Every finding on record at Glengariff Health Care Center

Based on observations, record review, and interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified on one (1) (Unit 2) of six (6) resident units reviewed for the Sufficient Nursing Staffing Task. Specifically, the Centers for Medicare and Medicaid Services Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter Three (3) 2025 (April 1st- June 30th) indicated that the facility had excessively low weekend staffing. Additionally, two (2) (Resident #4 and #214) out of nine (9) residents in the Resident Council Task reported complaints about short staffing; and a random sampling of facility nursing staffing assignments did not reflect the staffing ratio as indicated in the Facility Assessment for Certified Nursing Assistants. The finding is:The Centers for Medicare and Medicaid Services Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter Three (3) 2025 (April 1st- June 30th) documented the facility triggered for the Metric of Excessively Low Weekend Staffing based on the facility's submitted staffing data.The Facility Assessment, last reviewed 09/04/2025, indicated the assessment had been reviewed previously on 07/31/2024, and again on 02/19/2025. The facility has a 262-bed capacity with an average daily census between 245-255 residents. The Facility Assessment did not include a census of each unit at full capacity. Part three (3) of the Facility Assessment documented facility resources needed to provide competent support and care for the resident population every day and during emergencies.The following staffing plan was determined for Unit [NAME] 2 :-During the Day shift (7:00 AM-3:00 PM), the unit required two (2) Licensed Practical Nurses and five (5) Certified Nursing Assistants.During an interview on 09/16/2025 at 09:34 AM, the Administrator stated that no update was required upon periodic review of the Facility Assessment since 07/31/2024. The Administrator stated the last review was completed on 09/04/2025.A review of the 7:00 AM-3:00 PM shift staffing schedule for Unit [NAME] 2, which had a capacity of 39 residents, indicated the following:- On 04/11/2025 (Friday), there were four (4) Certified Nursing Assistants assigned to Unit [NAME] 2 with a census of 34 residents.- On 05/02/2025 (Friday), there were four (4) Certified Nursing Assistants assigned to Unit [NAME] 2 with a census of 35 residents.- On 05/03/2025 (Saturday) and 05/04/2025 (Sunday), there were four (4) Certified Nursing Assistants assigned to Unit [NAME] 2 with a census of 36 residents.-On 05/05/2025 (Monday), there were three (3) Certified Nursing Assistants assigned to Unit [NAME] 2 with a census of 36 residents.- On 05/23/2025 (Friday), 05/24/2025 (Saturday), and 05/25/2025 (Sunday), there were four (4) Certified Nursing Assistants assigned to Unit [NAME] 2 with a census of 36 residents.- On 05/26/2025 (Monday), there were four (4) Certified Nursing Assistants assigned to Unit [NAME] 2 with a census of 35 residents.-On 06/13/2025 (Friday), there were three (3) Certified Nursing Assistants assigned to Unit [NAME] 2 with a census of 33 residents.- On 06/14/2025 (Saturday), there were four (4) Certified Nursing Assistants assigned to Unit [NAME] 2 with a census of 35 residents.- On 06/15/2025 (Sunday), there were four (4) Certified Nursing Assistants assigned to Unit [NAME] 2 with a census of 36 residents.- On 09/13/2025 (Saturday), there were four (4) Certified Nursing Assistants assigned to Unit [NAME] 2 with a census of 35 residents.- On 09/14/2025 (Sunday), 09/15/2025 (Monday), and 09/16/2026 (Tuesday), there were four (4) Certified Nursing Assistants assigned to Unit [NAME] 2 with a census of 34 residents.During the Resident Council meeting on 09/12/2025 at 12:32 PM, two (2) out of nine (9) residents stated the facility is very short-staffed. Resident #4 and Resident #214 both expressed staffing concerns, especially during the weekends. Both residents stated that poor staffing had led to a delayed response to the call bells for up to an hour, which affected their care.During an interview on 09/17/2025 at 02:03 PM, the Staffing Coordinator stated Unit [NAME] 2 had a maximum bed capacity of 39 residents, which would require two (2) licensed nurses and five (5) Certified Nursing Assistants to meet all residents' needs based on the par levels (required amount of nursing staff determined by the facility). The Staffing Coordinator provided a sheet of paper with no title, which showed the names of the units and the staffing par levels for each shift. The sheet indicated the Unit [NAME] 2 required five (5) Certified Nursing Assistants during the 7:00 AM-3:00 PM shift for a census of 39 residents. During interviews with two (2) anonymous nursing staff members, concerns were expressed related to overall nursing staff coverage during the day shift (weekdays and weekends), and the number of residents assigned to each Certified Nursing Assistant on a regular basis. Anonymous Nursing staff members stated that work can get overwhelming without sufficient staffing, which affects the quality of care they provide for each resident They stated they need to prioritize their work, for example getting residents ready for rehabilitation therapy or dialysis first and in trying to get to every resident, the last residents on their assignement may be rushed or may not receive timely care. Nursing staff members stated they often had to stay beyond their shift to finish their work. During an interview on 09/18/2025 at 01:25 PM, the Staffing Coordinator stated they scheduled Certified Nursing Assistants on each unit based on the current census and acuity. The Staffing Coordinator stated that four (4) Certified Nursing Assistants were adequate for Unit [NAME] 2 when the resident census was between 29-36 residents. The Staffing Coordinator stated that although a ratio of one (1) Certified Nursing Assistant to eight (8) residents was generally applied when considering staffing, one (1) to two (2) Certified Nursing Assistants could take one extra assignment if the census was slightly over.During an interview on 09/18/2025 at 02:49 PM, the Director of Nursing Services stated that there was no staff shortage on [NAME] 2. The Director of Nursing Services stated that the actual staffing need on each unit is determined by the actual resident census and acuity level of those residents. The Director of Nursing Services stated that four (4) Certified Nursing Assistants are sufficient unless the unit has a full census or the acuity of the resident is assessed otherwise.During an interview on 09/18/2025 at 02:53 PM, the Administrator stated the Facility Assessment was developed to represent what the facility had assessed and suggested the staffing needs to meet all residents' needs based on census and acuity. The Administrator stated the actual staffing schedule is determined based on the actual census and acuity at the time of the schedule. The Administrator stated the facility does not have to follow the Facility Assessment regarding the staffing needs because the Assessment was a suggestion of staffing ratio under full capacity. The Administrator stated there was no Certified Nursing Assistant shortage on Unit [NAME] 2, despite a discrepancy reflected on the actual staffing schedule with fewer Certified Nursing Assistants than indicated on the Facility Assessment. The Administrator stated they were aware that the Payroll-Based Journal triggered for low weekend staffing; however, they did not implement any new intervention or measures to address the low weekend staffing. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews, during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that each resident's medical record was in accordance with accepted professional standards and practices and was complete and accurately documented. This was identified for one (1) (Resident #7) of two residents reviewed for Urinary Catheter. Specifically, Resident #7's Foley Catheter was removed on 06/11/2025 for a voiding trial (an assessment to see if the resident can effectively urinate after a catheter is removed); however, the Physician's order, comprehensive care plan, and nursing assistant instruction (Kardex report) continued to document that Resident #7 required Foley Catheter care until September 2025.The finding is:The facility's policy titled Physician Orders last revised on 09/04/2025, documented if any order is unclear or appears incorrect, the nurse must contact the ordering Physician for clarification prior to confirming the order in the medical record. Resident #7 was admitted with diagnoses including Obstructive and Reflux Uropathy (urine cannot drain through the urinary tract and may back up into the kidneys) and Functional Urinary Incontinence. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, which indicated the resident had intact cognition. The Minimum Data Set assessment Section H documented the resident had an indwelling catheter. Resident #7's urinary continence was not rated due to catheter use.A physician's order dated 06/03/2025 documented to use Foley Catheter 16 French, ten (10) cubic centimeter balloon, and to change the Foley catheter every month and as needed for Neuromuscular Dysfunction of Bladder. The order was discontinued on 09/16/2025.A physician's progress note dated 06/10/2025 documented Resident #7 was seen for a complaint of low back pain and dysuria (painful urination). The resident's family member reported that the resident was screaming during the Foley catheter [placement]. The Physician documented Resident #7's Foley Catheter was draining clear urine, and there was no hematuria (blood in urine). Plan to start voiding trial: to remove the Foley catheter and continue bladder scan every six (6) hours for three (3) days.A physician's progress note dated 06/11/2025 documented Resident #7 was seen for [urine] voiding trial, day one (1). The resident was alert and oriented. The Foley catheter was removed, and Resident #7 denied any abdominal pain. The Physician documented a trial of voiding initiated, and recommended a new order for bladder scan every 6 hours, straight catheter as needed.A physician's progress note dated 06/12/2025 documented Resident #7 was seen for a [urine] voiding trial, day two (2). The Foley catheter was removed, and Resident #7 was voiding well. Resident denied abdominal or pelvic pain, no hesitancy, urgency, or dysuria.A physician's monthly progress note dated 06/30/2025 documented Resident #7 had a positive trial of void and will be followed periodically for diagnosis of Uropathy. A review of the progress note from June 2025 to September 2025 revealed Foley catheter was not re-inserted for Resident #7. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, which indicated the resident had intact cognition. The Minimum Data Set assessment Section H documented that the resident had an indwelling catheter. Resident #7's urinary continence was not rated due to catheter use.The Comprehensive Care plan titled Indwelling Foley Catheter dated 6/3/2025 and last revised 7/30/2025 documented that the resident has an indwelling Foley catheter related to the diagnosis of Obstructive Uropathy. The last care plan review was completed on 09/12/2025, and the Foley catheter care plan remained active.A review of Resident #7's September 2025 nursing task instruction report (Kardex report- care instructions provided to the Certified Nursing Assistants) included providing catheter care with soap and water, checking for leaks, documenting the output, and monitoring Resident #7 for pain and discomfort due to catheter use.A review of Resident #7's September 2025 Certified Nursing Assistant Accountability Record revealed that catheter care was not performed due to the care not being applicable.During an interview on 09/11/2025 at 10:26 AM, Resident #7 stated they did not have an indwelling Foley catheter. The resident was unable to state how long they had not been using the Foley catheter.During a re-interview on 09/16/2025 at 01:33 PM, Resident #7 again stated they voided in their brief. Resident #7 stated that when their brief is soiled, they ask staff to change them (Resident #7).During an interview on 09/16/2025 at 01:42 PM, Licensed Practical Nurse # 9 stated that Resident #7 required a Foley catheter briefly when they returned from the hospital back in June 2025. Licensed Practical Nurse #9 stated the Foley catheter was discontinued a while ago, and Resident #7 did not currently have an indwelling catheter. Licensed Practical Nurse #9 was not aware that the resident had an active Physician's order for a Foley catheter and stated that the order should have been discontinued.During an interview on 09/16/2025 at 01:53 PM, Physician #1 stated that Resident #7 had a diagnosis of Obstructive Uropathy and a history of Dysuria and briefly required a Foley catheter, which was discontinued after the resident had a successful voiding trial in June 2025. Physician #1 stated Resident #7 did not need a Foley catheter at this time, and the order for the Foley catheter should be discontinued. During an interview on 09/17/2025 at 10:18 AM, Certified Nursing Assistant #3 stated that they had been regularly assigned to Resident #7 in the past month, and Resident #7 did not have an indwelling catheter. Certified Nursing Assistant # 3 stated that last month, they had reported the discrepancy to the unit nurses regarding the Foley catheter care instruction documented on the Kardex and that the resident did not have a Foley catheter. Certified Nursing Assistant # 3 stated that they continued to document Not applicable under catheter care because the resident did not have a Foley catheter.During an interview on 09/18/2025 at 08:49 AM, the Director of Nursing Services stated the documentation of care for Resident #7 did not accurately reflect the resident's actual needs. The Director of Nursing Services stated the resident's care profile should be updated and revised when the resident no longer requires their Foley catheter.10 NYCRR 415.22(a)(1-4)

