practical Nurse #8 that documented no witnesses to the event. There was no documented evidence of a statement from Certified Nurse Aide #1. There was no documentation of when or where the resident was last seen prior to being found on the floor. (b.) Resident #114 and #181 A complaint received by the New York State Department of Health on 3/12/2026, documented Resident #114 was seated in their wheelchair at the nurse's station when Resident #181 pushed the wheelchair forward causing Resident #114 to fall out of the wheelchair and the wheelchair fell on top of them. The complaint documented that Resident #114 suffered from a neck fracture as a result. The Facility Investigation Summary dated 9/08/2025, documented on the evening of 9/08/2025, Resident #114 was in A wing hallway in their wheelchair speaking to a nurse when Resident #181 came up from behind and made contact with Resident #114's wheelchair causing the resident to fall from the wheelchair. A statement written by Resident #114 on 9/08/2025, documented that they were talking with Licensed Practical Nurse #8 about their cell phone being stolen by Resident #181, when Resident #181 grabbed their wheelchair and flipped them out of the chair. Then Resident #181 yelled, that was what you get for accusing me of stealing your cell phone. A statement written by Resident #181 on 9/08/2025, documented they overheard Resident #114 accusing them of stealing their cell phone at the nurse's station. They documented they lost their cool and pushed Resident #114's wheelchair enough to jar himthem, which caused Resident #114 to come to somewhat of standing position, and then they fell down on their right side. It further documented they did not touch Resident #114, only the back of their wheelchair. An Accident/Incident Statement form completed by Licensed Practical Nurse #8 dated 9/08/2025, documented Resident #114 was speaking to them about another resident. Resident #181 came behind Resident #114 and pushed the resident out of the wheelchair onto the floor. They immediately removed Resident #181 from the area and checked on Resident #114. Interviews: During an interview on 5/29/2026 at 11:41 AM, Licensed Practical Nurse #5 stated if they observed or were made aware of a resident-to-resident altercation they would separate the residents, redirect them, and then inform the Assistant Director of Nursing, Director of Nursing, Medical Provider, and Administrator. They stated they would complete skin checks, obtain an order from the medical provider for behavior monitoring, and call the family. They stated depending on if it were physical or verbal abuse, they would separate the residents into different units. Licensed Practical Nurse #5 stated they would complete an Incident and Accident Report for each resident, get states from anyone that witnessed the incident, put in notes and then pass it along. Licensed Practical Nurse #5 stated resident-to-resident altercations could be considered abuse depending on the circumstances. They stated if there was injury, it was reportable to the Department of Health. During an interview on 5/29/2026 at 12:35 PM, Director of Nursing #1 stated they were not sure if Resident #181 was intentionally trying to hurt Resident #114, but it was considered a resident-to-resident altercation. They stated if someone was intentionally trying to hurt someone then it would be considered abuse. Director of Nursing #1 stated in their investigation they ruled out abuse, neglect, and mistreatment, so they did not report it to the Department of Health. They further stated if they ruled out abuse, then they did not need to report it. During an interview on 06/01/2026 at 12:45 PM, Director of Nursing #1 stated an unwitnessed fall with a significant injury would be considered an injury of unknown origin. They further stated resident-to-resident allegations and incidents would be abuse. They stated an injury of unknown origin and any accusations of abuse would need to be reported to the Department of Health within a two (2) hour time frame from when they became aware. During an interview on 6/01/2026 at 12:07 PM, Administrator #1 stated there was an allegation that Resident #181 pushed Resident #114 out of their wheelchair. Resident #114 called the police, but charges were not pressed. They stated in real time, they separated the residents, but Resident #181 discharged shortly after. Administrator #1 stated the facility completed an investigation but could not recall the outcome. Administrator #1 stated if they were able to rule out abuse, then that was why it was not reported to the Department of Health. They stated if they could not rule out abuse then it would be reported. 10 New York Codes, Rules, and Regulations 483.12 (c) (1)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure residents were discharged according to professional standards for one (Resident #182) of one resident reviewed. Specifically, the facility refused to accept Resident #182 back to the facility following a brief hospital evaluation. Findings include: The facility policy, Discharge- Transfer Discharge Process,reviewed 02/2025, indicated the facility would coordinate a safe transfer or discharge for residents leaving the facility; residents were permitted to remain in the facility unless an allowable discharge criterion was met; residents and/or their representatives would receive written notice of a transfer or discharge, including appeal rights; residents who appealed a transfer or discharge would not have been discharged while the appeal was pending unless specified exceptions applied; a hospital was not an appropriate discharge destination; and residents had the right to return to the facility upon completion of a hospital stay. The facility policy, Resident Rights, revised 05/28/2024, indicated residents have the right to self-determination and are to be supported by the facility in exercising their rights. Residents had the right to communicate with and access to people and services both inside and outside the facility. The facility policy Behavior - Managing Emergencies, last reviewed 05/2020, indicated that behavioral emergencies require assessment and intervention to maintain resident and staff safety; staff are to utilize appropriate clinical and behavioral management strategies; physician notification and appropriate follow-up are required; and residents experiencing behavioral emergencies may require transfer for evaluation and treatment when clinically indicated. Resident #182 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, paroxysmal atrial fibrillation (an irregular heartbeat), and cerebrovascular accident with left-sided hemiparesis (a stroke that caused weakness on the left side of the body). The 06/19/2024 care plan identified the resident's discharge goal as returning to the community/shelter. Interventions included interdisciplinary discharge planning and education regarding community resources. The Minimum Data Set (an assessment tool) dated 06/26/2024, documented the resident was cognitively intact, could be understood, and could understand others. Review of a 07/17/2024: interdisciplinary care plan meeting documented Resident #182 had exhibited yelling, profanity, crying, and pounding fists on the table while discussing discharge planning and personal belongings. Social Services documented efforts to identify community resources and discharge options. Review of 07/17/2024 the medical provider documented the resident had a history of significant behaviors, including threatening and accusatory behavior. The resident was medically stable and had recently been sent out for aggressive behavior and returned to the facility. Review of 07/30/2024 Social Services progress note documented continued efforts to secure housing through the [NAME] Department of Social Services; the process was pending the resident's signature on a release form. Review of the 07/30/2024 Transfer/Discharge Notice identified St. Mary's Hospital as the discharge destination and cited physically aggressive behavior as the reason for discharge. The resident refused to sign the notice. Review of the 07/30/2024 Hospital records documented the resident was psychiatrically evaluated, did not require psychiatric hospitalization, and was cleared for discharge back to facility. Hospital documentation indicated the resident was discharged back to the facility via ambulance. Review of the 07/30/2024 hospital discharge documented, Resident #184 was transported to St. Mary's Healthcare for a mental health evaluation following an incident involving aggressive behavior toward facility staff. The resident was alert and oriented, cooperative, denied suicidal and homicidal ideation, denied hallucinations, and had not appeared psychotic or delusional. The resident acknowledged grabbing a staff member's shirt but denied striking anyone. The resident reported being upset with the facility however expressed a desire to return to facility. The Diagnostic and Statistical Manual of Mental Disorders (a book used by mental health professionals to diagnose mental health conditions) documented the resident had an appropriate appearance, cooperative attitude, stable mood, appropriate affect, good insight, normal behavior, normal thought content, intact thought processes, and normal perception. Judgment was noted as impulsive. The psychiatric evaluation determined the resident had not required a psychiatric admission Hospital documentation indicated the resident would be discharged back to facility. Review of the complaint dated 08/02/2024 received from a police officer reported, per the ambulance crew, the resident was sent to the hospital for mental evaluation, cleared to return to the facility on [DATE], was sent back to the facility and had been denied entry The facility supervisor stated that the resident was discharged to the hospital, and they would not have been accepting them back. The ambulette brought the resident back to the hospital who stated that the resident was discharged back to the facility. Resident #182 was again brought back to the facility; the doors were locked and the supervisor stated that the resident assaulted a staff, and they were a danger to others. The resident was again sent back to the hospital, left in the parking lot crying because they wanted to return home. The resident had been living in the facility for 30 days. Complainant stated that the resident was housed overnight at the hospital. During an interview on 05/29/2026 1:55 PM, Administrator #1and Regional Registered Nurse #1 both had indicated the incident happened prior to their employment at the facility. Their understanding was that the resident was sent for a mental evaluation on 07/30/2024 and the hospital had discharged them into the community therefore they had not been a resident of the facility any longer. Resident #182 was not safe to be in the facility. According to the regional nurse, the resident was discharged to the department of social services. They were unable to elaborate on that statement. During an interview on 06/01/2026 12:25 PM, Director of Nursing #1recalled the resident was sent out for evaluation however the incident having happened in 2024 was difficult to recall yet stated any resident sent to the hospital for a psychiatric evaluation would have been allowed back once discharged from the hospital. A one-on-one constant observation would have been initiated and psychiatric care ordered. If needed the facility could try to place them elsewhere. The facility was equipped to care for residents with mental health conditions and had been trained in the proper aspects of their care. 10 New York Codes, Rules, and Regulations: 415.3(i)(1)

Based on interviews and record review conducted during a survey, the facility failed to ensure that Preadmission Screening and Level II Preadmission Screening and Resident Review's (PASARRs) were completed according to professional standards of practice prior to admission and as needed for two (Resident #'s 19 and 180) of three residents reviewed. Specifically, (a.) Resident #19's Preadmission Screening and Resident Review instrument indicated the resident had serious mental illness, was admitted to the facility for convalescent care, and a new screen was not completed at the end the residents convalescent care stay when the resident remained in the facility, and (b.) Resident #180 was admitted to the facility prior to receiving Level II PASARR recommendations. The facility policy titled Pre-admission Screening and Resident Review Instrument (PASARR) reviewed 10/22/2026, documented every admission to the facility would have a Preadmission Screen and Resident Review (PASARR) completed prior to admission to validate the resident was appropriate for admission to the facility. It further documented that any admission whose Level I screen indicated a level II Preadmission Screen and Resident Review (PASARR) was required must have the Level II Preadmission Screen and Resident Review (PASARR) evaluation completed prior to admission and arrival at the facility. Level II Preadmission Screen and Resident Review (PASARR) recommendations would be incorporated into the resident's plan of care. Additionally if a resident's admission Level I screen indicated they had a serious mental illness and/or intellectual disability but did not require a Level II Preadmission Screen and Resident Review (PASARR) at the time of admission due to meeting exemption criteria, but they no longer met the criteria for that exemption, a Level I Screen and Level II Preadmission Screen and Resident Review (PASARR) evaluation would be completed within the appropriate timeframe according to state regulations. Resident #19 Resident #19 was admitted to the facility with diagnoses of bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels), schizoaffective disorder, bipolar type (mental health condition that combines symptoms of schizophrenia with mood disorders such as depression), and depression (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life). The Minimum Data Set (an assessment tool) dated 3/13/2026, documented the resident was cognately intact, could be understood, and could understand others. A Hospital Psychiatric admission Note dated 8/25/2025, documented Resident #19 had diagnoses of schizoaffective disorder, bipolar type, depression, and anxiety. It documented Resident #19 presented at the emergency department via ambulance for a mental health evaluation. It further documented that chart review indicated the patient was admitted to another hospital for inpatient psychiatric treatment from 7/29/2025 to 8/22/2025 Resident #19's Preadmission Screen and Resident Review (PASARR) was completed on 9/08/2025. The screen documented that Resident #19 had serious mental illness, qualified for convalescent care and was to be admitted for a brief and finite stay. There was no documented evidence that a new Level 1 Screen was completed and Level II referral was made for Resident #19 after they were in the facility for more than120 days for convalescent care. During an interview on 5/27/2026 at 12:28 PM, Director of Social Work #1 stated they and the hospital liaison reviewed screens. In discussing Resident #19, who was identified as being at the facility longer than 120 days for convalescent care and had serious mental illness, Director of Social Work #1 stated the resident would need a new screen completed. They stated they would check when the residents' last Patient Review Instrument (PRI) was completed and initiate a new Level 1 Screen. They stated Resident #19 had a diagnosis of schizoaffective disorder since admission and was last seen by psych on 5/11/2026. Resident #180 Resident #180 was admitted to the facility on [DATE] with diagnoses of down syndrome (a genetic condition caused by an extra full or partial copy of chromosome 21), anxiety (a mental health condition characterized by excessive fear or anxiety that interferes with daily activities), and dementia (a group of conditions that cause a progressive decline in cognitive abilities). The Minimum Data Set, dated [DATE], documented the resident was usually able to understand others, was usually understood by others, and was severely cognitively impaired. A complaint received by the New York State Department of Health on 4/15/2026, documented the Office for People with Developmental Disabilities (OPWDD) Preadmission Screen and Resident Review (PASARR) Program had become aware that Resident #180 was admitted to the facility without a Preadmission Screen and Resident Review (PASARR) for developmental disabilities being completed prior to admission. Resident #180's Preadmission Screen and Resident Review (PASARR) was initiated on 2/24/2026 and completed on 3/04/2026 after receiving recommendations from the Level II referral for intellectual disabilities. The resident was admitted to the facility on [DATE], prior to receiving the recommendations from the Level II referral. During an interview on 5/27/2026 at 12:33 PM, Director of Social Work #1 stated the facility may take a resident that was pending a Level II referral depending on the case, what the family wanted and if everyone was in agreement on what the care was and what the resident needed. Director of Social Work #1 stated the Level II was a process and sometimes it took them a while to come back with a response. They stated the Level II referral for Resident #180 was submitted prior to admission and the Office for People with Developmental Disabilities (OPWDD) did not typically provide many recommendations. They stated Resident #180's screen indicated other services. Director of Social Work #1 stated they would let the liaison at the hospital know that they would need the Level II recommendations prior to admitting a resident to the facility. During an interview on 6/01/2026 at 12:07 PM, Administrator #1 stated the purpose of the Preadmission Screen and Resident Review (PASARR) was to make sure that the facility could take residents/meet their needs prior to admission. They stated it screened for mental illness or psychosocial issues so that the facility could care for residents properly to be admitted . They stated they believed the regulation stated a Level II should be done prior to admission. 10 New York Code of Rules and Regulations S483.20(k)(1)-(3)

Based on record review and interviews during the survey, the facility failed to ensure the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs for four (Residents #26, 79, 161, and 175) of 43 residents reviewed for comprehensive care plans. Specifically, for (a) Resident #26, the comprehensive care plan did not include care areas that addressed the need for multiple medications including Ropinirole HCl two milligrams for restless leg syndrome, Tizanidine HCl four milligrams for muscle spasms, Kenalog-49 injection suspension 40 milligrams per milliliter for pain, and Lidocaine HCl injection solution one percent 10 milliliters to mix with Kenalog; for (b) Resident #79, the comprehensive care plan did not include a care area that addressed Resident #79's self-management of their ostomy pouch; for (c) Resident #161, the comprehensive care plan did not include a care area that addressed the resident's physical therapy needs; and for (d) Resident #175, the comprehensive care plan did not include a care area that addressed the resident's aggressive behaviors and refusal of care. Findings include: The policy and procedure titled Care Plans - Comprehensive, reviewed 8/02/2024, documented the comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The documented procedure included (in pertinent part): (1) The Interdisciplinary Team, in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident; (2) The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment; (4) Each resident's care plan would be consistent with the resident's rights to participate in the development and implementation of his or her plan of care; (7) The care planning process would include an assessment of the resident's strengths and needs and incorporate the resident's personal and cultural preferences in developing the goals of care; (8) The comprehensive, person-centered care plan would include measurable objectives and timeframes, describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect the resident's expressed wishes regarding care and treatment goals, identify the professional services that were responsible for each element of care, enhance the optimal functioning of the resident by focusing on a rehabilitative program, and reflect currently recognized standards of practice for problem areas and conditions; (10) Identified problem areas and their causes, and developed interventions that were targeted and meaningful to the resident; and (13) Assessments of resident were ongoing and care plans were revised as information about the residents and the residents' conditions change. Resident #26 Resident #26 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a progressive, long term lung disease that causes restricted airflow and breathing-related difficulties), heart failure (when the heart muscle is too stiff or weak to pump effectively), and restless leg syndrome (uncontrollable, overwhelming urge to move the legs). The Minimum Data Set (an assessment tool), dated 3/03/2026, documented the resident was able to understand others, was able to be understood, and was cognitively intact. A Physician Order dated 4/15/2026 at 10:49 AM documented Resident #26 was ordered Kenalog-40 Injection Suspension 40 milligrams per milliliter (Triamcinolone Acetonide). Inject 40 milligrams intramuscularly as needed for pain to be administered by Medical Doctor #1. A Physician Order dated 4/15/2026 at 10:29 AM documented Resident #26 was ordered Lidocaine HCl Injection Solution one (1) percent (Lidocaine HCl (Local Anesth.)). Inject 10 milliliters intramuscularly as needed for mix with Kenalog to be administered by Medical Doctor #1. A Physician Order dated 9/24/2025 at 8:59 AM documented Resident #26 was ordered Ropinirole HCl oral tablet two (2) milligrams (Ropinirole Hydrochloride). Give one (1) tablet by mouth at bedtime for restless leg syndrome. A Physician Order dated 4/15/2026 at 10:49 AM documented Resident #26 was ordered Tizanidine HCl Oral Tablet four (4) milligrams (Tizanidine HCl). Give four (4) milligrams by mouth three times a day for muscle spasm. The comprehensive care plan for alteration in comfort related to aging process and skin tear, created 12/11/2024, documented that Resident #26 was able to request pain medications. There was no documented evidence that a care plan area for muscle spasms or the need for muscle relaxers had been created. Resident #161 Resident #161 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a progressive irreversible lung disease that restricts airflow), type 2 diabetes (a chronic condition where the body either resists the effects of insulin or doesn't produce enough of it to maintain normal glucose levels), and obesity (excessive body fat that poses a serious risk to overall health). The Minimum Data Set, dated [DATE], documented the resident was able to be understood, able to understand others and was cognitively intact. A nursing note dated 3/07/2026 documented that Resident #161 was found on the floor after sliding from their wheelchair. Resident #161 was to have a physical and occupational therapy evaluation after their evaluation. A note dated 3/09/2026 at 3:07 PM by Physical Therapist #2 documented that Resident #161 was demonstrating their baseline functional mobility and there were no changes required at that time. A note dated 5/07/2026 at 11:03 AM by Physical Therapist #1 documented Resident #161 demonstrated functional mobility status consistent with baseline level of function at that time, with no significant decline noted requiring additional skilled physical therapy intervention. Resident #161 was agreeable to participate in open gym program to support ongoing mobility, strength, and activity tolerance. Recommended nursing for application of moist heat pack to left foot prior to gym participation to assist with pain management. Suggested heat application schedule from 9:00 AM-9:30 AM, as Resident #161 typically attended gym program from 9:30 AM-10:00 AM. The comprehensive care plan related to risk for falls, dated 1/30/2025, documented the intervention of physical therapy to evaluate and treat as ordered. The comprehensive care plan related to limited physical mobility related to right below the knee amputation, dated 1/27/2026 had no documented evidence of physical therapy being utilized. There was no documented evidence of a physical therapy care area noted in the comprehensive care plan. During an interview on 5/21/2026 at 12:10 PM, Resident #161 stated that they had asked for therapy to strengthen their left lower extremity and keep their right stump strong to be ready for the prosthesis they were eventually expecting to receive. Resident #161 stated they were told by physical therapy that insurance would not cover their therapy and therefore was not initiated. During an interview on 5/28/2026 at 11:29 AM, Director of Rehabilitation #1 stated that Resident #161 was discharged from physical and occupational therapy after receiving services from 3/26/2026 to 4/16/2026. Resident #161 had also received physical and occupational therapy from 1/27/2025 through 4/23/2025 and 11/22/2024 through 12/18/2024. Director of Rehabilitation #1 stated that Resident #161 did ask for therapy so that they did not decline. Resident #161 was offered open gym after being discharged from therapy and no longer met the requirements for therapy. Resident #175 Resident #175 was admitted to the facility with the diagnoses of type 2 diabetes mellitus (the body does not produce enough insulin to maintain normal blood glucose levels), major depressive disorder (a mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), and adjustment disorder with mixed disturbance of emotions and conduct (a mental health diagnosis for individuals who develop both emotional distress and behavioral issues in response to a major life stressor). The Minimum Data Set, dated [DATE], documented the resident was usually understood, was sometimes able to understand others, and was severely cognitively impaired. A Physician Order date started 1/12/2026 and continued through 2/23/2026, documented that Resident #175 was ordered Lorazepam Tablet 0.5 milligram. Give one (1) tablet by mouth three times a day for Anxiety. A Physician Order dated 2/06/2026 at 11:37 AM, documented Resident #175 was ordered Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 milligrams (Divalproex Sodium). Give two (2) capsules by mouth every morning and at bedtime for conduct. A Physician Order dated 2/23/2026 at 11:57 AM documented Resident #175 was ordered Klonopin Oral Tablet 0.5 milligrams (Clonazepam). Give one (1) tablet by mouth three times a day for Anxiety. A Nursing Note on 1/03/2026 at 8:55 PM documented that Resident #175 displayed behaviors such as yelling out, and outbursts and addressing their roommate in a derogatory way numerous times during the shift. A Nursing Note on 1/04/2026 at 8:55 PM documented that Resident #175 displayed behaviors such as yelling out, and outbursts and addressing their roommate in a derogatory way numerous times during the shift. A Nursing Note on 1/08/2026 at 9:48 PM documented that Resident #175 displayed behaviors such as yelling out, and outbursts and addressing their roommate in a derogatory way. A Nursing Note on 1/13/2026 at 1:57 PM documented that Resident #175 displayed behaviors such yelling, kicking, scratching, verbally aggressive, and spitting at nursing staff. A Nursing Note on 1/13/2026 at 10:05 PM documented that Resident #175 displayed behaviors such as yelling out, and outbursts and addressing their roommate in a derogatory way for a short period of time. A Nursing Note on 1/14/2026 at 9:20 PM documented that Resident #175 displayed behaviors such as yelling out, disrobing and having delusions. A Nursing Note on 1/15/2026 at 9:24 PM documented that Resident #175 displayed behaviors such as verbal and physical outbursts, refusal of care, disturbing other residents in the hallway. Resident #175 was medicated with Tylenol and Ativan with no effect. Offered food and water, resident refused, checked and changed, resident was soiled with urine, but continued to holler out shortly after. Plan of care continued. A Nursing Note on 1/16/2026 at 2:16 PM documented that Resident #175 displayed behaviors such as yelling out, and outbursts and disrobing. A Nursing Note on 1/17/2026 at 10:10 PM documented that Resident #175 displayed behaviors such as yelling out, and outbursts and addressing their roommate in a derogatory way. A Nursing Note on 1/22/2026 at 9:48 AM documented that Resident #175 displayed behaviors such yelling, kicking, scratching, verbally aggressive, and spitting at nursing staff. A Nursing Note on 1/23/2026 at 11:10 AM documented that Resident #175 refused to be in their wheelchair while yelling/hollering in the hallway, called staff derogator names. Resident was reapproached by other nurses on the station but was still aggressive. Unit Manager made aware, and provider notified. Nursing notes from 1/23/2026 documented Resident #175 also refused multiple doses of medication throughout the day. A Nursing Note on 1/26/2026 at 8:14 PM documented that Resident #175 displayed behaviors such as verbal outbursts. A Nursing note on 1/28/2026 at 10:44 AM documented that Resident #175 was in the common area by the nurse's station yelling. Licensed Practical Nurse #9 came out of their office to see the resident. Resident #175 jumped forward out of their wheelchair onto the floor. They tTried to obtain vital signs which they refused. Assisted back in to their chair by mechanical lift, skin intact, neuro checks initiated. Placed into bed per resident request. Request for provider to initiate a medication review. Provider and Director of Nursing aware. A nursing note on 1/31/2026 at 2:29 PM documented Resident #175 was non-stop yelling/hollering and called staff derogatory names. Resident #175 Comprehensive Care plan for activities, dated 9/16/2025, documented Resident #175 did not express an interest in recreational activities and to respect Resident ##175's refusals. Resident #175 Comprehensive Care Plan for difficulty communicating with others related to low brief interview for imental satus, dated 9/12/2025, documented to engage Resident #175 to participate in simple structured activities, introduce self and explain care before doing it, present just one thought, idea, question or direction at a time, provide activities that accommodated the resident's abilities, anticipate the resident needs, monitor and document physical/nonverbal indicators of discomfort or distress, and follow-up as needed, therapy as ordered, and validate resident's message by repeating aloud. Resident #175's Comprehensive Care Plan for grief over the loss of a family member, dated 9/12/2025, documented to allow the resident to verbalize their grief and demonstrate effective coping behavior. Social Work to provide support visit as needed. Resident #175's Comprehensive Care Plan for displayed or reported mood symptoms as evidenced by high Patient Health Questionnaire-9 (a standard 9-question self-report tool used by clinicians to screen for, diagnose, and measure the severity of depression), dated 9/12/2025, documented that Resident #175 would remain social with peers/staff, staff would encourage activities of choice, provide opportunity for the resident to express themselves, and provide support and reassurance. During an interview on 5/29/2026 at 12:51 PM, Licensed Practical Nurse #3 stated that care plans were done by unit managers, social work and the Director of Nursing. During an interview on 5/29/2026 at 12:53 PM, Licensed Practical Nurse #6 stated that the Director of Nursing and Nurse Educator did the care plans. They went over each topic, included in the care plans with staff. During an interview on 5/29/2026 at 12:57 PM, Licensed Practical Nurse #9 stated that they were able to add interventions to the care plans but the creation of care plans wasere done by the Director of Nursing, the Minimum Data Set Nurse, and the Nurse Educator. Licensed Practical Nurse #9 stated that Resident #175 had a slow decline over time and eventually became problematic behaviorally. Resident #175 refused a lot of care. Staff had asked Psych to see the resident, but Resident #175 refused to speak with them. The providers would give staff different ideas on how to work with the resident. During the interview on 5/29/2026 at 1:21 PM, Director of Nursing #1 stated that they created the care plans. The nurse educator that resigned also did care plans. Director of Nursing #1 stated that there should have been a care plan for the spasmodic medications that Resident #26 was taking and that there should be care plan areas for all medications that residents were taking. Changes in behavior should also have been reflected in the care plans. It was also expected that resident care needs would be documented in the care plan. 10 New York Codes, Rules, and Regulations 415.11 (c)(1)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial wellbeing for two (2) (Resident #'s 105 and 110) of three (3) residents reviewed. Specifically, (a.) Resident #105 was bed bound and was not offered to attend activities or provided with activities; and (b.) Resident #110 was observed in bed on multiple occasions without stimulation or activities present and there was no documentation to support that they were offered, provided with, or attended activities The facility policy titled Activity Program last reviewed 5/2019, documented the facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. Individualized and group activities were provided that: (a.) reflected the schedules, choices and rights of the residents; (b.) were offered at hours convenient to the resident; (c.) reflected the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents; and (d.) appealed to men and woman as well as those of various age groups residing in the facility. It further documented that activities were not necessarily limited to formal activities being provided only by activity staff. Other facility staff, volunteers, visitors, residents, and family member may also provide activities. Resident #105 Resident #105 was admitted to the facility with diagnoses of multiple sclerosis ((a chronic, often debilitating disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body), adult failure to thrive (a geriatric syndrome characterized by complex multi-factorial decline in physical, mental, and functional health), and peripheral vascular disease (a condition that affects the blood vessels outside of the heart, typically in the legs and arms). The Minimum Data Set (an assessment tool) dated 4/08/2026, documented the resident could be understood, could understand others, and was moderately cognitively impaired. Resident #105's Comprehensive Care Plan for Activities dated 1/06/2026, documented the resident was able to make recreation and leisure preferences known. Interests included all kinds of exercise, word search, painting, adult coloring, crafting, dogs, and comedy movies. Interventions included: assist Resident #105 with finding programs of interest, provide the resident with independent leisure supplies, and provide monthly calendar/daily schedule of events. During an observation on 5/22/2026 at 11:36 AM, Resident #105 was bed bound. They were observed in bed for 2 days. During an observation on 5/29/2026 at 11:42 AM, Resident #105 was observed in bed. Resident #105 was not observed out of bed during any observations made from 5/22/2026 to 5/29/2026. During an interview on 5/29/2026 at 11:45 AM, Recreation Director #1 stated residents that did not come out of their rooms received one-to-one visits. They stated the last one-to-one visit provided to Resident #105 was yesterday when they went and talked the to the resident about the weather and asked if they wanted to come to activities. Recreation Director #1 stated there was no documentation for activities. They stated the plan going forward was to get the computer program to document and in the meantime they would document on paper. Recreation Director #1 stated Resident #105 did not come to activities because staff did not bring them down. Resident #110 Resident #110 was admitted to the facility with diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), depression (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life), and peripheral vascular disease. The Minimum Data Set (an assessment tool) dated 4/27/2026, documented the resident was sometimes understood, sometimes understood others, and was severely cognitively impaired. It further documented that the resident had severely impaired vision or no vision or saw only light, colors or shapes. Resident #110's Comprehensive Care Plan for Activities documented the resident was able to make recreation and leisure preferences known. Interests included: enjoys the coffee cart and music appreciation. Some interventions included: assist the resident with finding programs of interest and introduce distracting stimuli (such as music, conversation, and touch). During an observation on 5/21/2026 at 12:04 PM, Resident #110 was observed in bed, their gown was partially covering their face, and they had a half-eaten breakfast tray in front of them. The television was not on and there was no other stimulation or activities present. During an interview on 5/21/2026 at 12:04 PM, Resident #110's roommate stated that Resident #110 was technically blind. During an interview on 5/22/2026 at 10:36 PM, Resident #110 was observed in bed, using their fingers to lick leftover food off their breakfast tray in front of them, in the dark with no lights on and the blind down. The television was not on and there was no other stimulation or activities present. During an interview on 6/01/2026 at 11:25 AM, Recreation Director #1 stated Resident #110 loved music, to drum on the table, liked the refreshment cart, and came to the activities room. They stated Resident #110 was in the military and enjoyed visits with the veteran that came to the facility for visits. They stated Resident #110 was offered to attend activities such as patio time, music, and karaoke. Recreation Director #1 stated the activities department had not been documenting resident participation of activities. They had just started paper charting last week and should have the computer program to document back soon. They stated they had no excuse as to why they did not chart. Recreation Director #1 was not able to provide proof that Resident #110 was offered, provided with, or attended activities. During an interview on 5/29/2026 at 12:17 PM, Administrator #1 stated they were made aware the previous day that activities staff had not been documenting. They stated going forward they had established a manual documentation system until a computer documentation system could be in place. Administrator #1 further stated the activities department worked with nursing to ensure residents were brought to activities. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