Based on observation, record review, and interviews during the Recertification Survey, initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for two (2) (Resident #99 and #238) of four (4) residents observed during Medication Administration. Specifically, during the medication administration observation, Licensed Practical Nurse #5 did not perform hand hygiene after administering medications for Resident #238 and before preparing the medications to administer to Resident #99.The finding is:Resident #238 was admitted to the facility with diagnoses including Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Diabetes. The Quarterly Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition.Resident #9 was admitted to the facility with diagnoses including Cerebral Palsy and Muscle Weakness. The Quarterly Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition.During an observation on 09/12/2025 at 08:30 AM, Licensed Practical Nurse #5 administered medications to Resident #238. The nurse prepared and administered the following medications:Lisinopril 10 milligram Oral Tablet for Hypertension.Aspirin 81 milligram Oral Tablet (prophylactic).Gapagliflozin 10 milligram Oral Tablet for Diabetes.Haloperidol 2 milligram per milliliter, give 2.5 milliliter for Schizophrenia.The oral tablets were put in a souffle cup. The liquid Haloperidol was poured into a cup of water at the resident's request. The nurse handed the cup of water/Haloperidol, and the souffle cup to the resident who was sitting in their wheelchair in the hallway. The resident swallowed the oral tablets and drank the water/Haloperidol, and handed the souffle cup and the water cup back to the nurse to discard. Directly after completing the medication administration for Resident #238, Licensed Practical Nurse #5 began preparing medications for Resident #99. The nurse did not perform hand hygiene between the two residents. The nurse opened the medication cart drawer and took out Resident #99's first blister pack for Furosemide (diuretic) 40 milligram Oral Tablet and popped one of the tablets into a souffle cup. At this time, the surveyor told the nurse that the nurse did not perform hand hygiene. The nurse stated they should have performed hand hygiene, but forgot. The nurse then performed hand hygiene by using the alcohol gel dispenser on the wall, and then the nurse stated they had just noticed the hand hygiene wipes on top of the medication cart. The nurse did not discard the Furosemide and continued with the medication pass.During an interview on 09/15/2025 at 8:15 AM, Assistant Director of Nursing Services/Infection Preventionist #1 stated Licensed Practical Nurse #5 was required to perform hand hygiene between residents during medication administration. During an interview on 09/17/2025 at 7:55 AM, Registered Nurse Educator #1 stated nurses are taught to wash or sanitize their hands before starting medication pass for a resident, so after they finish with one resident, they have to sanitize or wash their hands before starting medication administration for the next resident.During an interview on 09/17/2025 at 8:08 AM, the Director of Nursing Services stated the standard of practice is to perform hand hygiene between residents when performing medication administration.10 NYCRR 415.19(b)(4)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that a resident who is unable to carry out Activities of Daily Living (ADL) receives the necessary services to maintain grooming and personal hygiene. This was identified for one (1) (Resident #131) of two (2) residents reviewed for Activities of Daily Living. Specifically, Resident #131, who had severely impaired cognition and required staff assistance with Activities of Daily Living, was not dressed and assisted out of bed until after 2:00 PM. The assigned Certified Nursing Assistant #2 did not provide morning care to Resident #131 because they were providing care to the other residents on their assignment. The finding is:The facility's policy titled Activities of Daily Living, dated 12/09/2022, documented that all residents shall be supported in performing Activities of Daily Living to the greatest extent of their ability. Staff will provide individualized care and assistance in accordance with each resident's care plan, promoting autonomy, safety, and quality of life. Activities of Daily Living include basic self-care tasks, including but not limited to: dressing and mobility (walking, transferring, positioning). Activities of Daily Living assistance levels will be documented in the care plan. Staff are responsible for providing Activity of Daily Living support in accordance with care plans and best practices. Resident #131 was admitted with diagnoses of Dementia, Alzheimer's Disease, and Unsteady on Feet. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident had severely impaired cognition. The Minimum Data Set under the mood section documented that the resident had little interest or pleasure in doing things and was feeling down, depressed, or hopeless. The resident had no behavioral symptoms and did not reject care. The resident required supervision assistance for sit to stand and upper body dressing; partial/moderate assistance of one (1) staff member for lower body dressing. The resident was frequently incontinent of bladder and bowel. The Comprehensive Care Plan (CCP) for Activities of Daily Living, dated 08/21/2025, documented the resident had an actual self-care deficit related to impaired cognition, balance, and mobility. Interventions included but were not limited to: assist with bed mobility, transfers, toileting, and bathing as required; encourage the resident to participate to the fullest extent possible with each interaction; supervision assistance for sit to stand and upper body dressing, and partial assistance of one (1) staff member for lower body dressing. The Certified Nursing Aide Kardex Report (instruction for resident care to the Certified Nursing Assistants) documented that the resident required supervision assistance for sit to stand and upper body dressing; partial/moderate assistance of one (1) staff member for lower body dressing.A review of the resident's electronic medical record revealed no documented history of refusal or non-compliance with care.During an observation on 09/11/2025 at 10:05 AM, Resident #131 was observed sitting upright on the side of their bed. Resident #131 was wearing a hospital gown with a white bed blanket wrapped around their upper body. Resident #131 stated they wanted to get changed but did not know who was supposed to help them. Resident #131 was unable to state when and what care had been offered and provided to them this morning (09/11/2025). During an observation on 09/15/2025 at 10:33 AM, Resident #131 was observed sleeping in bed in a side position facing the door. Resident #131 was wearing a gray top with a zipper and a white brief, which was visible because the resident was not wearing any bottom clothing. During an observation on 09/15/2025 at 02:10 PM, Resident #131 was again observed sleeping in bed in a side position facing the door. Resident #131 was still wearing the same gray top with a zipper and a white brief, which was visible because the resident was not wearing any bottom clothing.During an interview on 09/15/2025 at 02:18 PM, Certified Nursing Assistant #2, who was assigned to Resident #131 during the 7:00 AM - 3:00 PM shift on 09/15/2025. Certified Nursing Assistant #2 stated they had not yet provided the morning care to Resident#131. They were about to go to the resident's room now because Resident #131 was the last resident on their assignment that they had to provide care for. Certified Nursing Assistant # 2 stated they first provided care to the residents who required Dialysis or Rehabilitation Therapy to make sure those residents were ready for their appointments. Certified Nursing Assistant # 2 stated they checked in on Resident #131 during the day and moved on to the other residents' rooms without providing any care to this resident because the resident was sleeping. Certified Nursing Assistant # 2 stated they did not try to wake the resident because they had to provide care to other residents first. During an interview on 09/18/2025 at 08:43 AM, the Director of Nursing Services stated that Certified Nursing Assistants should assist residents in their Activities of Daily Living if the resident requires it. The Director of Nursing Services stated they do not expect residents to still be waiting for care at 2:30 PM in the afternoon unless the resident preferred to be in bed or refused care. The Director of Nursing Services stated that Certified Nursing Assistant #2 should have notified the nurse of any care-related issues. 10NYCRR- 415.12(a)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #5) of five (5) residents reviewed for Accident Hazards. Specifically, a tube of unlabeled Lidocaine and Prilocaine (local anesthetic that numbs tissue) cream 2.5 percent was observed on Resident #5's overbed table. There was no Nursing staff in the vicinity of Resident #5 's room. Resident #5 was not assessed to self-administer their medications. The finding is:The facility's policy titled Medication Labeling Storage Policy, last revised on 06/19/2025, documented that the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to the keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Only the dispensing pharmacy may label or alter the label on a medication container or package. Resident #5 was admitted with Diagnoses including Type 2 Diabetes, End Stage Renal Disease, and Hypotension (low Blood Pressure). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The Quarterly Minimum Data Set (MDS) assessment documented that Resident #5 had pain and received scheduled pain medications. A review of Resident #5's Electronic Medical Records revealed that Resident #5 did not have a Physician's Order for the Lidocaine and Prilocaine 2/5 percent cream. A review of Resident #5's Electronic Medical Records revealed that Resident #5 did not have a self-administration of medication assessment. A Comprehensive Care Plan (CCP) dated 12/18/2024 documented that Resident #5 was at risk for pain related to a decrease in mobility. Resident #5 had interventions including administering medications as ordered by the Physician and monitoring, recording, and reporting to the Nurse any complaint of pain or request for pain treatment. During an observation on 09/11/2024 at 10:40 AM, Resident #5 was in bed sleeping. A tube of unlabeled Lidocaine and Prilocaine 2.5 percent cream with an expiration date of 03/2026 was stored on top of Resident #5's overbed table. During an interview on 09/11/2025 at 10:45 AM, Licensed Practical Nurse #7, charge nurse, stated that they did not know why Resident #5 had medications on their overbed table. Licensed Practical Nurse #7 stated that the resident did not have an order for the Lidocaine and Prilocaine cream and should not have any medications in their room that were left unattended. Licensed Practical Nurse #7 stated that the Nurses administer Resident #5 their medications. During an interview on 09/11/2025 at 11:15 AM, Licensed Practical Nurse #1 stated that they did not see the Lidocaine and Prilocaine cream on Resident #5's overbed table when they did the medication administration in the morning. Licensed Practical Nurse #1 stated that Resident #5 should not have any unattended medications left in their room. During an interview on 09/18/2025 at 8:23 AM, the Director of Nursing Services stated that Resident #5 should not have any medications stored in their room. The Director of Nursing Services stated that all medications should be labeled and stored in a locked compartment. The Director of Nursing Services stated there is an ongoing issue at the facility with resident family members bringing medications from home, despite education. The Director of Nursing Services stated that staff should be vigilant in checking rooms and reporting any unattended medications in the resident's room. 10NYCRR 415.18(e) (1-4)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (2609906) initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure the medical care of each resident was supervised by a Physician. This was identified for one (1) (Resident #246) of three (3) residents reviewed for Hospitalization. Specifically, Resident #246's Physician indicated in multiple progress notes that the resident's Foley urinary catheter should be flushed with normal saline. However, there was no physician's order written for flushing the catheter, and no documented evidence that the catheter was flushed by the nursing staff.The finding is:The undated facility policy titled Foley Catheter Care and Privacy documented the catheter should be monitored for patency (free flowing). If signs of blockage occur, for example, reduced or no urinary output, appropriate steps should be taken, including irrigating the catheter, if necessary, with a physician's order.Resident #246 was admitted with diagnoses including Obstructive Uropathy (a blockage in the urinary tract that prevents normal urine flow), Chronic Obstructive Pulmonary Disease, and Malnutrition. The 04/04/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 11, indicating the resident had moderate cognitive impairment. The resident had a urinary catheter and a diagnosis of Benign Prostatic Hyperplasia (enlargement of the prostate gland that can affect urine flow).A physician order dated 03/29/2025 documented a 16 French (a scale indicating diameter of catheter) Foley catheter; Foley catheter care every shift; and to document [urinary] output. Change the Foley catheter every month and when needed.A The nursing progress note dated 04/04/2025 documented the resident had 450 milliliters of brown color urine output.A nursing progress note dated 04/06/2025 documented the resident had brown colored 600 milliliters of urine output.A progress note dated 04/08/2025, written by Physician #2, documented a Foley catheter in place, change every month, urology referral, Flush with 60 cubic centimeters twice a day; hematuria (blood in urine) likely traumatic; continue to follow, if worsening hold Eliquis (blood thinner) twice a day.A Urology consult note dated 04/14/2025 documented Assessment/Plan: Obstructive and reflux Uropathy, Foley care-Flush as needed.A progress note dated 04/18/2025, written by Physician #2, documented obstructive uropathy; Foley catheter in place; change every month; Flush [urinary catheter] with 60 cubic centimeters as needed.A review of the medical record revealed that there was no physician's order placed for flushing of the Foley catheter.A review of the April 2025 Treatment Administration Record revealed no documentation that the nurses had flushed the Foley catheter.During an interview on 09/15/2025 at 3:20 PM, Physician #2 stated when they write recommendations in their progress notes, they notify the nursing staff to enter an order related to those recommendations. Physician #2 stated that if their progress notes indicated recommendations for flushing the Foley catheter, then that was verbalized to the charge nurse. Physician #2 could not state why there was no physician order to flush Resident #246's Foley catheter.During an interview on 09/16/2025 at 9:10 AM, Licensed Practical Nurse #3 stated they did not remember Resident #246. Licensed Practical Nurse #3 stated they would need a physician's order to flush a Foley catheter, and after the procedure, they would document provision of care on the treatment administration record.During an interview on 09/16/2025 at 9:43 AM, Licensed Practical Nurse #4 stated a physician's order is required to flush the Foley catheter, and then the nurses must document that the care was provided according to the physician's order on the treatment administration record.During an interview on 09/16/2025 at 9:50 AM, Registered Nurse Supervisor #2 stated if a resident's Foley catheter needed flushing, the nurses must obtain an order from the Physician. As-needed orders to flush the Foley catheter are not acceptable because, then it is difficult to keep track of when the Foley was flushed.During a re-interview on 09/16/2025 at 12:57 PM, Registered Nurse Supervisor #2 stated they had reviewed all the notes; the Physician may have thought they gave an order for flushing the Foley catheter, but there was no order; there may have been a miscommunication between the Physician and the nursing staff.During an interview on 09/16/2025 at 2:28 PM, the Director of Nursing Services stated nurses need an order to flush the catheter, including the amount of fluid needed to flush the catheter. If the Physician indicated the need to flush the catheter in the medical progress note, the Physician should have written an order or given a verbal order to the nursing staff. During an interview on 09/16/2025 at 3:21 PM, Medical Director #1 stated as per the facility protocol, an order to flush the Foley catheter should have been placed by the Physician or provided a verbal order for the nursing staff to enter the order in the electronic medical record. 10 NYCRR 415.15(b)(1)(i)(ii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that each resident was treated with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one (1) (Resident #5) of one (1) resident reviewed for Dignity. Specifically, on 09/11/2025, Resident #5 was observed in bed sleeping with a clear plastic bag tied to their bed rail, visible from the hallway. The plastic bag was filled with soiled briefs, smeared feces, and used tissues. There was no staff within the vicinity of Resident #5's room. The finding is:The facility's policy titled Dignity, last revised on 09/04/2025, documented that residents are treated with dignity and respect at all times. Each resident shall be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff promote, maintain, and protect resident privacy, including bodily privacy. Resident #5 was admitted with diagnoses including Type 2 Diabetes, End Stage Renal Disease, and Hypotension (low Blood Pressure). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The Quarterly Minimum Data Set (MDS) assessment documented that Resident #5 had frequent bowel and bladder incontinence. A Comprehensive Care Plan (CCP) dated 04/15/2025 documented that Resident #5 had bladder incontinence. The interventions included changing clothing after incontinence episodes and incontinence care that includes washing, rinsing, and drying the perineum. A Comprehensive Care Plan (CCP) dated 04/15/2025 documented that Resident #5 had bowel incontinence with interventions including checking the resident every two hours and assisting with toileting as needed. A Physician's Order dated 07/30/2025 documented Sennoside (stool softener) tablet 8.6 milligrams, two tablets by mouth twice a day for Constipation. A Physician's Order dated 07/30/2025 documented Lactobacillus Capsule, one capsule by mouth twice a day for Diarrhea (watery stool). During an observation on 09/11/2025 at 10:40 AM, Resident #5 was sleeping in bed. A clear plastic bag was tied to Resident #5's bed rail, beside Resident #5's head. The bag was visible from the hallway. The plastic bag was filled with used incontinence briefs smeared with feces and used tissues. There was no staff within the vicinity of Resident #5's room. During an observation on 09/12/2025 at 10:52 AM, an empty clear plastic bag was tied to Resident #5's bed rail. Resident #5 was out of bed in a wheelchair in their room. The resident did not remember who put the bag there. During an interview on 09/12/2025 at 10:57 AM, Certified Nursing Assistant #1 stated that they did not put the clear plastic bag at the resident's bedside the morning of 09/11/2025. Certified Nursing Assistant #1 stated that a family member had visited Resident #5, and they were not sure if they (family member) were the one who put the plastic bag. Certified Nursing Assistant #1stated they always pick up any soiled garbage, including dirty incontinence products, after providing care to Resident #5. During an interview on 09/15/2025, Registered Nurse #1, the charge nurse, stated that the staff should not be tying plastic bags as a trash bag and leaving the bag hanging by the resident's bed due to infection control. During an interview on 09/16/2025 at 3:17 PM, the Infection Preventionist stated that the plastic bag filled with soiled incontinence products should not have been tied and left tied to the resident's bed. The Infection Preventionist stated that soiled incontinence products should be disposed of immediately. During an interview on 09/18/2025 at 9:00 AM, the Director of Nursing Services stated that their expectation is for the nursing staff to throw any soiled incontinence products and not leave them by the resident's bed. The Director of Nursing Services stated that they expect all staff to keep the residents' environment clean. 10 NYCRR 415.5(a)

Based on record review and interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure the Minimum Data Set (MDS) assessment was completed to accurately reflect each resident's status. This was identified for one (1) (Resident #6) of five (5) residents reviewed for Nutrition and for one (1) (Resident #7) of two (2) residents reviewed for Urinary Catheter or UTI (Urinary Tract Infection). Specifically, 1) Resident #6 had a significant weight loss, which was not identified in the 5-Day Minimum Data Set assessment dated [DATE], and 2) Resident #7's bladder and bowel function related to the use of an indwelling catheter was not accurately reflected in the quarterly Minimum Data Set assessment dated [DATE].The findings are: The facility's policy titled MDS (Minimum Data Set) Accuracy, dated 09/04/2025, documented the information captured on the assessment reflects the status of the resident during the observation period for that assessment. Any person who completes any portion of the Minimum Data Set assessment is required to sign the assessment certifying the accuracy of that portion of that assessment. 1) Resident #6 had diagnoses that included Diabetes Mellitus and Hypertension. The 5-Day Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderately impaired cognitive skills for daily decision making. Section K - Swallowing/Nutritional Status documented the resident's height was 67 inches, and the resident's weight was 190 pounds. The Minimum Data Set documented the resident had no weight gain or loss of 5% or more in the last one (1) month or 10% or more in the last six (6) months. Section K was completed by Dietitian #1 on 08/20/2025 and 08/21/2025. The entire 5-Day Minimum Data Set assessment dated [DATE] was signed off by Registered Nurse Minimum Data Set Assessor #1. The resident's weight history documented the resident weighed 202.4 pounds on 07/15/2025 and 190.2 pounds on 08/14/2025, which reflected a 6.03% weight loss in one (1) month. During an interview on 09/15/2025 at 10:30 AM, Registered Dietitian #1 stated they should have documented in the resident's 5-Day Minimum Data Set (MDS) assessment dated [DATE], the resident's weight of 190 pounds reflected a weight loss of 5% or more in the last one (1) month. Registered Dietitian #1 stated it was their mistake and probably miscalculated when filling out the weight question in Section K. During an interview on 09/15/2025 at 10:50 AM, Registered Dietitian Chief Clinical Nutrition Manager #1 stated Registered Dietitian #1 made a data entry error when filling out the weight question in Section K in the resident's 5-Day Minimum Data Set (MDS) assessment dated [DATE]. During an interview on 09/15/2025 at 11:15 AM, Registered Nurse Minimum Data Set Assessment Coordinator #1 stated it was the responsibility of Registered Nurse Minimum Data Set Assessor #1 to ensure the completion and accuracy of the resident's 5-Day Minimum Data Set assessment dated [DATE], based on the resident's medical record, because it was their final signature on the assessment before it was submitted. During an interview on 09/15/2025 at 11:45 AM, Registered Nurse Minimum Data Set Assessor #1 stated when they sign off at the end of any Minimum Data Set assessment, they are attesting only that the assessment was completed on that date, and each discipline was responsible for the accuracy of their own section they are completing. During an interview on 09/18/2025 at 09:00 AM, the Director of Nursing Services stated that by signing at the end of the resident's 5-Day Minimum Data Set assessment dated [DATE], Registered Nurse Minimum Data Set Assessor #1 was attesting to the completion and accuracy of that Minimum Data Set assessment, whether it was their discipline or not. 2) Resident #7 was admitted with diagnoses including Obstructive and Reflux Uropathy (urine cannot drain through the urinary tract and may back up into the kidneys) and Functional Urinary Incontinence. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, which indicated the resident had moderately impaired cognition. The Minimum Data Set assessment Section H documented that the resident had an indwelling catheter. Resident #7's urinary continence was not rated due to catheter use. A physician's order dated 06/03/2025 documented to use a Foley catheter 16 French, ten (10) cubic centimeter balloon, and to change every month and as needed for Neuromuscular Dysfunction of Bladder. The order was discontinued on 09/16/2025. A physician's progress note dated 06/11/2025 documented that Resident #7 was seen for [urine] voiding trial, day one (1). The resident was alert and oriented. The Foley catheter was removed, and Resident #7 denied any abdominal pain. The Physician documented a trial of voiding initiated and recommended a new order for bladder scan every 6 hours, straight catheter as needed. A physician's progress note dated 06/12/2025 documented that Resident #7 was seen for a [urine] voiding trial, day two (2). The Foley catheter was removed, and Resident #7 was voiding well. Resident denied abdominal or pelvic pain, no hesitancy, urgency, or dysuria. A physician's monthly progress note dated 06/30/2025 documented Resident #7 had a positive trial of void, and will be followed periodically for diagnosis of Uropathy. A review of the progress note from June 2025 to September 2025 revealed Foley catheter was not re-inserted for Resident #7. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, which indicated the resident had moderately impaired cognition. The Minimum Data Set assessment Section H documented that the resident had an indwelling catheter. Resident #7's urinary continence was not rated due to catheter use. The Minimum Data Set Assessor, who completed the Quarterly Minimum Data Set assessment dated [DATE], was no longer employed in the facility and, therefore, was not interviewed. During an interview on 09/17/2025 at 12:03 PM, the Director of Minimum Data Set stated the Quarterly Minimum Data Set assessment dated [DATE] did not accurately reflect Resident #7's bladder function, as the assessment inaccurately indicated Resident #7 had an indwelling catheter. The Director of Minimum Data Set stated that the Minimum Data Set assessors mainly review the resident's medical record when completing a Minimum Data Set assessment. The Director of Minimum Data Set stated that they did not know if the assessor who completed the Quarterly assessment observed the resident for the presence of the Foley catheter. The Director of Minimum Data Set stated that the Minimum Data Set assessors may not have time to check on each resident in person when completing the Minimum Data Set assessments, due to the number of assessors on staff and the number of assessments they are required to complete and submit. During an interview on 09/18/2025 at 08:49 AM, the Director of Nursing Services stated that all Minimum Data Set assessments should accurately reflect each resident's condition. 10 NYCRR 415.11(b)