Based on observation, record review and interviews conducted during a survey, the facility did not ensure that residents were provided with Quality of Care according to professional standards of practice for two (Residents #65, and #29) of forty-three residents reviewed. Specifically, Resident #65 was prescribed injectable medication for Diabetes Mellitus (body cannot process sugars, leading to high blood sugars) without the diagnosis of Diabetes Mellitus causing the resident to have a significant drop in blood sugar. Resident #29 had bilateral upper extremity dressings that were observed not to be intact for several hours a day after nursing was made aware. Findings include: The facility policy titled Medication Regimen Review dated 09/10/2025 documented the Consultant Pharmacist shall review the medication regimen of each resident at least monthly and will report irregularities as required by state and/or federal regulations, whichever is most stringent. The primary purpose of the medication regimen review is to validate the medications each resident receives are clinically indicated, identify irregularities, and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications prescribed for residents. As part of the medication regimen review, the Consultant Pharmacist will consider these factors: a. Whether the medication(s) have indications for use through a review of the diagnoses, progress notes, and additional health information in the resident's clinical record and/or communication with the healthcare team, b. Whether the medication dose, frequency, route of administration, and duration are consistent with the resident's condition, manufacturer's recommendations, and applicable standards of practice. The facility policy titled Wound-Treatment dated 04/29/2026 documented the facility provides safe, effective, and clinically appropriate wound and skin care treatments. Wound and skin care treatments will be performed in accordance with health care providers orders, evidence-based clinical practice, resident rights, Federal and state regulations, and state Nurse Practice Act scope of practice for a Registered Nurse and Licensed Practical Nurse. Resident #65 Resident #65 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), morbid (severe) obesity due to excess calories (weighing in excess of 100 pounds of one's ideal weight). cellulitis of right lower limb (spreading skin infection). The Minimum Data Set, dated [DATE], documented that the resident could be understood, could understand others, and was cognitively intact. Record Review: Comprehensive review of resident's diagnosis list revealed no document evidence of a diagnosis of Diabetes Mellitus. Review of provider orders documented on 04/06/2026 an order for Mounjaro Subcutaneous Solution Auto-injector 10 milligrams/0.5 milliliter (injectable medication for Diabetes Mellitus), Inject 10 milligrams subcutaneously one time a day every Wednesday for Diabetes Mellitus by Medical Director #1. Review of Registered Nurse assessment by Director of Nursing #1 on 05/26/2026 documented the resident reported they did not feel right. Skin was pale, cool and diaphoretic. Blood sugar obtained and was 56, provider was updated and order to give Glucagon 1 milligram intermuscular was obtained. Blood sugar was repeated 30 minutes later and was 71. Provider was updated and order was received to give another Glucagon 1 milligram intermuscular was obtained. Blood sugar was 81 30 minutes later; provider was notified and ordered the resident to be sent to the emergency department. Resident #29 Resident #29 was admitted to the facility with diagnoses of necrotizing fasciitis (a rare but severe bacterial infection that destroys the tissue beneath the skin), need for assistance with personal care, unspecified open wound of unspecified upper arm (an injury to the arm between the shoulder and elbow where the skin is broken). The Minimum Data Set, dated [DATE], documented that the resident could be understood, could understand others, and was cognitively intact. Record Review: Review of provider orders 05/2026 documented: Starting 05/14/2026, Cleanse right forearm surgical/graft site with normal saline pat dry. Apply xeroform cut to size of wound bed every three (3) days and as needed. Starting 05/14/2026, Cleanse left forearm surgical/graft site with normal saline pat dry. Apply xeroform cut to size of wound bed every three (3) days and as needed. Review of Medication Administration Record for 05/2026 revealed no documented evidence of any as needed dressing changes. Observations: During an observation on 05/22/2026 at 10:00 AM, Resident #29 was sitting on their bed in their room. [NAME] gauze dressings dated 05/21/2026 noted on bilateral upper extremities both extending elbows to hands. Dressings were noted to be loose and not intact. The right upper extremity dressing was loose at the elbow area with tape that did not adhere to dressing and loose on the hand allowing visible reddened area to be exposed on the top of the hand. The left upper extremity dressing was noted to be loose from the elbow to the hand with a reddened area exposed on the outer forearm. Subsequently at 1:30 PM, dressings on bilateral upper extremities had not been changed. At 3:30 PM dressings were changed and dated 05/22/2026. During an observation on 05/26/2026 at 10:00 AM, Resident #29 was in their room sitting on their bed talking on their phone. [NAME] gauze dressings dated 05/25/2026 noted on bilateral upper extremities both extending elbows to hands. Dressings were noted to be loose and not intact. The dressing on the left upper extremity had become loose from the hand up to the mid forearm. The dressing on the right extremity was loose at the elbow and hand, an exposed red area on the top of hand was noted, with a small amount of bright red blood. Subsequently, at 2:10 PM dressings were not changed, Registered Nurse #2 then entered the residents room. Interviews: During an interview on 05/22/2026 at 10:00 AM, Resident #29 stated that their dressings had come loose overnight and they had told the nurse that morning when they received their medications. The dressings fell off often when they slept. At 1:30 PM resident stated the nurse has not had a chance to change my dressing yet. At 3:30 PM, the resident stated the nurse had come a short time ago and changed the dressings. During an interview on 5/26/2026 at 10:00 AM, Resident #29 stated their dressing had become loose again over night. They had let the nurse know when they had their medications earlier that morning. At 1:00 PM they stated the nurse had brought in supplies a while ago but never came back. During an interview on 5/26/2026 at 2:10 PM, Registered Nurse #2 stated Resident #29's bilateral upper extremity dressings were ordered to be changed every three (3) days and as needed. They had changed the residents' dressings the day before. They stated residents should not have loose dressing left all day. They had not been working on that unit all day and were there now to change the dressing. During an interview on 05/27/2026 at 9:37 AM, Licensed Practical Nurse #6 stated Resident #29 dressing on their upper extremities fell off a lot and was to have dressing changes as ordered. If dressings were falling off and a nurse was alerted the dressing should be changed dressing within 30 minutes. During an interview on 06/01/2026 at 12:45 PM, Director of Nursing #1 stated if a residents dressing became loose, they would expect the nurse assigned would change the dressing within one (1) hour of being notified. New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on observations, record review, and interviews during a recertification survey, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing of pressure ulcers for two (2) (Resident #10 and #105) of four (4) residents reviewed. Specifically, Resident #105's left heel pressure ulcer showed significant decline. There was no daily documentation of the wound assessment and staff did not notify the provider of the decline. Resident #10 was noted with a Stage Four pressure ulcer with a care planned intervention and physicians order for wound vacuum. The wound vacuum dressing ordered was not in place. No dressing was observed on the wound bed, and no removed dressing was observed in the resident's bed linens or surrounding area. Findings include: The facility's Policy and Procedure titled Skin and Pressure Injury Prevention revised 6/2/2024, documented This facility will assess residents for risk in the development of pressure injuries and implement preventative measures in accordance with current standards of practice. Risk Assessment: 3. Weekly Skin Monitoring by Licensed Nurse 4. Staff inspect the skin when performing or assisting with personal care.a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; Prevention: Friction and Shear - 3. Monitor the placement of splints and casts to assure they are not placing friction on the resident's skin. 4. Positioning devices should be monitored to prevent pressure. 6. Contractures should be addressed and managed to prevent skin integrity disruption. 7. Protect bony prominences as needed. Resident #10 was admitted to the facility with diagnoses of Pressure Ulcer, Sepsis (extreme life-threatening response to an infection), Acute Respiratory Failure. The Minimum Data Set (an assessment tool) dated 3/17/2026 documented severe cognitive impairment and presence of a pressure injury. The Alteration in Skin Integrity Comprehensive Care Plan dated 3/12/2026 for resident #10 documented a Stage Four Pressure Ulcer to left upper back and sacrum. Documented intervention dated 04/07/2026 included apply wound vac to back and sacrum, notify nurse if alarming. Resident #10's Active Physician's Orders were reviewed and included an order for a wound vac. The Physician's Orders lacked evidence of an as needed dressing or order. During an observation on 5/21/2026 at 11:35 AM, Resident #10 Certified Nurse Aide #5 entered the resident's room, placed gloves on, turned Resident #10 on their side, and stated they were going to do incontinent care. A large open wound was present. The wound lacked a wound vac, or evidence that a wound vac had recently been in place. The bedding did not contain any wound foam, or dressings. The tubing to the wound vac was at the foot of the bed, and wound vac was not running. During an interview on 05/28/2026 at 8:38 AM, Infection Preventionist #1, they stated, Stage three or four wounds there should always be a treatment in place and an as needed treatment order in the event it comes off. If there was no treatment in place, this could place the resident at risk for a multi-drug-resistant organism or worsening wound. If the wound vac had just come off a green foam sponge and Tegaderm would have been present. Resident #105 was admitted to the facility with diagnosis of Multiple Sclerosis (a disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain, optic nerve; Adult Failure to Thrive ( a non-specific syndrome of physical, cognitive, and functional decline, primarily affecting older adults); and Non-pressure chronic ulcer of left foot. The Minimum Data Set (an assessment tool) dated 04/08/2026, documented they could understand and be understood, others, and was cognitively intact. During an observation on 05/27/2026 at 10:12 AM, Licensed Practical Nurse # 11, assisted by Licensed Practical Nurse #11 performed dressing change as ordered to left heel for resident #105. The wound was noted open with depth, irregular borders, foul smelling, moderate amount of bloody / serosanguinous ( a thin, watery wound fluid with a pale pink or light red hue) drainage with white material in the bed of the wound. Resident #105 had contractures (permanent tightening or shortening of muscles, tendons, skin, or other soft tissues that causes joints to become stiff and restricts normal movement) of bilateral lower extremities with left heel pressed underneath right leg. The wound was cleansed with normal saline gauze, Medihoney (a medical-grade, sterilized honey (primarily derived from Manuka/Leptospermum plants) used for advanced wound and burn care), applied and covered with a thin dry dressing equivalent to a band aid. During an interview on 05/27/2026 at 10:30 AM, Licensed Practical Nurse #5 was asked if they measured the wound? They replied, No, this resident is followed by our wound care consultants and is seen by their physician every Tuesday who measures the wound. Licensed Practical Nurse #11 added, the wound has worsened since the resident was admitted eighteen (18) months ago, i.e.: 1/3/2025. Licensed Practical Nurse #5 and #11 were asked what their next steps would be after conducting a dressing change? Licensed Practical Nurse #5 stated that the treatment is checked off in Point Click Care (the facility's tracking and documentation system) as completed. They stated no other documentation is done after wound treatments. During record review, wound care consultant note dated 5/26/2026 documented Stage 4 pressure wound of the left medial heel full thickness. Wound size: (L X W X D): 3.5 X 2 X 0.2 CM Surface Area: 7.00 CM^2 Exudate: Light Serous Granulation tissue: 100 % Wound progress: Not at goal due to generalized decline of patient. During record review, wound care consultant note dated 9/23/2025 documented Stage 4 pressure wound of the left heel, medial heel full thickness Wound size: (L X W X D): 0.5 X 0.5 X 0.1 CM; Surface Area: 0.25 CM^2 Exudate: Light Serous; Granulation Tissue: 100 %. During record review the Comprehensive Care Plan dated 3/4/2026 documented Limited physical mobility related to Contractures, Pain, Weakness, Multiple Sclerosis. Interventions: Initiate interventions to prevent skin breakdown or injury. Monitor/document/report S/S of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown and related injury through the next review date. During an interview on 05/27/2026 at 11:24 AM, Director of Nursing #1 stated the Wound Care Consultant manages all facility wounds and is in the facility every Tuesday for an assessment. In between Nurse Practitioner #1 follows wounds. Director of Nursing #1 stated it is the responsibility of the treatment nurse to document any wound changes and notify physician and or nurse practitioner with any changes. During an interview on 05/29/2026 at 12:59 PM, Nurse Practitioner #1 stated they do not routinely follow wounds. Wound updates are sent to the Nurse Practitioner weekly and if there are any concerns noted or issues with decline in the wound noted by wound care consultant, then the Nurse Practitioner would follow up as well. They stated they were not made aware of any changes in Resident #105's wound. However, they assessed the wound today and did order an x-ray to rule out osteomyelitis. Nurse Practitioner #1 stated it is the expectation of the nursing staff to notify them of any wound changes. 10 New York Codes, Rules, and Regulations 415.12(c)(1)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for four (Cart A 300-hall, Cart B 400-hall, Cart D 700 hall and Cart D 800 hall) out of four medication carts reviewed. Specifically, one stock medication had expired; one bottle of Flonase was uncapped; one loose pill was found in cart; one inhaler had an open date but was never opened; one stock medication had conflicting expiration dates; one Lantus kwik pen had no open date; one Lantus vial had no open date; five inhalers had no open and or expiration dates; one inhaler had no label at all; three narcotic count shifts were signed out prior to actual count reconciliation and change of shift; another narcotic book had multiple missing signatures for shift change. The facility's Policy and Procedure titled, Medication - Storage and Labeling reviewed 1/2026 documented This facility will store Medications safely and securely and in a manner that maintains the integrity of the product in accordance with manufacturer's recommendations, current standards of practice and federal and state regulations. 4. Medications will be stored in an orderly, organized manner in a clean area. 7. Medications (including ophthalmic, otic drops and house stock medications ) may be used until the listed manufacturer expiration date unless otherwise specifically indicated or labeled. 8. Medication injection pens including insulin pens and cartridges are single patient use only and will be labeled and stored for resident individual use. 9. A multi-dose vial or injection pen that has been opened or accessed (e.g., needle-punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different date for that opened vial or injection pen. a. If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date. b. The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should not exceed the manufacturer's original expiration date. b. Do not use insulin beyond the expiration date stamped on the vial, pen, or cartridge that is supplied from the drug manufacturer. c. Do not use insulin beyond the Discard On date listed on the auxiliary label. 11. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed in accordance with state and federal regulations. During an observation on [DATE] at 10:23 AM, Medication Cart B on 400 hall contained (1) Lantus insulin kwik pens and (1) Lantus insulin vial with no open dates; (3) albuterol inhalers (1) budesonide inhaler all with no open and or expiration dates; (1) Trilogy inhaler with no expiration date; (1) Trilogy inhaler with no label at all. During an observation on [DATE] at 11:02 AM, Medication Cart A on the 300-hall contained (1) Pro Air inhaler with an open date of [DATE], but the inhaler had not been opened for use; (1) stock bottle Vitamin D with two expiration dates, exp 3/08 and 12/26. The narcotic sheet dated [DATE], 3pm - 11pm shift change was signed as reconciled in advance of end of shift. During an observation on [DATE] at 2:35 PM, Medication cart D 800 hall contained (1) expired stock bottle of Thiamin B1 100 milligrams; (1) uncapped bottle of Flonase nasal spray; and (1) loose yellow pill identified as carbidopa/levodopa. The narcotic book shift change sheet for unit 800 had multiple missing signatures. During an observation on [DATE] at 2:35 PM Narcotic Book shift change sheet for the 100-hall had multiple missing signatures and, Licensed Practical Nurse #4 had signed for 3:00pm shift change at 2:37pm. During an interview on [DATE] at 11:02 AM Licensed Practical Nurse #1 stated they sign the narcotic count sheet in advance routinely so that they will not forget to do it at end of shift. Licensed Practical Nurse #5 stated they would never sign for any item or medication given in advance. During an interview on [DATE] at 10:50 AM, Director of Nursing #1 stated prior to administering medication, all nurses are checked off on competencies including medication administration, drugs with shortened expiration dates after opening, multi- dose vial medications and narcotic counts. It is the medication nurse's responsibility to ensure all meds are labeled with open and expiration dates. During an interview on [DATE] at 10:32 AM, Licensed Practical Nurse #2 stated they had not signed the narcotic count book yet because it had been a busy morning. They stated they should have signed when the first came on shift. During an interview on [DATE] at 11:02 AM, Licensed Practical Nurse #1 stated they signed the narcotic count book in advance as the outgoing nurse routinely, so they did not forget. During an interview on [DATE] at 11:05 AM, Licensed Practical Nurse #5 stated the narcotic count book should never be signed in advance, that would be signing for something that was not done. During an interview on [DATE] at 12:45 PM, Director of Nursing #1 stated they had been auditing the narcotic count books and would be increasing the audits due to missing signatures and nurses signing in advance. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation, record review and interviews during the survey, the facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in the central kitchen. Specifically, skim milk cartons were found past expiration dates. Findings include: During inspection in the central kitchen on 5/21/2026, the following items were found to be out of compliance with New York State food safety regulations: At 11:00AM approximately 15 cartons of skim milk were identified in the walk-in cooler placed in a small plastic cooler which were past the expiration date ( 5/17/2026) At 12:15 PM this cooler was identified to be at the tray line, and the expired milk was being placed on the lunch trays for the residents During interview, on 5/21/2026 at 12:15PM, Director of Food Services #1 stated the milk which was in the coolers [NAME] on the tray line to be used and it [NAME] precooled and separated to maintain temperature during tray preparation. When it was pointed out that there were approximately 15 cartons of skim milk which were past expiration date ( 5/13/2026) by over a week the staff were instructed to dispose of the expired cartons and a dietary staff representative went through the facility to ensure none of the expired cartons had left the kitchen or remained in any nourishment rooms, 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, record review, and interview conducted during the survey, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #10) of 43 residents reviewed for infection control practices. Specifically, 1.) Certified Nurse Aide # 5 failed to utilize Enhanced Barrier Precautions during resident care, increasing the risk of cross- contamination for a resident with a stage four pressure ulcer. These deficient practices placed the residents at risk for potential infection and compromised care delivery. Findings include: The Facility's Policy and Procedure titled Enhanced Barrier Precautions dated 8/2022 (last updated 2/25/2026), documented the Enhanced Barrier Precautions is applicable for residents with Wounds (e.g., any type of wound requiring a dressing). EBP requires wearing disposable gloves and an isolation gown prior to high contact activity. High Contact care activities include transferring and providing hygiene. Resident #10 Resident #10 was admitted to the facility with diagnoses of Pressure Ulcer, Sepsis (extreme life-threatening response to an infection), Acute Respiratory Failure. The Minimum Data Set (an assessment tool) dated 3/17/2026 documented severe cognitive impairment and presence of a pressure injury. The Active Physician's Orders were reviewed and lacked an order for Enhanced Barrier Precautions. The Certified Nurse Aide Kardex (Care Guide) dated 5/28/2026 documented Resident #10 was dependent for toileting hygiene. The Kardex lacked Enhanced Barrier Precautions. During an observation on 5/21/2026 at 11:35 AM, Resident #10 Certified Nurse Aide #5 entered the resident's room, placed gloves on, turned Resident #10 on their side, and stated they were going to do incontinent care. A large open wound was present. The Certified Nursing Assistant lacked a gown. Certified Nurse Aide returned the resident to her back and exited the room. During an interview on 05/28/2026 at 8:38 AM, Infection Preventionist #1, they stated Resident #10 is on Enhanced Barrier Precautions for a wound. They stated the Certified Nurse Aide would wear a gown and gloves with high care. 10 New York Codes, Rules, and Regulations 415.19

Based on record review and interview during an abbreviated survey (Case #455653), the facility did not ensure a final accounting of resident funds to the probate jurisdiction (a court that hears matters surrounding a person's death) administering the resident's Estate, within 30 days of the resident's death in accordance with State law for 1 resident (Resident #1) of 3 resident reviewed for transfer of personal funds upon death to the probate jurisdiction administering the resident's Estate. Specifically, Resident #1's date of death was [DATE]. A check dated [DATE] issued by the facility from the Resident Fund Trust Account was paid to the order of New York State Department of Health.This was evidenced by: The Policy and Procedure titled, Resident Funds Accounts (RFA) created 8/2014 and last updated 8/2020 documented upon the death of a resident: a. Unutilized resident funds and a final accounting of those funds shall be conveyed to the appointed executor or administrator of the resident's estate within thirty (30) days. b. In the absence of an executor or administrator of the estate, the County Public Administrator shall be the designated receiver of such resident funds. The Facility shall convey the balance of the resident's funds, and a final accounting of such funds, within thirty (30) days. c. Where applicable, the Facility shall turn over the funds in accordance with requirements of the Surrogate Court Procedure Act Section 1310.A statement dated [DATE], signed by facility's Finance Director documented when Resident #1 passed away [DATE], company policy was to wait 6 months. In [DATE], they mailed a check to the County Department of Social Services that oversaw Resident #1's Medicaid. The Department of Social Services called them and stated they were returning the check because the county no longer accepted Personal Needs Account funds, and they would include a letter with the address where the check was to be sent. The returned Personal Needs Account check was voided, and a new check was to be sent to the address provided. A letter from the County Attorney (the same county as the Department of Social Services) dated [DATE] documented the county no longer accepted Personal Needs Account checks for Medicaid reimbursement. It was to be sent to New York State Department of Health at the address provided. A copy of a check dated [DATE] from the Resident Fund Trust Account, was paid to New York State Department of Health in amount of $10,785.41 to close Resident #1's account. A New York State Department of Health email from the Division of Legal Affairs to the New York State Department of Health Complaint Resolution Unit, documented funds of a deceased resident must be returned within 30 days of their death. During an interview on [DATE] at 2:00 PM, Director of Finance #1 stated they were new to the position when this incident occurred and there was some confusion as to where and when the money should have been sent, along with some family dynamic issues that caused problems with disbursement of the funds. They have been able to learn the process and have not had any issues since this incident in 2022. 10 New York Codes, Rules, and Regulations 415.26(h)(5)

Based on observation and interview during abbreviated survey (case #NY00329501), the facility did not provide effective maintenance services one (1) of 4 resident units and 3 dining areas. Specifically, furniture in the facility was not in good repair. This is evidenced by: During observations on 01/10/2024 from 10:26 AM through 1:31 PM, resident chairs had worn upholstery in the following areas: Golden Hours Room dining and recreation room: 3 chairs. Mountain View Dining Room: 2 chairs. Evergreen Dining Room: 6 chairs. D Unit nurse station: 2 chairs. During an interview on 05/08/2024 at 2:52 PM, Administrator #1 stated that Director of Maintenance #1 would be directed to remove that worn chairs, and new chairs would be ordered. 10 New York Codes, Rules, and Regulations 415.5(h)(4)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure residents who needed respiratory care for 4 (Resident #'s 4, 41, 46, and 73) of 7 residents reviewed for respiratory care were provided such care, consistent with professional standards of practice. Specifically, for Resident #4, the facility did not ensure supplemental oxygen was provided as ordered by the physician on 11/10/2023, 11/13/2023, 11/14/2023, and 11/15/2023 and did not ensure supplemental oxygen tubing was dated and labeled to reflect the tubing was changed as ordered; for Resident #41, the facility did not ensure supplemental oxygen was provided as ordered by the physician on 11/10/2023, 11/13/2023, and 11/14/2023 and the resident's nasal cannula (NC) and humidifier bottle were changed as ordered by the physician on 11/08/2023; for Resident #46, did not ensure oxygen tubing was labeled with a time and date in accordance with physician orders on 11/09/2023, 11/10/2023, and 11/16/2023; and for Resident #73, did not ensure supplemental oxygen tubing was dated and labeled to reflect the tubing was changed as ordered. This was evidenced by: The policy and procedure (P&P) titled Oxygen Administration, dated 10/2019, documented oxygen would be administered by licensed nurses with a physician's order. All tubing would be changed at least weekly, more often if soiling with secretions occurred. When humidification was used, disposable bottles would be changed weekly or when empty. Resident #4: Resident #4 was admitted to the facility on [DATE] with the diagnoses of end-stage renal disease (ESRD), chronic respiratory failure, and essential hypertension. The Minimum Data Set (MDS - an assessment tool) dated 9/22/2023, documented the resident could be understood, and could understand others. The comprehensive care plan (CCP) titled Alteration in Respiratory System, dated 10/10/2023, documented to provide oxygen per physician orders and maintain/change tubing per protocol. A review of physician orders documented: - 9/15/2023; supplemental oxygen 4 liters per minute via nasal cannula (LNC) to maintain oxygen saturation greater than 90% every shift. - 9/15/2023; oxygen equipment maintenance every night shift on Wednesday; change oxygen tubing (mask, nasal cannula (NC), humidifier bottle, ear protectors (if applicable) weekly). During observations on: - 11/10/2023 at 11:48 AM, the resident's oxygen was running at 5LNC via concentrator. The NC tubing was dated 10/25/2023. - 11/13/2023 at 10:46 AM, the resident's oxygen was running at 5LNC via concentrator. The NC tubing was dated 10/25/2023. - 11/14/2023 at 10:25 AM, the resident's oxygen was running at 5LNC via concentrator. The NC tubing was dated 10/25/2023. - 11/15/2023 at 10:02 AM, the resident's oxygen was running at 5LNC via concentrator. The NC tubing was dated 11/15/2023. The Medication Administration Record (MAR) dated 11/10/2023, 11/14/2023 and 11/15/2023, documented the resident was using supplemental oxygen via 4LNC during the dayshift by Licensed Practical Nurse (LPN) #7 and #8. The MAR dated 11/13/2023 documented the resident was using supplemental oxygen via 2LNC during the dayshift by LPN #8. The Treatment Administration Record (TAR) dated 11/15/2023, documented the resident's NC was changed on the night shift by LPN #11. There was no additional documentation for changing the resident's tubing recorded during the previous weeks. A review of progress notes dated 11/10/2023 - 11/14/2023, did not include documentation that the resident required oxygen administered at a higher rate than what was ordered. During an interview on 11/15/2023 at 10:31 AM, LPN #7 stated that the resident was on oxygen per physician order. LPN #7 stated the resident was usually on two (2) liters per minute (LPM) of oxygen during the daytime and four (4) LPM at nighttime, and when researching the physician's order, they stated the resident should be on four (4) LPM constantly. LPN #7 stated that while the nurse was performing resident care, they should verify the liter flow of oxygen. They stated the resident should not change the concentrator liter flow; only a nurse can change it. LPN #7 stated they did not know why the liter flow on the resident's concentrator was set at five (5) LPM and was not sure why the documentation in the MAR did not match the documented observations on 11/10/2023, 11/13/2023, 11/14/2023, and 11/15/2023. They stated the night LPN would change the oxygen tubing for the resident every week, and it should have been changed on 11/1/2023 and 11/8/2023. During an interview on 11/15/2023 at 11:06 AM, LPN #9 stated that the resident was on oxygen that should be set per physician orders in the resident's computer chart. They stated that residents were not allowed to change the concentrator settings, and nurses checked the liter flow during their care during the day and evening, then document it in the resident's chart. LPN #9 stated they did not know why the documentation and observed liter flows were different. During an interview on 11/15/2023 at 11:36 AM, Registered Nurse (RN) #3 stated that the resident's oxygen was set per physician order at four (4) LPM. RN #3 stated nurses should check the oxygen level during their routine care and document the findings in the resident's files. RN #3 stated they did not know why the documentation did not match the observations, and nurses would report to them if there were any changes in settings. During an interview on 11/16/2023 at 11:00 AM, the Director of Nursing (DON) stated residents on oxygen had care plans and physician orders that documented the liter flow residents were to receive. Nurses were the only staff who should be adjusting oxygen liter flow. Resident #41: Resident #41 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (COPD), anxiety disorder, and atrial fibrillation (irregular and rapid heart rate). The Minimum Data Set (MDS - an assessment tool) dated 10/08/2023, documented the resident was able to make themselves understood, able to understand others, and was severely cognitively impaired. The comprehensive care plan (CCP) titled Alteration in Respiratory System, dated 9/19/2023, documented to provide oxygen per physician orders, and maintain/change tubing per protocol. Finding #1 The facility did not ensure supplemental oxygen was provided as ordered by the physician on 11/10/2023, 11/13/2023, and 11/14/2023. A review of physician orders documented: - 07/03/2023: supplemental oxygen 2 liters per minute via nasal cannula (LNC) to maintain oxygen saturation greater than 90% every shift. During observations on: - 11/10/2023 at 11:15 AM, the resident's oxygen was running at 3LNC via concentrator. - 11/13/2023 at 08:41 AM, the resident's oxygen was running at 3LNC via concentrator. - 11/14/2023 at 09:46 AM, the resident's oxygen was running at 3LNC via concentrator. - 11/14/2023 at 10:31 AM, the resident's oxygen was running at 3LNC on the concentrator. The Medication Administration Record (MAR) dated 11/10/2023, 11/13/2023, and 11/14/2023, documented the resident was using supplemental oxygen via 2LNC during the dayshift by Licensed Practical Nurse (LPN) #4. Review of progress notes dated 11/10/2023 - 11/14/2023 did not include documentation the resident required oxygen administered at a higher rate than what was ordered. Finding #2 The facility did not ensure the resident's NC and humidifier bottle were changed as ordered by the physician on 11/08/2023. A review of physician orders documented: - 07/03/2023; oxygen equipment maintenance every night shift on Wednesday; change oxygen tubing (mask, NC, humidifier bottle, ear protectors, and storage bags weekly. During observations on: - 11/10/2023 at 11:15 AM, the resident's oxygen NC tubing was dated 10/05/2023, and the humidifier bottle was dated 07/13/2023. - 11/13/2023 at 08:41 AM, the resident's oxygen NC tubing was dated 10/05/2023, and the humidifier bottle was dated 07/13/2023. - 11/14/2023 09:46 AM, the resident's oxygen NC tubing was dated 10/05/2023, and the humidifier bottle was dated 07/13/2023. - 11/14/2023 at 10:31 AM, the resident's oxygen NC tubing was dated 10/05/2023, and the humidifier bottle was dated 07/13/2023. The Treatment Administration Record (TAR) dated 11/08/2023, documented the resident's NC and humidifier bottle were changed on the night shift by LPN #5. During an interview on 11/14/23 at 10:31 AM, LPN #4 stated when residents were on oxygen, they had physician orders that were reflected on the MAR, which normally required the nurse to check the flow rate of the oxygen during each shift. Equipment used for oxygen delivery, like NCs and humidifier bottles, needed to be changed weekly and typically done on the night shift. They did not know why the resident's oxygen was currently running at 3LNC, it was running at 2LNC when they documented it earlier. They did not know why their documentation of the resident's oxygen liter flow rate did not match what the resident's oxygen was observed running at by the surveyor on 11/10/2023, 11/13/2023, and 11/14/2023. The resident was incapable of changing the liter flow themselves, and nurses were the only staff who were supposed to be adjusting this. LPN #4 stated the resident's humidifier bottle and NC should have been replaced and dated on 11/08/2023 when it was documented they were changed. During an interview on 11/16/2023 at 11:16 AM, LPN #2 stated residents on oxygen had physician's orders that included the flow rate and type of delivery device, and for equipment monitoring/maintenance that included changing the NC and humidifier bottle weekly and as needed. These were documented on the MAR and TAR. Nurses were the only ones that managed oxygen flow rate. Residents on oxygen also had a respiratory CCP; Resident #41's documented to provide oxygen per physician orders and change the NC per protocol. On 11/10/2023, 11/13/2023, and 11/14/2023, the resident's oxygen should have been running at 2LNC as ordered, they did not know why it was observed running at 3LNC. The resident's NC and humidifier bottle should have been changed when they were signed off by LPN #5 on 11/08/2023. They had already spoken with LPN #5 and were told they misread the oxygen equipment order. They thought they were supposed to just be monitoring the NC and humidifier bottle and did not realize they were supposed to be changing these items. During an interview on 11/16/2023 at 12:09 PM, the Director of Nursing (DON) stated residents on oxygen had a CCP and physician orders that included documentation of the liter flow, delivery equipment used, and how often to change the equipment. Nurses were the only staff who should be adjusting oxygen liter flow. Resident #41's oxygen should have been running at 2LNC and not 3LNC as ordered on 11/10/2023, 11/13/2023, and 11/14/2023. If a higher flow rate than what was ordered was required, the physician should have been called and a progress note written. The resident's NC and humidifier bottle should have been changed on 11/08/2023 when it was documented it was done. Resident #46: Resident #46 was admitted to the facility with diagnoses of metabolic encephalopathy (a series of neurological disorders not caused by primary structural abnormalities but rather result from systemic illness), osteomyelitis (inflammation or swelling that occurs in the bone) due to a stage 4 pressure sore, and asthma requiring continuous oxygen. The Minimum Data Set (MDS) dated [DATE], documented the resident was understood, could usually understand and had severely impaired cognition. During observations on 11/9/2023 at 11:07 AM, 11/10/2023 at 10:23 AM, and 11/16/2023 at 12:18 PM, Resident #46's oxygen tubing was not labeled with a time and date. The comprehensive care plan (CCP) titled Alteration in Respiratory System, dated 10/28/2023, documented to provide oxygen per physician orders, and maintain/change tubing per protocol. A review of physician orders documented: - 10/28/2023: Supplemental oxygen 2 liters (2L)/minute via nasal cannula (NC) to maintain oxygen saturation greater than 90% every shift. - 10/28/2023: Oxygen equipment maintenance every night shift on Wednesday; change oxygen tubing (mask, NC, humidifier bottle, ear protectors, and storage bags weekly. The Medication Administration Record (MAR), dated 11/2023 documented the resident was using continuous oxygen 2L via NC. The Treatment Administration Record (TAR), dated 11/8/2023, documented the resident's NC and humidifier bottle were changed on the night shift. Review of progress notes dated 11/01/2023 - 11/16/2023 did not include documentation the resident's oxygen tubing had been changed. During an interview on 11/13/2023 at 11:23 AM, Certified Nursing Assistant (CNA) #10 stated nurses were the only ones who took care of oxygen and tubing. If a resident had an oxygen tank that was low, or if there was a problem with the concentrator, they would notify the nurse and the nurse would resolve it. CNA #10 stated they had not noticed whether oxygen tubing was dated. During an interview on 11/16/2023 at 9:57 AM, Licensed Practical Nurse Unit Manager (LPNUM) #10 stated the oxygen tubing was changed and respiratory equipment was cleaned every Wednesday night on the 11 PM to 7 AM shifts and documented on the electronic treatment administration record (eTAR). LPNUM #10 stated when the tubing was changed it was dated and timed. LPNUM #10 stated if the eTAR was signed but the tubing was not dated, no one would know if it was done. LPNUM #10 further stated that they were just recently educated in changing and placing the date and time on the tubing. Resident #46 went out to the hospital on 11/10/2023 in the afternoon but returned on 11/15/2023 in the afternoon and was still on continuous oxygen. During an interview on 11/16/2023 at 10:06 AM, the Director of Nursing (DON) stated they had just recently reeducated staff on care of the respiratory equipment and changing tubing weekly. The DON further stated the inservice highlighted the importance of dating tubing to ensure tubing had been changed, and that additional education would be required. 10 NYCRR 415.12(k)(6)

Based on record review, observations and interviews during the recertification survey dated 11/9/2023-11/16/2023, the facility did not ensure that each resident received, and the facility provided, food and drink that was palatable, attractive, and at a safe and appetizing temperature for 5 of 5 units. Specifically, on 11/15/2023, the facility did not ensure food served was pleasant tasting and that cold food was served at temperatures less than 41 degrees Fahrenheit (F), and warm food was served at temperatures greater than 135 F. This was evidenced by: Food Council Meeting Minutes dated August 2023 through October 2023 documented the following: - 9/26/2023 - Residents complained that the food was served cold, and trays delivered late. - 10/24/2023 - Residents complained that trays were delivered. and sat in the hallways for 20 minutes because staff were not present to pass the trays and that coffee and eggs were served cold. Unit A During an observation on 11/15/2023 at 1:33 PM, the last lunch tray was served, and a test tray provided. The test tray temperatures were taken, and items served were tasted. The results were as follows: Water; 62.6 degrees Fahrenheit (F), cool, tasted like water Mandarin oranges; 66.8 F, consistency and taste was ok Coffee; 136.6 F, warm, tasted like coffee Green Beans; 127.4 F, mushy, not flavorful and lacked seasoning Pasta; 127.3 F, sticky, overcooked, and starchy Chicken; 128.1 F, hard to cut, and dry Alfredo sauce; 113 F, warm, gritty, clumpy and congealed The overall taste of the lunch meal was not palatable (pleasant to taste). Unit B On 11/15/2023 at 1:40 PM, the last lunch tray was served, and a test tray provided. The test tray temperatures were taken, and items served were tasted. The results were as follows: Chicken with sauce; 120.4 F, warm, not hot, sauce was thickened and clumped. Green beans; 112F, cool, soggy, and tasteless. Noodles with sauce; 123.2 F, mushy and clumped together (could not wind around fork) Mandarin oranges; 50.2 F Water; 65.1 Coffee directly from the serving container; 119.4 F, lukewarm. Unit C On 11/15/2023 at 12:38 PM, the last lunch tray was served, and a test tray provided. The test tray temperatures were taken, and items served were tasted. The results were as follows: Coffee: 122.0 F, warm tasted like coffee Cup of water: 65.5 F slightly cool, almost room temperature, tasted like water Cup of mandarin oranges: 58.1 F, tasted possibly like canned mandarin oranges Chicken with sauce: 119.1 F, chicken was very dry, sauce thickened on top of chicken and tasted very salty. Green Beans: 118.4 F, overcooked and very mushy consistency. Noodles with sauce: 122.0 F, noodles were overcooked, some noodles were hard and stuck together, and some of the noodles had cold spots once tasted. Unit D/E On 11/15/2023, at 12:28 PM, the last lunch tray was served, and a test tray provided. The test tray temperatures were taken, and items served were tasted. The results were as follows: Chicken Alfredo; 114.4 F, cool Pasta Alfredo; 122.2 F, cool and the [NAME] sauce was cold, and tasted salty Green beans; 118.9 F, cool Black coffee; 119.1 F, warm and tasty Cup of water; 64.6 F Mandarin oranges; 50.7 F Salt, pepper, & sugar packets were present on the ticket and tray. Interviews: During an interview on 11/14/2023 at 12:49 PM, a resident stated lunch was sometimes served cold on Unit A, and residents had tried asking staff to reheat it for them in the past but was told there was no microwave available on the unit. The resident further stated they had not asked about it since. During an interview on 11/16/2023 at 10:34 AM, Certified Nurse Aide (CNA) #4 stated that residents had sometimes reported their food was too cold, and as of result, their food would be reheated in the microwave if needed. CNA #4 further stated residents most frequently asked for their dinner food to be reheated. During an interview on 11/16/2023 at 12:06 PM, CNA #10 stated that if a resident complained their food was cold, staff would get the resident a sandwich because they were hungry and didn't want to wait for food to be heated. CNA #10 further stated that when residents complain about hot food being too cold, staff would relay the information to dietary. During an interview on 11/16/2023 at 12:59 PM, the Food Service Director (FSD) stated the afternoon meal was temped prior to plating the food, with the chicken temped at 165 F prior to plating to resident trays. The FSD stated the food was taken directly to resident units and transported in open carts. The FSD further stated residents had continued to complain about hot food being cold, and that the facility had planned to purchase new closed carts for transporting food to the units. The FSD stated keeping food at the proper temperature was an issue September 2023 but was related to equipment; the facility addressed the issue after the Food Committee meeting occurred. The FSD stated that they believed continued complaints of hot food being cold was due to hot food being transported in open carts, and that enclosed food carts were needed. The FSD stated they were not aware if the facility investigated or had taken temperatures of the food once the carts had left the kitchen, were transported to the units, and left with staff to pass the food trays to residents. The FSD stated that only two units had microwaves to reheat food. The FSD further stated a complaint of cold trays and late passing of trays was brought up in Resident Food Council meeting. During an interview on 11/16/2023 at 12:56 PM, the Administrator stated they were not aware of any trends regarding issues related to food temperature or quality. The Administrator further stated that they were aware of complaints about the taste of the facility's soups mentioned by residents during the facility's food team meetings but were not aware of any changes that had been made regarding the soups. 10NYCRR415.14(d)(1)(2)