Based on observations, record review, and interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident's medical and nursing needs. This was identified for one (1) resident (Resident #1) of three (3) residents reviewed for Respiratory Care and for one (1) (Resident #80) of one (1) resident reviewed for Insulin. Specifically, 1) Resident #1 had a Physician Order for Oxygen continuously at two (2) liters per minute. During observations on 09/11/2025, Resident #1 was receiving oxygen at five (5) liters per minute, and on 09/12/2025, the resident was receiving oxygen at three (3) liters per minute. 2) Resident #80's comprehensive care plan was not person centered to include the use of a continuous glucose monitoring device used by the resident for Diabetes management.The findings are: The facility's policy titled Oxygen Administration was last revised on 09/04/2025, documented that Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. Licensed Nursing staff are responsible for administering and monitoring oxygen therapy and verifying that a physician's Order is available for oxygen therapy. 1) Resident #1 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), End Stage Renal Disease, and Pulmonary Hypertension. The Significant Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of five (5), which indicated Resident #1 had severe cognitive impairment. The Significant Minimum Data Set (MDS) assessment documented that Resident #1 had an active diagnosis of Pneumonia and Asthma. The Significant Minimum Data Set (MDS) documented that Resident #1 was receiving continuous oxygen therapy. A Physician Order dated 06/10/2025 documented Oxygen at two (2) liters per minute via nasal cannula continuously every shift. Change oxygen tubing and storage bag, wipe down oxygen equipment, and date weekly on Wednesday night: every night shift. A Comprehensive Care Plan (CCP) titled, Alteration in Respiratory Status related to Chronic Obstructive Pulmonary Disease (COPD) dated 08/06/2025, documented intervention including administering oxygen therapy as ordered by the Physician and monitoring signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD), including shortness of breath, wheezing, chest tightness, and chronic cough. During an observation on 09/11/1015 at 10:48 AM, Resident #1 was in bed using an oxygen concentrator through a nasal cannula. The oxygen concentrator was set to deliver oxygen at five (5) liters per minute. During an observation on 09/12/2025 at 2:34 PM, Resident #1 was sitting in their wheelchair in their room. Resident #1 was using an E-Cylinder oxygen tank (a portable, lightweight metal cylinder for oxygen), which was set to deliver oxygen at three (3) liters per minute. During an interview on 09/12/2025 at 2:40 PM, Registered Nurse #1, charge nurse, stated that the Nurses were responsible for making sure that Resident #1 received the correct amount of oxygen as per the physician's order at two (2) liters per minute continuously. During an interview on 09/16/2025 at 11:13 AM, Licensed Practical Nurse #2, the medication nurse, stated that the medication nurses were responsible for ensuring the resident was receiving the correct oxygen amount. Licensed Practical Nurse #2 stated that Resident #1 goes to dialysis, and usually returns to the unit during the medication administration time, and at times, the Nurses are busy administering medications to other residents. The Nurses should be checking that Resident #1 is using two (2) liters of oxygen continuously when Resident #1 returned to the unit. During an interview on 09/17/2025 at 9:43 AM, Licensed Practical Nurse #1 stated that they were the Medication Nurse in the unit on 09/11/2025. Licensed Practical Nurse #1 stated that the resident was receiving oxygen at two (2) liters when they saw Resident #1 early that morning. Licensed Practical Nurse #1 stated that when Resident #1 returned from therapy and was placed back in the bed, they were not sure how many liters of oxygen Resident #1 was receiving. Licensed Practical Nurse #1 stated they should have checked the oxygen when Resident #1 returned, but they were busy doing their medication administration with other residents. During an interview on 09/18/2025 at 8:19 AM, the Director of Nursing Services stated that the Nurses in the unit are responsible for making sure that Resident #1's oxygen was at two (2) liters continuously as ordered by the Physician. The Director of Nursing Services stated that the Nurses should be checking the oxygen before Resident #1 goes to dialysis and when they (Resident #1) return to the unit. 2) The facility's policy and procedure titled Comprehensive Care Plans, last revised 09/04/2025, documented the interdisciplinary team, in conjunction with the resident, develops and implements a comprehensive person-centered care plan for each resident. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of their plan of care. Assessment of residents is ongoing, and care plans are revised as information about the resident and the resident's conditions change. Resident # 80 was admitted with diagnoses including Type 2 Diabetes Mellitus and Acute Respiratory Failure. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The Minimum Data Set assessment documented that Resident #80 received hypoglycemic medication, including insulin injections. A physician's order dated 8/22/2025 documented to administer Insulin Glargine Subcutaneous solution 14 units at bedtime for Diabetes Mellitus. A physician's order dated 9/6/2025 documented to administer Metformin oral tablet 500milligrams one (1) tablet by mouth every 12 hours for Diabetes Mellitus. A physician's order dated 9/9/2025 documented to administer Insulin Lispro Subcutaneous solution 22 units with meals for Diabetes Mellitus. Hold if the fingerstick blood glucose level is less than 130 [milligrams per deciliter]. During an observation and interview on 09/11/2025 at 10:31 AM, Resident #80 stated that they had Diabetes and utilized a continuous glucose monitoring device, which they acquired themselves through their insurance, to track their glycemic level. A round adhesive patch was observed on Resident #80's left upper inner arm, which Resident #80 indicated was where the device was attached. Resident #80 stated that the device continuously measured their blood glucose level and alerted them (Resident #80) of the readings through their cellphone, including the critically low levels. Resident #80 stated that they replaced the monitoring device themselves after every ten (10) days. Resident #80 stated that facility staff were aware that they were using the continuous blood glucose monitoring device. Resident #80 stated they continued to comply with nurses checking their fingerstick as ordered by the Physician despite the use of the continuous glucose monitor. The Comprehensive Care Plan for Diabetes Mellitus, dated 08/23/2025, documented interventions including Diabetes medication as ordered by the doctor and monitor/document for side effects and effectiveness; educate [resident] regarding medications and importance of compliance, and to have the resident verbally state an understanding; and consult dietary for nutritional regimen and ongoing monitoring. The Comprehensive Care Plan did not include documentation of the use of a continuous glucose monitoring device. During an interview on 09/15/2025 at 12:42 PM, Licensed Practical Nurse #8 stated that they were aware that Resident #80 utilized a continuous glucose monitoring device that they (Resident #80) brought with them from admission. Licensed Practical Nurse #8 stated the device provided Resident #80 a 'peace of mind' to know their blood glucose level at all times. Licensed Practical Nurse # 8 stated that Resident #80 was able to care for the device on their own, and the nurses were not responsible for the device, as there were no physician's orders or nursing instructions for the device. Licensed Practical Nurse # 8 stated they were not responsible for creating or revising the care plans. During an interview on 09/15/2025 at 03:19 PM, Physician #2 stated they were aware Resident #80 wore a continuous glucose monitoring device to monitor their own blood glucose level. Physician #2 stated they did not give any order for the care and monitoring of the device. Physician #2 stated they expected that when the resident reported an episode, especially one of hypoglycemia, from the monitoring device, staff would check and confirm the resident's blood glucose level right away and notify them (Physician #2) as necessary. During an interview on 09/17/2025 at 9:19 AM, the Minimum Data Set Assessor, a Registered Nurse, stated that a care plan for the use of the continuous glucose monitoring device should have been developed because the resident preferred to use the device to manage their Diabetes. During an interview on 09/17/2025 at 11:00 AM, Registered Nurse #2, stated they were one of the Registered Nurses responsible for ensuring the completion and revision of residents' comprehensive care plans. Registered Nurse # 2 stated they were aware Resident #80 utilized the continuous glucose monitor and periodically checked the device; however, they did not develop a care plan as the facility staff was not responsible for caring for the device. During an interview on 09/18/2025 at 08/43 PM, the Director of Nursing Services stated they did not believe a care plan for the use of continuous glucose monitoring was needed as the resident was utilizing the device on their own. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (1) (Resident #27) of three (3) residents reviewed for Hydration. Specifically, Resident #27 was observed on 9/11/2025 at 10:53 AM with a peripheral intravenous catheter (a short flexible tube inserted into a peripheral vein to deliver fluids, medications, and blood products directly into a patient's bloodstream) to the left forearm covered with a transparent dressing that was dated 08/28/2025. Additionally, there was no Physician's order to flush the intravenous catheter and monitor the area. The finding is:The facility's policy titled Peripheral Intravenous Catheter Insertion, last revised on 09/04/2025, documented that Peripheral Intravenous Catheter Insertion is performed by the Licensed Nurses according to state law and facility policy. The policy included that a catheter shall be placed for a definitive therapeutic and/or diagnostic indication upon the order of a Physician. A new peripheral catheter shall be utilized for each catheter insertion attempt. Peripheral catheter sites are rotated every 72-96 hours and sooner for signs or symptoms of complications. After catheter insertion, label dressing with date, time, catheter gauge, and length, and initials of the person who inserted the catheter. Document date and time of procedure, site location and assessment, dressing type, patient response to procedure and/or medication, and patient teaching on the appropriate nursing document. Resident # 27 was admitted with diagnoses including Atrial Fibrillation, Anemia, and Muscle Weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #27 had intact cognition. The Quarterly Minimum Data Set (MDS) assessment documented that Resident #27 did not receive any intravenous medications. The Quarterly Minimum Data Set (MDS) assessment documented an Active Diagnosis of a Medically Complex Condition. A Comprehensive Care Plan dated 07/21/2025 titled High Nutrition/Dehydration Risk related to low albumin (protein that is synthesized in the liver and released into the bloodstream) levels, documented interventions including monitoring oral intake of food and fluids, monitoring for signs and symptoms of dehydration, and educating the resident and family regarding diet and fluid intake. A Physician's order dated 08/27/2025 documented Dextrose -Sodium Chloride Intravenous Solution 5-0.45 percent (an intravenous solution that provides water, electrolytes, and calories to the body). Use 75 milliliters per hour intravenously every hour for hydration for three (3) days. The order was completed on 08/30/2025.A Physician's order dated 09/01/2025 documented Dextrose -Sodium Chloride Intravenous Solution 5-0.45 percent. Use 75 milliliters per hour intravenously every hour for hydration for three (3) days. This order was completed on 09/04/2025.A review of the electronic medical record revealed no Physician's order for the insertion of an intravenous catheter, including flushing and monitoring the intravenous catheter site area from 08/27/2025 until 09/11/2025. A review of the electronic medication administration record revealed that Resident #5 was receiving Dextrose -Sodium Chloride Intravenous Solution every hour for hydration for three (3) days from 08/27/2025 until 08/30/2025 and from 09/01/2025 until 09/04/2025. A review of the electronic medical record revealed that Resident #5's intravenous catheter was not rotated, and there was no documentation of the catheter care or monitoring of the intravenous catheter site by the Nursing staff. A Comprehensive Care Plan dated 09/01/2025 titled Intravenous Line Administration of Intravenous Fluids documented interventions, including assessing the intravenous line insertion site for redness, tenderness, or swelling; assessing the dressing to make sure it is clean, dry, and intact; and changing the dressing as ordered and as needed. During an observation on 09/11/2025 at 10:53 AM, Resident #27 was in bed with a loose Kling wrap (a gauze roll) on the left wrist. A transparent dressing was observed on Resident #27's left forearm covering a peripheral intravenous catheter dated 08/28/2025. The resident was not receiving any intravenous therapy. During an interview on 09/11/2025 at 11:00 AM, Resident #27 stated there is a needle in their arm, and they did not remember the last time the Nurses took care of the dressing on their arm. Resident #27 stated they have not been receiving intravenous fluids. During an interview on 09/15/2025 at 11:20 AM, Registered Nurse #1, the Charge Nurse, stated that they were not aware that Resident #27 had a peripherally inserted intravenous line on their left forearm. Registered Nurse #1 stated that the intravenous line on Resident #27 should have been discontinued after the intravenous therapy was completed. During an interview on 09/16/2025 at 1:57 AM, Physician #1 stated the intravenous dressing should be changed every five days to avoid any infection. Physician #1 stated that the intravenous line should be flushed every day to keep the patency of the intravenous line. Physician #1 stated that the Nursing staff should have called them (Physician #1) to discontinue the intravenous catheter after the intravenous therapy was completed. During an interview on 09/17/2025 at 9:39 AM, Licensed Practical Nurse #1 stated they took out the intravenous catheter for Resident #27 on 09/11/2025 after the Physician had given the order to discontinue the catheter. Licensed Practical Nurse #1 stated they forgot to document that they took out the intravenous catheter and should have documented that the intravenous catheter was removed, including the resident's response, and how the skin area around the catheter was.During an interview on 09/18/2025 at 8:33 AM, the Director of Nursing Services stated that they expect the dressing change on the intravenous site to be changed weekly. The Director of Nursing Services stated that a saline flush on the intravenous catheter should be done before and after intravenous therapy daily. The Director of Nursing Services stated that the intravenous catheter should have been discontinued on 09/04/2025 after the intravenous therapy was completed. The Director of Nursing Services stated the Nurses should have documented the resident's response to the treatment, the order from the Physician, and the monitoring of the site for signs and symptoms of infiltration and infection.10 NYCRR 415.12

Based on record review and staff interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that the resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (1) (Resident #240) of five (5) residents reviewed for Nutrition. Specifically, Dietitian #2 recommended Resident #240 to receive a liquid nutritional supplement of Two Cal HN (protein and calorie-dense supplement) twice daily for additional calories and protein; however, the supplement was never ordered. The finding is: The facility's policy titled, Interdisciplinary Management and Prevention of Significant Weight Loss Nursing Facility Residents, reviewed 09/04/2025, documented the Clinical Dietitian will communicate to the Physician and Head/Charge Nurse any nutritional recommendations based on assessment.Resident #240 had diagnoses that included Urinary Obstruction and Shortness of Breath. The 5-Day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderately impaired cognitive skills for daily decision making. Section K - Swallowing/Nutritional Status documented the resident's height was 60 inches, and the resident's weight was 115 pounds. Section K also documented that the resident had a weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regimen. The Weight Loss Nutrition Note dated 08/20/2025, written by Dietitian #2, documented: Resident triggered for a significant weight loss during the first month of their stay (06/12/2025-07/15/2025). Provide Two Cal HN Medication Pass (4 ounces of the supplement provided when the resident receives their medications) twice daily, which provides 475 kilocalories and 20 grams of protein. The Comprehensive Care Plan entitled Resident at high nutrition risk related to diagnosis of brain cancer, advanced age, initiated on 06/13/2025, documented as an intervention/task: Provide Two Cal HN BID (twice daily) (475 kilocalories, 20 grams protein), initiated on 08/20/2025.A review of the resident's current Physician Orders in their Electronic Medical Record (EMR) on 09/17/2025 at 04:05 PM revealed no documented evidence that the resident was receiving the Two Cal HN supplement.A review of the resident's Medication Administration Records (MARs) dated August 2025 and September 2025 on 09/17/2025 at 04:10 PM revealed no documented evidence that the resident was provided with the Two Cal HN supplement.During an interview on 09/18/2025 at 09:40 AM, Registered Dietitian #2 stated they made an error and should have put a Physician's Order into the resident's Electronic Medical Record, for the Two Cal HN supplement they were recommending, for the resident's Physician to sign. Registered Dietitian #2 stated they had recommended the Two Cal HN supplement to help the resident maintain their weight or regain the significant weight they had lost. During an interview on 09/18/2025 at 9:50 AM, Registered Dietitian Chief Clinical Nutrition Manager #1 stated Registered Dietitian #2 should have put a Physician's Order into the resident's Electronic Medical Record after recommending the resident receive the Two Cal HN supplement on 08/20/2025. Nursing would then contact the resident's Physician, review the Order with the Physician, and the Physician would either confirm the Order or deny it. 10 NYCRR 415.12(i)(1)

Based on record review and interviews during the Recertification Survey initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure that residents and their representatives had a full understanding of arbitration agreements. This was identified for four (Residents #14, #24, #15, and #131) of the four residents reviewed for the Arbitration task. Specifically, interviews with Residents #14, #24, #15, and a representative for Resident #131 all stated they were not aware that they had accepted an arbitration agreement and did not have a full understanding of the agreement.The finding is:The facility's policy titled Binding Arbitration, dated 11/05/2024, documented residents or representatives are informed of the nature and implications of any proposed binding arbitration agreement so as to make informed decisions on whether to enter into such agreements. The terms and conditions of a binding arbitration agreement are explained to the resident or representative in a way that ensures understanding of the agreement, including that the resident may be giving up their right to have a dispute decided in a court proceeding. The terms and conditions of the binding arbitration agreement are explained to the resident or representative in a form and a manner that they understand. A signature alone is not a sufficient acknowledgement of understanding. The resident or representative must verbally acknowledge understanding, and that the verbal acknowledgement is documented by the staff member who explains the agreement. Residents or representatives are provided 30 days after signing to fully review and rescind any agreement not understood at the time of admission.During an interview on 09/17/2025 at 1:14 PM, the Administrator stated that the arbitration agreement documents are part of the admission package. The Administrator stated the facility offers the arbitration agreements as of 02/15/2025, and at this time, there were no residents who signed an arbitration agreement. The Administrator stated that if any resident entered into an arbitration agreement, this would be brought to their attention.During an interview on 09/17/2025 at 1:55 PM, Concierge #2 stated they were not very familiar with the arbitration agreement process, and that residents either signed that they accepted or declined the agreement. Concierge #2 stated they were not aware of any record or list of residents who may have signed an arbitration agreement.During an interview on 09/17/2025 at 2:18 PM, the Administrator stated that as of 02/15/2025, all residents have accepted arbitration agreements, and no resident has declined. The Administrator stated that the resident/representative are provided with a copy of the agreement, and a copy is kept in the resident's Electronic Medical Record.Resident #14's 07/25/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact.During an interview on 09/18/2025 at 8:25 AM, Resident #14 stated they do not remember signing an arbitration agreement, and they did not know what an arbitration agreement was. When the surveyor explained the arbitration agreement to the resident, the resident stated they would prefer to use their own attorney if there were any problems with the facility.A review of Resident #14's Electronic Medical Record revealed the resident accepted the Alternative Dispute Resolution (arbitration) Agreement on 07/19/2025 as indicated by the resident's signature.Resident #15's 04/10/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact.During an interview on 09/18/2025 at 8:30 AM, Resident #15 stated I do not remember signing the arbitration agreement, and I do not know what it is.A review of Resident #15's Electronic Medical Record revealed the resident accepted the Alternative Dispute Resolution (arbitration) Agreement accepted the Alternative Dispute Resolution Agreement on 04/03/2025, evidenced by the resident's signature.Resident #24's 07/03/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact.During an interview on 09/18/2025 at 9:30 AM, Resident #24 stated they did not really understand the binding arbitration agreement. When the surveyor explained the binding arbitration agreement to the resident, the resident stated they were surprised they accepted the binding arbitration agreement and did not know there was a 30-day requirement to rescind the agreement; Resident #24 stated maybe the facility should explain the agreement better.A review of Resident #24's Electronic Medical Record revealed the resident accepted the Alternative Dispute Resolution (arbitration) Agreement accepted the Alternative Dispute Resolution Agreement on 06/27/2025, evidenced by the resident's signature.Resident #131 was admitted with diagnoses including Alzheimer's disease and Dementia. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 4, indicating the resident had severe cognitive impairment.On 09/18/2025 at 8:35 AM, Resident #131 was sleeping in bed and not easily arousable for an interview. The accepted Alternative Dispute Resolution Agreement on 08/21/2025 was signed by the resident as indicated by the resident's signature. The legal representative space was blank.During an interview on 09/18/2025 10:25 AM, Concierge #1 stated they and Concierge #2 are responsible for reviewing the admission documents with residents and representatives and having them sign the documents. Concierge #1 stated they could not specifically explain what the arbitration agreement is. I am not going to give the resident the whole law on arbitration, but we explain that the resident will be using arbitration and giving up their right to file a lawsuit in court. We use a computer tablet to go through the documents. At the beginning of the admission packet is a signature page, and on each attachment, there is an accept button. As we go through the admission packet and each attachment, each attachment (for example, Attachment F, Alternative Dispute Resolution Agreement) has an accept button that I will press as being accepted or declined. If accepted, the signature from the signature page gets prepopulated to that attachment, so the resident does not have to sign each attachment.Review of the admission Agreement Signature Page from the admission Packet documented the following: By signing below, the undersigned consents to be legally bound by this Agreement and acknowledges that, in advance of signing, the undersigned read the Agreement, any questions asked regarding the Agreement were adequately answered, and after the parties signed the Agreement, the undersigned received a complete copy of the executed Agreement and all parts of this Agreement that are attached and incorporated by reference. I also certify that my signature in this Agreement and its Attachments, whether by my name, a mark, or my initials, represent my present intention to authenticate this Agreement.During an interview on 09/18/2025 at 11:29 AM, the family member (first contact) of Resident #131 stated they did not sign the tablet device to accept the arbitration agreement. If explained, they would have never accepted the arbitration agreement. The family member stated they would want outside representation in the case of a dispute.During an interview on 09/18/2025 at 12:38 PM, the Administrator stated there are no residents who declined the arbitration agreement, and therefore, the facility did not maintain a list of residents who accepted the arbitration agreement. The Administrator stated that the concierge can read the arbitration agreement to the residents and/or representatives, and if the resident does not understand the agreement, the concierge should explain the agreement to them.10 NYCRR 415.30

Based on observation, interviews and record review during an abbreviated survey conducted on 3/19/2025 through 04/21/2025 for case number NY00375018 the facility failed to protect each resident's right to be free from physical abuse. This was identified for one (Resident #1) of three residents reviewed for physical abuse. Specifically, video surveillance showed Licensed Practical Nurse #1 pointing their right finger at Resident #1's face. Licensed Practical Nurse #1 reaches forward with both hands, places them at Resident #1's neck, and pushes them backwards in their wheelchair. The incident was discovered when a staff member was reported as injured by Resident #1. The findings are: The facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating created on 3/2022 and revised on 6/21/24 documented that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports their suspicion to the state licensing/certification agency responsible for surveying/licensing the facility immediately within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #1 was admitted on [DATE] with diagnosis that include dementia, major depressive disorder, and obesity. A Minimum Data Set Brief Interview for Mental Status dated 03/08/2025 documented a score of 13 indicating full cognition. A Comprehensive Care Plan titled, 'At risk for abuse' dated 11/05/2024 documented interventions which include investigate all allegations of abuse and neglect promptly and provide a safe person to report abuse/ neglect to and Provide support and ensure resident is free from abuse or neglect. The Comprehensive Care Plan was not updated or amended following the incident. Accident and Investigation report for Resident #1 dated 03/13/2025 documented Licensed Practical Nurse #1 was immediately removed from the care of Residents and terminated from employment. Resident #1 had a full body assessment and follow-up assessment with Medical Doctor. There were no signs of physical injury. The investigation concluded that abuse had occurred. Licensed Practical Nurse #1 refused to provide a statement. Video surveillance of the unit's Nurse station and hallway submitted by the facility was reviewed with the Administrator on 03/18/2025 at 10:01AM. Licensed Practical Nurse #1 can be seen pointing their right finger at Resident #1's face. Resident #1 was seated in a wheelchair in the hallway. Licensed Practical Nurse #1 reaches forward with both hands, places them at Resident #1's neck, and pushes them backwards in their wheelchair. Certified Nursing Assistant #2 was seen by the computer and lifted their head from the computer and stood up and watched the incident. Certified Nursing Assistant #1 intervened and separated Resident #1 from Licensed Practical Nurse #1. Certified Nursing Assistant #2, Certified Nursing Assistant #3, and Licensed Practical Nurse #2 can be seen seated behind the nurse's station. During an interview with Certified Nursing Assistant #1 on 3/19/25 at 09:44AM they stated they heard Resident #1 arguing with the Licensed Practical Nurse #1. Certified Nursing Assistant #1 stated they got into an altercation, and they separated them by standing in between them to de-escalate situation. Certified Nursing Assistant #1 stated they did not report Licensed Practical Nurse to the supervisor because they did not see Licensed Practical Nurse #1 push Resident #1. During an interview with Certified Nursing Assistant #2 on 03/19/2025 at 13:03 they stated that at the time of incident they were by the nurse's station working on the computer. They stated they did not report the alteration between Licensed Practical Nurse #1 and Resident #1 to anyone. Certified Nursing Assistant #2 added that shortly after the incident Resident #1 attacked them (Certified Nursing Assistant #2), which they reported to the supervisor. During an interview with Resident #1 on 03/19/2025 at 1:05 PM they stated they have no recollection of an incident with Licensed Practical Nurse #1 on 03/13/2025. On 03/19/2025 at 10:35 AM a telephone interview with Licensed Practical Nurse #1 they stated they will not answer any questions regarding the incident. During an interview with Medical Doctor on 3/19/25 at 2:07 PM they stated they did not witness incident. They assessed Resident #1 following the incident with no signs or symptoms of injury. No change in appetite or sleeping. No behavioral incidents since. The recommendation was to continue monitoring Resident #1. During an interview with Registered Nurse Supervisor #1 on 3/19/2025 at 1:30 PM they stated they were informed by Certified Nursing Assistant #2 that Resident #1 attacked them. Registered Nurse Supervisor #1 stated they did an assessment on Resident #1 following the incident on 03/13/2025. Resident #1 denied pain and had no physical signs of injury, and they made a referral for psychiatry for further evaluations. Registered Nurse Supervisor #1 stated they were unaware of the incident involving Licensed Practical Nurse #1 and Resident #1. During an interview with Director of Nursing on 04/03/2025 at 08:58 AM they stated they learned of the incident when Nursing Supervisor #1 called about a staff fall. Nursing Supervisor #1 did not report Licensed Practical Nurse #1 grabbing and pushing Resident #1. Director of Nursing stated they learned of the assault when they viewed the video of the staff member being kicked and falling. They began to investigate the assault on Resident #1 by Licensed Practical Nurse #1. The findings of the investigation were that it was wrong of Licensed Practical Nurse #1 to grab and push Resident #1. During a telephonic reinterview with Director of Nursing on 04/21/2025 at 2:29 PM they reiterated the incident and stated that Licensed Practical Nurse #1 refused to provide a statement. 10NYCRR 483.12 (a)(1)