Based on record review and interviews during a partial extended abbreviated survey (Case #s NY 908 and NY 073) from 01/11/2022 to 01/28/2022, the facility failed to protect each resident's right to be free from abuse for 2 (Resident #s 1 and 2) of 4 residents reviewed. Specifically, on 12/27/2021 night shift, LPN #1 did not report an allegation of abuse to the Administrator per the facility's abuse Policy and procedure. Resident #2 reported to LPN #1 that CNA #2, a provisional employee assigned to B Unit, had touched them inappropriately. Additionally, on 12/27/2021, CNA #5 did not report to Administration or Supervisors when CNA #2, was on the A Unit going in and out of resident rooms looking in Resident #1's room with their cell phone flashlight. On the 12/31/2021 evening and night shifts, CNA #s 1 and 3 did not report their concerns to Administration or Supervisors when CNA #2, assigned to the D Unit, was observed in Resident #1's room on A Unit. Subsequently, Resident #1, who was cognitively intact and had lower extremity [CONDITION(S)], was sexually abused in their room on Unit A by CNA #2, on the 12/31/2021 evening shift, and in the morning of 1/1/2022. This resulted in Immediate Jeopardy to resident health and safety and Substandard Quality of Care. This is evidenced by: Refer to R0514 - Monitoring Provisional Staff Refer to F609 - Reporting Alleged Violations The Policy and Procedure (P&P) titled Abuse last revised 2/2019, documented the Administrator and Director of Nursing (DON) were responsible for the investigation and reporting of abuse. Implementation and ongoing monitoring consisted of screening, training, prevention, identification, protection, investigation, and reporting. Sexual abuse included but was not limited to humiliation, harassment, coercion, or assault. All potential employees, contracts, consultants who would have access to residents were screened for a history of abuse of residents during the hiring process. Screening included criminal background checks. The facility was to ensure prevention techniques were implemented in the facility, including ongoing supervision of employees through visual observation of care delivery. The facility was to have sufficient and appropriate supervisory staff to identify inappropriate behaviors. The P&P titled CHRC/Fingerprinting - NY last revised 3/2021, documented a Criminal History Records Check (CHRC) was to be initiated at the time of job offer and acceptance. Direct supervision was to be provided to the applicant while the applicant was in the facility or with residents. The supervisor would be present on the unit with the applicant at all times during direct care of the residents. Documentation of the supervised time was to be maintained in the employee file. Resident #2: Resident #2 was readmitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 12/19/2021, documented the resident was cognitively intact. Resident #2 resided on the A Unit. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) last revised 9/16/2021, documented Resident #2 required assistance with ADLs related to ALS and was totally dependent on two staff for bed mobility. The Staffing Schedule dated 12/27/2021 for the 11:00 PM to 7:00 AM shift, documented CNA #2 was assigned to the B Unit. An email dated 1/4/2022 at 2:34 PM from Resident #2's ALS Coordinator (ALSC) to the Social Worker (SW) #2, documented they were writing on behalf of Resident #2 and their spouse. The ALSC documented the resident's husband notified them that Resident #2 claimed they were assaulted/molested by a CNA a couple days ago. The ALSC stated they were bringing it to SW #2's attention because it was urgent and needed to be addressed. A New York State Incident Report by the local police department dated 1/4/2022 at 5:03 PM, documented that the incident type was sexual offense after fact that occurred at the facility. The victim was Resident #2. The alleged perpetrator was CNA #2, and their [NAME] name was also documented. The call to the police department was made by the Assistant Director of Nursing (ADON). The ADON reported CNA #2 touched Resident #2 in a sexual manner. The ADON told the police Resident #2 reported CNA #2 caressed their inner thigh as well as their face and arms. At the time of the incident, CNA #4 was also in the resident's room and failed to prevent the incident from occurring while witnessing the event. The ADON stated the incident was not initially reported to facility administration but was reported to the resident's ALSC (by the resident's spouse). A Behavior Note dated 1/4/2022 at 5:24 PM by the ADON, documented they followed up with Resident #2 following an incident. There were no signs of psychological harm. The physician was made aware and there were no new orders. A Care Plan Note dated 1/5/2022 at 3:59 PM by the ADON, documented an outside agency (the ALSC) had notified the facility by email of an allegation of abuse that had been reported to the outside agency. Resident #2 was interviewed, there were no injuries or skin alterations and there was no psychological harm noted to Resident #2. CNA #2 was removed from the schedule pending investigation. A facility Investigation Form, with a completion date of 1/7 /2022, and signed by the ADON, documented that on 1/4/2022 at approximately 2:34 PM, the ADON was contacted by the SW #2 about an email sent from Resident #2's ALSC regarding a sexual abuse allegation. The concerns detailed by Resident #2 were that CNAs #2 and #4 touched them inappropriately on their face, hair, leg, and inner thigh. A written statement obtained from CNA #4 by the ADON on 1/5/2022 at 4:13 PM, documented that on 12/26/2021 or 12/27/2021, on the 11:00 PM to 7:00 PM shift, they were asked to assist with moving Resident #2, who resided on the A Unit, up in bed. The resident required the assistance of two staff members, so CNA #2 helped them to move the resident up in the bed. CNA #4 stated they were aware of the accusation that was made and said it was not true and was not warranted. An undated written statement by LPN #1, documented they were in Resident #2's room and CNA #2 walked in. Resident #2 asked CNA #2 to get out. Resident #2 then told LPN #1 that CNA #2 came in their room with CNA #4, and CNA #2 rubbed their head, arms, and leg. LPN #1 asked the resident where CNA #4 was at that time and the resident stated they were standing right there in the room, laughing. LPN #1 documented they asked CNA #4 about the situation, and they denied it. There was no documented evidence LPN #1 reported the allegation to the Administrator or Supervisors. During an interview on 1/11/2022 at 3:50 PM, Resident #2 stated CNA #4 was in the room with the resident when CNA #2 came into the room. CNA #2 then touched them without permission and their hand on their knee and started to move their hand up the resident's thigh. Resident #2 said they realized CNA #2 was not going to leave unless CNA #4 left, and so Resident #2 asked CNA #4 to leave and told CNA #2 there was no reason for them to be there. Resident #2 said both CNAs left the room. During an interview on 1/25/2022 at 9:06 AM, LPN #1 stated Resident #2 told them CNA #2 touched their head and leg and made them feel uncomfortable. Resident #2 also told them CNA #4 was in the room and was laughing. LPN #1 stated they talked to CNA #4 who said CNA #2 only came in the resident's room to help slide the resident up in bed. LPN #1 said it happened during the night shift but could not recall the date. LPN #1 said they did not report this allegation. During an interview on 1/25/2022 at 1:38 PM, CNA #2 stated they were never assigned to work on the A Unit, and that they did not know who CNA #4 was. During an interview on 1/26/2022 at 8:39 AM, CNA #5 stated they worked the 11:00 PM to 7:00 AM shift on the A Unit on 12/27/2021, and CNA #2 was assigned to the B or C Unit. CNA #5 stated they saw CNA #2 going in and out of quite a few resident rooms on the A Unit during that shift, and that there were no call lights on for any of the rooms CNA #2 was entering. There was no documented evidence CNA #5 reported their concerns about CNA #2. During an interview on 1/13/2022 at 3:12 PM, the ADON stated they started obtaining statements from staff after they received the email from the ALSC on 1/4/2022. The ADON said they received LPN #1's statement on 1/5/2022. Based on what LPN #1 wrote in their statement, it should have been reported to the ADON at the time the resident made the complaint. The ADON said LPN #1 did not report anything about the 12/27/2021 allegation prior to 1/5/2022. During an interview on 1/13/2022 at 4:13 PM with the Administrator, Director of Nursing (DON), and the Human Resource Director (HRD), the Administrator stated the LPN assigned to the unit was supposed to be supervising staff on the unit including provisional staff. The Administrator stated LPN #1 was terminated because they did not report the allegation made by Resident #2 on 12/27/2021. LPN #1 was assigned to A Unit and should have been supervising the CNAs, including the provisional CNAs. Resident #1: Resident #1 was readmitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented the resident was cognitively intact. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) related to limited mobility, [CONDITION(S)], and limited range of motion in the right upper arm, last revised on 8/26/2021, documented Resident #1 was independent and required no assistance or supervision with all ADLs except for walking, which they were unable to do. Incident #1: Resident #1 was sexually abused in their room by CNA #2, on the 12/31/2021 evening shift. The Investigation Form dated 1/3/2022 for date of incident 1/1/2022 by the ADON, documented on 1/1/2022 at approximately 7:42 AM, the ADON was contacted by the 11:00 PM - 7:00 AM supervisor about a sexual abuse allegation. Resident #1 reported that a staff member touched them inappropriately in their genitalia. Resident #1 reported they did not know who the staff member was. Resident #1 described the staff member (later identified as CNA #2). The local police department was contacted by Resident #1's family member. During assessment, Resident #1 reported CNA #2 was touching me down there, looked like rubbing my vagina. CNA #2 was then assisted by CNA #3 to get Resident #1 onto the shower chair on the evening shift on 12/31/2021. An undated written statement by CNA #2, attached to the facility investigation, documented they helped CNA #3 lift a resident into a chair and CNA #3 was present with them during the whole care treatment. CNA #2 documented that on 12/31/2021 in they worked on the D Unit and helped out on the A Unit. A written statement dated 1/3/2022 by CNA #3, documented they worked on the A Unit on 12/31/2021 during the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts. CNA #3 stated that, when they came back from a break, they saw CNA #2 peeping out of Resident #1's room, then went back in, and then came back out and said the resident wanted a shower. CNA #2 then said the resident was bleeding. When CNA #3 went into the room, they saw CNA #2 wiping the resident with a towel. CNA #2 then proceeded to open the resident's labia to show them where they were bleeding from. CNA #3 stated they did not see any blood. It made CNA #3 feel uncomfortable, so they took over the resident's care. CNA #2 then helped CNA #3 put the resident in the chair. A written statement dated 1/2/2022 by LPN #1, documented the CNA for the 3:00 PM to 11:00 PM shift was CNA #1. For the 11:00 PM to 7:00 AM shift CNA #1 and CNA #3 were assigned to the A Unit. LPN #1 stated CNA #2 was stationed on the D Unit but was at the nurses station on A Unit talking to them (LPN #1). At that time, the light went off for Resident #1's room and LPN #1 asked CNA #2 to assist the resident. CNA #2 assisted the resident to the bathroom and returned to the nurses station. CNA #2 was then asked by CNA #3 to assist Resident #1 onto the shower chair. CNA #2 then returned to the D Unit. During an interview on 1/11/2022 at 12:58 PM, Resident #1 stated they were preparing to take a shower when a staff member (later identified as CNA #2), whom they had never seen before, came into their room and said they were going to fix their catheter. Resident #1 said CNAs did not adjust their catheter and they did not know if the staff member was a nurse or a CNA at that point. Resident #1 stated CNA #2 touched their vagina. Resident #1 stated they felt uncomfortable, and that it looked weird, but since they did not know who the staff member was, they did not want to be accusatory. A short time later, CNA #3 came in with the shower chair and they put the resident in the shower. During an interview on 1/11/2022 at 3:50 PM, Resident #2 (who was in their room across the hall from Resident #1) stated they saw CNA #2 go into Resident #1's room a couple times alone during the night of 12/31/2021. CNA #2 had a flashlight on, that was on their phone when they went into Resident #1's room. During an interview on 1/24/2022 at 4:41 PM, CNA #3 stated that, on 12/31/2021, they worked the A Unit and CNA #2 was supposed to be on the D Unit. CNA #3 went on a break and when they returned to the A Unit, they saw CNA #2 peek their head out of Resident #1's room, stating Resident #1 wanted a shower. CNA #2 then said they needed to show CNA #3 something. CNA #3 went into the resident's room and CNA #2 was wiping the resident with a towel and said the resident was bleeding. CNA #2 then separated the resident's labia. CNA #3 said they looked at the vaginal area but did not see any blood. CNA #3 asked the resident if they had their period, and they said they did not know. CNA #3 said the encounter with CNA #2 made them feel uncomfortable. CNA #3 said they did not know what was going on at time, did not ask CNA #2 what they were doing and did not want to wrongly accuse them. Right after that CNA #3 got the shower chair and CNA #2 helped get the resident in the shower. CNA #3 said they did not say anything about CNA #2 because they were not sure but still did not feel right about them. During an interview on 1/25/2022 at 9:06 AM, LPN #1 stated they worked on the A Unit on 12/31/2021 during the evening and night shifts. CNA #2 was not assigned to the A Unit on 12/31/2021 but came to the A Unit during the evening shift. LPN #1 said they were at the nurse station the entire time and did not see CNA #2 go into Resident #1's room. During an interview on 1/25/2022 at 1:38 PM, CNA #2 stated that on 12/31/2021, they were assigned to the D Unit and went to the A Unit to talk to their friend, LPN #1. CNA #2 said while they were on the A Unit, they answered Resident #1's call light. CNA #2 said they went into the resident's room alone and was not supervised by any staff. CNA #2 stated the resident wanted a shower. CNA #2 also stated they could see that the resident was bleeding. The resident was sitting with nothing on and there was blood on their belly. CNA #2 also stated that CNA #3 also saw the blood. CNA #2 stated they then helped CNA #3 get Resident #1 into the shower. Incident #2: Resident #1 was sexually abused in their room by CNA #2, on the morning of 1/1/2022. A Nursing Clinical Evaluation dated 1/1/2022 at 7:42 AM by the ADON, documented Resident #1 reported inappropriate conduct of a male staff member. There were no skin alterations or discoloration, no report of pain/discomfort and no signs and symptoms of psychosocial concerns. No psychological harm noted. A Care Plan Note dated 1/1/2022 at 10:15 AM by the ADON, documented the interdisciplinary team (IDT) met to discuss alleged sexual abuse allegations. The alleged staff member (later identified as CNA #2) was removed from the schedule pending investigation. An RN Assessment Note dated 1/1/2022 at 4:41 PM by Registered Nurse Supervisor (RNS) #2, documented staff reported Resident #1 called 911 requesting an ambulance to go to the hospital for further evaluation related to an earlier alleged incident. A Nursing Progress Note dated 1/2/2022 at 4:08 AM, documented Resident #1 returned to the facility, and stated they were upset to be returning. The resident was told that CNA #2 was not in the facility. The New York State Incident Report by the local police department dated 1/1/2022 at 8:01 AM, documented the incident type was sexual offense after fact that occurred at the nursing home. The victim was Resident #1. The alleged perpetrators were CNA #1 and CNA #3. The call to the police department was made by Resident #1's family member. It was documented that Resident #1's roommate could not see what was going on behind the curtain but stated they heard the unknown male asking Resident #1 if they could feel that numerous times. Subsequently, the facility called the police department on 1/4/2022, to report an incident that occurred with Resident #2 on 12/31/2021 and named CNA #2 as the alleged perpetrator of the abuse of both Resident #'s 1 and 2. A facility Investigation Form dated 1/3/2022 by the ADON, documented that on 1/1/2022 at approximately 7:42 AM, the ADON was contacted by the 11:00 PM to 7:00 AM supervisor about a sexual abuse allegation involving Resident #1. Resident #1 reported that, at approximately 6:00 AM, CNA #2 came back into Resident #1's room, pulled their pants down and was touching the resident's vagina and inserted their fingers. CNA #2 told Resident #1 they were pushing the indwelling urinary catheter back in. Resident #1 reported to the police, that afterwards, the resident checked herself, and their vagina was moist. The resident reported that CNA #2 came around to the right side of my bed and was looking at my whole body. The resident asked CNA #2 if they were a medication nurse. CNA #2 responded that they were new at this, then flipped me over and looked at my butt but I refused to move, and he left with his gloves on. CNA #3 stated they witnessed CNA #2 come out of Resident #1's room and CNA #2 told them the resident wanted a shower. CNA #2 then asked CNA #3 to come into the room because the resident was bleeding. CNA #3 said they did not see any bleeding. During an interview on 1/11/2022 at 12:58 PM, Resident #1 stated that at around 6:00 AM or 7:00 AM on 1/1/2022, CNA #2 came into their room and said they needed to check their catheter. Resident #1 said CNA #2 then pulled their shorts down. Resident #1 said CNA #2 had a glove on and was inside me, fingering me, for over a minute. When CNA #2 stopped, they asked CNA #2 if they were a medication nurse and CNA #2 said they were new at this. Resident #1 said they then told CNA #2 they were paralyzed. Resident #1 said CNA #2 started poking the lower part of their left leg and kept poking upwards along the front left side of their body and stopped after they touched their left breast. CNA #2 was asking the resident if they could feel that while they were poking them. Resident #1 said CNA #2 asked them to turn over so that they could look at their butt and said something about the catheter. Resident #1 said no, and CNA #2 left the room with the glove on. Afterwards, Resident #1 called the facility phone number and talked to Registered Nurse Supervisor (RNS) #1. When RNS #1 arrived at the resident's room, Resident #1 stated the roommate was in the room during the incidents, but the curtain was closed. They did not know if the roommate was awake, and there were no other staff in the room. During an interview on 1/24/2022 at 4:41 PM, CNA #3 stated that, on 12/31/2021, they worked the A Unit and CNA #2 was supposed to be on the D Unit. CNA #3 went on a break and when they returned to the A Unit they saw CNA #2 peek their head out of Resident #1's room, stating Resident #1 wanted a shower. CNA #2 then said they needed to show CNA #3 something. CNA #3 went into the resident's room and CNA #2 was wiping the resident with a towel and said the resident was bleeding. CNA #2 then opened the resident's labia. CNA #3 said they looked at the vaginal area but did not see any blood. CNA #3 asked the resident if they had their period, and they said they did not know. CNA #3 said the encounter made them feel uncomfortable. CNA #3 said they did not know what was going on at that time, did not ask what they were doing and did not want to wrongly accuse CNA #2. After that CNA #3 got the shower chair and CNA #2 helped get the resident in the shower. CNA #3 said they did not say anything about CNA #2 because they were not sure what happened but did not feel right about CNA #2's behavior. During an interview on 1/25/2022 at 1:38 PM, CNA #2 stated that on 12/31/2021, they were assigned to the D Unit and went to the A Unit to talk to their friend, LPN #1. CNA #2 helped CNA #3 get Resident #1 into the shower. CNA #2 stated they left the unit and then left the facility to go on their lunch break and did not return to the facility for quite a while. During an interview on 1/19/2022 at 12:53 PM, local law enforcement agency Investigator #1 stated that on 1/2/2022, the facility called to report CNA #2 was the alleged perpetrator of an alleged incident of sexual abuse of Resident #1 that occurred on the A Unit on 12/31/2021. Investigator #1 stated they did a background check and CNA #2 was hired at the facility under a false name and date of birth. CNA #2 had a criminal history in California and Georgia which included burglary, numerous robberies, battery with serious bodily injury, and indecent exposure. Investigator #1 said CNA #2 left New York State and the investigation was ongoing. During an interview on 1/13/2022 at 10:10 AM, the ADON stated they went into the facility on [DATE], immediately after they received a call about an allegation of abuse made by Resident #1. Upon arrival to the facility, Resident #1's grandmother was on the phone. While explaining --the facility's process to the grandmother, the police arrived. The ADON stated the resident's grandmother and mother called the police. The ADON brought the 2 police officers to Resident #1's room, with the nursing supervisor. The ADON stated Resident #1 was not upset and went through everything that happened. The ADON asked the roommate if they had concerns, and the roommate stated it was someone they did not know. The ADON checked the staffing schedule after they assessed and interviewed Resident #1 and said CNA #s 1 and 3 had been on the schedule for the 12/31/2021 night shift. The ADON said they did not know about CNA #2 until after they received LPN #1's written statement on 1/2/2022. The ADON removed CNA #2 from the schedule on 1/2/2022. The ADON called CNA #2 but could not reach them. During an interview on 1/13/2022 at 4:13 PM with the Administrator (ADMIN); Director of Nursing (DON), and the Human Resource Director (HRD), the ADMIN stated all staff received abuse training during orientation. The ADMIN stated the LPN assigned to the unit was supposed to be supervising staff on the unit, including provisional staff. The ADMIN and the DON both said that LPN #1 was assigned to Unit A and should have been supervising the CNAs, including provisional CNAs. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review and staff interview during a partial extended abbreviated survey (NY 598) the facility failed to thoroughly investigate incidents and accidents to ensure assessments, care plans and interventions were initiated to prevent unsafe wandering and elopement. Specifically, resident # 25 with a history of unsafe wandering was found on 10/1/13 sleeping outside in the patio area. The facility failed to thoroughly investigate for the prevention of additional incidents. The facility failed to accurately identify the incident as an elopement and failed to report the incident to the Department of Health. On 11/10/13, the resident was found in an unsecured area outside of the facility after exiting through a window, fell and sustained minor injuries. The facility failed to thoroughly investigate the incident to ensure that environmental safeguards were in place to prevent residents from leaving the facility through windows. This resulted in no actual harm that has the potential for serious harm that is Immediate Jeopardy to the health and safety of the residents and Substandard Quality of Care. This is evidenced by: The facility was able to remove the immediacy prior to exit by implementing the following: The facility ensured all resident windows could not be opened more than 6 inches. All windows will be monitored weekly. The Policy and Procedure regarding a thorough investigation of all resident incidents has been revised. This includes language of preventing recurrence of all incidents including elopement. The facility has a system to check the placement of the wander bracelets every shift by recording it in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility also has a system to check the function of the wander guard with the manufacturer approved device every day. Elopement policy will be reviewed by QA Committee and be revised if necessary. All staff have been inserviced on the above changes. Observation on 11/15/13 at 8:30 am of 9 resident rooms revealed windows were able to be opened to their full width. Policy and Procedure titled " Roam Alter - Door Alarm System for Wandering Residents " last revised in July 2013, documented that the roam alert system has been installed on all exit doors and placed on all residents who wander freely throughout the building, continually attempting to exit the building or are a high risk for elopement. The policy documented that the alarm system within the building is not a substitute for the supervision of residents, but an added safety measure. The Procedure to follow include, a Registered Nurse (RN) assessment on every resident at admission, quarterly, significant change or when behaviors indicate. Residents determined to be at high risk will wear roam alert bracelets. Bracelets will be placed on residents in a position so that residents are least likely to remove them. The policy documented that the Certified Nurses Assistants (CNA) will check the placement of the roam alert on residents every shift and will check the residents' whereabouts every two hours. In addition, the medication nurse with check bracelet placement each shift and document in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #25 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Minimum Data Set ((MDS) dated [DATE] assessed the resident as unable to participate in the Brief Interview for Mental Status due to severe cognitive impairment. Form entitled "Independent Mobility Privileges to the Patio/Gazebo" 9:00 am - 8:00 pm dated 5/6/13 signed by Resident #25 and Registered Nurse (RN) #1 documented that Resident #25 had patio privileges. "Risk of Elopement/Wandering Review" documented reviews on 2/1/13, 6/1/13, and 8/1/13 assessed the resident was not at risk for elopement/wandering. The review dated 9/23/13 documented that the resident was at risk for elopement/wandering as evidenced by: Wanderguard. There was no comprehensive care plan for wandering for Resident# 25 for the period of 5/21/12 through 11/7/13. Incident and Accident (I&A) Report dated 10/1/13 documented that at 11:05 pm, Resident #25 was identified as missing from his room at the change of shifts by a CNA. The report documented that a Code Green (emergency code for a missing resident) was called when the resident could not be located at 11:25 pm. The report documented that the resident was located asleep soundly on the patio between Units A and B in his wheelchair and was returned to his unit by staff. A check for his Wanderguard (device worn or affixed to a resident or a resident ' s personal assistive device to alert staff of potential unsafe wandering) was conducted by the supervisor. Recommendations documented on the I&A were documented to ensure that the Wanderguard is on the resident's wheelchair every shift and to monitor to the resident's room for scissors or other instruments to use to remove his Wanderguard. An I&A facility statement form for CNAs dated 10/1/13 at 11:15 pm, unidentified and unsigned, documented " When I went to check on residents at the beginning of my shift, the resident was not in his room and the off going aide did not know where the resident was. " A check mark is placed next to the question , was the resident on your assignment. An I&A facility statement form for Licensed Nurses dated 10/1/13 at 11:25 pm, unidentified and unsigned, documented that the nurse was notified by the 11:00 pm - 7:00 am CNA that the resident was not in his room. The form documented " I commenced a search, after 10 minutes a code green was called outside perimeter search by designated staff. " The statement documented that the resident was found outside between A wing and B wing. I&A Investigation Summary Report for Resident #25 ' s incident on 10/1/13 at 11:05 pm documented that the resident desires independence as a contributing factor to the incident and documented that the care plan was followed. The team conclusion documented "that the resident was found in an enclosed area, has independent outdoor patio privileges/enclosed area, that the resident was reeducated stating to staff whereabouts, room was searched and no sharp objects found. Wanderguard in place to resident's wheelchair, checked each shift and the Wanderguard was placed on the resident's wheelchair in an area the resident is unable to access it easily". Comprehensive Care Plan initiated on 11/8/13 documented Resident #25 is at actual/potential risk for elopement due to cognitive impairments, disordered thinking and communication deficit. The goal of the care plan included that the resident's attempts to elope will decrease through the next review and place a new wander bracelet on the resident's walker and wheelchair. I&A Report dated 11/10/13 at 7:25 pm documented that CNA # 5 reported that the resident was not in his room, his wheelchair was there and stated his screen was out of the window and the window was open. A code green was immediately called. The I&A documented that the window screen was cut and removed. The resident was found with pain in the right lower extremity, right foot and with a questionable slight bruise to the right foot. Nurse's note dated 11/11/13 at 1:29 am documented that the RN was called to the resident ' s room at about 7:25 pm when staff noted resident not in his room or in his wheelchair during safety checks. Staff reported the window screen as broken/removed and the window open. Immediately went to room and called code green and a search was initiated, resident located at about 7:35 pm on facility grounds dressed for the elements with walker and packed bag in hand. Resident stated " I've been caught " and reported he climbed out of the window, fell when he was outside and complained of pain in right foot. Investigative Summary (undated) signed by the Director of Nursing (DON) documented that Resident #25 was noted as missing from his room on 11/10/13 at 7:25 pm. The DON documented that the resident had been placed on 15 minute checks earlier in the evening after an altercation with another resident and when the CNA went to check on him, the resident was not in his room. The screen was removed and the window was open. The resident was located outside on the grounds and complained of pain of the right foot. The resident stated he went out the window and fell . The conclusion documented that there was no evidence of abuse or neglect, the care plan was followed and the facility responded promptly to the occurrence. During an interview on 11/14/13 at 4:00 pm, RN Manager(RNM) #2 stated that she and RNM #1 manage the unit together. In the absence of RNM #1, RNM #2 reviewed the resident's medical record and stated that a screen was conducted by RNM #1 on 5/16/13 that allowed the resident to go out onto the patio. RNM #2 identified an assessment dated [DATE] signed by RNM #1 that documented that a Wanderguard was initiated for the resident on 9/23/13. RNM #2 stated that because of the placement of the Wanderguard, Resident #25's independent patio privileges would have been revoked and he would only be allowed out on the patio supervised. RNM#2 stated that she was aware that Resident #25 was found on 10/1/13 asleep on the patio after he was identified as missing and a code green was called. RNM #2 stated that Resident #25 ' s room was changed on 11/8/13 and she was informed that on 11/10/13, the resident left the facility after opening a bedroom window and cutting through the screen. RNM#2 stated that Resident #25 was located a short time later down the hill on the facility property. RNM #2 stated that the resident had apparently cut off his Wanderguard as it was found the following day behind his dresser. RNM #2 stated that the placement of the Wanderguard on the residents are checked each shift by the nurses and documented in the MAR indicated [REDACTED]. During an interview on 11/15/13 at 6:05 am, the RN Supervisor # 1 (RNS) stated that it is his responsibility to check the function of each resident ' s Wanderguard on the 11:00 pm - 7:00 am shift. The RNS stated that if the Wanderguard bracelet is function properly, a check mark is placed on the Bracelet Alarm System check sheet and the check mark corresponds to each resident and the date he is conducting the test. The RNS stated that he did not work on 11/10/13 - 11/12/13, however, he did conduct the functionality checks on 11/13/13. The RNS reviewed Resident #25 ' s wheelchair and walker alarm entry and stated, " I placed an ' X ' next to Resident #25' s name and his wheelchair entry because I didn't check it as he was not in the facility. " When asked what the check mark next to Resident #25's walker indicated, the RNS stated " I don't know why I put that there, he was not in the facility so I would not have checked it. " During an interview on 11/15/13 at 9:15 am, the Director of Nursing (DON) stated that she was called on 11/10/13 and informed that Resident #25 had gotten through a window and was found not far from the facility on the ground. The DON stated that the resident was returned to the facility, complained of right foot pain and placed on one-to-one supervision. The DON stated that she was not sure if the resident had his Wanderguard on at the time of the incident, however, " when you go out a window, the Wanderguard system is not going to work. " The DON stated she was informed that it looked like the screen had been slashed and removed. The DON stated that the resident had opened the window "he was not a frail little man, if you really tug on the window, it will open. " The DON stated that on 11/10/13, after the incident, maintenance checked all of the windows and made sure the windows were secure and there were no other issues with the windows. The DON stated that because the Wanderguard system is in place, all wandering residents are allowed to wander throughout the facility and each of the exit doors are alarmed should a resident get too close to an exit. During an interview on 11/15/13 at 9:35 am, the Administrator stated he was informed on the evening of 11/10/13 that Resident #25 left the facility via a window. The Administrator stated he spoke with a member of maintenance and directed maintenance staff to immediately secure the window. The Administrator stated that the following day, he and the Director of Maintenance looked at various windows throughout the facility, and for added protection to prevent recurrence, the Administrator directed that an additional piece of hardware be added to the windows. The Administrator stated that at the time of this interview all windows were secured. The Administrator stated that his guess was that the resident was in a fit of rage and was able to open a window that was secured by pin designed to limit the opening. The Administrator and the DOH surveyor entered a different bedroom on another unit that lead to an unsecured area of the facility. The Administrator was easily able to open the window to its full width. The Administrator stated, " I didn ' t check all of the windows in the facility, I assumed the windows that had these pins in them were secured by the pins so we weren ' t so worried about these. Our plan was to reinforce all of the windows". The Administrator stated that because he was unaware that the windows in the facility could still be opened, he did not initiate any additional monitoring of wandering residents within the facility. During a follow-up interview on 11/15/13 at 1:30 pm, after the DOH surveyor received Resident #25' s I&A dated 10/1/13, the DON stated the incident was investigated, but because the resident had outside patio privileges and was located in a secured area of the facility, a report was not made to the Department of Health as unsafe wandering or an elopement. The DON stated that a resident with a Wanderguard could not exit the building without the alarm sounding or without the assistance of staff. The DON stated a Code Green was called for Resident # 25. The DON stated that they learned through the investigation that the Resident had removed his Wanderguard and therefore it was placed on his wheelchair and walker. The DON stated that her investigation into the 11/10/13 incident did not reveal that the every shift checks by the nurses were not being done. The DON stated that she had not identified that a wandering assessment or care plan was not done after the 10/1/13 incident, but that the facility was working on getting them done now as well. 10NYCRR 415.4(b)(1)(2)(3)

Based on observation, record review and staff interview during a partial extended abbreviated survey (# NY 598 ), the facility failed to ensure that environmental safeguards were in place to prevent residents from leaving the facility for 3 ( Resident#s 25, 26 and 27)of 23 residents reviewed. The facility did not ensure that residents at risk for elopement were consistently and accurately assessed, care planned, monitored and supervised to prevent elopement. Specifically, a resident # 25 with a history of unsafe wandering exited the facility through a bedroom window and was found outside on the facility property in an unsecured area. Additionally, Wanderguard bracelets were not accurately checked for placement. This has the potential to effect all residents at risk for unsafe wandering/elopement. This resulted in no actual harm that has the potential for serious harm that is Immediate Jeopardy to the health and safety of the resident and Substandard Quality of Care. This is evidenced by: The facility was able to remove the immediacy prior to exit by implementing the following: The facility ensured all resident windows could not be opened more than 6 inches. All windows will be monitored weekly. The Policy and Procedure regarding a thorough investigation of all resident incidents has been revised. This includes language of preventing recurrence of all incidents including elopement. The facility has a system to check the placement of the wander bracelets every shift by recording it in the Medication Administration Record (MAR). The MARs are monitored weekly. The facility also has a system to check the function of the Wanderguard with the manufacturer approved device every day. Elopement policy will be reviewed by QA Committee and be revised if necessary. All staff have been inserviced on the above changes. Observation on 11/15/13 at 8:30 am of 9 resident rooms revealed the windows could be opened to their full width. Policy and Procedure titled " Roam Alert - Door Alarm System for Wandering Residents " last revised in July 2013 documented that the roam alert system has been installed on all exit doors and placed on all residents who wander freely throughout the building, continually attempting to exit the building or are a high risk for elopement. The policy documented that the alarm system within the building is not a substitute for the supervision of residents, but an added safety measure. The Procedure to follow included, a Registered Nurse (RN) assessment on every resident at admission, quarterly, significant change or when behaviors indicate. Residents determined to be at high risk will wear roam alert bracelets. Bracelets will be placed on residents in a position so that residents are least likely to remove them. The policy documented that the Certified Nurses Assistants will check the placement of the roam alert on residents every shift and will check the resident's whereabouts every two hours. In addition, the medication nurse will check bracelet placement each shift and document in the Medication Administration Record (MAR). The 11:00 pm - 7:00 am shift supervisor will check each resident's alarm for proper function and document in the facility log. Resident #25 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Minimum Data Set ((MDS) dated [DATE] assessed the resident as unable to participate in the Brief Interview for Mental Status due to severe cognitive impairment. Independent Mobility Privileges to the Patio/Gazebo 9:00 am - 8:00 pm dated 5/6/13 signed by Resident #25 and Registered Nurse (RN) #1 documented that Resident #25 had patio privileges. Risk of Elopement/Wandering Review documented reviews on 2/1/13, 6/1/13, and 8/1/13 assessed the resident as not at risk for elopement/wandering. Review dated 9/23/13 documented that the resident was at risk for elopement/wandering as evidenced by: Wanderguard. Resident's medical record for the period of 5/21/12 through 11/7/13 lacked a comprehensive care plan for unsafe wandering/elopement. Incident and Accident (I&A) Report dated 10/1/13 documented that at 11:05pm, Resident #25 was identified as missing from his room at the change of shifts by a Certified Nurses Assistant (CNA). The report documented that a Code Green (emergency code for a missing resident) was called when the resident could not be located at 11:25 pm. The report documented that the resident was located asleep soundly on the patio between Units A and B in his wheelchair and returned to his unit by staff. A check for his Wanderguard (device worn or affixed to a resident or a resident ' s personal assistive device to alert staff of potential unsafe wandering) was conducted by the supervisor. Recommendations documented on the I&A were documented to ensure that the Wanderguard is on the resident's wheelchair every shift and to monitor the resident's room for scissors or other instruments to use to remove his Wanderguard. A I&A facility statement form for CNAs dated 10/1/13 at 11:15 pm, unidentified and unsigned, documented " When I went to check on residents at the beginning of my shift, the resident was not in his room and the off going aide did not know where the resident was." A check mark is placed next to the question, was the resident on your assignment. A I&A facility statement form for Licensed Nurses dated 10/1/13 at 11:25pm, unidentified and unsigned, documented that the nurse was notified by the 11:00pm - 7:00 am CNA that the resident was not in his room. The form documented " I commenced a search, after 10 minutes a code green was called, outside perimeter search by designated staff. " The statement further documented that the resident was found outside between A wing and B wing. I&A Investigation Summary Report for Resident #25's incident on 10/1/13 at 11:05 pm documented that the resident desires independence as a contributing factor to the incident and documented that the care plan was followed. The team conclusion documented that "the resident was found in enclosed area, has independent outdoor patio privileges/enclosed area, that the resident was reeducated stating to staff whereabouts, room was searched and no sharp objects were found. Wanderguard in place to resident's wheelchair, checked each shift and that the Wanderguard was placed on the resident ' s wheelchair in an area the resident is unable to access it easily". Nurse's note dated 11/7/13 at 4:01 am documented that the resident is staying in the hallway on A wing and will not return to his own station for bed, no reason given, just states something about buying a car. Nurse's note dated 11/7/13 at 12:37 pm documented that the resident was walking toward front lobby and then noted at the front door with two staff members, hitting, swearing and spitting. RN determined it was better to accompany him outside, walked around parking lot for 10 minutes until resident was placed in a wheelchair and returned inside. Note further documented that the resident had a Wanderguard on his wheelchair and " we have now placed one on his walker. " Nurse's note dated 11/7/13 at 2:15 pm, documented resident wandering frequently this shift, not easily redirected but allowed people to accompany him without incident. Nurse's note dated 11/7/13 at 11:38 pm, documented that the resident received a phone call, resident was yelling and became quite upset. Resident sat out in the lobby for a while, was able to bring him back to the unit for dinner and again attempted for bed. Resident refused and is again at the A station, sitting quietly. Nurse's note dated 11/8/13 at 6:26 am documented that the resident spent the night on A wing and refused to come back to his room, was wheeled back to his unit, tried to hit staff, and proceeded back to A wing. Social Service note dated 11/8/13 at 10:53 am documented that the resident approached the social worker requesting a room change, had social worker follow to the unit managers desk to request room change to D wing. Nurse's Note dated 11/8/13 at 2:18 pm documented that Resident #25 was moved to a new room. Nurse's Note dated 11/8/13 at 6:27 pm documented that Resident #25 was noted going to his old room, was redirected and reminded that his room had been changed. Comprehensive Care Plan initiated on 11/8/13 documented Resident #25 is at actual/potential risk for elopement due to cognitive impairments, disordered thinking and communication deficit. The goal of the care plan included that the resident's attempts to elope will decrease through the next review and place a new wander bracelet on the resident's walker and wheelchair. I&A Report dated 11/10/13 at 7:25 pm documented that CNA reported that the resident was not in his room, his wheelchair was there, his screen was out of the window and the window was open. A code green was immediately called. The I&A documented that the window screen was cut and removed. The resident was found with pain in the right lower extremity, right foot and with a questionable slight bruise to the right foot. Nurse's note dated 11/11/13 at 1:29 am documented that the RN was called to the resident ' s room at about 7:25 pm when staff noted resident not in his room or in his wheelchair during safety checks. Staff reported the window screen as broken/removed and the window open. Immediately went to room and called code green and a search was initiated, resident located at about 7:35 pm on facility grounds dressed for the elements with walker and packed bag in hand. Resident stated " I've been caught" and reported he climbed out of the window, fell when he was outside and complained of pain in right foot. Investigative Summary (undated) signed by the Director of Nursing (DON)documented that Resident #25 was noted as missing from his room on 11/10/13 at 7:25 pm. The DON documented that the resident had been placed on 15 minute checks earlier in the evening after an altercation with another resident and when the CNA went to check on him, the resident was not there, the screen was removed and the window was open. The resident was located outside on the grounds and complained of pain of the right foot. The resident stated he went out the window and fell . The conclusion is documented that there was no evidence of abuse or neglect, the care plan was followed and the facility responded promptly to the occurrence. Social Service note dated 11/12/13 documented that the resident's brother had spoken to the resident and that the resident had a plan in place. The resident had told him that he wanted to go back to that room at the end of the hall. That he put on layers of clothing and packed a bag when he went out the window and even laughed and said " I had them fooled. " It further noted that the resident's brother reported that the resident had eloped from a previous nursing home. During an interview on 11/14/13 at 4:00 pm, RN Manager (RNM) #2 stated that she and RNM #1 manage the unit together. In the absence of RNM #1, RNM #2 reviewed the resident's medical record and stated that a screen was conducted by RNM #1 on 5/16/13 that allowed the resident to go out onto the patio. RNM #2 identified an assessment dated [DATE] signed by RNM #1 that documented that a Wanderguard was initiated for the resident on 9/23/13. There was no evidence of a comprehensive care plan for this new care issue of Resident # 25 being at risk for elopement until 11/8/13. RNM #2 stated that because of the placement of the Wanderguard, Resident #25's independent patio privileges would have been revoked and he would only be allowed out on the patio supervised. RNM#2 stated that she was aware that Resident #25 was found on 10/1/13 asleep on the patio after he was identified as missing and a code green was called. RNM #2 stated that Resident #25 ' s room was changed on 11/8/13 and she was informed that on 11/10/13, the resident left the facility after opening a bedroom window and cutting through the screen. RNM#2 stated that Resident #25 was located a short time later down the hill on the facility property. RNM #2 stated that the resident had apparently cut off his Wanderguard as it was found the following day behind his dresser. RNM #2 stated that the placement of the Wanderguard on the residents are checked each shift by the nurses and documented in the MAR or in the treatment administration record (TAR), however, upon review, there were no entries on the MAR or TAR to initiate a check of the resident's Wanderguard for November. During an interview on 11/15/13 at 6:05 am, the RNS # 1 stated that it is his responsibility to check the function of each resident's Wanderguard on the 11:00pm - 7:00 am shift. The RNS stated that if the Wanderguard bracelet is functioning properly, a check mark is placed on the Bracelet Alarm System check sheet and the check mark corresponds to each resident and the date he is conducting the test. The RNS stated that he did not work on 11/10/13 - 11/12/13, however, he did conduct the functionality checks on 11/13/13. The RNS reviewed Resident #25's wheelchair and walker alarm entry and stated, " I placed an ' X ' next to Resident #25's name and his wheelchair entry because I didn't check it as he was not in the facility. " When asked what the check mark next to Resident #25 ' s walker indicated, the RNS stated " I don ' t know why I put that there, he was not in the facility so I would not have checked it. " During an interview on 11/15/13 at 9:15 am, the DON stated that she was called on 11/10/13 and informed that Resident #25 had gotten through a window and was found not far from the facility on the ground. The DON stated that the resident was returned to the facility, complained of right foot pain and placed on one-to-one supervision. The DON stated that she was not sure if the resident had his Wanderguard on at the time of the incident, however, " when you go out a window, the Wanderguard system isn't going to work. " The DON stated she was informed that it looked like the screen had been slashed and removed. The DON stated that the resident had opened the window and " he was not a frail little man, if you really tug on the window, it will open. " The DON stated that on 11/10/13, after the incident, maintenance checked all of the windows and made sure the windows were secure and there were no other issues with the windows. The DON stated that because the Wanderguard system is in place, all wandering residents are allowed to wander throughout the facility and each of the exit doors are alarmed should a resident get too close to an exit. During an interview on 11/15/13 at 9:35 am, the Administrator stated he was informed on the evening of 11/10/13 that Resident #25 left the facility via a window. The Administrator stated he spoke with a member of maintenance and directed maintenance staff to immediately secure the window. The Administrator stated that the following day, he and the Director of Maintenance looked at various, but not all windows throughout the facility, and for added protection to prevent recurrence, the Administrator directed that an additional piece of hardware be added to the windows. The Administrator stated that at the time of the this interview all windows were secured. The Administrator stated that his guess was that the resident was in a fit of rage and was able to open a window that was secured by pin designed to limit the opening. The Administrator and the DOH surveyor entered a different bedroom on another unit that lead to an unsecured area of the facility, the Administrator was asked to open the window, which he easily did, to it ' s full width. The Administrator stated, " I didn ' t check all of the windows in the facility, I assumed the windows that had these pins in them were secured by the pins so we weren ' t so worried about these. Our plan was to reinforce all of the windows. " The Administrator stated that because he was unaware that the windows in the facility could still be opened, he did not initiate any additional monitoring of wandering residents within the facility. During a follow-up interview on 11/15/13 at 1:30 pm after the DOH surveyor received Resident #25 ' s I&A dated 10/1/13, the DON stated the incident was investigated but because the resident had outside patio privileges and was located in a secured area of the facility, a report was not made to the Department of Health as unsafe wandering or an elopement. The DON stated a resident with a Wanderguard could not exit the building without the alarm sounding or without staff assistance. The DON stated a Code Green was called for Resident # 25. The DON stated that they learned through the investigation that the Resident had removed his Wanderguard and therefore it was placed on his wheelchair and walker. The DON stated she was unaware that there was no wandering assessment or care plan after the 10/1/13 incident. Resident #26 was admitted to the facility on [DATE] diagnosed with [REDACTED]. MDS dated [DATE] assessed the resident with severe cognitive impairment. Comprehensive Care Plan initiated on 6/17/13 documented that the resident was at actual risk for elopement due to non-acceptance of long term placement. An intervention to check Wanderguard placement each shift for a history of removing the Wanderguard was initiated on 11/9/13 and revised on 11/15/13. Resident #26 ' s MAR for November 2013, documented an entry " check Wanderguard - R wrist " initiated on 11/15/13 on the 11:00 pm - 7:00 am shift. During an interview on 11/15/13 at 6:30 am, Licensed Practical Nurse (LPN) #1 stated that LPNs check each resident with a Wanderguard each shift for placement and document it on the MAR. LPN #1 stated that this morning, Resident #26 ' s Wanderguard could not be located and had to be issued another one. During an interview on 11/15/13 at 9:15 am, Resident #26 approached the DOH Surveyor, two units from her own, and stated " she told me I was crazy " and " I'm mad because that girl made me put this (pointing to the Wanderguard bracelet) on this morning and I don ' t want it on. " Resident #26 was observed on 11/15/13 at 12:15 pm, sitting in the common area without her Wanderguard bracelet. During an interview on 11/15/13 at 12:15pm, the RNM #2 stated that the Wanderguard was on Resident #26' right wrist, however, when she approached Resident #26, the Wanderguard could not be located and Resident #26 verbalized that she took it off. During a follow-up interview on 11/15/13 at 12:35 pm, RNM #2 stated that the Wanderguard was found in Resident #26 ' s pocketbook and had been apparently been cut off with nail clippers. Resident #27 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Resident was assessed with [REDACTED]. Wandering Risk assessment dated [DATE] at 10:33 pm documented that the resident was at moderate risk for elopement. Comprehensive Care Plan initiated on 10/28/13 documented that the resident was at potential risk for elopement due to a new environment, adjustment reactions, cognitive impairments and communication deficits. Interventions included to place a wander bracelet on resident. Resident #27 ' s October MAR contains no entries for Wanderguard check each shift. Resident #27 ' s November MAR documented " Check wanderguard every shift for placement - left ankle " and documented signed checks beginning 11/8/13 through 11/15/13, on the 7:00 am - 3:00 pm shift, with exception of the 3:00 pm to 11:00 pm shift on 11/13/13. During an interview on 11/21/13 at 3:00 pm, RNM #1 reviewed Resident #27 ' s medical record and stated that the resident was assessed on 10/24/13 at 10:30 pm to be at moderate risk for elopement, however, it does not appear that the resident was given a Wanderguard at that time. RNM#1 stated that a care plan was initiated for unsafe wandering/elopement on 10/28/13 however she is not sure when the Wanderguard was placed on the resident. RNM #1 stated she reviewed everything and " it was difficult to determine what happened and when, there is documentation that on 10/27/13, the resident was in the lobby waiting for a taxi to pick him up, maybe it was then. " RNM#1 stated that information should have been documented on a care plan. RNM#1 stated that on or about 11/8/13, one of the medication nurses from another part of the facility was filling in on the unit and identified that not all Wanderguard checks were on the MAR. RNM #1 stated it is unclear when the Wanderguard was issued to Resident #27, but the Wanderguard checks were not being done prior to 11/8/13 if it had been placed. 10NYCRR 415. 12 (h)(1) (2)

Based on medical record review and staff interview during a partial extended abbreviated survey (#NY 570) the facility failed to ensure that residents were free of significant medication errors. Specifically, for 6 (#s- 2, 3, 4, 5, 6 and 7) of 17 residents reviewed the facility failed to ensure residents received significant necessary medications. Record review noted significant medication omissions included a 24 hour delay with the administration of [MEDICATION NAME] (antihypertensive), and other medications critical to resident care such as Insulin, [MEDICATION NAME], Xeralto, [MEDICATION NAME] and [MEDICATION NAME]. Interviews revealed facility staff did not follow the established system to ensure physician's orders [REDACTED]. This is a repeat deficiency from May 2012 and a repeat Immediate Jeopardy from the abbreviated survey of May 2013. This had the potential to affect all residents receiving medication. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. This is evidenced by: The facility was able to remove the immediacy prior to exit by implementing the following: Only Registered Nurse(RN) will obtain orders from physicians and reconcile orders. A triple check will be done by RNs. Revisions have been made to the Medication Reconciliation Policy and Pharmacy Policy. Audit tool was revised to accurately assess the appropriate administration and timeliness of medications for all admission and re-admissions. System put in place to "audit the auditors". This QA is to check the work of those responsible for doing the audits mentioned above. The Administrator and Director of Nurses (DON) are solely responsible for this function. Software company contacted and function to include the time a new admission arrives has been added to better reflect when medications should be administered. All licensed nursing staff have been inserviced on the new procedures. Finding: Policy & Procedure (P&P) dated June 2013 and entitled Reconciliation of Medications on Admission/Re-Admission documented the purpose of this procedure is to ensure medication safety by accurately accounting for the residents medications, routes and dosages upon admission or readmission to the facility. General guidelines included; medication reconciliation is the process of generating a master list of resident's current medications; medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption in the correct dosages and routes during admission/transfer process; and review pharmacy fax cut off times as medication orders sent after the cut off time will not be processed for delivery within a few hours or delivered timely, leaving residents not receiving necessary medications. If medications will not be delivered by the next medication run, the nurse must: check the list of medications in the Emergency Kit (E-kit); let the Registered Nurse Supervisor (RNS) know that medication is available in E-kit or not available; call physician who will instruct and provide orders to take from the E-kit, substitute with something else, obtain medication from the back-up pharmacy or hold until medication available (hopefully on the next run) or send to the emergency room for administration of medication. The nurse must document this process in the medical record and on the 24 hour report. P&P dated May 2013 and entitled Pharmacy Policy documented guidelines for obtaining medications from pharmacy, hours of operation included Monday through Friday 7:00 am to 7:00 pm, weekends/holidays 7:00 am to 2:30 pm and there is always a pharmacist on call 24/7. After hours communication included; page on-call pharmacist; for new admission/readmission on Friday or Saturday hours, fax and call the on-call pharmacist who will arrange delivery with back-up pharmacy. Delivery reminder documented anything faxed over after the cut-off time will be sent; next scheduled delivery for new orders; next day for refills; if you need something sooner call the pharmacy. Back Up documented; if medications do not arrive from pharmacy let RNS know; physician needs to be notified and further orders obtained; orders may be to withhold medication, give an alternative medication from E-kit, or call local pharmacy for prescription to be filled; if physician states to obtain from the back up pharmacy, facility pharmacy is to be called and informed that they will need to contact the back up pharmacy to obtain the needed medications; the facility will send a staff member to go and pick up the medication; secondary back up pharmacy and delivery of medication may be arranged by the on call pharmacist and facility pharmacy as needed. In the event that the back up pharmacy is unable to provide the medication the physician is to be called and the resident may need to transfer to hospital. If the physician is unable to be reached and a call has not been returned in fifteen minutes then a call must be placed to Medical Director. In the event the Medical Director is not able to be reached the DON must be contacted. Any medication that is not administered a Medication Error report will be completed. P&P dated March 2013 and entitled Administering Medications documented medications shall be administered in a safe and timely manner, and as prescribed. The DON will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must initial the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR/ treatment administration record (TAR) space provided for that drug and dose must be reported to the Unit Manager/RNS/and/or physician. P&P dated July 2013 and entitled Identifying and Managing Medication Errors and Adverse Consequences documented the staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. Types of errors can be omissions, incorrect dosage, incorrect route of administration, incorrect dosage form, incorrect time of administration, incorrect preparation of dose, incorrect administration technique, or administration of medication without a valid order. The staff must report the medication error to the charge nurse/RNS and fill out the Medication Error Report before the end of the shift. Nursing staff will document appropriately detailed accounts of any incidents on an appropriate report form. The DON will investigate the report; counsel staff members as needed; educate staff members on how to avoid similar errors; file the report according to state and federal guidelines, share the report with Quality Assurance, Administrator, Medical Director, and Safety Committee; maintain report on file in the Director of Nursing's office according to state and federal regulations. The Medical Director, DON, and Consultant Pharmacist shall review medication errors and adverse medication consequences as part of the facility's Quality Assurance Process. Resident # 3: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident was readmitted to the facility from the hospital on [DATE] with a new [DIAGNOSES REDACTED]. Resident has long and short term memory impairment with severely impaired decision making according to the Minimum Data Set ((MDS) dated [DATE]. Facility Receiving Report for New and Returning Residents dated 10/10/13 and unsigned, documented report was called at 2:40 pm. Hospital Transfer Summary dated 10/10/13, with no time written, documented admitting [DIAGNOSES REDACTED]. Nursing progress note dated 10/10/13 at 9:11 pm documented medications reviewed with Nurse Practitioner, orders obtained. There was no documentation what time the Resident arrived at the facility. Nursing progress note dated 10/10/13 at 11:52 pm documented resident returned from hospital with new [DIAGNOSES REDACTED]. There was no time of Resident arrival to the facility documented. Physician orders [REDACTED]. MAR dated October 2013 documented 10/10/13 [MEDICATION NAME] Sprinkles 500 mg qid and scheduled to be given at 9:00 am, 12:00 pm, 5:00 pm and 9:00 pm. The box to be initialed after administration was signed for the 10/10/13 5:00 pm dose. The box to be initialed after administration was left blank for the 10/10/13 at 9:00 pm dose, indicating not given. The box to be initialed after administration was left blank for the 10/11/13 at 9:00 am dose, indicating not given. Review of facility Emergency medication list included [MEDICATION NAME] Sodium (could be used as substitute for [MEDICATION NAME] Sprinkles) 124 mg capsule was available. physician progress notes [REDACTED]. A scan of the head showed mild atrophy and chronic microvascular ischemic white matter changes, tow ring-like [MEDICAL CONDITION] in the right cerebral hemisphere which may be [MEDICAL CONDITION], neoplastic or vascular. There was no midline shift and right ventricular compression was seen due to lesion in the right basal ganglion. During an interview on 11/19/13 at 10:40 am RN Manager (RNM) # 2 stated that there was a book on every unit with the list of medication in the E-kits, and these list have recently been placed on the front of each MAR indicated [REDACTED]. During a review of a MAR indicated [REDACTED]. During an interview on 11/19/13 at 3:30 pm, Licensed Practical Nurse (LPN) # 2 stated when the discharge summary comes in from the hospital, the physician is called and medication orders are obtained. The orders should be faxed to the pharmacy and a phone call to the pharmacy should follow. If the medications are not going to be available the nurse should check the E-kit for availability of the medication, if not available let physician know. LPN # 2 stated it is not OK to put an arrow through the box in the MAR indicated [REDACTED]. During an interview on 11/19/13 at 3:45 pm, LPN # 1 stated that it does happen that new or readmitted residents do not always get their medications on the evening of admission. Stated that it almost seems normal, and there is no talk of correcting the problem. Resident # 5: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set documented the resident was alert and oriented with periods of confusion due to decreased oxygen supply. The resident utilized a [MEDICAL CONDITION] machine at home and in the facility. The MDS documented the resident to be an extensive assist for transfers, mobility and activities of daily living. Physician discharge orders from the hospital dated 8/22/13 and admission orders [REDACTED]. The facility's Medication Reconciliation Form for a new admit, listed the admitted as 8/22/13 time of admission was left blank. The transcription of the orders was completed by Licensed Practical Nurse (LPN), and nursing notes dated 8/22/13 at 3:29 pm documented a call to the hospital was made by the Registered Nurse Manager (RNM) to clarify orders. The signature was verified by the Assistant Director of Nursing (ADON), and the DON on 11/19/13. During an interview with the RNM on 11/20/13 at 12:29 pm, the RNM stated that this resident could have come to the unit during a change of shift. At that time the RNM will do a admission assessment of the resident and the LPN will transcribe the orders and fax this over to the pharmacy. Review of the MAR for October revealed there was no evidence the medications [MEDICATION NAME], Xarelto, [MEDICATION NAME] and [MEDICATION NAME], evening doses were administered on 8/22/13. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. the first dose given was on 8/23/13 at 6 pm, [MEDICATION NAME]1 unit four times daily before meals and at bedtime was not transcribed on the MAR. A review of the pharmacy emergency kit inventory ( Medications kept in the facility) indicated that the following medications were available on admission: [MEDICATION NAME]. During an interview with the ADON and DON on 11/17/13 at approximately 1:00 pm they stated resident arrived in time for the medications to be administered and any in house medications should have been administered. Additionally they stated that there are two local pharmacies that the medications could have been obtained. During an interview with the Medical Director on 11/19/13 at approximately 1:00 pm, he stated that he was not aware that the E-Kit and pharmacy inventory were not being utilized by the nursing staff, before the medical staff were called. Additionally he stated that this process was not acceptable. and that the staff need to do medications checks in house or utilize the local pharmacies that the facility contracts with before the medical staff are called to hold a medication. During an interview with the Physician Assistant (PA) on 11/19/13 at approximately 3:00 pm, the PA stated that medications should be checked in house for availability prior to notifying the PA that they are not available. The PA was not aware that the E-Kit and pharmacy inventory were not being utilized by the nursing staff. Resident # 6 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set was not completed on this resident since he was newly admitted . The New Admission form is dated 11/15/13 and timed 4:00 pm. The Nursing Notes dated 11/15/13 documented the resident arrived on the unit approximately at 6:00 pm. The discharge orders from the hospital documented the resident was to receive [MEDICATION NAME] 1mg,([MEDICATION NAME] is used to treat [MEDICAL CONDITION] and symptoms of [MEDICAL CONDITION] disorder.) [MEDICATION NAME] 300 mg ([MEDICATION NAME] is used to treat some types of [MEDICAL CONDITION] and for postherpetic neuralgia (nerve pain caused shingles). [MEDICATION NAME] 25 mg is used to treat [MEDICAL CONDITION] (chest pain) and hypertension (high blood pressure) and [MEDICATION NAME] 100 mg ( used to treat depression, obsessive-compulsive disorder and panic and anxiety disorders ) These medications were documented to be given at 8:00pm on 11/15/13. During a review of the MAR, [MEDICATION NAME] and [MEDICATION NAME] were not administered at 8:00 pm on 11/15/13. A review of the pharmacy emergency kit inventory ( medications kept in the facility) indicated that the following medications were available on admission. [MEDICATION NAME] and [MEDICATION NAME]. During an interview with 3 LPN's on 11/16/13 at approximately 11:30 am, they stated they did not utilized the E-Kit or the pharmacy inventory. During an interview with the RNM # 1 on 11/18/13 at approximately 12:45 pm the RNM stated that she did not utilize the pharmacy inventory, did not think about it. During an interview with the ADON and DON on 11/17/13 at approximately 1:00 pm they stated, the resident arrived in time for the medications to be administered and any in house medications should have been administered. Additionally they stated that there are two local pharmacies that the medications could have been obtained from. During an interview on 11/19/13 at 1:00 pm the Medical Director stated that he thought everything was going well, he had no idea that medications were not be administered to residents on readmission or admission evenings. He was receiving calls for missing medications, we were thinking everything was OK. He stated that he was not aware that the E-Kit and pharmacy inventory were not being utilized by the nursing staff, before the medical staff were called. He stated that this process was not acceptable, and that the staff need to do medications checks in house or utilize the local pharmacies that the facility contracts with before the medical staff are called to hold a medication. Medical Director stated there was an emergency QA meeting held today to discuss the situation with the medications not being administered, and a few changes were discussed. During an interview with the Physician Assistant (PA) on 11/19/13 at approximately 3:00 pm, the PA stated that medications should be checked in house for availability prior to notifying the PA that they are not available. The PA was not aware that the E-Kit and pharmacy inventory were not being utilized by the nursing staff. PA stated she had no idea that the problem existed with the admissions/readmissions not receiving their medications. Stated that she is in the facility most days and does take after hours on-call and she does receive some calls for medications not available, was not aware of this concern. During an interview on 11/18/13 at 4:30 pm the DON stated the charge nurse would be responsible for transcribing the physician orders [REDACTED]. Stated the list of available medications in the Emergency kits were on each unit for the nurses to review if a medication was not available. DON stated that she had changed the protocol and that from here on only RNs would take care of admitting and readmitting the residents. During an interview on 11/18/13 at 4:30 pm the Administrator stated the Nurse Managers were responsible for completing the audits of admissions and readmissions receiving their medications. The audits would be forwarded to the ADON who would then report to the QA committee. What was being presented to the Administrator and QA was that there were no issues with the audits. Administrator stated that all the nurses have been inserviced on the E-kits and Pharmacy. During an interview on 11/20/13 at 9:05 am, RNS # 1 stated that when a readmission or new admission came in the medication list would be sent to the pharmacy but the nurses would have to call the pharmacy as well to ensure the medications were delivered. There are also two back-up pharmacies, one in town and the other from Saratoga. RNS was not aware of admission or readmissions not getting their medications on the evening shift, he stated that the Emergency kit contained a good amount of medications. 10NYCRR 415.12(m)(2) .