Based on observation, interviews and record review during an abbreviated survey conducted on 9/3/24 through 9/27/24, the facility did not ensure that the alleged violations involving abuse, including injuries of unknown source, neglect, or mistreatment were reported within 24 hours to the New York State Department of Health. This was identified for two (Resident #1 and Resident #2) of three resident records reviewed for Abuse. 1) Specifically, Resident #1 was observed with areas of bruises to their forehead and area above their right eye. The cause of this injury was unknown. 2) Resident #2 was pushed by another resident and fell to the ground hitting their head on 08/06/2024 and neither (Resident #1 and Resident #2) incidents were not reported to the New York State Department of Health as required. The findings are: 1) The facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating created on 3/2022 and revised on 6/21/24 documented that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports their suspicion to the state licensing/certification agency responsible for surveying/licensing the facility immediately within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #1 admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Anxiety and Depression. The Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status score of 4 which identified Resident #1's cognitive status as severely impaired. There was no documented hallucination, delusions, or behaviors. Resident #1 required supervision to moderate assistance with activities of daily living. The Occurrence Investigative Summary dated 9/2/24 and completed by Unit Manager #2 documented that the type of occurrence was an ecchymoses (bruise) area to Resident #1's right side of forehead and above the right eye. The Occurrence Investigative Summary that on 9/2/24 at 8:15AM during rounds Resident #1 was noted with Ecchymoses (bruise) area to right side of their forehead. There was no documented evidence that the facility reported Resident #1's injury of unknown origin to the New York State Department of Health. During an interview with Certified Nursing Assistant #1 on 9/3/24 at 11:45 AM, they stated that they observed the bruise to Resident #1's face at 8:15 AM on 9/2/24 and reported it to License Practical Nurse #1. During an interview with the Director of Nursing on 9/3/24 at 3:53 PM they stated they were only aware of the incident today. Resident #1 had gone out with family member and returned with a bruise. Resident #1 was noted with ecchymosis (bruise) to right side of forehead and area above right eye of unknown origin. They stated any injury of unknown origin is reportable and they were not able to rule out that abuse occurred. During an interview with Licensed Practical Nurse #1 on 9/3/24 at 4:21 PM, they stated that on 9/2/24 at 8:15 AM Certified Nursing Assistant #1 reported that Resident #1 had a bruise on their face. Unit Manager #2 and Assistant Director of Nursing checked Resident #1. During an interview with Assistant Director of Nursing on 9/5/24 at 11:35 AM, they stated that they were informed by Unit Manager #2 that Resident #1 had discoloration to area above right eye. During the assessment by the Assistant Director of Nursing they stated that they did not think it was an abuse case because of what Resident #1 had told them and they did not report it. During an interview with Unit Manager #2 on 9/5/24 at 1:04 PM they stated that Licensed Practical Nurse #1 informed them that Resident #1 had discoloration to right side of their forehead and area above their right eye. Unit Manager #2 stated they did not think of it as abuse and reported to the Assistant Director of Nursing because the resident did not know what happened. During a phone interview with the Risk Manager on 9/11/24 at 3:38 PM, they stated that they were off during the investigation of the incident. They stated that the Incident Report was completed by the supervisor and reviewed by Director of Nursing. During a phone interview with the Risk Manager on 9/24/24 at 9:19 AM they stated that they reviewed the incident and they did not report it because it was not considered an injury of unknown origin since Resident #1's family member was able to tell them that the bruise was from a bug bite when they went to the botanical garden. 50951 2) Resident #2 was admitted on [DATE] with documented diagnosis that included mild cognitive impairment, history of falls, and osteoarthritis. Resident had a Minimum Data Set, dated dated dated [DATE] that documented a Brief Interview of Mental Status score of 12. Resident #2 passed away at the facility on 08/09/24. A Nurses Note dated 8/6/2024 at 10:20 AM documented that Resident #6 pushed Resident #2 to the floor. Resident #2 fell to the floor onto their buttock and elbows and then hit their head on floor. The physician assessed the resident and ordered Ativan for agitation. During a record review there was no documented evidence that the facility reported the altercation between Resident #2 and Resident #6 which resulted in a fall of Resident #2. During an interview with Administrator on 09/25/2024 at 2:13 PM the Administrator was interviewed and stated that the facility could not find an Accident and Investigation report for Resident #2 and Resident #6 on 08/06/2024 at 10:20. During an interview with Manager on 09/25/2024 at 4:49 PM Risk Manager stated that they did not know why a report was not made to the New York State Department of Health for this incident. During an interview with the Licensed Practical Nurse Unit Manager on 09/26/2024 at 12:59 PM that the reason an Accident and Investigation was not completed for this incident was because the Administrator looked at the video and did not see any altercation, push, or fall for Resident #2. During an interview with Administrator on 09/26/2024 at 1:52 PM The administrator stated they could not recall reviewing the video for this incident. The Administrator stated that if they had seen a fall or altercation on the video there would have been an Accident and Investigation form completed and the incident would have been reported to the New York State Department of Health within two hours. During a telephone Interview with Director of Nursing on 09/26/2024 at 2:18 PM the Director of Nursing stated they arrived on unit when resident to resident incident and fall was reported on 08/06/2024. The Director of Nursing stated they did not start an Accident and Investigation because when they arrived on the unit, Resident #1 was alert and agitated, walking around. The Administrator viewed the video footage and did not see the altercation or fall. 10NYCRR 415.4 (b) (1) (ii)

Based on observation, interviews and record review during an abbreviated survey conducted on 9/25/24 through 9/27/24, the facility did not ensure that care was provided in accordance with professional standards and by individuals qualified to do so. Specifically, the facility had a Licensed Practical Nurse serving in the capacity of Unit Manager completing assessments for 17 out of 17 reviewed records following accidents and falls on their unit. This Licensed Practical Nurse placed their name on the form in the space titled Registered Nurse Supervisor and signed their name and title on the completed document which is out of the scope of practice for a Licensed Practical Nurse. The findings are: An undated job description for Registered Nurse or Licensed Practical Nurse Unit Manager was reviewed and documented Prepare incident/accident reports events and observations using the Electronic Medical Record system. There was no documented evidence of who should complete the assessment in the Unit Manager Job Description. Resident #2 was admitted on [DATE] with documented diagnosis that included mild cognitive impairment, history of falls, and osteoarthritis. Resident had a Minimum Data Set, dated dated dated [DATE] that documented a Brief Interview of Mental Status score of 12. Resident #2 passed away at the facility on 08/09/24. Accident and Investigation form for Resident #2 on 08/06/2024 was completed by Unit Manager Licensed Practical Nurse # 1 Accident and Incident form documented a title of: Registered Nurse Supervisor on the top of the first page. On page two (2) of the Accident and Incident form Registered Nurse Supervisor was identified as Unit Manager Licensed Practical Nurse #1 by their printed name in black ink. A review of Accident and Incident reports completed by Unit manager Licensed Practical Nurse #1 documented that Seventeen of Seventeen Accident and Incident reports were completed and Signed by Unit Manager Licensed Practical Nurse #1 included an assessment on the form outside of their scope of practice. Unit Manager Licensed Practical Nurse #1 was printing their name on the line that states Registered Nurse Supervisor: acknowledging that the assessment was completed by them and not a Registered Nurse as required. During an interview with the Administrator on 09/25/2024 at 4:49 PM they stated they were aware that Registered Nurses must make assessments not Licensed Practical Nurses. During an interview with Unit Manager Licensed Practical Nurse #1 on 09/26/2024 at 1:35 PM they stated they were given a job description of the Unit Manager responsibilities when they were promoted. The job description states that the Unit Manager completes Accident and Investigation forms. During an interview with Unit Manager Licensed Practical Nurse #1 on 09/25/2024, at 3:52PM they stated that their role was to help with everything if there is an incident or accident, they are called. Unit Manager Licensed Practical Nurse #1 stated they do an assessment of the resident, provide care, complete the investigation, and notify the family of the incident. The Unit Manager Licensed Practical Nurse #1 reviewed an Accident and Investigation Report that was completed and signed by them Unit Manager Licensed Practical Nurse #1 acknowledged it was their handwriting and signature in the Registered Nurse Supervisor Box and signature line. Unit Manager Licensed Practical Nurse #1 stated they printed their name in the Registered Nurse Supervisor box because it was their job. Unit Manager Licensed Practical Nurse #1 denied completing the assessment contained in the report and stated that they only wrote down the assessment that the Registered Nurse or physician completed. There is no documented evidence that a Registered Nurse or Physician signed any of the documents reviewed. During a telephonic reinterview with the Director of Nursing on 10/07/2024 at 12:41 PM they stated that they were aware that Unit Manager Licensed Practical Nurse #1 was completing the Accident and Investigation forms. 10NYCRR 483.21(b)(3)(i)