Based on record review and staff interviews during a partial extended abbreviated survey (#NY 570) the Administration failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practicable well-being and safety of each resident. Specifically, for 6 (#s- 2, 3, 4, 5, 6 and 7) of 17 residents reviewed the Administration failed to ensure residents received significant necessary medications. This is a repeat deficiency from May 2012 and a repeat Immediate Jeopardy from the abbreviated survey of May 2013. This had the potential to affect all residents admitted and/or readmitted who will be receiving medication. In addition the Administration failed to thoroughtly investigate elopements and ensure assessments, care plans and interventions were initiated to prevent unsafe wandering and elopement. This resulted is no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of the residents. This was evidenced by: Refer to F-333, Scope and Severity- L- Medication Errors The facility was able to remove the immediacy of F-333, prior to exit by implementing the following: Only Registered Nurse(RN) will obtain orders from physicians and reconcile orders. A triple check will be completed on all new orders by RNs. Procedures changed that all calls to the on-call providers shall be made only by a Registered Nurse (RN). Procedure of reconciliation of medications will only be completed by an RN and will be triple checked. Revisions have been made to the Medication Reconciliation Policy and Pharmacy Policy. Audit tool was revised to accurately assess the appropriate administration and timeliness of medications for all admission and re-admissions. System put in place to "audit the auditors". This QA is to check the work of those responsible for doing the audits mentioned above. The Administrator and Director of Nurses (DON) are solely responsible for this function. Software company contacted and function to include the time a new admission arrives has been added to better reflect when medications should be administered. All licensed nursing staff have been inserviced on the new procedures. During an interview on 11/18/13 at 4:30 pm the DON stated the charge nurse would be responsible for transcribing the physician orders [REDACTED]. Stated the list of available medications in the Emergency kits (E-kits)were on each unit for the nurses to review if a medication was not available. DON stated that she had changed the protocol and that from here on only RNs would take care of admitting and readmitting the residents. During an interview on 11/18/13 at 4:30 pm the Administrator stated the Nurse Managers were responsible for completing the audits of admissions and readmissions receiving their medications. The audits would be forwarded to the Assistant Director of Nursing (ADON)who would then report to the QA committee. What was being presented to the Administrator and QA was that there were no issues with the audits. Administrator stated that all the nurses have been inserviced on the E-kits and the pharmacy policies. During an interview on 11/19/13 at 10:40 am RNM # 2 stated that there was a book on every unit with the list of medication in the E-kits, and these list have recently been placed on the front of each Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During review of a MAR indicated [REDACTED]. During an interview on 11/19/13 at 1:00 pm the Medical Director stated that he thought everything was going well, he had no idea that medications were not be administered to residents on readmission or admission evenings. He was receiving calls for missing medications, we were thinking everything was OK. He stated that he was not aware that the E-Kit and pharmacy inventory were not being utilized by the nursing staff, before the medical staff were called. He stated that this process was not acceptable, and that the staff need to do medications checks in house or utilize the local pharmacies that the facility contracts with before the medical staff are called to hold a medication. Medical Director stated there was an emergency QA meeting held today to discuss the situation with the medications not being administered, and a few changes were discussed. During an interview with the Physician Assistant (PA) on 11/19/13 at approximately 3:00 pm, the PA stated that medications should be checked in house for availability prior to notifying the PA that they are not available. The PA was not aware that the E-Kit and pharmacy inventory were not being utilized by the nursing staff. PA stated she had no idea that the problem existed with the admissions/readmissions not receiving their medications. Stated that she is in the facility most days and does take after hours on-call and she does receive some calls for medications not available, was not aware of this concern. Refer to F-225, Scope and Severity-L-Investigations Refer to F-323, Scope and Severity-L-Free of Accidents/Hazards The facility was able to remove the immediacy F-225 and F-323 prior to exit by implementing the following: The facility ensured all resident windows could not be opened more than 6 inches. All windows will be monitored weekly. The Policy and Procedure regarding a thorough investigation of all resident incidents has been revised. This includes language of preventing recurrence of all incidents including elopement. The facility has a system to check the placement of the wander bracelets every shift by recording it in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility also has a system to check the function of the Wanderguard with the manufacturer approved device every day. Elopement policy will be reviewed by QA Committee and be revised if necessary. All staff have been inserviced on the above changes. During an interview on 11/15/13 at 9:15 am, the DON stated that she was called on 11/10/13 and informed that Resident #25 had gotten through a window and was found not far from the facility on the ground. The DON stated that the resident was returned to the facility, complained of right foot pain and placed on one-to-one supervision. The DON stated that she was not sure if the resident had his Wanderguard on at the time of the incident, however, " when you go out a window, the Wanderguard system isn't going to work." The DON stated she was informed that it looked like the screen had been slashed and removed. The DON stated that the resident had opened the window " he was not a frail little man, if you really tug on the window, it will open. " The DON stated that on 11/10/13, after the incident, maintenance checked all of the windows and made sure the windows were secure and there were no other issues with the windows. The DON stated that because the Wanderguard system is in place, all wandering residents are allowed to wander throughout the facility and each of the exit doors are alarmed should a resident get too close to an exit. During an interview on 11/15/13 at 9:35 am, the Administrator stated he was informed on the evening of 11/10/13 that Resident #25 left the facility via a window. The Administrator stated he spoke with a member of maintenance and directed maintenance staff to immediately secure the window. The Administrator stated that the following day, he and the Director of Maintenance looked at various windows throughout the facility, and for added protection to prevent recurrence, the Administrator directed that an additional piece of hardware be added to the windows. The Administrator stated that at the time of the this interview however, all windows were secured. The Administrator stated that his guess was that the resident was in a fit of rage and was able to open a window that was secured by pin designed to limit the opening. The Administrator and the DOH surveyor entered a different bedroom on another unit that lead to an unsecured area of the facility. The Administrator was able to open the window to its fullest width. The Administrator stated, " I didn ' t check all of the windows in the facility, I assumed the windows that had these pins in them were secured by the pins so we weren ' t so worried about these. Our plan was to reinforce all of the windows. " The Administrator stated that because he was unaware that the windows in the facility could still be opened, he did not initiate any additional monitoring of wandering residents within the facility. During a follow-up interview on 11/15/13 at 1:30 pm the DON stated the incident was investigated but because the resident had outside patio privileges and was located in a secured area of the facility, a report was not made to the Department of Health as unsafe wandering or an elopement. The DON stated a resident with a Wanderguard could not exit the building without the alarm sounding or without the assistance of a staff member. The DON stated a code green was called for Resident #25 . The DON stated that they learned through the investigation that the Resident had removed his Wanderguard and therefore it was placed on his wheelchair and walker. The DON stated that her investigation into the 11/10/13 incident did not reveal that the every shift checks by the nurses were not being done but that those checks were being added to the MAR indicated [REDACTED]. 10NYCRR 415.26

Based on medical record review and staff interview during a partial extended abbreviated survey (#NY 570) the facility failed to ensure that the Quality Assurance Committee (QA) identified issues that had the potential to cause serious harm to residents. Specifically, for 6 (#s- 2, 3, 4, 5, 6 and 7) of 17 residents reviewed the QA failed to ensure residents received significant necessary medications. This is a repeat deficiency from May 2012 and a repeat Immediate Jeopardy from the abbreviated survey of May 2013. This had the potential to affect all residents admitted and/or readmitted to the facility. In addition the Administration failed to thoroughtly investigate elopements and ensure assessments, care plans and interventions were initiated to prevent unsafe wandering and elopement. This resulted is no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety. This was evidence by: Refer to F-333, Scope and Severity- L- Medication Errors The facility was able to remove the immediacy of F-333, prior to exit by implementing the following: Only Registered Nurse(RN) will obtain orders from physicians and reconcile orders. A triple check will be done on all new orders by RNs. Revisions have been made to the Medication Reconciliation Policy and Pharmacy Policy. Audit tool was revised to accurately assess the appropriate administration and timeliness of medications for all admission and re-admissions. System put in place to "audit the auditors". This QA is to check the work of those responsible for doing the audits mentioned above. The Administrator and Director of Nurses (DON) are solely responsible for this function. Software company contacted and function to include the time a new admission arrives has been added to better reflect when medications should be administered. All licensed nursing staff have been inserviced on the new procedures. During an interview on 11/18/13 at 4:30 pm the Director of Nurses (DON) stated the charge nurse would be responsible for transcribing the physician orders [REDACTED]. Stated the list of available medications in the Emergency kits (E-kits)were on each unit for the nurses to review if a medication was not available. DON stated that she had changed the protocol and only RNs would take care of admitting and readmitting the residents. During an interview on 11/18/13 at 4:30 pm the Administrator stated the Nurse Managers were responsible for completing the audits of admissions and readmissions receiving their medications. The audits would be forwarded to the Assistant Director of Nursing who would then report to the QA committee. What was being presented to the Administrator and QA was that there were no issues with the audits. The Administrator oversees the QA Committee that meets monthly and attendees include Unit Managers, Department Heads, Administrator, DON, and recently line staff have been invited. The Quarterly QA meetings also include the Medical Director and Pharmacy Representative. During an interview on 11/19/13 at 10:40 am RN Manager (RNM) # 2 stated there was a book on every unit with the list of medication in the E-kits. These lists have recently been placed on the front of each Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During a review of a MAR indicated [REDACTED]. During an interview on 11/19/13 at 1:00 pm the Medical Director stated that he thought everything was going well, he had no idea that medications were not being administered to residents on readmission or admission evenings. He was receiving calls for missing medications, we were thinking everything was OK. He stated that he was not aware that the E-Kit and pharmacy inventory were not being utilized by the nursing staff, before the medical staff were called. He stated that this process was not acceptable, and that the staff need to do medications checks in house or utilize the local pharmacies that the facility contracts with before the medical staff are called to hold a medication. Medical Director stated there was an emergency QA meeting held today to discuss the situation with the medications not being administered, and a few changes were discussed. During an interview with the Physician Assistant (PA) on 11/19/13 at approximately 3:00 pm, the PA stated that medications should be checked in house for availability prior to notifying the PA that they are not available. The PA was not aware that the E-Kit and pharmacy inventory were not being utilized by the nursing staff. PA stated she had no idea that the problem existed with the admissions/readmissions not receiving their medications. Stated that she is in the facility most days and does take after hours on-call and she does receive some calls for medications not available, but was not aware of this concern. Refer to F-225, Scope and Severity-L-Investigations Refer to F-323, Scope and severity-L-Free of Accidents/Hazards The facility was able to remove the immediacy F-225 and F-323 prior to exit by implementing the following: The facility ensured all resident windows could not be opened more than 6 inches. All windows will be monitored weekly. The Policy and Procedure regarding a thorough investigation of all resident incidents has been revised. This includes language of preventing reoccurrence of all incidents including elopement. The facility has a system to check the placement of the wander bracelets every shift by recording it in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility also has a system to check the function of the Wanderguard with the manufacturer approved device every day. Elopement policy will be reviewed by QA Committee and be revised if necessary. All staff have been inserviced on the above changes. During an interview on 11/15/13 at 9:15 am, the DON stated that she was called on 11/10/13 and informed that Resident #25 had gotten through a window and was found not far from the facility on the ground. The DON stated that the resident was returned to the facility, complained of right foot pain and placed on one-to-one supervision. The DON stated that she was not sure if the resident had his Wanderguard on at the time of the incident, however, " when you go out a window, the Wanderguard system isn't going to work. " The DON stated she was informed that it looked like the screen had been slashed and removed. The DON stated that the resident had opened the window " he was not a frail little man, if you really tug on the window, it will open. " The DON stated that on 11/10/13, after the incident, maintenance checked all of the windows and made sure the windows were secure and there were no other issues with the windows. The DON stated that because the Wanderguard system is in place, all wandering residents are allowed to wander throughout the facility and each of the exit doors are alarmed should a resident get too close to an exit. During an interview on 11/15/13 at 9:35 am, the Administrator stated he was informed on the evening of 11/10/13 that Resident #25 left the facility via a window. The Administrator stated he spoke with a member of maintenance and directed maintenance staff to immediately secure the window. The Administrator stated that the following day, he and the Director of Maintenance looked at various windows throughout the facility, and for added protection to prevent recurrence, the Administrator directed that an additional piece of hardware be added to the windows. The Administrator stated that at the time of this interview, all windows were secured. The Administrator stated that his guess was that the resident was in a fit of rage and was able to open a window that was secured by pin designed to limit the opening. The Administrator and the DOH surveyor entered a different bedroom on another unit that lead to an unsecured area of the facility. The Administrator was able to open the window to it's fullest width. The Administrator stated, " I didn't check all of the windows in the facility, I assumed the windows that had these pins in them were secured by the pins so we weren't so worried about these. Our plan was to reinforce all of the windows." The Administrator stated that because he was unaware that the windows in the facility could still be opened, he did not initiate any additional monitoring of wandering residents. During a follow-up interview on 11/15/13 at 1:30 pm after the DOH surveyor received Resident #25's I&A dated 10/1/13, the DON stated the incident was investigated but because the resident had outside patio privileges and was located in a secured area of the facility, a report was not made to the Department of Health as unsafe wandering or an elopement. The DON stated a resident with a Wanderguard could not exit the building without the alarm sounding or without the assistance of a staff member. The DON stated a code green was called for Resident #25. The DON stated that they learned through the investigation that the Resident had removed his Wanderguard and therefore it was placed on his wheelchair and walker. The DON stated that her investigation into the 11/10/13 incident did not reveal the every shift checks by the nurses were not being done, but that those checks were being added to the MAR indicated [REDACTED]. 10NYCRR 415.27(a-c)

Based on observation, medical record review and staff interviews during a partial extended abbreviated survey ( #NY 570) it was determined that the facility did not ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #18) of five residents reviewed. Specifically, Resident # 18 was not appropriately assessed and monitored upon his return from the emergency room . Approximately 10 hours later Resident # 18 complained of severe pain and continued to complain of severe pain, requesting to go to the hospital, despite receiving pain medication twice. Subsequently, the Resident phoned 911 and was transferred to the hospital where he later expired due to Cardiopulmonary Arrest. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Policy and Procedure (P&P) dated [DATE] and entitled [MEDICAL TREATMENT] Documentation, stated: It is the policy of Fulton Center for Rehab for residents who require [MEDICAL TREATMENT] to receive treatment at an on-site or off-site treatment center. Documented under procedure, Pre [MEDICAL TREATMENT] Notes on unit; administer medication as per physician's orders [REDACTED]. Post [MEDICAL TREATMENT] Notes on unit; record blood pressure and temperature, pulse and respirations in the [MEDICAL TREATMENT] notes, observe for any changes in the Resident's status, review the communication book upon return from [MEDICAL TREATMENT], and notify physician of any abnormal labs results or unusual events as communicated by the [MEDICAL TREATMENT] staff. Resident # 18 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident was alert and oriented with a Brief Interview for Mental status (BIMS) score of 15 according to the Minimum (MDS) data set [DATE]. Finding # 1: Physician orders [REDACTED]. Weekly on Monday, paracentesis (a procedure to remove fluid that has accumulated in the abdominal cavity) at hospital radiology. Hospital Emergency Department Registration Form dated [DATE] at 9:54 am documented reason for visit was [MEDICAL CONDITION]. Vital signs documented at 9:23 am, blood pressure ,[DATE] (normal ,[DATE]), pulse 88. Hospital Transfer Record dated [DATE] documented; report given to Fulton Center at 12:46 pm, patient and nurse expressed understanding of discharge to home responsibility. Nursing progress note dated [DATE] at 3:08 pm documented, resident returned from [MEDICAL TREATMENT] at 1:45 pm. There was no documentation of a nursing assessment or blood pressure monitoring. Twenty four hour report dated [DATE] documented on the 7:00 am-3:00 pm shift; 5:15 am left for [MEDICAL TREATMENT], 8:00 am [MEDICAL TREATMENT] called and patient sent to emergency room for blood pressure of ,[DATE], returned at 1:45 pm. The 3:00 pm-11:00 pm shift documented OK. The 11:00 pm-7:00 am shift documented; transferred to hospital via ambulance at 3:45 am for complaints of right upper leg pain. There was no documentation of nursing assessment or blood pressure for the twenty four hour period. Nursing progress note dated [DATE] at 5:26 am documented the Resident was complaining of right leg pain at beginning of our shift, assessed patient and skin was warm, dry and intact. There was no mention of a cardiac assessment or blood pressure. Review of computer vital signs summary revealed there were no vital signs documented for [DATE] or [DATE]. Hospital Discharge Summary dated [DATE] documented the patient expired at 5:52 pm, cause of death was Cardiopulmonary arrest secondary to [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:50 pm LPN # 9 stated that when Resident # 18 returned from the hospital there should have been a Registered Nurse (RN) assessment, and vital signs (blood pressure, pulse, respirations) should have been done for three days. The physician should have been made aware of the hospital visit as well. During an interview on [DATE] at 12:00 pm LPN # 10 stated when the Resident returned from the hospital on [DATE] there should have been vital signs done. That the Resident would tell them now and then that he felt his blood pressure was low. The physician should have been notified of the resident being in the hospital on [DATE] and why he was there. During an interview on [DATE] at 1:30 pm Registered Nurse Manager (RNM) # 1 stated that on the resident's return from the hospital on [DATE] an RN assessment should have been done and the physician should have been notified. During an interview on [DATE] at 1:00 pm the Medical Director stated that the resident should have been assessed by an RN when he returned from the hospital, and the physician should have been notified. During an interview on [DATE] at 9:05 am the RN Supervisor # 1 (RNS) stated that he remembers hearing that the resident had been in the hospital on the morning of [DATE] but did not remember the reason. Usually when a resident is sent to the hospital an RN should see them on return to the facility. RNS stated he did not know if vital signs were being done for Resident # 18, stated he would have monitored him if he had known he was in the hospital for [MEDICAL CONDITION]. Finding # 2: Nursing progress note dated [DATE] at 5:26 am and written by the RNS # 1 documented Resident # 18 was complaining of right leg pain at beginning of shift. The resident was assessed and skin was warm, dry and intact. Resident stated was a burning sensation deep into his leg. The physician (MD) was called and an additional 10 milligram (mg) [MEDICATION NAME] IR (used to treat moderate to severe pain) was ordered and given. Patient stated he was not getting any relief from the medication and another call was placed to the MD. Additional orders were given for fluid to be encouraged and an Xray be ordered for the morning. At approximately 3:15 am the patient dialed 911 and requested an ambulance to come and get him, I received a call from the dispatcher about the call and in turn called the MD once again and requested an order to transfer the resident to the hospital for further evaluation. Ambulance arrived and transported the resident to the hospital at 3:45 am. SBAR (Physician/NP/PA Communication and Progress Note) form, physician communication and progress note, for new symptoms, signs and other changes in condition, was undated, untimed, and signed by the Licensed Practical Nurse # 7 (LPN) and RNS # 1 that did work on [DATE] on the 11:00 pm to 7:00 am shift. Documented the Situation of right leg pain, upper burning that started at 11:00 pm. Vital signs are documented as Blood pressure ,[DATE], pulse 98, respirations 20 and a pain level of ,[DATE]. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On the back of the MAR indicated [REDACTED]. The prior administration of this prn medication was documented on [DATE] and [DATE]. Physician order [REDACTED]. MAR dated [DATE] documented; [MEDICATION NAME] IR, 10 mg one dose now. Initials were in the box dated [DATE] at 2:00 am indicating medication was given. Physician order [REDACTED]. Physician order [REDACTED]. Twenty four hour report dated [DATE] documented on the 11:00 pm to 7:00 am shift; transferred to hospital via ambulance at 3:45 am for complaints of right upper leg pain. [MEDICATION NAME] at 12:30 am and new order to give one extra dose [MEDICATION NAME] at 2:00 am. Twenty four hour report dated [DATE] documented on the 7:00 am to 3:00 pm shift the resident was admitted to the hospital for [MEDICAL CONDITION] of the right leg. Hospital Discharge Summary dated [DATE] documented under diagnosis, [MEDICAL CONDITION] of the right thigh, this was the original reason for admission. During an interview on [DATE] at 12:00 pm CNA # 1 stated that Resident #18 described the pain to his left leg as being on fire. The resident was crying in pain at the beginning of the 11:00 pm to 7:00 am shift, and was asking to be sent to the hospital. The resident was medicated for pain and he said it did not work and he continued to cry out in pain until he went to the hospital at approximately 3:30 am. The resident was usually quiet and never screamed out in pain. CNA # 1 stated that the nurse called the physician three to four times and they still would not send him to the hospital. The Resident asked to use a cell phone and he called 911 himself. During an interview on [DATE] at 9:00 am LPN # 7 stated the ,[DATE] shift nurse had mentioned the resident was hollering out but did not mention he was having pain. LPN # 7 gave him prn pain medication at 12:30 am and when that was ineffective she called the DNP and received an order for [REDACTED]. DNP was called a second time and was told that the Resident was requesting to go to the hospital and he said the Physician Assistant (PA) would be there in a few hours and would see the resident then. LPN # 7 told the supervisor that the resident was asking to go to the hospital and that the pain medication did not relieve the pain. It has happened before that the nurse would feel a resident needed to be seen in an emergency room and the physician would say no. During an interview on [DATE] at 10:15 am LPN # 8 stated that on [DATE] she remembers the resident was his usual self on the 3:00 pm to 11:00 pm shift. While LPN # 8 was completing her paperwork she did remember hearing him cry out in pain sometime between 11:00 pm and 12:00 pm. During an interview on [DATE] at 12:00 pm LPN # 10 stated that the resident had no history of behaviors or calling out, that if he was crying out in pain there had to be something wrong. During an interview on [DATE] at 12:15 pm CNA # 2 stated that she was not assigned to the resident but she was working his unit on [DATE]. She heard him screaming in pain and saying he wanted to go to the hospital. He never stopped screaming in pain from the start of the 11:00 pm shift til he went to the hospital. She heard the RNS pushing the physician (DNP) for an order to transfer to the hospital after 911 was already called. CNA # 2 stated Resident # 18 had no prior behaviors where he would yell out in pain. During an interview on [DATE] at 1:30 pm Registered Nurse Manager (RNM) # 1 stated that on the Resident's return from the hospital on [DATE] an RN assessment should have been done and the physician should have been notified. She had heard that Resident # 18 had went to the hospital on the night shift of [DATE] for leg pain. She stated that if she felt a resident really needed to go to the hospital and the physician disagreed that she would have called the Medical Director or DON. During an interview on [DATE] at 3:05 pm the DON stated that the physician should be updated on complaints of unusual pain. DON stated that if the Supervisors feel a resident should go to the hospital and the physician disagrees and does not give an order, the Supervisors can call the Medical Director and/or DON. During an interview on [DATE] at 9:05 am the RNS # 1 stated that on [DATE] he was standing by when LPN # 7 called the DPN and heard her (LPN # 7) tell him (DPN) that the Resident was crying out in pain, and an order was received for an additional dose of pain medication. The second phone call the LPN made the RNS was not there for and the order was to encourage fluids and the resident would be seen in the morning. The RNS stated that a resident could not be sent out without a physician's orders [REDACTED]. RNS called the DPN the third time and asked for an order to send the resident to the hospital which the DPN did not want to do. At that time the RNS stated that the resident had called 911 himself and then he did receive an order to send the resident to the emergency room . During an interview on [DATE] at 12:40 pm with the DPN who was taking calls from the facility on [DATE] he stated he had no memory of the phone calls for Resident # 18 that night. He stated the name does not sound familiar and he does not remember the case. The DPN is on call frequently for the facility but he does not go to the facility in person, he works in the other facilities. He stated he never saw this resident, and for the most part the facility usually gives them a good report for him to act on. He stated he really cannot say what orders he would have given in that scenario because there would be too many factors to consider. He repeated that he did not remember this case or the resident name. 10NYCRR 415.12

Based on medical record review and staff interviews during an extended recertification survey it was determined that the facility failed to have an effective system in place to ensure physician's orders [REDACTED]. Lack of a effective system resulted in residents not receiving significant necessary medications. Specifically, delays were noted for 9 (#'s: 52, 63, 68, 82, 175,176,177,178 and 180 ) of 14 newly admitted or readmitted residents reviewed. Significant medication omissions included a 24 hour delay with the administration of [MEDICATION NAME] (anticonvulsant), [MEDICATION NAME] (anticoagulant medicine), [MEDICATION NAME] (anticonvulsant), [MEDICATION NAME] (antihypertensive), [MEDICATION NAME](fast-acting mealtime insulin) , [MEDICATION NAME] (long-acting insulin), and [MEDICATION NAME] (used for [MEDICAL CONDITION] and pain) were not administered the evening of admission. In addition, finger stick blood sugar requiring insulin coverage was not transcribed or obtained for two days after the resident's admission. This resulted in no actual harm but has the potential for serious harm that is Immediate Jeopardy to the health and safety of the residents and Substandard Quality of Care . This is evidenced by: The facility form titled "Pharmacy Info form for Nursing Staff", undated, documented pharmacy phone and fax numbers, with hours of operation listed as Monday - Friday 7:00 am to 7:00 pm, and weekends/holidays as 7:00 am to 2:00 pm. Delivery schedule documented Monday thru Friday, new orders/new admissions/re-admissions: fax cut off time of 9:00 am and order will leave pharmacy at 11:00 am, fax cut off time of 4:00 pm and order will leave pharmacy at 6:00 pm, fax cut off time of 9:00 pm and order will leave pharmacy at 12:00 am, Delivery schedule documented Weekend, new orders fax cut off time of 9:00 am and order will leave pharmacy at 11:00 am, New admissions/re-admissions, fax cut off time of 2:30 pm and order will leave pharmacy at 6:00 pm. Note below delivery schedules documented, Orders faxed after cut-off will come on following delivery unless pharmacy is called about their urgency (new orders or refills). Emergency Contact (after hours) phone number is provided on the form. Pharmacy Policy and Procedure (P&P) titled Emergency Drug Kit and undated, documented the purpose to have a selection of medications available in the facility for immediate use. Policy documented the emergency kit contains a supply of oral and non-oral medications that may be required for immediate administration. An entire list of the contents of the kit, is posted on the kit. The pharmacy and Therapeutics Committee will determine the contents of the emergency kit. Procedure for obtaining medication from the emergency kit included, a valid physician's orders [REDACTED]. P&P entitled Back-up pharmacy and undated, documented the purpose to ensure that the facility and its residents have pharmacy service available 24-hours per day, seven days a week. Policy documented the provider pharmacy may use the services of a local back-up pharmacy to provide service to the facility for "stats" or after hours medication needs. Procedure included the facility should always contact the provider pharmacy when a medication is needed. The provider pharmacy determines that a medication should be provided to the facility via the back-up pharmacy. The pharmacist will then call the appropriate order into the back-up pharmacy. The pharmacist will direct the back-up pharmacy to deliver enough medication to suffice until the next scheduled delivery to the facility. Resident # 63: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of five according to the Minimum Data Set ((MDS) dated [DATE]. The Nursing Admission Evaluation from the facility was dated as completed on 4/30/13 at 2:30 pm. The Hospital Discharge instructions dated 4/30/13 documented the following medications; [MEDICATION NAME] ([MEDICATION NAME], used to treat and prevent ulcers in the stomach and intestines) 20 milligram (mg), with next dose due 4/30/13 in the evening. [MEDICATION NAME] (treats hypertension) 25 mg, with next dose due 4/30/13 at 8:00 pm. Levetiracetam ([MEDICATION NAME], an anticonvulsant) 750 mg, with next dose due 4/30/13 in the evening. [MEDICATION NAME] (treats hypertension) 100 mg, with next dose due 4/30/13 in the evening. [MEDICATION NAME] ([MEDICATION NAME], an anticonvulsant)300 mg, with next dose due 4/30/13 in the evening. [MEDICATION NAME] ([MEDICATION NAME], anticoagulant) 3 mg, with next dose due 4/30/13 in the pm. The physician orders [REDACTED]. [MEDICATION NAME] 20 mg daily at bedtime . [MEDICATION NAME] 25 mg four times daily for hypertension. Levetiracetam 750 mg twice daily for [MEDICAL CONDITION]. [MEDICATION NAME] 100 mg twice daily, for hypertension. [MEDICATION NAME] 300 mg at bedtime for [MEDICAL CONDITION]. [MEDICATION NAME] 3 mg daily for [MEDICAL CONDITION]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] 20 mg daily at 9:00 pm, the box to be initialed after administration was left blank for the 4/30/13 dose. This indicated the medication was not administered. [MEDICATION NAME] 25 mg four times daily, scheduled for 9:00 pm, the box to be initialed after administration was left blank for the 4/30/13 dose. This indicated the medication was not administered. [MEDICATION NAME] 750 mg twice daily, scheduled for 9:00 pm, the box to be initialed after administration was left blank for the 4/30/13 dose. This indicated the medication was not administered. [MEDICATION NAME] 100 mg twice daily, scheduled for 9:00 pm, the box to be initialed after administration was left blank for the 4/30/13 dose. This indicated the medication was not administered. [MEDICATION NAME] 300 mg at bedtime, scheduled for 9:00 pm, the box to be initialed after administration was left blank for the 4/30/13 dose. This indicated the medication was not administered. [MEDICATION NAME] 3 mg daily scheduled to be administered at 8:00 pm was also not signed for, indicating the medication was not given. Physician orders [REDACTED]. The MAR indicated [REDACTED] [MEDICATION NAME] 20 mg daily at bedtime, scheduled for 9:00 pm had box initialed indicating first dose was given on 5/1/13 at 9:00 pm. [MEDICATION NAME] 25 mg four times daily, scheduled for 9:00 am, 1:00 pm, 5:00 pm and 9:00 pm had box initialed indicating first dose was given on 5/1/13 at 9:00 am. [MEDICATION NAME] 750 mg twice daily, scheduled for 9:00 am and 9:00 pm had box initialed indicating first dose was given on 5/1/13 at 9:00 am. [MEDICATION NAME] 100 mg twice daily, scheduled for 9:00 am and 9:00 pm had box initialed indicating first dose was given on 5/1/13 at 9:00 am. [MEDICATION NAME] 300 mg at bedtime, scheduled for 9:00 pm had box initialed indicating first dose was given on 5/1/13 at 9:00 pm. [MEDICATION NAME] 3 mg daily, scheduled for 8:00 pm but documented that the medication was discontinued on 5/1/13, contrary to the physician's orders [REDACTED]. The facility form titled "[MEDICATION NAME] Medication Administration Record" dated 5/1/13 documented 3 mg [MEDICATION NAME] daily . The signature box for 5/1/13 was blank and then there were two letter "X"'s in the boxes for 5/2 & 5/3/13. This indicated the medication was not given as ordered. An additional entry dated 5/3/13, documented [MEDICATION NAME] 3 mg daily. It was signed as being given on 5/2/13, prior to receiving this order. The facility was not able to provide additional documentation to indicate that the [MEDICATION NAME] had been admnistered on 4/30/13 or on 5/1/13. The interdisciplinary progress notes dated 4/30/13 and 5/1/13 included no nursing documentation that medications were not administered as ordered by physician. The Unit 24 hour report dated 4/30/13 and 5/1/13 were reviewed and contained no documentation regarding the evening medications not administered or the arrival of the medications. There was no evidence of a Medication Error Report completed, for the medications not having been administered on the day of admission. The DON was asked for medication error reports. The DON was not able to produce any reports for the newly admitted residents who did not receive their medications. The DON was not aware of the newly admitted residents not receiving their medications and stated there were no medication error reports completed. During an interview on 5/14/13 at 9:00 am RNM (Registered Nurse Manager) # 1, who is the nurse manager for unit A and unit D, stated that she was not aware that medications were not given to new admissions on the day of admission. She stated that the charge nurse or RNM #1, would call the physician for their order. The orders would be transcribed onto the MARs (Medication Administration Record) and TARs (Treatment Administration record) and would be faxed to the pharmacy. If medications were not available for administration the medication nurse should notify the Supervisor, check the Emergency kits and if the medication was not in the facility the physician should be notified and receive orders when to give the medication. RNM #1 stated the only medication issue she was aware of was the delivery of Narcotics for administration and this issue was resolved. The RNM #1 stated a Resident should never miss a scheduled medication without the physician being notified. During an interview on 5/14/13 at 9:30 am LPN # 11 stated the MEDICATION ORDERS FOR [REDACTED]. The facility would not receive a new admission ' s medications until the next day. LPN# 11 stated it must be OK with the physician because that is how it happens. LPN #11 does not remember getting specific orders for medications when they are not available. During an interview on 5/14/13 at 10:25 am LPN # 2 stated the process for new admissions orders would be to review the orders, call the physician and review the orders with him, then fax the orders to the pharmacy. LPN #2 stated a call should be made to the pharmacy to let them know the orders are for a new admission. LPN # 2 stated that the admission orders [REDACTED]. She stated the physician should be notified if the medications are not available for administration. The LPN stated she works the day shift and does not run into that problem. During an interview on 5/15/13 at 1:10 pm the Registered Nurse Educator stated that she was not aware of an issue with newly admitted residents not receiving their medications on day one of admission. She stated the system with the new pharmacy is the same as the old pharmacy. She stated there was an in-service done by the new pharmacy when they started and the nurses were told to call the pharmacy after faxing orders if the medications were needed right away. The facility has Emergency kits with a variety of medications that can be utilized and there is a local back-up pharmacy. There is no reason for a resident not to receive their medications. Resident # 176: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Resident was oriented to person, place and time according to the Admission Nursing Evaluation dated 4/16/13. There was no MDS available due to the resident discharge of 4/22/13. Nursing Admission Evaluation from the facility, dated as completed on 4/16/13 at 6:15 pm and was signed by a Registered Nurse. The Hospital Discharge instructions dated 4/16/13 documented the following medications; [MEDICATION NAME] nebulizer treatments (inhalation treatment for [REDACTED]. [MEDICATION NAME] (lowers blood sugar) 30 units subcutaneously (sq) at hour of sleep. [MEDICATION NAME](pain medication) 15 mg every 12 hours. [MEDICATION NAME] (antibiotic) 500 mg two times daily. [MEDICATION NAME] (anticoagulant) sq every 8 hours. [MEDICATION NAME] (hypertension) 6.25 mg two times daily. The Physician orders [REDACTED]. [MEDICATION NAME] 0.5 mg/3 mg, 3 milliliter (ml) four times daily. [MEDICATION NAME] 100 units/ml, give 30 units sq at bedtime. [MEDICATION NAME] Clavulanate ([MEDICATION NAME]) 500 mg/125 mg, one tablet twice daily, time 5 days. [MEDICATION NAME] 5,000 units/ml, 1 ml sq every 8 hours. [MEDICATION NAME] 6.25 mg one two times daily. Fingersticks before meals and at bedtime for 72 hours. The MAR indicated [REDACTED]. The box to be initialed after administration of medication indicated the first dose was given on 4/17/13 at 8:00 am. [MEDICATION NAME] give 30 units sq at bedtime. The box to be initialed after administration of medication indicated the first dose was given on 4/17/13 at 8:00 pm [MEDICATION NAME] Clavulanate 500 mg/125 mg, one tablet twice daily at 8:00 am and 8:00 pm, times 5 days. The box to be initialed after administration of medication indicated the first dose was given on 4/17/13 at 8:00 am. [MEDICATION NAME] 5,000 units sq every 8 hours at 8:00 am, 4:00 pm and 12:00 am. The box to be initialed after administration of medication indicated the first dose was given on 4/17/13 at 8:00 am. [MEDICATION NAME] 6.25 mg one tablet two times daily at 8:00 am and 8:00 pm. The box to be initialed after administration of medication indicated the first dose was given on 4/17/13 at 8:00 am. Fingersticks before meals and at bedtime for 72 hours at 7:00 am, 12:00 pm, 5:00 pm and 9:00 pm. Call MD if below 70 or greater than 450. The box to be initialed after administration indicated the first fingerstick was done on 4/17/13 at 8:00 am. The interdisciplinary progress notes dated 4/16/13 and 4/17/13 included no nursing documentation that medications were not administered as ordered by physician. There was no evidence of a Medication Error Report completed, for the medications not having been administered on the day of admission. The DON was asked for medication error reports and none could be produced for the newly admitted residents who did not receive their medication. DON was not aware of the newly admitted residents not receiving their medications and stated there were no medication error reports completed. During an interview on 5/14/13 at 9:00 am RNM # 1, who is the nurse manager for unit A and unit D, stated that she was not aware that medications were not given to new admissions on the day of admission. She stated that the charge nurse or RNM, would call the physician for their order. The orders would be transcribed onto the MARs and TARs and would be faxed to the pharmacy. If medications were not available for administration the medication nurse should notify the Supervisor, check the Emergency kits and if the medication was not in the facility the physician should be notified and receive orders when to give the medication. RNM #1 stated the only medication issue she was aware of was the delivery of Narcotics for administration and this issue was resolved. The RNM stated a Resident should never miss a scheduled medication without the physician being notified. During an interview on 5/14/13 at 9:30 am LPN # 11 stated the MEDICATION ORDERS FOR [REDACTED]. The facility would not receive a new admission ' s medications until the next day. LPN# 11 stated it must be OK with the physician because that is how it happens. LPN #11 does not remember getting specific orders for medications when they are not available. During an interview on 5/14/13 at 10:25 am LPN # 2 stated the process for new admissions orders would be to review the orders, call the physician and review the orders with him, then fax the orders to the pharmacy. LPN #2 stated a call should be made to the pharmacy to let them know the orders are for a new admission. LPN # 2 stated that the admission orders [REDACTED]. She stated the physician should be notified if the medications are not available for administration. The LPN stated she works the day shift and does not run into that problem. During an interview on 5/15/13 at 1:10 pm the Registered Nurse Educator stated that she was not aware of an issue with newly admitted residents not receiving their medications on day one of admission. She stated the system with the new pharmacy is the same as the old pharmacy. She stated there was an in-service done by the new pharmacy when they started and the nurses were told to call the pharmacy after faxing orders if the medications were needed right away. The facility has Emergency kits with a variety of medications that can be utilized and there is a local back-up pharmacy. There is no reason for a resident not to receive their medications. Resident # 175: The Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as having moderate cognitive impairment with a BIMS score of 6. The Nursing Admission Evaluation from the facility was dated as completed on 3/5/13 with no time documented . The Hospital Discharge instructions dated 3/5/13 documented the following medications; [MEDICATION NAME] (used to treat dementia) 10 mg tablet two times per day, with next dose due on 3/5/13 at 9:00 pm. [MEDICATION NAME] (treats Hypertension) 12.5 mg two times per day, with next dose due 3/5/13 at 9:00 pm. [MEDICATION NAME] (cholesterol-lowering medication) 80 mg once per day at bedtime, with next dose due on 3/5/13 at 9:00 pm. The Physician orders [REDACTED]. [MEDICATION NAME] 10 mg tablet two times per day. [MEDICATION NAME] 12.5 mg two times per day. [MEDICATION NAME] 80 mg once per day at bedtime. The MAR indicated [REDACTED]. [MEDICATION NAME] 12.5 mg two times per day, scheduled for 9:00 am,and 9:00 pm, the boxes for initialing indicated the first dose was administered on 3/6/13 at 9:00 am. [MEDICATION NAME] 80 mg once per day at bedtime, scheduled for 9:00 pm had box initialed indicating first dose was given on 3/6/13 at 9:00 pm. The interdisciplinary progress notes dated 3/6/13 and 3/7/13 included no nursing documentation that medications were not administered as ordered by physician. There was no evidence of a Medication Error Report completed, for the medications not having been administered on the day of admission. The DON was asked for medication error reports and none could be produced for the newly admitted residents who did not receive their medication. DON was not aware of the newly admitted residents not receiving their medications and stated there were no medication error reports completed. During an interview on 5/14/13 at 9:00 am RNM # 1, who is the nurse manager for unit A and unit D, stated that she was not aware that medications were not given to new admissions on the day of admission. She stated that the charge nurse or RNM, would call the physician for their order. The orders would be transcribed onto the MARs and TARs and would be faxed to the pharmacy. If medications were not available for administration the medication nurse should notify the Supervisor, check the Emergency kits and if the medication was not in the facility the physician should be notified and receive orders when to give the medication. RNM #1 stated the only medication issue she was aware of was the delivery of Narcotics for administration and this issue was resolved. The RNM stated a Resident should never miss a scheduled medication without the physician being notified. During an interview on 5/13/13 at 9:30 am LPN # 12 stated there was trouble with the new pharmacy with the MARs and TARs, that there were many things on them that should not have been and many corrections had to be made. LPN stated she was not inserviced by the new pharmacy, that she worked the night shift. During an interview on 5/14/13 at 9:30 am LPN # 11 stated the MEDICATION ORDERS FOR [REDACTED]. The facility would not receive a new admission's medications until the next day. LPN# 11 stated it must be OK with the physician because that is how it happens. LPN #11 does not remember getting specific orders for medications when they are not available. During an interview on 5/14/13 at 10:25 am LPN # 2 stated the process for new admissions orders would be to review the orders, call the physician and review the orders with him, then fax the orders to the pharmacy. LPN #2 stated a call should be made to the pharmacy to let them know the orders are for a new admission. LPN # 2 stated that the admission orders [REDACTED]. She stated the physician should be notified if the medications are not available for administration. The LPN stated she works the day shift and does not run into that problem. During an interview on 5/15/13 at 1:10 pm the Registered Nurse Educator stated that she was not aware of an issue with newly admitted residents not receiving their medications on day one of admission. She stated the system with the new pharmacy is the same as the old pharmacy. She stated there was an in-service done by the new pharmacy when they started and the nurses were told to call the pharmacy after faxing orders if the medications were needed right away. The facility has Emergency kits with a variety of medications that can be utilized and there is a local back-up pharmacy. There is no reason for a resident not to receive their medications. During an interview on 5/15/13 at 12:10 pm, the Director of Nurses (DON) stated she was not aware of a problem with newly admitted residents receiving their medications. She stated that there was one instance this past week when she was notified by an LPN, that a new Resident ' s medications did not arrive for the first administration. The DON stated the pharmacy and MD were notified of this occurrence. The DON stated she did not look at other new admissions. DON stated that when the new pharmacy began a couple of months ago the pharmacy staff were in the facility for a week in-servicing nurses. The DON stated that there were no medication issues discussed in QA. The DON stated that new admissions were discussed in morning meeting and she would ask if medications arrived and was never told that the medications did not come in until the following day. Nurses should have been using the E-kits for medications and notifying the physician and pharmacy. The facility had a local back-up pharmacy as well. During an interview on 5/15/13 at 12:50 pm, the Administrator stated the only medication issues he had been made aware of was that the Emergency Kits (E-kits) needed to obtain more narcotic pain medications and that issue was resolved. The Administrator stated he was not aware of the problem with newly admitted or readmitted residents not having their medications administered until the following day and would have expected the nurses to have notified the physician and the pharmacy. He stated that this information should have come up the chain and reached the DON then himself. He stated if he had been made aware of this problem, his role would have been to initiate a meeting with the Medical Director and Pharmacy to correct the problem immediately. During an interview on 5/14/13 at 11:00 am, the Medical Director stated he was not aware that the newly admitted residents were not receiving their medications until the day after admission. His expectation would be to call the medical provider on call, so a decision could be made about whether the medication can be held, or have other arrangements made. Stated the insulin is an issue and the provider would want to know why it was not available, stated it sounds like a communication problem. 10NYCRR 415.12(m)(2) ,

Based on record review, and staff interviews, the Administration failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practicable well-being and safety of each resident. Specifically, the facility administrtion failed to ensure 9 (#'s: 52, 63, 68, 82, 175,176,177,178 and 180 ) of 14 residents reviewed during the extended recertification survey were provided routine and emergency medication in a timely manner as ordered by the physician, the administration failed to have an effective system in place to ensure that physician's orders [REDACTED]. This resulted in no actual harm with the potential for serious harm to affect all residents that is Immediate Jeopardy to resident health and safety. Interviews revealed staff failed to complete the admission or readmission process for newly admitted and readmitted residents in a timely manner resulting in residents not receiving significant medications as ordered by the physician. Investigation further revealed that the staff were not following the facility policy by notifying the physician, pharmacy and supervisor when medications were not available for administration. Investigation further revealed that the omission of medications were not investigated to determine the root cause of the medication omissions and to prevent further incidence. This was evidenced by: Refer to F 333 Significant Medication Errors - scope and severity- L- Quality of Care During an interview on 5/13/13 at 2:00pm the Administrator stated he was not aware of the medication omissions/ errors until the survey team brought it to his attention. He stated he received medication error reports but they were not for omissions or for medication being unavailable. Additionally, he stated he was unaware that the Nursing Supervisors or staff members did not comply with the Pharmacy Policy that the facility had in place. The Administrator stated that the physician should have been notified immediately so a decision could have been made to hold or obtain medications from another source. The Administrator stated that this practice was unacceptable and would be corrected immediately. During an interview on 5/14/13 at 11:00 am, the Medical Director stated he was not aware that the newly admitted residents were not receiving their medications until the day after admission. His expectation would be to call the medical provider on call, so a decision could be made about whether the medication can be held, or have other arrangements made. Stated the insulin is an issue and the provider would want to know why it was not available, stated it sounds like a communication problem. During an interview on 5/15/13 at 12:10 pm, the Director of Nurses (DON) stated she was not aware of a problem with newly admitted residents receiving their medications. She stated that there was one instance this past week when she was notified by an LPN, that a new Resident ' s medications did not arrive for the first administration. The DON stated the pharmacy and MD were notified of this occurrence. The DON stated she did not look at other new admissions. DON stated that when the new pharmacy began a couple of months ago the pharmacy staff were in the facility for a week in-servicing nurses. The DON stated that there were no medication issues discussed in QA. The DON stated that new admissions were discussed in morning meeting and she would ask if medications arrived and was never told that the medications did not come in until the following day. Nurses should have been using the E-kits for medications and notifying the physician and pharmacy. The facility had a local back-up pharmacy as well. During an interview on 5/15/13 at 1:10 pm the Registered Nurse Educator stated that she was not aware of an issue with newly admitted residents not receiving their medications on day one of admission. She stated the system with the new pharmacy is the same as the old pharmacy. She stated there was an in-service done by the new pharmacy when they started and the nurses were told to call the pharmacy after faxing orders if the medications were needed right away. The facility has Emergency kits with a variety of medications that can be utilized and there is a local back-up pharmacy. There is no reason for a resident not to receive their medications. 10 NYCRR 415.26

Based on interview, during an extended recertification survey the facility did not ensure the quality assessment and assurance committee (QA) identified issues that had the potential to cause serious harm to residents. Specifically, residents who were newly admitted or readmitted did not receive their physician ordered medications on the evening shift of their admission/readmission. Lack of a effective system resulted in residents not receiving significant necessary medications. Interviews revealed staff were not completing the admissions in a timely manner to ensure medications were available and there was a lack of communication between the unit nurses and nursing supervisors. The QA Committee failed to complete investigations when medications were omitted, when significant medication errors occurred and when standards of practice were not followed for the timely administration of medications. This had the potential to affect all residents in the facility. This resulted in no actual harm with the potential for serious harm that is IMMEDIATE JEOPARDY to resident health and safety. This was evidenced by: Refer to F 333 scope and severity- L- Medication Errors During an interview on 5/15/13 at 12:10 pm, the Director of Nurses (DON) stated she was not aware of a problem with newly admitted residents receiving their medications. She stated that there was one instance this past week when she was notified by an LPN that a new Resident ' s medications did not arrive for the first administration. The DON stated the pharmacy and MD were notified of this occurrence. The DON stated she did not think to look into other newly admitted residents. DON stated that when the new pharmacy began a couple of months ago that the pharmacy was in the facility for a week in-servicing nurses. DON stated that there was no medication issues discussed in QA. Stated that new admissions were discussed in morning meeting and she would ask if medications arrived and was never told that the medications did not come in until the following day. Nurses should have been using the back-up box for medications and notifying the physician and pharmacy, the facility had a local back-up pharmacy as well. During an interview on 5/15/13 at 12:50 pm, the Administrator stated the only medication issues he had been made aware of was that the Emergency Kits (E-kits) needed to obtain more narcotic pain medications and that issue was resolved. The Administrator stated he was not aware of the problem with newly admitted or readmitted residents not having their medications administered until the following day and would have expected the nurses to have notified the physician and the pharmacy. He stated that this information should have come up the chain and reached the DON then himself. He stated if he had been made aware of this problem, his role would have been to initiate a meeting with the Medical Director and Pharmacy to correct the problem immediately. The Administrator stated that he and the DON chaired the Quality Assurance Committee (QA). QA would meet on a quarterly basis and all department heads, Administrator, DON, and pharmacy would attend. Staff would be assigned to ad hoc teams if a problem arose that needed to be looked into. The QA Committee had not monitored any medication issues that he was aware of. During an interview on 5/14/13 at 11:00 am, the Medical Director stated he was not aware that the newly admitted residents were not receiving their medications until the day after admission. His expectation would be to call the medical provider on call, so a decision could be made about whether the medication can be held, or have other arrangements made. Stated the insulin is an issue and the provider would want to know why it was not available, stated it sounds like a communication problem. 10NYCRR 415.27(a-c)

Based on medical record review and staff interviews during an abbreviated survey (Case # 6) it was determined for one (Resident #45) of two residents reviewed that the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, an ordered PT/OT evaluation was not completed and the resident experienced two falls resulting in the resident being admitted in the Intensive Care Unit (ICU). This resulted in actual harm for Resident #1, that is not Immediate Jeopardy. This is evidenced by the following: Resident #45: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to be cognitively intact. The facility form titled "Fall Assessment" dated 11/12/12 documented that the resident is at moderate risk for falls. A comprehensive care plan (CCP) was initiated on 12/10/12, titled "at risk for falls" with documented as an intervention, educate the resident about safety reminders and what to do if a fall occurs. A physician's orders [REDACTED]. The order was transferred onto a facility form titled "Rehabilitation Referral", which is dated 4/16/13, for assessment of safety of ambulation for long distances, complained of unsteadiness. The referral form has no other pertinent documentation related to the assessment. The facility form titled "Accident/Incident report" dated 4/18/13 at 12:20 am documented that the resident was found on his knees at the foot of the bed, and the resident stated he rolled out of bed. The recommended steps to prevent reoccurrence were documented as "instruct resident to use call light to call for assistance." under the section titled "type of injury" it was documented an abrasion to the right forehead. An additional form titled "RN Supervisor" documented under the section titled "What actions did you take?", assessed resident for injury, two centimeter abrasion to right forehead. Under the section titled "Environmental Factors" it was documented that the call bell was within reach, the bed was in low position, two bed rails, resident didn't have socks on. An additional form title "Certified Nurses Aide" (CNA) documented the resident was sitting at the side of the bed somewhat disoriented. The resident stated he attempted to get up, missed his side rail, slipped and hit the floor. Nurse's note documented by an LPN on 4/18/13 (untimed) on the 11:00 pm to 7:00 am shift, that the resident was found on the floor next to his bed at 12:25 am. It is documented that the resident admitted that he hit his head. Neuro checks initiated at 12:30 am within normal limits. No complaints of pain noted. Supervisor was aware and assessed resident. An additional note written by the RN supervisor at 7:07 am documented that the resident had an unwitnessed fall in his room. The resident stated he rolled out of bed. The resident was assessed for injuries with a small two centimeter abrasion noted to the right forehead. No treatment required. No other injuries noted. There was no documentation of the neuro checks. The facility form titled "Neuro Checklist" documented that neuro checks should be completed every fifteen minutes times two; every thirty minutes times two; every two hours times two; every shift for twenty-four hours or discontinued by physician. The form is dated 4/18/13 at 12:30 am. There is an entry for a neuro check completed at 12:30 am; 2:00 am; 2:15 am; 2:45 am; 3:15 am; 5:15 am and 7:15 am. The form was missing neuro checks from 12:30 am until 2:00 am, contrary to the facility neuro check protocol. The facility form titled "Accident/Incident report" dated 4/18/13 at 11:20 am documented that the resident was found on the floor next to the bed in respiratory distress, and was sent to the emergency room . Nurse's note documented by the Registered Nurse Manager (RNM) on 4/18/13 at 11:19 am that ) was called to the room to assess the resident who was found on the floor next to his bed. Upon arrival the resident was holding on to the side rail. The resident was blue in color, eyes were open and he was gasping for air. The resident was incontinent of urine, and the pupils were fixed and non-reactive. The resident's speech was slurred and he was unable to hold his hands in the supine position. The resident was transferred to the hospital. LPN #3 was interviewed on 4/24/13 at approximately 4:00 pm and stated the resident had fallen on 4/18/13 at approximately 12:20 am. She stated she was very busy with another resident, and never started the neuro checks until 2:00 am. She stated after the fall, the RN supervisor assessed the resident and stated to her that the resident was OK; so when she documented the 2:00 am neuro checks, she wrote her findings for the initial checks, which she assumed the RN supervisor completed. LPN #3 stated the resident seemed very tired and wouldn't sit up for his 6:00 am medications with noted slurred speech, but she "brushed it off." The RN supervisor was interviewed on 4/25/13 at approximately 9:30 am and stated he was notified that the resident was on the floor and found the resident on his floor mats (which the resident was not care planned for). He stated the resident had a red mark on his forehead. He stated he was not familiar with the resident. He stated he completed an assessment, the accident & incident report, and had the aides complete their statements. The RN supervisor stated he never initiated the neuro check sheet. Certified Nurse's Aide (CNA) #1 was interviewed on 4/23/13 at approximately 11:00 am and stated on the day the resident was sent to the hospital (4/18/13) she was responsible for providing personal care to the resident. CNA #1 stated it was told in morning report to keep an eye on the resident. CNA #1 said the resident was not himself and it was reported to LPN #1. LPN #1 was interviewed on 4/23/13 at approximately 11:30 am, who stated that she is new to the unit and doesn't know any of the residents very well and depends on the CNA to alert her to changes. LPN #1 stated that on 4/18/13 she received report from the night nurse who reported to her that the resident had fallen and was not acting right. LPN #1 stated vital signs were taken on the resident with neuro checks at approximately 7:00 am, which were normal. LPN #2 reported to LPN #1 that the resident was not right. LPN #1 stated when the RNM came back from morning meeting, she asked the RNM to do an assessment because of the fall on the night shift. LPN #1 did not report the concerns of LPN #2 regarding the change in condition and that the resident was not himself. LPN #2 was interviewed on 4/23/13 at approximately 12:30 pm and stated on 4/18/13 she received report from the night nurse who reported the resident had fallen and neuro checks were done. LPN #2 stated after report at approximately 8:00 am, she checked on the resident. The resident was confused, vague, had slurred speech and looked shaky. LPN #2 stated she reported the findings to LPN #1, who was the charge nurse and LPN #1 stated the RNM was in report. LPN #2 stated around 9:00 am she checked on the resident who was out of bed. The resident's breathing was erratic, and she reported it to LPN #1. LPN #2 asked LPN #1 about the resident's neuro checks, because the pupils were now pin point and fixed. LPN #1 told her that the RNM was still in report, and would do the assessment when available. When the RNM came back onto the unit, LPN #2 stated the resident was found on the floor, he was gurgling, cyanotic, foaming at the mouth, and had [MEDICAL CONDITION] motion. 911 was called and the resident was sent out to the hospital. LPN #2 stated she notified LPN #1 seven times that the resident wasn't right and asked if it was going to take all day to get the resident assessed. The RNM was interviewed on 4/23/13 at approximately 1:30 pm and stated on the day the resident fell , she heard in report about the fall, and asked LPN #1, who was the charge nurse, to get the resident's vital signs, who told her that they were within normal limits. When she returned from the morning meeting, which was extra long, she asked the charge nurse again, and was told the resident was OK. The RNM didn't get into the resident's room right away because of an additional concern. Later, was called to the room because the resident was found on the floor, was unresponsive, cyanotic and gurgling. The RNM stated she was never told the concerns of LPN #2. Ward Clerk #1 was interviewed on 4/23/13 at 1:40 pm and stated she saw that the order for the PT/OT assessment had not been carried through properly and written up on a referral slip on 4/15/13. She stated she immediately went to the Director of Nursing (DON) to advise her. She then completed the referral form but it had to be signed by a nurse. She was unsure what happened to the form after that. She stated LPN #2 reported to LPN #1, several times, her concerns regarding the resident's status on 4/18/13. The Physician's Assistant was interviewed on 4/23/13 at approximately 2:40 pm and stated she completed the monthly renewal for the resident on 4/15/13 when he complained to her about "feeling unsteady when he gets out of bed, and described feeling like he was going to fall backwards". The PA stated that she wrote an order for [REDACTED]. The Physical Therapy Director was interviewed on 4/23/13 at approximately 3:15 pm and stated evaluations are usually completed within seventy-two hours, but never received a referral for this resident. Review of the hospital medical records dated 4/18/13 documented that the resident was admitted to the ICU. 10 NYCRR 415.12.

Based on record review and staff interview during an abbreviated survey (NY 756, NY 534) the facility did not ensure that 2 (#'s 1 and 3) of four residents reviewed with pressure sores received the necessary treatment and services to promote healing, prevent infections and prevent the development of new pressure sores. Specifically, for Resident # 1 the facility did not ensure an initial assessment of a sacral pressure sore was completed and documented upon admission to the facility. For Resident # 3 the facility failed to provide the care necessary to prevent the development of a Stage 3 pressure sore, and following discovery of the pressure sore the physician treatment order was not followed. The resident was found with a Stage 3 area on the right heel. The resident subsequently required hospitalization for osteo[DIAGNOSES REDACTED]. This resulted in actual harm for Resident # 3 and for Resident #1 this had the potential for more than minimal harm that is not immediate jeopardy. This was evidenced by: The Policy & Procedure (P&P) entitled, Skin Care Protocol, dated 9/2011 documented under the heading Procedure for skin integrity documentation and assessment that for all alterations in skin integrity, the Registered Nurse (RN) would perform an assessment and complete the documentation using this checklist: Identify type of skin issue including the location and cause, fill out a white non-ulcer flow sheet for any area except ulcers and place in the skin book, if an ulcer, fill out a peach color ulcer sheet and place in the skin book, apply treatment if needed and enter in treatment book. The non-ulcer flow sheet included choices to be check marked; skin tear, abrasion, excoriation, and other and included width, length and depth of wound, color of wound, drainage, surrounding skin and pain scale. The Ulcer flow sheet included width, length and depth of wound, shape, tissue type, exudate (drainage) type and amount, surrounding tissue, pain and odor. Under the heading for Assessment, the P&P documented all residents will be assessed for risk of pressure ulcer development utilizing the Braden Pressure Ulcer Risk Assessment. The Braden Pressure Ulcer Risk assessment is completed by a Registered Nurse(RN), residents who score at risk for pressure ulcer development will have a preventative care plan established using the pressure ulcer risk reduction guidelines. Under preventative care it is documented routine preventative care for all residents shall include: bathing as needed, lotion may be used for dry skin, adequate diet and fluids will be offered, maintain and improve mobility, activity and range of motion, Diabetic-foot inspection two times a day, turn and position if residents cannot self-turn. Resident # 3: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident had short and long term memory problems and was severely impaired in decision making according to the most recent Minimum Data Set Assessment (MDS). According to the MDS dated [DATE] the resident required total assistance of two people with bed mobility, transfer, toileting and personal hygiene and required extensive assistance of two people with dressing. The residents behavior was documented as verbal behavioral symptoms not directed toward others for 4 to 6 days of a 7 day look-back. Physical behaviors are documented as not exhibited. Finding # 1: Resident required extensive to total assistance with his Activities of Daily Living (ADL). The resident had a history of [REDACTED]. The resident was noted to have a Stage 3 pressure sore on his right heel on January 15, with no reported signs of breakdown prior to discovery. Staff interviews revealed inconsistencies in who was responsible for his daily bathing routine. The Braden Scale for predicting pressure sore risk dated 12/19/12 and signed by an RN, documented a score of 13 for risk of developing pressure sores. The scores of 13 to 14 indicated a person had a moderate risk of developing pressure sores. The Skin Care Protocol Assessment had listed under "additional factors to consider" documented that any factors that are answered with a yes, then the resident should then be considered high risk for pressure sores. The factors that were documented yes included: refusing intervention, history of pressure ulcer, pain and dementia. The Comprehensive Care Plan (CCP) dated 10/5/12 entitled resident was at risk for pressure ulcer development related to (r/t) decrease mobility and incontinence listed the interventions of : bed mobility total assist of two persons dated 12/6/12, Braden assessment quarterly and as needed (prn) dated 12/6/12, contoured mattress dated 12/6/12, lotion to feet and legs at bedtime (hs) dated 12/6/12, turn and position every two hours dated 12/6/12. The CCP dated 11/9/12, entitled the resident has pain r/t fracture right hip. Interventions included administer [MEDICATION NAME] (for relief of pain) as per orders and evaluate the effectiveness. The CCP dated as revised 11/9/12 entitled resident has impaired visual function r/t [MEDICAL CONDITION]. Interventions included resident will have activities/care to provide for safety and promote independence, room and things arranged to promote independence. The CCP dated 11/9/12 entitled resident has communication problem r/t hearing deficit. Interventions included anticipate and meet needs, be conscious of resident position when in groups to promote proper communication with others. The CCP dated 10/16/12 entitled resident is resistive to care r/t anxiety. Interventions included, give clear explanation of all care activities prior to and as they occur during each contact, provide consistency in care to promote comfort with ADLs, maintain consistency in timing of ADLs caregivers and routine as much as possible. The Resident Profile (an outline of how care was to be delivered by Certified Nurse Aides (CNA)) dated 11/28/12 documented under the heading ADL levels, two care givers at all times, non-ambulatory, extensive assist with bathing and dressing, and total assistance with hygiene. Documented under bed mobility heading, total assist of two for positioning side to side, turn and position every two hours, pillow between knees and heels off bed pillow under the heels when in bed, non skid socks when in bed, dependent of staff for wheelchair mobility and leg rests to wheel chair. Documented under the heading skin care, lotion to feet and legs at hs, and foot booties are marked no. Documented under behavior, yells periodically, hard of hearing and legally blind, shower with extensive assist of two care givers on Wednesdays during the 7-3 shift. There was no documentation in regards to the physical behavior or how to approach the Resident who was hearing impaired and legally blind. A Physical Therapy discharge summary note dated 10/22/12 documented the resident was often reluctant to participate. Decreased cognition paired with violent behaviors have limited his progress. Resident does not comprehend his need for physical therapy. A Psychiatry note dated 1/17/13 documented the resident was generally manageable although he remains combative with care. He is on [MEDICATION NAME] and [MEDICATION NAME], and on an increased dose of [MEDICATION NAME]. Continue same regimen. The twenty four hour report sheets from 1/1/13 through 1/13/13 contained no documentation that resident's behavior interfered with his care. The twenty four hour report sheet dated 1/14/13 on the 3:00 pm to 11:00 pm shift ( evening shift) documented no behaviors were noted. There was no documentation of an open area on the right heel. The twenty four hour report sheet dated 1/15/13 on the 7:00 am to 3:00 pm shift (day shift) documented that there was a Stage 3 area on the right heel, new treatment. Nurse notes dated 1/15/13 at 1:29 pm by an RN, documented the resident had a new stage three pressure area on right heel. The physician was notified. A Zero-G heel cushion boot would be applied at all times, off for care. The Ulcer Flow Sheet dated 1/15/13 documented a Stage 3 pressure sore measuring 3.6 centimeters (cm) x 2.0 cm x 0.2 cm in depth, irregular shaped with necrotic tissue, sero-sanguinous drainage, red wound bed and surrounding tissue as soft and discolored. A physician order [REDACTED]. Consult with the wound physician and culture the right heel. Laboratory report dated as collected 1/15/13 and received 1/16/13 documented the wound culture was positive for [MEDICAL CONDITION]-resistant staphylococcus aureus. The physician order [REDACTED]. On 1/20/13 documented an order for [REDACTED]. Containing the same live cultures found in yogurt), one by mouth twice per day for ten days. A Wound Physician note dated 1/22/13 documented the area was unstageable due to necrosis. The cause was pressure and measured 7 cm x 9 cm x depth not measurable. The area was debrided (remove infected tissue, remove thick adherent eschar and devitalized tissue). Dressing ordered was Silver Absorbing Agent, dry protective dressing, twice per day. Laboratory report dated as collected 2/3/13 and received 2/4/13 documented wound culture with results of positive for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) and positive for Proteus Mirabilis. The physician order [REDACTED]. Laboratory report dated as collected 3/6/13 and received 3/6/13 documented wound culture with results positive for Proteus Mirabilis. Physician order [REDACTED]. Portable X-ray report dated 2/26/13, documented the right heel demonstrated a large soft tissue ulcer eroding down to the level of the dorsal calcaneus. Bone scan is needed to rule out osteo[DIAGNOSES REDACTED]. Diagnostic imaging report dated 3/8/13, documented the Bone Scan was positive for osteo[DIAGNOSES REDACTED] of the right calcaneus. A physician order [REDACTED]. Physician order [REDACTED]. Needs surgical debridement and IV antibiotic. Medical Imaging report dated 3/28/13, during the residents hospitalization documented there is a massive deep ulcer overlying a large portion of the posterior aspect of the calcaneus. There is diffuse increased T2 low T1 signal throughout the posterior calcaneus and also extending into the anterior/inferior aspect of the calcaneus, which is consistent with osteo[DIAGNOSES REDACTED]. During an interview on 4/9/13 at 12:00 pm RNM # 1 stated the Resident was total care and it was inexcusable that the wound developed. During an interview on 4/9/13 at 2:40 pm, CNA # 3 stated that Resident # 3 was so combative that two caregivers would do him fast by cleaning his face, armpits and peri area only. Socks would stay on, and the resident never wore shoes. CNA # 3 stated she remembered Resident # 3 complaining about his feet having pain, and stated she would have reported that. CNA # 3 remembers the resident's heel having "mushy skin" and that she reported this to a nurse, she did not remember exactly when but before the pressure sore. During an interview on 4//9/13 at 2:50 pm, Physician # 1 stated Resident # 3 needs a lot of assistance with his care. The physician stated there must have been something underlying going on with his heel to have a discovery of a stage three wound; someone missed something. During an interview on 4/9/13 at 3:00 pm, CNA # 1 stated she worked the day shift and that the 11:00 pm to 7:00 am shift (night shift) washed and dressed Resident # 3 and he could be in bed or up in a wheelchair when the day shift came in. Sometimes the day shift would wash him up if he was not dressed. The CNAs would not be told whether or not Resident # 3 had been washed or not. CNA # 1 stated the resident did not have the heels up pillow in the bed a whole lot, that he would frequently kick it off the bed. CNA#1 stated when the resident was out of bed, he sat in a high back wheelchair with non-skid socks on his feet and they rested on the metal footrests. During an interview on 4/9/13 at 3:15 pm, CNA # 2 (7:00am-3:00pm)stated she had no recollection of bathing Resident #3 on the day shift. CNA #2 stated that the night shift takes his socks off and bathes him. CNA#2 stated that those residents who wear socks only have them taken off if a shower is scheduled or if a nurse tells them to take them off. CNA #2 stated Resident # 3 could be combative with care and needed two caregivers. During an interview on 4/10/13 at 10:00 am, LPN # 1 stated that she was not assigned to Resident # 3's wing but would see him sitting at the nurse station. He sat in a high back wheelchair with socks on his feet sitting on the metal foot pads. LPN stated that bed bath consisted of face, hands, under arms, bottom and back. Residents with diabetes would have their feet checked daily. CNAs are supposed to check the Residents skin, nurses do not do skin checks. During an interview on 4/10/13 at 11:00 am, LPN # 2 stated that the resident was non-compliant with his feet up on the pillows and he could be verbally and physically aggressive. LPN stated bathing should be done twice a day, am and pm care and it would be done if the resident did not beat them up. CNAs should report any care that was not done and the nurse should document it. LPN # 2 stated that when out of bed the resident was in a high back wheelchair. He wore non-skid socks with his feet on the footrests, which he would often kick his feet off of. During an interview on 4/10/13 at 11:45 am, CNA # 4 stated that Resident # 3 was never cooperative with the pillow to keep his feet elevated in bed, that he would kick it to the floor. CNA #4 stated that sometimes the day shift would bathe Resident # 3 and sometimes the night shift would do it. If Resident # 3 was combative with care the CNA would leave and return later. CNA # 4 stated everyone should get their socks changed, and that the nurse only looks at their skin if needed. CNA stated that prior to the discovery of the stage three wound that the Resident would complain that his foot hurt and this was reported to the nurses. During an interview on 4/10/13 at 1:00 pm the Director of Rehabilitation (DR)stated that Resident # 3's right leg was extremely limited. The DR stated the resident could be extremely agitated, constantly shearing his heels into the mattress and he did have a heels up in bed care planned for. Stated booties were ordered after the discovery of the pressure sore to the right heel. During an interview on 4/10/13 at 1:00 pm the Director of Nursing (DON) stated the CNAs should be looking at skin once per day and they should be checking the feet. Nurses do not check skin, the CNAs are to report any skin issues to the nurses. The DON stated she was not aware that Resident # 3's behaviors were affecting the amount of care he received. She was not aware that the socks were not taken off with care if the resident was combative. DON stated she thought that Resident # 3 was a night shift get-up which would include the daily bathing. During an interview on 4/11/13 at 10:00 am the facility Psychiatrist stated the Resident was very demented, had yelling behaviors and was aggressive with care. The psychiatrist stated that he was not made aware of the Residents behavior interfering with his care. He stated that he possibly would have ordered something to help calm the Resident. During an interview on 4/11/13 at 4:00 pm, RNM # 1 stated that the CNAs were responsible to report to the nurses if care was not completed on a resident. If Resident #3 was gotten up on the night shift they should have given care to the Resident. RNM # 1 stated that even a partial bath should include taking socks off. RNM was not aware of problem with the resident's feet or his complaints of pain. RNM stated she saw the wound a couple days after discovery and at that time it was necrotic, and definitely open at the base but it was unstageable at that time. RNM stated the staff were told to leave the Resident and go back when he exhibited his behaviors. Stated he was post [MEDICAL CONDITION] and they should have been aware of possible circulation problems. During an interview on 4/12/13 at 8:30 am, Administrator stated there was a behavior log to record problem behaviors and that the Social Worker would be responsible to notify the Psychiatrist. The Administrator stated he had gone to the unit and had spoken to Resident # 3 and stated he felt, that the way the Resident was approached was very important, given his [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. He stated that he had talked to some staff members about approaches for this resident. There was no formal inservice done on managing these behaviors. The Administrator stated he was not aware that staff were having problems providing care due to his behaviors and that staff members were assuming that other shifts were providing ADL care to the Resident. During an interview on 4/12/13 at 9:15 am, the Social Worker (SW) stated that she does not review the behavior log documentation unless it is brought to a meeting. She stated nursing completes the behavior careplan and that Social Work completes the cognition, [MEDICAL CONDITION] and mood careplan. SW stated that she knew about his behaviors and they were discussed in careplan meetings and morning report. He was recently given a private room because his yelling was disturbing others. SW was aware that staff would need to leave the resident at times and reapproach. The SW was not aware that care was not being done at times. Stated if she had known she would have done some teaching herself. During an interview on 4/12/13 at 10:20 am, LPN # 8 stated that the resident would kick the heels up pillow off the bed and he said it hurt his heels. LPN# 8 was not sure who knew this. LPN # 8 stated there was no special monitoring for his heels prior to the pressure sore discovery and stated booties were ordered after the discovery of the pressure sore. During an interveiw on 4/12/13 at 3:15 pm, the DON stated that the night shift highlites the names of residents on the assignment sheet that are to be given baths and gotten up in early am. The DON stated that Resident # 3 was not highlited for an early get-up. During an interview on 4/18/13 at 9:20 am, CNA # 5 stated that during the night shift, the resident received incontinence care three times a night. CNA # 5 was always assigned to Resident # 3 on the night shift. He was never bathed and gotten up on the night shift. The Resident's socks were never taken off on the night shift. CNA stated the resident would never keep the pillow under his feet. The CNA did not report this because she stated that everyone knew about his behaviors and noncompliance. Once the Resident's pressure sore was discovered the booties were ordered and the Resident did keep those on. CNA did not remember any special training or instruction on how to care for the Resident's behaviors. During an interview on 4/23/13 at 9:00 am, CNA # 6 did not remember giving the Resident a shower the night before the pressure sore discovery (1/14/13). CNA# 6 stated Resident # 3 was periodically assigned to her and received his showers on the evening shift. CNA stated that the day shift was supposed to give the Resident his complete wash up. CNA # 6 stated that Resident # 3 was always soaking wet when the evening shift came on duty, and that this was reported to the day and evening nurses and the Nurse Manager. CNA did not remember the Resident using a heels up pillow when in bed. CNA stated that when Resident refused a shower they would do a bed bath and that he sometimes would not let them take his socks off, and he always complained of pain to his legs and feet. During an interview on 4/24/13 at 10:40 am a former Registered Nurse Manager (RNM) # 2 stated that she was the first nurse to assess the area to the right heel. RNM stated that it was very upsetting to see this area and that it should never have happened. The area looked like it could have been blister like and opened up and she did not remember seeing necrotic tissue. She stated the wound looked clean and the wound bed was deep, more than a stage two would have been. RNM # 2 stated the Resident was hard of hearing and blind and if he was not approached properly he could be combative. RNM is not aware of any inservice or instructions given in regards to caring for Resident # 3. Finding # 2: A Stage 3 pressure sore was discovered on Resident # 3's right heel on 1/15/13. The area was assessed and orders were received for dressing changes to be done twice per day. The dressing to the Stage 3 pressure sore was not changed on the evening shift on eleven occasions from 1/16/13 to 1/29/13. The CCP entitled resident was at risk for pressure ulcer development, and dated 1/15/13 for Stage three pressure area on right heel listed the following interventions. administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing daily and prn, and report improvements and declines to the physician. A physician order [REDACTED]. Consult with the wound physician and culture the right heel. A Wound Physician note dated 1/22/13 documented, recommended a dressing of Silver Absorbing Agent, dry protective dressing, twice per day. Physician orders [REDACTED]. The dressing changes were documented in the treatment administration record and were to be initialed after completion on the day and evening shift. The evening dressing change was initialed and circled as not done on the following days: 1/16/13 through 1/21/13, 1/23/13, 1/24/13, 1/26/13, 1/28/13 and 1/29/13. Nurse notes dated 1/16/13 through 1/29/13 revealed there was no documentation in regards to the treatments not being done for Resident # 3, or notification to the physician. The physician note following the discovery of the pressure sore and dated 2/1/13 revealed no documentation that the physician was aware of the dressing not being done on eleven occasions on the evening shift. The twenty four hour report sheets from 1/16/13 through 1/29/13 for Resident # 3, contained no documentation for all three shifts that resident's dressing to right foot was not changed. During an interview on 4/12/13 at 8:30 am the DON stated she was not aware of the dressings being circled. She stated the circles should have been reported by the day nurses. A nurse who circles a treatment should document in the nurse notes and twenty four hour report sheets. The DON stated that someone should be responsible for monitoring the treatment and medication administration records. During an interview on 4/11/13 at 4:00 pm RNM # 1 was not aware of the dressing to the resident's right foot not being done on the evening shift. The RNM #1 stated that this should have been reported. Nurses are supposed to document when treatments are not done and why. During an interview on 4/12/13 at 10:05 am, LPN # 7 stated he remembers the wound, but does not remember circling his initials. LPN#7 stated the resident was in a lot of pain with dressing change, and needed at least two people to keep him calm. During an interview on 4/12/13 at 10:20 am, LPN # 8 stated she was usually very thorough with treatments, and only worked the one time on the hallway with Resident # 3. She stated it was a little hectic that day and the resident was kicking and screaming so she circled the initials. She stated could not remember if she went back to do the treatment later but she knows if there was no documentation that it wasn't done. LPN stated that the supervisor should be notified when a treatment is not done. During an interview on 4/12/13 at 10:45 am, LPN # 2 stated she does not remember changing the dressing to the Resident's right foot. Stated if initialed and circled, I did not do it. LPN # 2 was not aware of procedure to document treatments not done in nurse notes or if the supervisor should be notified. During an interview on 4/12/13 at 12:25 am, LPN # 4 stated the resident can be combative and refuse treatment. If I circled the treatment it means I did not do it. Agency LPNs cannot chart in the computer, they are to report to other nurses if not done. The reason the treatment was not done could have been his behavior. During an interview on 4/12/13 at 1:10 pm, LPN # 5 stated she was assigned to the resident on two days and remembers one day the dressing was not done because the resident refused, and she did do the dressing the second day. If circled LPN #5 stated it should be reported to the supervisor and the physician should be called, but was not. During an interview on 4/12/13 at 1:40 pm, LPN # 6 stated if I circled my initials, it was not done. I would not have notified the physician for not completing the treatment. I only would have told the oncoming shift. During an interview on 4/12/13 at 9:30 pm, LPN # 9 stated the resident refused a lot of care, and would not let him do the treatment. Circling around initials meant the treatment was not done. LPN always writes treatments not done on report, and reports to supervisor. LPN was sure that it was due to the residents behaviors that his treatment was not done. Resident # 1: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident had short term memory problems, and was able to make his needs known according to the nurses notes, there was no Minimum Data Set Assessment (MDS) available. Resident was admitted from the hospital with [MEDICATION NAME] ([MEDICATION NAME] dressing) to his sacral area. There was no documented assessment of the sacral area wound following admission to the facility. The hospital nursing discharge plan/instructions dated 3/1/13 documented [MEDICATION NAME] to coccyx, change today with [MEDICATION NAME]. Last change was 2/27/13. There was no documentation in regards to the wound beneath the [MEDICATION NAME] dressing. The hospital discharge summary dated 3/1/13 included no documentation in regards to the [MEDICATION NAME] to the coccyx. The admission nursing assessment dated [DATE] documented abraded area, [MEDICATION NAME]. The body picture was documented with a circle drawn around the sacral area. There was no further description of the sacral area to include measurements. The initial care plan, undated, documented under pressure sore/ulcer/skin at risk, [MEDICATION NAME] coccyx. The nurse note dated 3/1/13 and signed by a Registered Nurse (RN) documented Sacral area was excoriated/abraded, cleansed with normal saline applied [MEDICATION NAME]. There was no further documentation describing the sacral area. There was no evidence of a non-ulcer flow sheet or ulcer flow sheet being completed for Resident # 1. The physician orders [REDACTED]. The physician note dated 3/4/13 documented the resident was being seen for an acute visit related to vomiting this morning. Assessment and plan included Resident is stable. There was no documentation of the sacral area. The treatment administration record which was undated documented [MEDICATION NAME] to coccyx, change every three days and as needed. The box indicating the first (day of admission) and second of the month had a line through them indicating treatment not done. The box indicating the third day of the month was initialed as changed. The wound specialist initial evaluation dated 3/5/13 and signed by the wound physician documented the following wounds: Coccyx, pressure area, unstageable necrosis measuring 3 centimeters (cm) x 2 cm with depth not measurable. Left buttock, pressure area, unstageable necrosis measuring 3 cm x 3 cm with depth not measurable. Right buttock, pressure area, unstageable necrosis measuring 3 cm x 3 cm with depth not measurable. Dressing order was changed to dry protective dressing, santyl (Ointment is active enzymatic therapy that removes necrotic tissue from wounds), zinc to periwound, once daily. The RN that wrote the nurses note of 3/1/13 was not available for interview. During an interview on 4/18/13 at 3:30 pm, DON stated she searched the unit and could not find evidence that a wound assessment was done on admission. DON stated that a wound assessment should have been completed on the ulcer form with description and measurements. 10 NYCRR 415.12(c)(2)