Based on observation, interviews and record review during an abbreviated survey conducted on 9/3/24 through 9/18/24, the facility did not ensure that all alleged violations of resident abuse, neglect, exploitation, or mistreatment, including an injury of unknown origin were thoroughly investigated. This was identified for 2 of 3 residents reviewed for abuse. Specifically, 1) Resident # 1 was observed with an injury of unknown origin to the right side of their face and eyebrow area on 9/1/24. 2) Resident #2 was pushed by another resident and fell to the ground hitting their head on 08/06/2024.There is no documented evidence that the facility did a thorough investigation of the incidents to identify the root cause of the injury and to rule out Abuse, Neglect, and Mistreatment. This is a repeat deficiency. The findings are: 1) The facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating created on 3/2022 and revised on 6/21/24 documented that all allegations are thoroughly investigated. The administrator initiates investigations. Investigations may be assigned to an individual trained in reviewing, investigating, and reporting such allegations. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. Resident #1 admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Anxiety and Depression. The Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status score of 4 which identified Resident #1's cognitive status as severely impaired. There was no documented hallucination, delusions, or behaviors. Resident #1 required supervision to moderate assistance with activities of daily living. A nurses note dated 9/2/24 and completed by Unit Manager #2 documented that they were called to unit at 8:15 AM and informed that Resident #1 was observed with an ecchymosis (bruise) area to their forehead and above their right eye. Resident #1 denied any pain or discomfort. Resident#1's physician and family member were informed. A late entry nurses note dated 9/2/24 and completed by the Assistant Director of Nursing documented that they spoke with Resident #1 regarding the discoloration above their right eye and Resident #1 stated they were in bed when the phone rang and banged their face trying to answer the phone. A late entry nurses note dated 9/3/24 and completed by License Practical Nurse #2 documented that Resident #1 returned from out on pass on 9/1/24 and was noted with redness to the right side of their head/forehead. Resident #1's family member was questioned and stated, this is normal for them. The report from the morning shift nurse stated Resident #1 left the facility with no injury. The Medical Director note dated 9/3/24 documented that they were asked to see Resident #1 to check their right upper eye and forehead bruises after they returned from out on pass. Resident #1 provided different reasons on how they may have gotten the bruise. Resident #1 was prone to ecchymosis (bruises) due to fragile skin aging related to smoking. The ecchymosis (bruise) area was not tender to touch, eye muscles were intact and neurologic exam was at their baseline. The Incident Report dated 9/2/24 completed by Unit Manager #2 documented that the type of occurrence was an ecchymosis (bruise) area to right side of forehead and above the right eye that Resident #1 went out on pass on 9/1/24 and that on 9/2/24 Resident #1 was noted with an ecchymosis (bruise) area to right side of their forehead. The conclusion documented Resident #1 was in facility with no alteration in skin integrity prior to going out on pass. Resident #1 went out on pass with family member and returned with redness to right side of face and forehead. Family member was questioned and stated, this is normal and when further questioned they stated it could be from a bug bite when they went to the botanical park. Video surveillance was reviewed and confirmed that Resident #1 left without any ecchymosis (bruise). Upon discussion with Medical Director, they stated that Resident #1 was noted with a very vascular superficial forehead area and ecchymosis may have been from a burst capillary or vein. Upon investigation of this incident, there was no care plan violation and no indication of neglect or abuse found Comprehensive Care plan titled at risk for potential for abuse initiated on 4/9/24 noted with intervention to follow up with social services. During an interview with Resident #1 on 9/3/24 at 11:36 AM, they stated that they fell when they were walking outside of the building. During an interview with Certified Nursing Assistant #1 on 9/3/24 at 11:45 AM, they stated that they observed the bruise to Resident #1's face at 8:15 AM on 9/2/24 and reported it to License Practical Nurse #1. During a phone interview with Licensed Practical Nurse #2 on 9/3/24 at 2:57 PM, they stated that on 9/1/24 Resident #1 and their family member returned to the unit around dinner time. Licensed Practical Nurse #2 noticed a small redness to Resident #1's right side of face and brow area and when the family member was questioned, they stated that that's normal for them. Licensed Practical Nurse #2 did not report to their nursing supervisor because of what the family member had told them, and they did not think there was abuse. During a phone interview with Licensed Practical Nurse #3 on 9/3/24 at 3:46 PM they stated that they worked 11-7 shift on 9/1/24, they did not get report that Resident #1 returned to the facility from out on pass with a bruise and did not see Resident #1 during their shift. Licensed Practical Nurse #3 added that they don't see residents during their shift if they don't have scheduled medication for the resident. During an interview with the Director of Nursing on 9/3/24 at 3:53 PM they stated they were only aware of the incident today. Resident #1 had gone out with family member and returned with a bruise. Resident #1 was noted with ecchymosis (bruise) to right side of forehead and area above right eye of unknown origin. They stated any injury of unknown origin is reportable and they were not able to rule out that abuse occurred. During an interview with Licensed Practical Nurse #1 on 9/3/24 at 4:21 PM, they stated that on 9/1/24 around 1-1:30 PM Resident #1 left the unit with a family member for an out on pass with no skin impairment on their face. On 9/2/24 at 8:15 AM Certified Nursing Assistant #1 reported that Resident #1 had a bruise on their face and Unit Manager #2 and Assistant Director of Nursing checked Resident #1. Resident #1 was asked how they got the bruise, and they were told 5-6 different versions. During an interview with Unit Manager #2 on 9/5/24 at 1:04 PM they stated that Licensed Practical Nurse #1 informed them that Resident #1 had discoloration to right side of their forehead and area above their right eye. Resident #1 was evaluated for pain and Resident #1 could not remember how they got the bruise. The staff from 9/1/24 were interviewed and they did not see the bruise prior to Resident #1 going out on pass. Unit Manager #2 stated they did not think of it as abuse and reported to the Assistant Director of Nursing who also assessed Resident #1. During a phone interview with the Medical Director on 9/5/24 at 1:37 PM, they stated that Resident #1 was examined, area was not painful, and the discoloration may have been from a broken blood vessel without an injury. The Medical Director responded that they did not know, when asked if they can rule out abuse. During an interview with the Administrator on 9/5/24 at 4:18 PM they stated that they interviewed Resident #1 and was told that they got hit by their own phone but Resident #1's family member stated that it could be from a bug bite when they went to a botanical garden. Physician stated that it was vascular related, and that nursing and the physician did not suspect it was abuse related nor an injury of unknown origin. The video surveillance was reviewed, and Resident #1 left the facility with no bruise to their face. During an interview with Certified Nursing Assistant #4 on 9/18/24 at 2:30 PM, they stated that they worked 11-7 shift on 9/1/24 but they did not remember Resident #1 with a bruise, and no one asked them for a written statement regarding the incident. 50951 2) Resident #2 was admitted on [DATE] with documented diagnosis that included mild cognitive impairment, history of falls, and osteoarthritis. Resident had a Minimum Data Set, dated dated dated [DATE] that documented a Brief Interview of Mental Status score of 12. Resident #2 passed away at the facility on 08/09/24. A Nurses Note dated 8/6/2024 at 10:20 AM documented that Resident #6 pushed Resident #2 to the floor. Resident #2 fell to the floor onto their buttock and elbows and then hit their head on floor. The physician ordered Ativan for agitation. During a record review there was no documented evidence that the facility investigated the altercation between Resident #2 and Resident #6 which resulted in a fall of Resident #2. During an interview with Administrator on 09/25/2024 at 2:13 PM the Administrator was interviewed and stated that the facility could not find an Accident and Investigation report for Resident #2 and Resident #6 on 08/06/2024 at 10:20. During an interview with Manager on 09/25/2024 at 4:49 PM Risk Manager stated that the they did not know why an Accident and Investigation form was not completed for this incident. During an interview with the Unit Manager on 09/26/2024 at 12:59 PM that the reason an Accident and Investigation was not completed for this incident was because the Administrator looked at the video and did not see any altercation, push, or fall for Resident #2. During an interview with Administrator on 09/26/2024 at 1:52 PM The administrator stated they could not recall reviewing the video for this incident. The Administrator stated that if they had seen a fall or altercation on the video there would have been an Accident and Investigation form completed. During a telephone Interview with Director of Nursing on 09/26/2024 at 2:18 PM the Director of Nursing stated they arrived on unit when resident to resident incident and fall was reported on 08/06/2024. The Director of Nursing stated they did not start an Accident and Investigation because when they arrived on the unit, Resident #1 was alert and agitated, walking around. The Administrator viewed the video footage and did not see the altercation or fall. 10 NYCRR 415.4(b)(1) (ii

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00337626) initiated on 4/29/2024 and completed on 5/7/2024, the facility did not ensure that all incidents including the injury of unknown origin were thoroughly investigated. This was identified for two (Resident #530 and Resident #140) of six residents reviewed for Accidents and for one (Resident #133) of three residents reviewed for Abuse. Specifically, 1) on 2/16/2024 Resident #530 was found on the floor and sustained a hematoma (bruising) to the forehead and skin tears on both arms. The facility did not thoroughly investigate the incident to identify the root cause and to rule out Abuse, Neglect, and Mistreatment. Additionally, the facility did not ensure that the investigation summary of the incident was completed within 5 days as required. 2) Resident #140 had multiple injuries of unknown origin from 9/22/2023 to 5/6/2024 and the facility did not thoroughly investigate the injuries of unknown origin incidents to identify the root cause and to rule out Abuse, Neglect, and Mistreatment. 3) Resident #133 sustained an injury of unknown origin, discoloration to the left eye, on 3/28/2024 and the facility did not thoroughly investigate the incident to identify the root cause of the injury and to rule of Abuse, Neglect, and Mistreatment. The findings include but are not limited to: 1) The facility policy and procedure titled Accidents and Incidents-Investigating and Reporting last revised on 12/2023 documented that all incidents or accidents involving residents, employees, visitors, and vendors occurring in the facility shall be investigated and reported to the Director of Nursing Services and the Administrator. The nurse, supervisor, charge nurse, or department director shall complete a report of the incident/accident and submit it to the Risk Manager or the Director of Nursing. The following data, as applicable shall be included on the report of incident/accident form, the date and time the accident or incident took place, the nature of the injury, and illness, circumstances surrounding the accident or incident where the accident or incident took place. The names of the witnesses and their accounts of the incident or accident, if applicable should be included in the report. Resident #530 was admitted with Diagnoses of Malignant Neoplasm of the Lung, Chronic Kidney Disease, and Cerebrovascular Accident. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview of Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. The Minimum Data Set documented that Resident #530 needed maximum assistance from staff with sit-to-stand and chair-to-bed transfer. A Comprehensive Care Plan (CCP) dated 2/6/2024 documented that Resident #530 was at risk for fall due to impaired mobility. Interventions included but were not limited to a neurology examination (an assessment of motor responses, and reflexes to determine if the nervous system is impaired) will be conducted for each fall. A Progress Note dated 2/16/2024 at 11:58 AM documented that Resident #530 was observed lying on their left side adjacent to the bed. Head-to-toe assessment was completed by Registered Nurse #6. Resident #530 was noted with small skin tears and a hematoma (bruising) on their forehead. The physician was notified and a neuro check (neurologic examination that identifies and assesses the functions of vital portions of the nervous system) was ordered. The Accident/Incident investigation for the 2/16/2024 incident was provided by the Risk Manager. An Investigation Statement by the Registered Nurse was included. The statement was signed on 2/28/2024 and did not include a description of the incident. The Registered Nurse statement documented the resident was not considered at high risk for falls and did not document the resident sustained skin tear or hematoma. The Accident/Incident Investigation Form did not include a statement from the assigned Licensed Practical Nurse #9, the provided form was blank. The statement from the assigned Certified Nursing Assistant #13 did not include the time the incident occurred. The statement was signed by the assigned Certified Nursing Assistant #13 on 3/20/2024. There was no documented evidence that a summary to conclude the investigation was completed by the facility within 5 days. A Comprehensive Care Plan (CCP) dated 2/21/2024 documented that Resident #530 had an actual fall on 2/16/2024. The interventions included to keep the bed in the lowest position; to obtain a Physical Therapy consult for strength and mobility; and to keep Resident #530 in highly visible areas while awake. Registered Nurse #6, Unit Manager, was interviewed on 5/2/2024 at 11:26 AM and stated that they assessed Resident #530 on 2/16/2024 at 11:15 AM when the resident was observed by the charge nurse on the floor. Registered Nurse #6 stated they started the Accident/Incident investigation and were able to get the statement from Certified Nursing Assistant #13 who was assigned to the resident on 2/16/2024. Registered Nurse #6 stated they could not remember why Licensed Practical Nurse #9, the charge nurse, did not provide a statement on 2/16/2024. Registered Nurse #6 stated that the following day, Licensed Practical Nurse #9 resigned. Registered Nurse #6 stated they gave the investigation form to the Risk Manager to complete. The Assistant Director of Nursing/Risk Manager was interviewed on 5/2/2024 at 11:46 AM and stated that all Accident/Incident Investigation should be completed within 5 days. The Assistant Director of Nursing/Risk Manager stated that Resident #530 Accident/Incident investigation from 2/16/2024 was not completed within the 5-day timeframe because they were waiting for Licensed Practical Nurse #9's statement. The Assistant Director of Nursing stated they were not aware that Licensed Practical Nurse #9 had resigned the day after the incident. The Assistant Director of Nursing/ Risk Manager stated that the investigation should have been concluded within 5 days. The Director of Nursing Services was interviewed on 5/3/2024 at 10:00 AM and stated that all Accident/Incident Investigations must be completed within 5 days. All statements must be obtained and all areas of the investigation form must be completed. During a subsequent interview with the Director of Nursing Services on 5/6/2024 at 12:51 PM they stated that Licensed Practical Nurse #9 changed their status to a per-diem staff on 2/17/2024 and did not return to the facility. Licensed Practical Nurse #9 was subsequently terminated on 3/17/2024. The Director of Nursing Services stated they were not aware that a statement from Licensed Practical Nurse #9 was not obtained. The Director of Nursing Services stated that Resident #530's Accident and Incident investigation forms related to the incident on 2/16/2024 should have been completed and a conclusion should have been documented within 5 days to rule out abuse, neglect, and mistreatment. 