Based on record review and interview during an extended recertification survey and abbreviated survey (NY 534) the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrates that this is not possible for three ( #'s 3, 5 and 119) of six residents reviewed for weight (wt) loss. Specifically: for Resident #3, the facility did not perform a timely assessment of a significant weight loss, did not monitor intake records and did not ensure accuracy of weights; subsequently the resident developed an avoidable stage III pressure ulcer. For Resident # 5 intake records were not monitored. Resident # 119 was admitted to the facility for weight loss and rehabilitation and was not weighed for four months. This resulted in actual harm for Resident # 3 and potential for more than minimal harm for Resident # 5 and #119 that is not immediate jeopardy. This is evidenced by: The Policy and Procedure (P&P) entitled Food and Fluid Tracking documented the facility will monitor the residents intake each day using the approved food/fluid tracking sheet. The purpose documented was to use this data as part of an assessment to promote hydration and nutrition. Procedures included; resident is provided a tray on the unit or in the dining room; if assistance is required to consume then assist as needed (prn); at end of meal check residents water pitcher, glass, cups, soup, ice cream, and plates for amount consumed; document any nourishments during the shift; nurse will record all intake given to resident with medications; the evening (3:00 pm to 11:00 pm) shift unit nurse will total the forms and the evening supervisor will collect and sign them and deliver them to the night supervisor; night supervisor will highlite in pink those residents who did not consume 1200 cc of fluid in a 24 hour period and will begin the next twenty four hour period by marking a plus sign or star next to the resident's name. If a resident's triggers on day 3 a Hydration Protocol Sheet will be initiated for that resident. The P&P entitled Nutrition and Weight Risk Monitoring documented the Interdisciplinary Care Plan Team will identify residents at risk for nutritional depletion and attempt to promote improvement or maintenance of nutritional status and weight, as resident and clinical condition allow. Documented under the procedure was; If greater than 3 pound (lb) weight change, a reweigh is obtained by nursing staff as soon as possible prior to initiating Dietary Communication Form to verify the validity of the weight change; if significant weight change the RN, Dietician (RD), Diet technician (DT), or physician will complete a team assessment with input from other team members, if indicated to determine if this weight change is expected to be temporary or desirable; A significant weight change is any weight change greater than 5% in one month or greater than 10% in 6 months, also clinically significant is a weight change of greater than 7% in 3 months; If a weight change is determined to be temporary, weekly weights will be initiated through the following month, if weight change continues a new Dietary Communication Form will be initiated. Upon determination of weight change or other nutritional concern dietary will expedite the Interdisciplinary Nutritional Review Form and send to Unit Manager. The Interdisciplinary Nutritional Review will be completed prior to the weight rounds review by each discipline to provide a comprehensive review of possible contributing factors. The disciplines included, dietary, nursing, social service and occupational therapy. P&P entitled [MEDICAL TREATMENT] Residents, undated, documented residents requiring [MEDICAL TREATMENT] will have the following in effect: diet as ordered, fluid restriction as ordered, I&O prn, diet counseling prn, arrange for transportation to and from [MEDICAL TREATMENT], communication book to be sent to/from [MEDICAL TREATMENT]. Resident # 3: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. He had long and short term memory problems with severely impaired decision making according to the 3/17/13 Minimum Data Set (MDS). MDS documented the resident weighed 165 lbs, and had a significant weight loss, and required limited assistance of one for eating. Comprehensive Care Plan (CCP) dated 3/21/13, entitled potential nutritional problem related to (r/t) [DIAGNOSES REDACTED]. Resident intake is currently good. Dated 3/21/13-developed Stage 3 open heel wound. Interventions included, obtain and monitor laboratory work as ordered, OT to screen and provide adaptive equipment for feeding as needed, provide and serve supplements and snacks, Registered Dietician (RD) to evaluate and make diet change recommendations prn, weigh at same time of day and record monthly. The facility was unable to provide documentation of a CCP initiated when the pressure ulcer was discovered on 1/15/13. The Resident's weight (wt) record documented: 11/9/12 = 189 lbs, 12/8 =196 lbs with "questionable" written next to it, 12/20/12 = 185 lbs, 1/10/13 =179.4 lbs, 1/18/13 = 178 lbs, 2/18/13 =164.8 lbs. There were no documented reweighs. Intake records for Resident # 3 documented for December resident ate for breakfast: 100% 18 times. 75% 4 times. 50% 5 times. 25% 1 time. 0% 3 times lunch: 100% 23 times 75% 3 times 50% 2 times 25% 1 time 0% 2 times dinner: 100% 24 times 75% 4 times 50% 1 time 25% 1 time 0% 1 time Intake records for Resident # 3 documented for January resident ate for breakfast: 100% 8 times 75% 2 times 50% 3 times 25% 0 time. 0%16 times lunch: 100% 14 times 75% 5 times 50% 5 times 25% 5 time 0% 2 times dinner: 100% 8 times 75% 5 times 50% 6 time 25% 8 time 0% 4 times Intake records for Resident # 3 documented for February 1st thru 18 th resident ate for breakfast: 100% 10 times 75% 2 times 50% 0 times 25% 2 time. 0% 5 times lunch: 100% 5 times 75% 4 times 50% 2 times 25% 2 time 0% 5 times dinner: 100% 4 times 75% 8 times 50% 3 time 25% 0 time 0% 1 times Quarterly Nutrition note dated 12/20/12 by the Diet Technician (DT) documented weight at 185 lbs with a 1 lb increase in 3 months. Current solid intake at 3/4 to all, and current liquid intake 1,977 cc of fluid. Weight stable. Recommendations documented were to increase milk to 8 ounces (oz) every meal to help meet protein needs. Resident Weight Sheet documented weight on 1/10/13 was 179.4 lbs. (10 lbs "5%" weight loss in 2 months). The facility was unable to provide documentation that this weight loss was addressed. The Ulcer Flow Sheet dated 1/15/13 documented a Stage 3 pressure sore measuring 3.6 centimeters (cm) x 2.0 cm x 0.2 cm in depth, irregular shaped with necrotic tissue. Documented sero-sanguinous drainage, red wound bed and surrounding tissue as soft and discolored. Laboratory result dated 1/15/13 for [MEDICATION NAME] showed a result of 3.2 (reference range 3.4-5.0. The physician order dated 1/16/13 documented Give 60 cc of [MEDICATION NAME] (dietary supplement) by mouth with medication pass. A psychiatry note dated 1/17/13 documented resident with dementia. Recent medication changes for agitation. Now on increased dose of [MEDICATION NAME] and [MEDICATION NAME] (new), [MEDICATION NAME] (new). There was no documentation in regards to 10 lb weight loss in two months. Resident Weight Sheet documented weight on 1/18/13 was 178 lbs. (11 lb weight loss in 9 weeks) The facility was unable to provide documentation that this weight loss was addressed. Nutrition Assessment/Skin Breakdown note dated 2/1/13 and signed by the DT documented weight at 178 lbs, a decrease of 7 lbs since 12/20/12. Current solid intake 1/2, and current liquid intake 1339 cc of fluid. Recommendations/comments documented were to "request zinc level, adequate protein provided for healing with between meal supplements and [MEDICATION NAME] 60 cc with med passes-however intake has decreased." A physician note dated 2/1/13 and signed by the Physician Assistant (PA) documented the resident's weight has been stable this month. A physician note dated 2/6/13 and signed by the PA had no mention of the weight loss. Laboratory result dated 2/8/13 for [MEDICATION NAME] showed a result of 11.8 (reference range 20-40. laboratory results dated [DATE] for Iron at 25 (reference range 49-181), TIBC (total iron binding capacity) 130 (reference range 250-450), Ferritin (a protein in the body that binds to iron) 1090 (reference range 30-400). A physician note dated 2/15/13 and signed by the PA, addressed the lab results of 2/15/13 and ordered Vitamin C 500 mg daily to help the absorption of the iron. There was no mention of a weight loss. Resident Weight Sheet documented the residents weight on 2/18/13 was 164.8 lbs. (24 lb "12%" weight loss in 3 months). The facility was unable to provide documentation that this weight loss was addressed. Physician note dated 3/4/13 and signed by the facility physician documented the resident weighed 178 lbs on 1/20/13 and 164.8 lbs on 2/20/13. A loss of 13.2 pounds of weight this past month. There was no mention of a 24 lb weight loss in three months. A Quarterly Nutrition note dated 3/14/13, by the Diet Technician, documented the residents weight as 166 lbs, a 1 lb increase in one month. The note documented the resident had a gradual weight loss since 12/20/12, weight loss was due to illness. Current solid intake 3/4 of meals, and current liquid intake was 1,982 cc. It documented a weight change decrease of 19 lbs since 12/2012 was a significant weight loss. Recommendations were to change morning and evening Ensure to Ensure Plus for additional calories and protein, also change juice at breakfast to Resource. Resident weight record revealed the weight for 12/20/12 at 185 lbs, and the last weight recorded was 164.8 lbs on 2/18/13. This indicated a 20.2 lb loss since the 12/2012 weight. A physician note dated 3/15/13 and signed by the PA contained no documentation in regards to weight loss. The interdisciplinary progress notes from 12/1/12 through 3/26/13 had documented a note written on 3/21/13 by the Diet Technician that said see paper copy quarterly review note dated 3/14/13 re: undesirable weight loss 18 lbs in 6 months. The note does not mention the 24 lb weight loss from the 11/9/12 weight of 189 lbs through 2/18/13 164.8 lbs. The interdisciplinary progress notes from 12/1/12 through 3/26/13 revealed no documentation in regards to monitoring the resident's appetite or weight loss. The twenty four hour report sheets were reviewed from 1/1/13 through 1/31/13 and there was no documentation for Resident # 3 in regards to appetite, solid intake or weight loss. During an interview on 4/9/13 at 1:00 pm the Director of Nursing (DON) stated that intakes are documented daily and that dietary reviews them as well as nursing and if there is a problem it would be discussed at the weekly weight rounds. DON stated that a significant change assessment should have been considered given the weight loss and the discovery of the Stage 3 wound to the resident's heel on 1/15/13. During an interview on 4/10/13 at 2:50 pm the facility physician stated he wrote on 3/4/13 a 13 lb weight loss because that was what he had been made aware of. Stated that with the 13 lb loss he planned to monitor the Resident's weight to see if it became a pattern, because given his condition and being treated for [REDACTED]. He stated he was not made aware of a 24 lb weight loss in three months and that was a significant loss. Physician stated he would have looked at the 24 lb loss differently than the 13 lb loss and may have ordered some additional blood work or tests. During an interview on 4/11/13 at 4:00 pm RNM #1 stated that the evening shift (3:00 pm to 11:00 pm) Supervisor was supposed to monitor and review the intake sheets and the CNA's fill them out. RNM stated that a new intake is put out every day and the old is filed in a binder. RNM was not sure who was responsible for looking back at sheets for trends in appetite changes. Stated if there was an appetite change on a particular day it should be placed on twenty four hour report. During an interview on 4/12/13 at 9:00 am the DON stated that the CNA's are responsible to let the nurse know if there is a decline in appetite on a daily basis. Stated the Nurse Manager and Interdisciplinary Team would look at an appetite decline and weight loss together and discuss it. The DON while looking at the intake sheets for January stated that they did not put it together that the Resident's solid intake had changed. During an interview on 4/10/13 at 10:30 am the DT stated that she documented the Resident weight loss was due to illness in her note due to the Resident's wound infection and receiving IV antibiotics. DT stated that the Team makes the decisions if a significant change assessment should be done and this is discussed in the quarterly reviews. DT stated she does not notify the Team of weight loss, that nursing does. During an interview on 4/10/13 at 10:30 am the RD stated she was not aware of the weight changes in Resident # 3. Stated she should have been made aware and would have done an assessment and she would have referred to the physician to evaluate. RD does all initial assessments and care plans and attends the wound meetings. RD stated the DT assessments and interventions did look good but that the weight changes should have been questioned, and that a weight change of five lbs or more should always have a reweigh done. During an interview on 4/12/13 at 3:15 pm the DT stated she does a chart review quarterly with the MDS scheduled assessments. She only looks at the intake sheets during a quarterly review and she only looks back seven day. She only looks at Residents charts that are not scheduled for a review if she is told of a situation with a Resident's intake. DT stated there was weekly skin round meetings that she attends and they discuss intake and appetite issues then. Stated she was not sure what system was used to monitor the trends in the Residents appetites and intakes. Resident # 5: The Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident has moderate cognitive impairment according to the MDS dated [DATE]. MDS also documented there was no significant weight loss of 5% or more and required total assistance of one for eating his meals. The Comprehensive Care Plan (CCP) dated 1/3/13 initiated and revised on 4/1/13, entitled potential for nutritional problem r/t [MEDICAL CONDITION], chronic [MEDICAL CONDITION] with [MEDICAL TREATMENT], [MEDICAL CONDITION] (TBI), and cardiovascular accident ([MEDICAL CONDITION]) with dysphagia, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Unable to feed himself, refuses po intake. Intervention included are :weigh at same time of day and record, weigh every Wednesday after [MEDICAL TREATMENT]. There were no further interventions. The CCP dated 4/11/13 and entitled resident needs [MEDICAL TREATMENT] r/t [MEDICAL CONDITION], included the interventions of obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and blood pressure immediately. There were no further interventions. The Resident Profile (guide containing all assistance required for care by the Certified Nurse Aides), dated 4/13/13 documented Resident # 5 as requiring total assistance of one with meal consumption. The Resident's weight (wt) record from the facility documented: December 2012 = 176.8 lbs, January 2013 = 169 lbs, February 2013 = 145.8 lbs, 3/29/13 = 142.8 lbs, 4/5/13 = 132 lbs. Intake records for Resident # 5 documented for December resident ate for breakfast: 100% 14 times. 75% 2 times. 50% 3 times. 25% 1 time 0% 2 times lunch: 100% 12 times 75% 3 times 50% 0 times 25% 8 time 0% 4 times dinner: 100% 11 times 75% 7 times 50% 0 time 25% 3 time 0% 4 time Intake records for Resident # 5 documented for January resident ate for breakfast: 100% 29 times 75% 1 times. 50% 0 times. 25% 0 time. 0% 1 time lunch: 100% 16 times 75% 3 times 50% 4 times 25% 2 time 0% 6 times dinner: 100% 19 times 75% 3 times 50% 4 times 25% 1 time 0% 4 time Intake records for Resident # 5 documented for February for 23 days, resident ate for breakfast: 100% 13 times 75% 2 times. 50% 3 times. 25% 0 time. 0% 5 time lunch: 100% 9 times 75% 1 times 50% 2 times 25% 0 time 0%11 times dinner: 100% 9 times 75% 2 times 50% 1 times 25% 1 time 0% 10 time Intake records for Resident # 5 documented for March for 26 days, resident ate for breakfast: 100% 10 times. 75% 1 times. 50% 5 times. 25% 2 time 0% 9 times lunch: 100% 5 times 75% 1 times 50% 4 times 25% 6 time 0% 11 times dinner: 100% 6 times 75% 0 times 50% 2 times 25% 1 time 0% 18 times A Quarterly Nutrition note dated 1/16/13, signed by the RD, documented weight at 166 lbs with a 11 lb decrease in one month making it a 5% or greater weight change. Note documented that fluctuations likely related due to [MEDICAL TREATMENT]. Current solid intake at 75% and current liquid intake 1300 cc fluid. Comments documented that Resident refusing meals at times. Documented dry weight (weight following [MEDICAL TREATMENT] treatment) by [MEDICAL TREATMENT] as 159.5 lbs. Recommendations and changes documented included change 8 oz milk at lunch and supper to Boost Breeze to increase protein intake and decrease potassium intake. Reduce cottage cheese to 1/2 cup at night, continue to monitor weight, labs and skin. Resident weight sheet documented weight for February 2013 (no day documented) at 145.8 lbs (a 20.2 weight loss since nutrition note of 1/16/13). There was no reweigh documented for the weight of 145.8 lbs. The next nutrition note documented was dated 4/8/13. Physician note dated 2/4/13 and signed by Nurse Practitioner (NP) made no mention of weight loss. There was no other physician orders [REDACTED]. Nurse notes for the month of February contained no documentation of the weight of 145.8 lbs a 20.2 lb weight loss. Physician note dated 3/8/13 and signed by facility physician documented "no significant weight changes". A Physician order [REDACTED]. 2 cal, 60 milliliters (ml) with medication pass and weekly weights. Dietary Communication Form dated 3/12/13 documented physician order [REDACTED]. A Physician order [REDACTED]. Resident weight sheet documented weight for 3/29/13 as 142.8 lbs ( a 3 lb loss since last weight) A Physician note dated 4/1/13 and signed by facility physician documented staff informed physician of decrease food intake for the last couple of weeks. Looking at his weight he weighed 176.8 lbs in 12/2012, down to 169 lbs in 1/2013, and 145 lbs in 3/2013. He has been noted to have a decrease in the amount of food he has been eating. Plan to start on [MEDICATION NAME] 15 mg at bedtime. This will hopefully help with his poor food intake as well as [MEDICAL CONDITION] disorder and intermittent agitation. Resident weight sheet documented weight for 4/5/13 as 132 lbs (a 10.8 lb weight loss since 3/29/13). A RD note dated 4/5/13 documented Resident's intake is very poor at this time. Weights have been fluctuating all over the place. 164 lb on 3/11/13 per [MEDICAL TREATMENT] (post [MEDICAL TREATMENT] weight), 143 lb a week ago and 132 lb today. Weights tend to fluctuate due to fluids. Some of the weight difference is most likely real at this time. Resident is refusing to eat and take medications at this time. A Quarterly Nutrition Review dated 4/8/13 and signed by the DT and RD documented 132 lbs, a 21 lb decrease which was 5% or greater weight loss. The residents weighed 143 lb yesterday per RD at [MEDICAL TREATMENT]-post [MEDICAL TREATMENT] weight. 34 lb weight loss since December admission. Recommendations included discontinue low potassium diet until intake (illegible). Stimulant to improve appetite. Consider change in [MEDICATION NAME]. During an interview on 4/9/13 at 1:00 pm the Director of Nursing (DON) stated that intakes are documented daily and that dietary reviews them as well as nursing and if there is a problem it would be discussed at the weekly weight rounds. During an interview on 4/11/13 at 4:00 pm RNM #1 stated that the evening shift (3:00 pm to 11:00 pm) supervisor was supposed to monitor and review the intake sheets after the CNA's fill them out. RNM stated that a new intake is put out every day and the old is filed in a binder. The RNM was not sure who was responsible for looking back at sheets for trends in appetite changes. Stated if there was an appetite change on a particular day it should be placed on twenty four hour report. During an interview on 4/12/13 at 3:15 pm the DT stated she does a chart review quarterly with the MDS scheduled assessments. She only looks at the intake sheets during a quarterly review and she only looks back seven day. She only looks at residents charts that are not scheduled for a review if she is told of a situation with their intake. DT stated there was weekly skin round meetings that she attends and they discuss intake and appetite issues then. She was not sure what system was used to monitor the trends in the residents appetites and intakes. During an interview on 4/16/13 at 2:35 pm, DT stated residents are weighed weekly on admission for one month and normal weights are done monthly. DT stated she was not notified of weight of 145 lbs in February. During an interview on 4/16/13 at 3:09 pm, RD stated the resident was new on [MEDICAL TREATMENT] when he was first admitted in December 2012. An initial weight decrease was due to getting the fluid off with [MEDICAL TREATMENT]. The resident was eating well in the beginning and [MEDICAL TREATMENT] was adjusting his dry weight. The physician put him on a appetite stimulant. RD stated the facility should be using the [MEDICAL TREATMENT] weights, not the facility weights since they vary so greatly. Stated weights are usually dated but there is no consistency, and any change of 5 lbs or more should generate a reweigh. The RD stated that all initial weight loss was fluid, last month weight loss may be a problem. If there was no note from her in regards to the weight of 145 lbs in February that she was probably not told about it. During an interview on 4/17/13 at 3:00 pm, RD stated that she did not know where the February weight of 145 lbs came from, she checked the [MEDICAL TREATMENT] weights and the resident was in the low 160's in February. Then there was a drop in March after 3/12/13 to 144 lbs. RD stated that she was not sure staff are looking at weights and instructing reweighs to be done. CNAs are writing on the weight sheets and ward clerks are transcribing in the charts. The RD stated depending on the unit, there may not have been notifications of weight changes. Resident #119 The facility did not obtain a weight of the resident until he had been at the facility for four months. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognition and as being able to make himself understood and able to understand others. No weight was documented on the MDS. The Diet History and Admission Note dated 1/2/13 documented an admission weight of 586 pounds (lbs.). The Initial Nutritional assessment dated [DATE], documented the resident was to have an amputation of his right leg but needed to lose weight first. It further documented the resident was unable to be weighed so weights would be monitored based on body measurements. The Comprehensive Care Plan (CCP) for Nutrition dated 1/24/13 and revised on 5/11/13, documented the goal to prevent weight gain and promote weight loss and further documented that there was no scale available to weigh the resident because the resident refused to use the ceiling lift. The Resident Profile (used by the staff to know what care the resident required) revised on 3/30/13 documented under the heading of How (the resident was to be) Weighed, that it was " to be determined. " The Physician ' s Note dated 3/29/13, documented that the resident was not weighed because he was obese to the point where there was no available scale to weigh him. The Interdisciplinary Team Meeting note dated 4/25/13, documented that weights were unable to be obtained. The Resident Weight Sheet documented measurements of the resident ' s abdomen, arm, and thigh on 1/9/13 and 1/16/13 and the resident ' s arm and thigh on1/23/13. No further measurements were documented on this sheet. An untitled document provided by the Dietician documented measurements of the resident ' s abdomen, arm, and thigh on 1/9/13, 1/16/13, 1/30/13, and 2/4/13. No further documentation of body measurements could be provided by the facility. A delivery receipt dated 4/26/13, documented that a bariatric lift (a mechanical lift with a higher weight capacity) was delivered to the facility. The Monthly Weight Report dated 6/2012 through 5/2013 documented a weight of 584.0 lbs. for 4/2013 and a weight of 576.6 lbs. for 5/2013. During an interview on 5/14/13 at 9:40 am the Diet Technician stated that she used the weight on the resident ' s admission transfer summary from the hospital as the resident ' s admission weight. They were unable to obtain a weight of the resident as he was scared to use the ceiling lift. She stated the resident was just recently weighed for the first time at the facility a few weeks ago. She further stated she thought that staff was measuring the resident ' s body but she did not know where those measurements were. During an interview on 5/14/13 at 10:35 am the Dietician stated she was aware that the resident was not being weighed but they were measuring his abdominal girth, arm, and thigh in order to measure his progress losing weight. She stated that she had some of the measurements but she did not know where they were now. During an interview on 5/15/13 at 11:30 am the DON stated that it was facility policy to obtain a resident ' s weight on admission, weekly for four weeks, and monthly thereafter. She stated she was not aware the resident was not being weighed at the facility, and that was not in compliance with their policy. She further stated they should have obtained the bariatric lift sooner as there was no way to measure the resident ' s goal of weight loss. During an interview on 5/15/13 at 12:15 pm, the Administrator stated that he had been working on getting budget approval from the Corporation for the bariatric lift since February. He stated the resident refused to get out of bed but he was unaware the resident was not being weighed in the facility, and this was against their policy. 10NYCRR 415.12(i)(1)

Based on medical record review and staff interviews conducted during a complaint investigation (Case # NY 590 ), it was determined that for one (Resident # 1) of 24 residents reviewed the facility did not notify the resident's physician (MD #1) in a timely manner when the resident refused to have blood drawn for a [MEDICATION NAME]/International Normalized Ratio (PT/INR) (blood test performed to determine clotting time and the required dose of [MEDICATION NAME] for this resident) or when the resident experienced continued hematuria/vaginal bleeding. Specifically, Resident # 1 was ordered to have a PT/INR drawn on 4/16/12 but refused to allow the technician to draw the blood and the test was never drawn again until 4/29/12, when the resident was sent to the emergency department (ED). At the ED, the residents INR was noted to be extremely elevated at "14" (the desired range for this resident was between 2 and 3) and the resident was hospitalized from [DATE] to 5/7/12. Additionally, the physician was not notified when the resident continued with hematuria/vaginal bleeding [MEDICATION NAME] five days. This is a repeat deficiency. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following information: Resident # 1 The resident was admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE], assessed the resident was cognitively intact. A physician's orders [REDACTED]. Nurses notes(NN) for the week of 4/24/12 to 4/29/12 documented the residents progress; on 4/24/12 at 4:13am, "Staff noted vaginal bleeding. Frank blood in attends"; on 4/24/12 at 1:15pm, vaginal bleeding was noted twice, the physician was made aware and ordered a gynecological consult; on 4/25/12 at 6:40am, vaginal bleeding was noted once; on 4/26/12, hematuria was noted twice. On 4/28/12 at 12:59pm,the resident continued to have vaginal bleeding with nickel size clots. On 4/29/12 at 6:38am NN documented the resident complained right rib pain, and hematuria was noted twice. At 7:34am, NN documented the resident passed large vaginal clots, and was sent to the ED. In the hospitalist admission note dated 4/29/12, under the residents problem list the physician wrote; 1. Coagulopathy due to [MEDICATION NAME]; 2. active GU ([MEDICAL CONDITION]) bleed. In a note dated 5/1/12 the hospitalist dictated that Resident # 1 was admitted on [DATE] with complaints of back pain and vaginal versus urethral bleeding and the resident is on anticoagulation therapy following a stroke. On admission to the hospital (4/29/12), the resident was found to be "Supertherapeutic from anti-coagulants with an INR of 14." A review Resident # 1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 5/16/12 at approximately 8:15am, a Licensed Practical Nurse (LPN #1) stated that she was the full time charge on Resident # 1's unit. On 4/24/12 she was notified by the night nurse that Resident # 1 had vaginal bleeding and /or hematuria during the night and when she reported this to the MD # 1 when he arrived to make rounds that day, he ordered the resident to be seen by a gynecologist. LPN #1 stated that the resident continued to have vaginal bleeding and/or hematuria over the next several days. She stated she did not tell the MD that the resident was on [MEDICATION NAME] when she discussed the hematuria/vaginal bleeding with him on 4/24/12 and she did not call the MD again over the next several days to report that the bleeding was continuing. During an interview on 5/15/12 at approximately 9:00am, a Registered Nurse Unit manager (RNUM) stated that Resident # 1 had been on [MEDICATION NAME] for many years and her [MEDICATION NAME] dose was determined on the results of PT/INR tests drawn every few days. On 4/9/12 the MD ordered [MEDICATION NAME] 1.5 mg each day and a PT/INR was to be drawn in one week (on 4/16/12). On the morning of 4/16/12 the resident refused to allow the technician to draw blood. The lab technician reported this to the night shift charge nurse and also wrote "refused" in the facility log book next to the resident's name. The RNUM stated that this was never reported to the doctor or the family and the resident never had another PT/INR drawn until 4/29/12 when she was admitted to the hospital and her INR was found to be 14. The RNUM could not explain why another attempt had not been made to draw the PT/INR after 4/16/12 or why the MD was not notified, but assumed it had been mistakenly overlooked. The RNUM stated that although she had been aware the resident was experiencing hematuria/vaginal bleeding starting on 4/24/12 and knew that an elevated INR could cause these conditions, she never considered that the two issues could be connected for this resident. During an interview on 5/15/12 at approximately 11:00am, Resident # 1 ' s attending physician (MD#1) stated that he did not recall being notified on 4/16/12 that the resident had refused to have blood drawn for INR but if he had he would have ordered another INR to be drawn the next day. He did recall being informed on 4/24/12, that the resident was having vaginal bleeding. He instructed the nurse to make an appointment for the resident to be seen by a gynecologist. He stated he was not reminded at that time that the resident was on [MEDICATION NAME] and added that if he had been reminded the first thing he would have checked would have been her most recent INR. MD #1 stated it was not possible for him to recall all of the medications that each of his resident's receive and he would expect that a nurse who was telling him about a resident who was taking [MEDICATION NAME] and experiencing vaginal bleeding or hematuria, would remind him that the resident was on [MEDICATION NAME]. He added that he was never notified that the resident's vaginal bleeding had continued and stated that if he had realized that the bleeding was ongoing he would have ordered more blood work or for the resident to be sent to the ED for evaluation. MD #1 stated he would have expected to be notified again regarding vaginal bleeding that occurred a second or a third time. 10NYCRR415.3(e)(2)(ii)(b)

Based on medical record review and staff interviews during a complaint investigation (complaint #NY 590) it was determined that for one ( # 1) of 24 residents reviewed, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho- social well-being in accordance with established policies and procedures and standards of practice. Specifically, after the resident refused on 4/16/12 to have a PT/INR ([MEDICATION NAME]/International Normalized Ratio; blood tests that evaluate clotting time and used to determine the dose of [MEDICATION NAME] required) drawn the test was not drawn again until 4/29/12 when the resident was sent to the emergency department (ED) with complaints of pain and hematuria/vaginal bleeding. At the ED, the resident ' s INR was noted to be extremely elevated at "14" (the desired range for this resident was between 2 and 3) and the resident was hospitalized from [DATE] to 5/7/12. Additionally, when the resident was discharged from the hospital on [DATE], her anti-convulsant medication was not reordered at the nursing home and on 5/11/12 the resident experienced grand mal [MEDICAL CONDITION] and was again transported to the ED for treatment. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following information: Resident # 1 The resident was admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] assessed the resident to be cognitively intact. A physician's (MD) order dated 4/9/12 documented to discontinue current [MEDICATION NAME] orders and start [MEDICATION NAME] 1.5 mg every day and repeat PT/INR next Monday (4/16/12). A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurses notes (NN) for the week of 4/24/12 to 4/29/12 documented the residents progress; on 4/24/12 at 4:13am, "Staff noted vaginal bleeding. Frank blood in attends"; on 4/24/12 at 1:15pm, vaginal bleeding was noted twice, the MD was made aware and ordered a gynecological consult; on 4/25/12 at 6:40am, vaginal bleeding was noted once; on 4/26/12, hematuria was noted twice. On 4/28/12 at 12:59pm,the resident continued to have vaginal bleeding with nickel size clots. On 4/29/12 at 6:38am NN documented the resident complained right rib pain and hematuria was noted twice. At 7:34am, NNs documented the resident passed large vaginal clots, and was sent to the ED. In the hospitalist admission note dated 4/29/12, under the residents problem list the physician wrote; 1. Coagulopathy due to [MEDICATION NAME]; 2. active GU ([MEDICAL CONDITION]) bleed. In a note dated 5/1/12 the hospitalist dictated that Resident # 1 was admitted on [DATE] with complaints of back pain and vaginal versus urethral bleeding and the resident is on anticoagulation therapy following a stroke. On admission to the hospital (4/29/12), the resident was found to be "Supertherapeutic from anti-coagulants with an INR of 14." The resident was discharged back to the facility on [DATE]. Nurses notes dated 5/11/12, chronicled the resident's condition; on 5/11/12 at 3:30am a nurse documented that she was called to the resident's room "stat" by a CNA and the resident was having a grand mal [MEDICAL CONDITION]. The CNA reported to the nurse that at 2:55 am, the resident spontaneously went into a grand mal [MEDICAL CONDITION], [MEDICATION NAME] 10 minutes. The MD, family and an ambulance were called and the resident was transported to the emergency room (ER); a second nurse documented at 8:06am that the resident has returned from the ER; at 11:41 am third nurse documented that the MD (MD #1) was in to see the resident and ordered [MEDICATION NAME] twice daily for the resident. In an ED history and physical, dated 5/11/12 the MD dictated the following: the patient was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. She was discharged back to the nursing home on 5/7/12 and was supposed to be on [MEDICATION NAME] 500mg every morning and 750mg every evening, but for some reason this medication was not given. On 5/11/12 the resident had a [MEDICAL CONDITION] at 2:55am on and a second [MEDICAL CONDITION] at 3:25 am. In the discharge instruction section of the H&P the physician dictated that he has instructed the facility to start the resident back on [MEDICATION NAME] twice a day. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 5/15/12 at approximately 9:00am, a registered nurse unit manager (RNUM) stated that the resident had been on [MEDICATION NAME] for many years and her [MEDICATION NAME] dose was determined on the results of PT/INR tests drawn every few days. On 4/9/12 the MD ordered [MEDICATION NAME] 1.5 mg each day and a PT/INR to be drawn in one week (on 4/16/12). On the morning of 4/16/12 the resident refused to allow the technician to draw blood. The lab technician reported this to the night shift charge nurse and also wrote "refused" in the facility log book next to the resident ' s name. The RNUM stated that this was never reported to the doctor or the family and the resident never had another PT/INR drawn until 4/29/12 when she was admitted to the hospital and her INR was found to be 14. The RNUM could not explain why another attempt had not been made to draw the PT/INR after 4/16/12 or why the MD was not notified, but assumed it had been mistakenly overlooked. The RNUM stated that although she had been aware the resident was experiencing hematuria/vaginal bleeding starting on 4/24/12 and knew that an elevated INR could cause these conditions, she never considered that the two issues could be connected for this resident. The RNUM was made aware on 4/30/12 that Resident # 1 had been admitted to the hospital on [DATE] with an elevated INR and vaginal bleeding/hematuria but she did not look back to review the resident's INR results and therefore was not aware that the resident had not had an INR drawn after 4/9/12 at the nursing home. The RNUM went on to explain that when Resident # 1 returned to the nursing home after being discharged from the hospital on [DATE], the hospital discharging MD had listed [MEDICATION NAME] (a medication the resident had taken for many years) as a medication to be resumed at the nursing home. When it was mistakenly omitted from the admission orders [REDACTED]. On 5/11/12 at 2:55am, the resident had the first of two grand mal [MEDICAL CONDITION] (second [MEDICAL CONDITION] occurred in transport) and was transported to the local ED, where it was first realized that the resident had not been taking [MEDICATION NAME]. On 5/11/12, Resident # 1 ' s family met with the RNUM and informed her that the resident had not had a PT/INR drawn after 4/9/12 at the nursing home and also that the resident had not received any [MEDICATION NAME] after returning to the facility on [DATE]. After that family meeting, the RNUM reviewed the resident ' s medical record and determined how the [MEDICATION NAME] had been mistakenly omitted. She explained that the mistake occurred when a nurse (LPN#1) copied a list of medications from the hospital discharge sheet to the nursing home MD order form and omitted the [MEDICATION NAME]. When LPN #1 reviewed the orders with the MD neither realized that the [MEDICATION NAME] had been omitted. The RNUM stated it was the responsibility of the nurses on the next two shifts (after the order was written) to verify that the orders were transcribed accurately and she did not understand how the mistake was not discovered at that time. During an interview on 5/15/12 at approximately 11:00am, the attending MD#1 stated that he did not recall being notified on 4/16/12 that the resident had refused to have blood drawn for INR but if he had he would have ordered another INR to be drawn the next day. He did recall being informed on 5/24/12, while at the facility, that the resident was having vaginal bleeding. He instructed the nurse to make an appointment for the resident to be seen by a gynecologist. He stated he was not reminded at that time that the resident was on [MEDICATION NAME] and added that if he had been reminded the first thing he would have checked would have been her most recent INR. MD #1 stated it was not possible for him to recall all of the medications that each of his resident ' s received and he would expect that nurses telling him about a resident with vaginal bleeding or hematuria would remind him that the resident was on [MEDICATION NAME]. He added that he was never notified that the resident ' s vaginal bleeding had continued and stated that if he had realized that the bleeding was ongoing he would have ordered more blood work or sent her to the ED for evaluation. MD #1 stated that on 5/11/12, after the resident returned from the hospital ED that he was made aware that the resident had not received any [MEDICATION NAME] after she returned from the hospital on [DATE] and that her [MEDICAL CONDITION] were a result of this error of omission. During an interview on 5/15/12 at approximately 2:30pm, the Director of Nursing (DON) was asked if she had a policy and/or procedure for administering medications, anti-coagulant medications, for transcribing orders or one that addressed drawing labs. The DON stated that she would look, but did not think the facility had any of those policies. In a follow-up interview on 5/16/12 at approximately 1:30pm, the DON stated that she had found a medication policy from the pharmacy but it did not address what to do when a resident refused to have bloods drawn. She stated that she felt a reasonable person would have notified the physician when any resident refuses to have blood drawn or at least make out a lab requisition to have blood drawn the following day. When asked about the procedure for calling a doctor for telephone orders for a resident being admitted from the hospital, the DON stated it would be her expectation that the nurse would read the list of medications from the hospital discharge list to the doctor on the phone and after the doctor agreed to the orders, to then transcribe the list of medications to the nursing home MD order form. She added that it was a procedure at the facility that the nurses on the two shifts after any order is written, are responsible to verify that the orders were accurately transcribed. She stated it would be her expectation that when the second and third check was done to verify the accuracy of Resident #1 ' s orders, that the nurses would use the hospital discharge medication list as a reference. She did not know why the omission of the resident' [MEDICATION NAME] was not identified during one of those two accuracy checks. During an interview on 5/16/12 at approximately 8:15am, a licensed practical nurse (LPN #1) stated that she was the full time charge on Resident # 1's unit. On 4/24/12 she was notified by the night nurse that Resident # 1 had vaginal bleeding and /or hematuria during the night and when she reported this to the MD # 1 when he arrived to make rounds that day, he ordered the resident to be seen by a gynecologist. LPN #1 stated that the resident continued to have vaginal bleeding and/or hematuria over the next several days. She stated she did not tell the MD that the resident was on [MEDICATION NAME] when she discussed the hematuria/vaginal bleeding with him on 4/24/12 and she did not call the MD again over the next several days to report that the bleeding was continuing. LPN #1 stated that although she knew [MEDICATION NAME] could cause hematuria and vaginal bleeding, it did not occur to her that Resident # 1's hematuria might be the result of an elevated INR. At that time, she was not aware that the resident had not had a PT/INR drawn since 4/9/12. LPN #1 stated that she was the nurse that made the medication error of omission with Resident #1 ' s anticonvulsant medication, [MEDICATION NAME]. She recalled taking the discharge list of medications from the hospital and transcribing them to the nursing home MD order form unknowingly omitting the residents [MEDICATION NAME]. She then called a physician (who was not the resident ' s attending physician) and read the list of orders to him for his approval. The physician agreed to each of the residents orders but because the [MEDICATION NAME] had already been omitted it was not ordered. LPN #1 could not explain why the nurses on the two shifts following her on 5/7/12, who were responsible to verify that the orders were transcribed accurately, had not found the error of omission. LPN#1stated that they might have looked at the nursing home MD order form for reference and not the hospital discharge list of medications, to reconcile the orders. 10NY CRR415.12

Based on observation, record review and staff interview, during a complaint investigation (Case #NY 525), it was determined that for 1 (Resident #5) of 4 residents reviewed, the facility did not ensure that the resident environment remained as free of accident hazards as possible. Specifically, the facility did not ensure that the resident's footrest was on the wheelchair. Subsequently, the resident slid out of the wheelchair and sustained an upper arm fracture. This resulted in actual harm that was not immediate jeopardy. This was evidenced by: Resident #5: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have severe cognitive impairment, and was totally dependent on the assist of two staff for transfers, and had impaired range of motion of one upper extremity. An undated Fall Risk Assessment documented that the resident required assistance an a device or the help of two people for balance, and that the resident was a moderate risk for falling. The Comprehensive Care Plan (CCP) for Falls, dated 2/2/11, documented that the resident had a history of [REDACTED]. As of 10/24/11, there was to be Dycem (a non-slip pad) on the wheelchair. The Resident Profile, used by the Certified Nurse Assistants (CNA) to know what care each resident required, dated 4/26/12, documented that the resident was to have Dycem above and below the lift sheet in the wheelchair to decrease sliding, and leg rests were to be used on the wheelchair. A nurses note dated 5/27/12 at 9:08 pm, documented that the resident was heard calling out for help. When the nurse entered the room, the resident was sliding out of her wheelchair, and the nurse was able to lower the resident's upper body to the floor. While assisting the resident to the floor, the resident's left arm got hung up on the bed and the resident complained of shoulder pain. The nurse practitioner was called and the resident was to receive a pain medication every four hours as needed. It was also documented that the resident's wheelchair brakes were not on, and the left leg rest was not in place on the wheelchair. The Accident and Incident Report (I&A) dated 5/27/12 at 5:00 pm, documented that the resident was witnessed sliding out of her wheelchair. The resident was dependent on the assist of two staff to be lifted for transfers, and the leg rests were not on the wheelchair. It was also documented that the resident complained of left shoulder pain and the physician was called. The Root Cause section of the I&A documented that the resident slid out of her wheelchair and that the care plan was followed, and the facility policy and procedure was followed. It was documented in the Approaches/Interventions section that staff were to be educated that the foot pedal needed to be in place. The I&A was signed by the Director of Nursing (DON) #1 (who was no longer employed at the facility at the time of this investigation), the Registered Nurse Manager (RNM) #1 (the nurse who witnessed the accident), RNM#2 (the nurse manager of this resident's unit) and DON#2, who at the time of the signing of the I&A was an RNM and was not the DON. There were no completed Involved Party Statements attached to the I&A. A physician's orders [REDACTED]. A nurses note dated 6/3/12 at 2:44 pm, documented that the x-ray report of the left shoulder showed severe osteoporosis and an acute fracture of the left humeral neck (upper arm) and subluxation (displacement) of the left humeral head (the end of the arm near the shoulder). A physician's orders [REDACTED]. A Transfer to Acute Care Facility (the hospital) form dated 6/3/12 documented that the resident was being sent to the hospital due to x-ray results after a fall. A Consultation Report dated 6/4/12 documented that the resident had a fracture of the left upper arm and that the arm was to be in a sling and the resident was to receive pain medication every six hours as needed. During an interview on 6/11/12 at 11:58 am, RNM#1 stated that on 5/27/12, she saw this resident sliding out of her wheelchair. She was able to assist the resident's upper body to the floor and that while sliding out of the wheelchair, the resident's left arm was hung up on the bed. She stated that at the time the arm got hung up on the bed, the resident complained of left shoulder pain. She called the nurse practitioner who ordered a pain medication for the resident. RNM#1 stated that when she saw the resident sliding out of the wheelchair, she noticed that the wheelchair brakes were not on, the left leg rest was not on the wheelchair, and that the two pieces of Dycem were under the lift sheet. She also stated that the CNA should have ensured that the resident was in the wheelchair properly and that the leg rest should have been on the wheelchair. During an interview on 6/11/12 at 2:42 pm, RNM#2 (the resident's unit manager) stated that based on RNM#1's description of the resident's positioning with her arm hung up on the bed, it seemed likely that the resident fractured her arm during the accident on 5/27/12. She stated that there had been no other incidents involving this resident between 5/27/12 and 6/3/12 when it was discovered that her arm had been fractured. The physician was notified on 6/3/12 that bruising had appeared on the resident's left arm and that was what had prompted an x-ray. She also stated that she thought that the CNAs had toileted the resident and forgot to put her leg rest back on the wheelchair and that the wheelchair leg rest was found on top of the resident's bed. RNM#2 reviewed the I&A for this incident and stated that she was in error for documenting that the care plan had been followed. The care plan had not been followed because the leg rest was supposed to be in place. During an interview on 6/12/12 at 11:25 am, the resident's physician reviewed the nurses notes and the I&A for 5/27/12 and stated that he thought that the resident fractured her arm during that accident. He stated that the resident's leg rest should have been on the wheelchair because that was a means of support for the resident and may have prevented the resident from sliding out of the wheelchair. During an interview on 6/12/12 at 11:45 am, the resident stated that when she slid out of her wheelchair she immediately felt pain in her shoulder area. During an interview on 6/12/12 at 12:05 pm, DON#2 stated that the resident's care plan had not been followed because the leg rest should have been on the wheelchair but was not. 10NYCRR 415.12(h)(1)(2)

Based on medical record review and staff interviews during a complaint investigation (NY 590), the facility did not ensure that one ( # 1) of 24 residents reviewed was free of significant medication errors. Specifically, the facility did not ensure that Resident # 1 continued to receive her anticonvulsant medication [MEDICATION NAME], after returning to the nursing home from the hospital. After being hospitalized from [DATE] to 5/7/12, the resident returned to the facility on [DATE] with a list of discharge medications that included [MEDICATION NAME], twice daily for a long-standing history of [MEDICAL CONDITION] disorder. The medication was omitted from the resident's admission orders [REDACTED]. On the morning of 5/11/12, the resident had two grand mal [MEDICAL CONDITION] and was transported to the local ED (emergency department). This resulted in actual harm for the resident that is not immediate jeopardy. This is evidenced by the following: Resident # 1 The resident was admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set ((MDS) dated [DATE] assessed the resident to have be cognitively intact. In an ED history and physical, dated 5/11/12 the physician (MD) dictated the following: the patient (Resident # 1) was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. She was discharged back to the nursing home on 5/7/12 and was suppose to be on [MEDICATION NAME] 500mg every morning and 750mg every evening, but for some reason this medication was not given. On 5/11/12 the resident had a [MEDICAL CONDITION] at 2:55am and a second [MEDICAL CONDITION] at 3:25 am. In the discharge instruction section of the H&P the physician dictated that he has instructed the facility to start the resident back on [MEDICATION NAME] twice a day. A hospital discharge sheet dated 5/7/12, listed the medications Resident # 1 was taking on discharge from the hospital. [MEDICATION NAME] (levetiracetam) is listed as being administered twice daily; 500mg (milligrams) in the morning and 750 mg in the evening. A review of Resident # 1's nursing home admission orders [REDACTED]. An MD order dated 5/11/12 at 10:30am, (after the resident has returned from the emergency room ), orders [MEDICATION NAME] twice daily. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurses notes dated 5/11/12, chronicled the resident's condition; on 5/11/12 at 3:30am a nurse documented that she was called to the resident's room "stat" by a CNA and the resident was having a grand mal [MEDICAL CONDITION] . The CNA reported to the nurse that at 2:55 am, the resident spontaneously went into a grand mal [MEDICAL CONDITION], [MEDICATION NAME] 10 minutes. The MD, family and an ambulance were called and the resident was transported to the emergency room (ER); a second nurse documented at 8:06am that the resident has returned from the ER; at 11:41 am third nurse documented that the MD (MD #1) was in to see the resident and ordered [MEDICATION NAME] twice daily for the resident. During an interview on 5/15/12 at approximately 11:00AM, Resident # 1 ' s attending physician (MD#1) stated the resident had been on [MEDICATION NAME] (a medication to prevent [MEDICAL CONDITION]) for a [MEDICAL CONDITION] disorder for many years. On 5/11/12 he was made aware that the resident had not received any [MEDICATION NAME] after she returned from the hospital on [DATE] and on that morning (5/11/12) she had experienced two [MEDICAL CONDITION] and was sent to the ED for treatment. He saw the resident when she returned from the hospitalER on the morning of 5/11/12 and he immediately ordered her to be on [MEDICATION NAME] twice a day, as she had been on for many years. MD #1 stated that the resident [MEDICAL CONDITION] were probably a result of the [MEDICATION NAME] being omitted. During an interview on 5/15/12 at approximately 9:00am, a registered nurse unit manager (RNUM) stated that when Resident # 1 returned to the nursing home from the hospital on [DATE], the hospital discharging physician had listed an order to resume the resident's long standing anticonvulsant medication [MEDICATION NAME]. When the new nursing home orders were obtained on 5/7/11 the medication was omitted and the resident did not receive any [MEDICATION NAME] from 5/7/12 to 5/11/12. On the morning of 5/11/12 the resident experienced a grand mal [MEDICAL CONDITION] and was transported to the local ED, where it was identified that the resident had not received any [MEDICATION NAME] after leaving the hospital on [DATE]. The RNUM stated on the afternoon of 5/11/12, she met with Resident # 1 ' s family per there request and it was then that she became aware that the resident had not received her anticonvulsant medication after returning to the facility on [DATE]. After that family meeting, the RNUM investigated and found that the [MEDICATION NAME] medication error occurred when the list of medications from the hospital was copied to the nursing home MD order form and the [MEDICATION NAME] was not carried over to the MD orders. The RNUM added that it was the responsibility of the nurses on the next two shifts (after the order was written) to verify that the orders were transcribed accurately and she did not understand how the mistake was not discovered during that accuracy check. During an interview on 5/16/12 at approximately 8:15AM, a licensed practical nurse (LPN #1) stated that she was the full time charge on Resident # 1's unit and she was the nurse that had made the medication error of omission with Resident #1 ' s anticonvulsant medication, [MEDICATION NAME]. She recalled when Resident # 1 returned from the hospital on [DATE], she took the resident ' s list of hospital discharge medications and transcribed them to the nursing home MD order form. While doing this she unknowingly omitted the resident ' s [MEDICATION NAME]. She then called a physician (who was not the resident ' s attending physician) and read the list of orders to him for his approval. The physician agreed to each of the resident ' s orders but because the [MEDICATION NAME] had already been omitted, it was not reordered. LPN #1 could not explain why the nurses on the two shifts following her on 5/7/12, who were responsible to verify that the orders were transcribed accurately, had not found the error of omission. During an interview on 5/15/12 at approximately 2:30pm, the Director of Nursing (DON) was asked if she had a policy and/or procedure for administering medications, or for transcribing orders. The DON stated that she would look, but did not think the facility had any of those policies. In a follow-up interview on 5/16/12 at approximately 1:30pm, the DON stated that she had found a medication policy from the pharmacy but it did not address transcribing orders. When asked about the procedure for calling a doctor for telephone orders for a resident being admitted from the hospital, the DON stated it would be her expectation that the nurse would read the list of medications from the hospital discharge list to the doctor and after the doctor agreed to the orders, to then transcribe the list of medications from the discharge list to the nursing home MD order form. She added that it was accepted procedure at the facility that nurses on the next two shifts after any order is written, are responsible to verify that orders were accurately transcribed. She stated it would be her expectation that when the second and third check was done to verify the accuracy of Resident #1 ' s orders, that the nurses would have used the hospital discharge medication list as a reference. She could not explain why the omission of Resident # 1 ' s [MEDICATION NAME] was not identified during one of those two accuracy checks. 10 NY CRR415.12(m)(2)

Based on medical record review and staff interviews during a complaint investigation (Case # NY 090), it was determined that the facility did not ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically, for one ( #1) of four residents reviewed, the facility did not accurately identify the resident's risk factors for the development of pressure sores, including, a history of pressure sores, contractures of the lower extremities, lower extremity paralysis and the need for total dependence of 2 for bed mobility. Subsequently, the resident developed a Stage III pressure sore to the right heel. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: The Skin Care Protocol dated 6/2010, documented that routine preventative skin care included the use of a pressure reduction mattress on all beds. High Risk Preventative measures included pressure relief by elevating heels completely off surfaces. Resident #1: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills, and was totally dependent on two persons for bed mobility. The resident was also assessed on the MDS to be at risk for developing pressure sores. The Resident Problem List, which listed the resident's diagnoses, dated 10/21/10 documented that the resident had dementia, and flaccid paralysis of the legs. The Physical Therapy Joint Mobility assessment dated [DATE], documented that the resident had contractures in both hips. The Braden Scale for Predicting Pressure Sore Risk dated 2/22/11, documented that the resident's ability to respond meaningfully to pressure-related discomfort was slightly limited. The resident's skin was occasionally moist, she was chairfast, and her ability to change and control her body position was very limited. It was also documented that the resident was identified to have problems due to friction and shearing actions due to requiring moderate to maximum assistance in moving. The resident was assessed to be at moderate risk for pressure sores. The Skin Care Protocol Assessment, assessed with [REDACTED]. Among the [DIAGNOSES REDACTED]. It was documented that the resident did not have two or more of the diagnoses. The Comprehensive Care Plan (CCP) for Pressure Ulcers dated 11/14/10, documented that the resident was at risk for pressure sores due to bed mobility problems and because she had a history of [REDACTED]. The Resident Profile Card, which the Certified Nursing Assistants (CNA) used to know what care each resident required, dated 2/23/11, documented that the resident was to wear booties (Heel Pillows which were a pressure reducing device). Heel offloading was not documented on the form. A Fact Sheet for the Heel Pillows (booties) dated 2011, documented that the booties were indicated for residents at low risk for skin breakdown. The Ulcer Flow Sheet, used to track the care and progress of pressure sores, documented that on 3/17/11 the resident was assessed to have a deep tissue injury (DTI, a pressure-related injury to the tissue under the skin). This new area was measured at 4.6 centimeters (cm) long and 6 cm wide, was irregularly shaped. A Physician's Note dated 3/18/11 at 4:34 pm, documented that the resident's right leg had a contracture at the right knee. There was a large, circular darkened area consistent with a pressure sore on the right heel. The Physician wrote an order to keep weight off the right heel at all times, which was documented on the resident's care card (used by personal care givers) but not documented on the treatment record. The Ulcer Flow Sheet, on 5/4/11 documented that the DTI had opened and was assessed to be a Stage III pressure sore (full thickness tissue loss). A Surgical Consultation Report dated 5/6/11, documented that the resident had a sore on her right heel due to pressure caused by the odd posturing (contracture) of her right leg. A Physician's note dated 6/6/11 at 10:34 am, documented that the right heel pressure sore had been debrided (removal of dead, damaged or infected tissue). The resident's legs were contracted and the right heel had a foul-smelling sore which was black around the perimeter. When the physician saw the resident, she was restless and yelling out. The physician ordered an urgent surgical consult to be done that day. A Physician's note dated 6/24/11 at 11:31 am, documented that the resident was in great distress when her foot was being examined. There was a large, deep necrotic (dead tissue) sore on her right heel. The physician documented concern that there may have been a bone infection. A Physician's note dated 7/1/11 at 1:32 pm, documented that another physician had assessed the resident and felt that the only viable option was for an amputation of a portion of the right leg. During an interview on 7/11/11 at 2:17 pm, the Physical Therapist (PT) stated that prior to developing a pressure sore on 3/17/11, the resident had been wearing standard booties which were a pressure-reducing device but were not pressure-relieving. She also stated that the resident's legs were contracted and that she could not move herself in bed. During an interview on 7/12/11 at 9:36 am, the Registered Nurse Manager (RNM) stated that the resident developed the wound on the right heel because her legs were contracted. Standard pressure-reducing booties had been in place, but the heels were not offloaded (heels off surfaces to eliminate pressure) prior to developing the sore. She stated that when she completed the Braden Scale Assessment, the resident scored as a moderate risk. The RNM stated that prior to developing the sore, she felt that the resident was a high risk to develop pressure sores but she was a new RNM in 2/2011 and did not know why the heels were not offloaded. During an interview on 7/12/11 at 10:49 am, the RNM stated that when she completed a Braden Scale Assessment, she only made determinations based on the score and the results of the Skin Care Protocol Assessment. She stated that when she completed the Skin Care Protocol Assessment on this resident, she identified that the resident had a [DIAGNOSES REDACTED]. The RNM also stated that she did not recognize the resident's lower extremity paralysis as [MEDICAL CONDITION], so these were not considered risk factors. She also stated that the resident's heels should have been offloaded prior to the development of the right heel pressure sore on 3/17/11. During this interview, the RNM also stated that she did not know what the criteria was to have a resident's heels offloaded. During an interview on 7/19/11 at 12:00 pm, the Director of Nursing (DON) reviewed the Skin Care Protocol Assessment for this resident. She stated that the resident's [DIAGNOSES REDACTED]. She stated that the resident scored as a moderate risk on the Braden Scale, and that was what nursing would go with. She also stated that, looking at the resident's total picture, her [DIAGNOSES REDACTED]. During a telephone interview on 7/20/11 at 3:42 pm, the resident's physician (MD) stated that prior to the development of the heel wound, the resident was a high risk for breakdown because of her contractures if for no other reason. It was very difficult to position the resident because of her lower extremity contractures. She also stated that she thought there had been a breakdown in communication prior to this resident developing the pressure sore on her heel. It was reported to the MD that CNAs and at least one nurse had noticed the resident's heel to be reddened in the days prior to the sore and that they had reported this to RNs but nothing was done about it until the resident had the sore. The MD said that by the time she saw the resident's heel on 3/18/11, it was already in bad shape. She stated that after this, she was very upset and had conversations with the nursing department that she did expect nursing to report to her as soon as there was a concern with any resident's skin and not to wait until there was a pressure sore. During an interview on 7/21/11 at 11:48 am, CNA #1 stated that prior to this resident's pressure sore opening on 3/17/11, she had reported to Licensed Practical Nurse (LPN) #1 that the resident's heel was red and swollen and was told to put cream on the heel. She stated that prior to the pressure sore, the resident's heel were always on the bed because of the position of her legs. During a telephone interview on 7/21/11 at 10:31 am, LPN#1 stated that prior to this resident's heel wound opening, three CNAs had reported to her that the right heel was red and swollen. When she saw the heel it was, "red and angry looking." When she reported this to RN#2, she was told to make sure the CNAs were putting cream on the heels. There was no documentation of this because she assumed RNM#2 would assess the heel and document the assessment. She also stated that prior to the heel wound, the resident's heels were not offloaded. 10 NYCRR 415.12(c) (1)(2)

Based on medical record review and staff interview the facility did not ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically, for 2 ( #s 100 and 101) of 3 residents reviewed, the facility did not assess the pressure sores weekly as stated in the plan of correction, and did not have care plans for active pressure sores. This caused no actual harm but had the potential for more than minimal harm that is not immediate jeopardy. This is a repeat deficiency from the standard recertification survey. This is evidenced by the following information: Finding 1 The facility's policy titled, Skin Care Protocol, updated August 2011, documented under Assessment, that "All wounds care will be documented on the Wound Flow Sheet. Wounds must be measured at least every seven days and when condition changes. Under the section titled, Procedure for skin integrity documentation and assessment, #11, stated Update the care plan and the Braden assessment/skin care protocol. Finding 2 The facility's POC documented that the skin care team would audit the skin care protocol assessment tool for accuracy and initiations of interventions on new admissions, and residents with a change of condition. The audit dated for the week ending 8/19/11 identified Residents 100 and 101 on the form, however, the areas for documentation were blank. 1. Resident #100 The resident was admitted on [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as being alert and oriented. The MDS also documented that the resident had one, stage II pressure sore. Nurse's notes dated 8/15/2011 documented that the resident had returned to the nursing home from the hospital. The note included that the resident had 2, stage II pressure areas, right buttocks (facility acquired) and on the left hip. The note documented that the resident would be on a turning schedule when in bed, and pressure relief for heels, booties have been placed on his heels on admission. The Braden Scale for Predicting Pressure Sore Risk was dated 8/15/11 and assessed the resident at risk. The back side of the form titled, Skin Care Protocol: assessment dated [DATE] listed additional factors to consider, and if any of the factors were a "yes", the resident was to be considered high risk for pressure ulcer. The resident had 8 additional factors noted. The resident's Ulcer Flow Sheet dated 8/15/11 documented a stage II pressure sore on the right buttocks. The sheet did not document the measurements of the sore. It did document that the sore was round, red and that the surrounding tissue was intact. The treatment documented Safegel, everyday and as needed. The sheet had areas for documentation of notifications to family, physical therapy, dietary and these were blank. This sheet did not document the pressure sore to the left hip. There was no documented evidence of a weekly assessment. The care plan titled, Pressure Ulcers, initiated on 4/28/11, did not document the right buttocks pressure sore. Interventions identified were, dietary notification, as needed. notify physical therapy, as needed. Notify physician of any signs and symptoms of infection. During an interview on 8/23/11 at 1:10 pm, the registered nurse manager (RNM) stated that she did not assess the sore, as wound rounds were done on Thursdays and that she thought it could wait until then. When asked about updating the pressure sore care plan, she stated that "I did not do that." 2. Resident #101 The resident was admitted on [DATE], with a [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident as being severely impaired and not at risk for pressure sore development. The Braden Scale for Predicting Pressure Sore Risk dated 8/10/11, assessed the resident as being at high risk. The Ulcer Flow Sheet dated 8/14/11, documented that the resident had a Stage I on the right gluteal fold, measuring 4.5 centimeters (cm) by 2 cm and no depth. The area was noted to be pink and the treatment was periguard. There was no documented evidence of further assessment. The care plan titled, Pressure Ulcers, initiated on 2/10/11 did not document the pressure ulcer on the right gluteal fold. During an interview on 8/23/11 at 1:10 pm, the registered nurse manager (RNM) stated that she did not assess the sore, as wound rounds were done on Thursdays and that she thought it could wait until then. When asked about updating the pressure sore care plan, she stated that "I did not do that." 10NYCRR 415.12 (c)(1)