41051 2) Resident #140 had diagnoses that included Dementia with Psychotic Disturbance, Anxiety Disorder, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 0 which indicated the resident had severe cognitive impairment. Resident #140 had no impairment in the upper and lower extremities. Resident #140 utilized a wheelchair for mobility. Resident #140's Fall Potential Care Plan revised on 11/16/2023 documented that Resident #140 was at high risk for falls related to impaired cognition, balance, and mobility due to Dementia, Depression, Anxiety with psychotropic medication use, and incontinence. The interventions included to identify the cause of falls. Resident #140's Abuse Care Plan revised on 10/4/2023 documented that Resident #140 was at risk of being a victim of abuse due to their inability to understand their surroundings related to being physically abusive, being verbally abusive, and having disruptive behavior. The interventions included to assess the resident for signs and symptoms of abuse and neglect (ex. bruises, behavior, weight loss, psychosocial status) and report to the appropriate resources. The interventions also included to investigate all allegations of abuse and neglect promptly, to provide support, and to ensure Resident #140 was free from abuse. Resident #140's Behavior Care Plan revised on 4/19/2024 documented that Resident #140 exhibited behavior symptoms which included being combative with care, being verbally aggressive and disruptive, vandalizing, and going from room to room to gather nightgowns, and pillows. The inventions were to assist Resident #140 to their room, redirect the resident, and remove the resident from the environment. A review of Resident #140's electronic medical record investigation report dated 12/3/2023 at 6:24 PM documented that Resident #140 was observed with a skin tear on their left flank and was unable to give a description. The electronic medical record investigation summary dated 12/3/2023 documented the resident had combative behavior and was observed with a skin tear to the left flank area. The resident was unable to describe the event. The Accident/Incident Investigation form Registered Nurse Investigation Statement dated 12/3/2023 documented a skin occurrence to the left hip at 9:40 PM. The statement did not include a description of the skin occurrence. The Accident/Incident Investigation form- Charge Nurse/Licensed Practical Nurse Statement (did not include the resident's name, date, or time) documented the Licensed Practical Nurse was informed by a Certified Nursing Assistant that a resident had a skin mark on their left hip. The Accident/Incident Investigation form- the Assigned Certified Nursing Assistant Statement dated 12/3/2023 at 9:40 PM documented they observed a mark on Resident #140's left hip and the incident was reported to the Charge Nurse. A Nursing Progress Note dated 12/4/2023 at 7:02 AM documented Resident #140 was observed with a skin tear on their left flank. The Medical Doctor was notified and a wound care consultation was ordered. A review of Resident #140's electronic medical record investigation report dated 12/18/2023 at 8:35 PM documented the Registered Nurse Supervisor was informed by a Certified Nursing Assistant that Resident #140 was noted with a skin opening to the left hip. The electronic medical record investigation summary dated 1/11/2024 documented, Upon investigation of this incident, there was no care plan violation. Nursing standards have been followed, and there was no indication of neglect or abuse found. The summary did not indicate the root cause of the injury and was not signed by the Director of Nursing Services or the facility Administrator. The electronic medical record investigation summary note dated 12/29/2023 documented there was no care plan violation, nursing standards were followed and there was no evidence of abuse, neglect, or mistreatment. The Assistant Director of Nursing Services/Risk Manager was interviewed on 5/7/2024 at 4:09 PM and stated they completed the investigation for Resident #140's injury of unknown origin that was identified on 12/3/2023 and 12/18/2024. The Risk Manager stated they ruled out abuse, neglect, and mistreatment based on one Certified Nursing Assistant statement and one Licensed Practical Nurse statement. The Risk Manager stated they did not notice the discrepancy between the wound sites on 12/3/2023 and 12/4/2023. The Risk Manager stated they did not complete an investigation for the left flank skin tear because they thought the injury was old. The Risk Manager stated that when an injury of unknown origin is discovered an investigation should be conducted and staff persons who provided care for the resident should be interviewed for the previous 72 hours depending on the severity of the injury and whether the resident had a history of combative or abusive behavior. The Risk Manager stated that Resident #140 had a history of combative and abusive behavior and based on the statements collected they determined a more extensive investigation did not need to be completed. The Director of Nursing Services was interviewed on 5/7/2024 at 5:09 PM and stated the Registered Nurse Supervisor is responsible for getting statements from the staff who worked 72 hours prior to identification of the injury of unknown origin irrespective of the resident's behavior. The Director of Nursing Services stated they reviewed and signed off on all investigations. The Director of Nursing Services stated they reviewed the Investigation summaries and the electronic medical record investigation reports; however, they did not review the statements completed by the staff because they found the Investigation Summary and electronic medical record investigation report acceptable. The Director of Nursing Services stated the investigations for the incidents dated 12/3/2023 and 12/18/2023 for Resident #140 did not have statements from staff who cared for the resident in the last 72 hours prior to the injury identification. The Director of Nursing Services further stated that the investigations were not thorough. 40696 3) Resident #133 was admitted to the facility with the diagnoses of Dementia, Psychotic Disorder, and Depression. The Quarterly Minimum Data set assessment dated [DATE] documented Resident #133 had severely impaired cognitive skills for daily decision-making, no recall ability, as well as long-term and short-term memory problems. Resident #133 had no impairment in the upper and lower extremities. Resident #133 utilized a walker and wheelchair for mobility. Resident #133's Abuse Care Plan revised on 4/20/2024 documented that Resident #133 was at risk of being a victim of abuse due to their inability to understand their surroundings related to Dementia and dependence on others for activities of daily living. The interventions included to help Resident #133 with activities of daily living and support to ensure that Resident #133 is free from abuse. Resident #133's Behavior care plan revised on 4/20/2024 documented that Resident #133 exhibited behavioral symptoms including wandering, anger towards staff and residents, continuous pacing, screaming, yelling, cursing, removing clothing, crawling on the floor, sitting on the floor, laying on the floor, and rolling on the floor. The interventions included assisting Resident #133 to the room; providing an activity of choice; redirecting Resident #133; and removing Resident #133 from the environment. The weekly skin observation note dated 3/28/2024 at 9:19 AM documented that Resident #133 was observed with a new skin bruise to the left eye. The nurse's progress note dated 3/28/2024 at 2:20 PM, written by Licensed Practical Nurse #5, documented the nurse was called to the unit at 1:00 PM and was made aware that Resident #133 had a discoloration to the left corner of the eye. Resident #133 and the unit staff were unable to state what happened. Resident #133 walks around freely in the unit. Resident #133 was evaluated by the Registered Nurse Supervisor. A review of all progress notes for March 2024 revealed that the resident had no documented behaviors on 3/25/2024, 3/26/2024, and 3/27/2024, preceding the incident on 3/28/2028. The Accident and Incident investigation report dated 3/28/2024 documented that on 3/28/2024 at 1:00 PM, Licensed Practical Nurse #5 observed Resident #133 with a dark spot to their left eye and notified the Registered Nurse Supervisor. Licensed Practical Nurse #5 documented that Resident #133 was agitated and then went to their room earlier in the day. Licensed Practical Nurse #5 administered medications to Resident #133 when they last saw Resident #133. The assigned Certified Nurse Aide #9's written statement dated 3/28/2024 documented that during the dayshift, Certified Nurse Aide #9 noticed a discoloration to Resident #133's left eye while providing morning care. Certified Nurse Aide #9 reported the observed discoloration to Licensed Practical Nurse #5. Certified Nurse Aide #9 documented they did not transfer Resident #133 and that Resident #133 required limited assistance with transfers. An undated written statement by the 11:00 PM to 7:00 AM shift Certified Nurse Aide #10 documented that on 3/27/2024 they made rounds all night and changed Resident #133 during the night. Certified Nurse Aide #10 documented they did not notice anything on Resident #133's face. The Investigation Summary dated 3/28/2024 at 1:10 PM documented that Resident #133 had Advanced Dementia and Diabetes Mellitus. Resident #133 was often aggressive towards staff and continued to display agitation. Resident #133 was redirected by staff numerous times throughout the day. The summary documented Can conclude that [Resident #133] may have acquired discoloration during [Resident #133's] periods of aggression. Upon investigation of this incident, there was no care plan violation. Nursing standards have been followed and no indication of neglect or abuse found. The Risk Manager was interviewed on 5/7/2024 at 10:56 AM and stated that they conducted the investigation for Resident #133 on 3/28/2024 and wrote the summary. The Risk Manager stated they interviewed the staff members who worked 24 hours before the discovery of the discoloration on Resident #133's left eye. The Risk Manager stated the staff told them that there were no physical behaviors that may have caused the incident during their shift. The Risk Manager stated that because of the resident's history of physically aggressive behavior, the discoloration of the resident's left eye may have been caused by the resident's aggressive behavior. The Director of Nursing Services was interviewed on 5/7/2024 at 11:12 AM and stated they reviewed the Accident and Incident report dated 3/28/2024. The statements from the staff members who provided care for Resident #133 did not include physical behaviors that may have caused the discoloration. The Director of Nursing Services stated that the staff statements should include whether the resident had a physical behavior that may have caused the discoloration. The Director of Nursing Services stated that the conclusion did not include how the resident sustained the discoloration to their left eye. The Director of Nursing Services stated that the investigation as written was not thorough. 10 NYCRR 415.4(b)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/29/2024 and completed on 5/7/2024, 1) the facility did not ensure that 1) medications were administered within one hour of the ordered administration time on two (Unit 2 [NAME] and Unit 1 West) of four units during unit observations, and 2) the drug records were in order and accounted for all controlled drugs on one (Unit [NAME] 1) of six units observed during the medication storage task. Specifically, 1) on 4/29/2024 on Unit 2 [NAME] in the Glengariff building, three residents (Resident #126, #131, and #32) did not get their 9:00 AM medications within one hour of the physician-ordered administration time; and on 4/30/2024 on Unit 1 [NAME] in the Glengariff building eleven residents (Resident #134, #151, #331, #82, #34, #92, #95, #8, #46, #157, #178) did not get their 9:00 AM medications within one hour of the physician-ordered administration time; and 2) During the medication storage task observation the controlled substance administration record for Resident #538 indicated a zero balance of Oxycodone (controlled substance medication) 10-milligram tablet; however, the medication blister pack had one tablet remaining. The findings include but are not limited to: The facility's Medication Administration policy, last revised 5/3/2024, documented that medications are administered in a safe and timely manner, and as prescribed; and medication administration times are determined by resident need and benefit. 1a) An example of one of the three residents affected on Unit 2 [NAME] in the Glengariff building: Resident #126 was admitted with diagnoses including End Stage Renal Disease, Diabetes Mellitus, and Depression. The 2/3/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Resident #126's physician orders as of 4/29/2024 included the following medications due for 9:00 AM administration: -Apixaban Oral Tablet 2.5 milligrams Give 1 tablet by mouth every 12 hours for Blood thinning. -Carvedilol Tablet 3.125 milligram Give 1 tablet by mouth every 12 hours for Hypertension. -Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 120 milligram Give 1 tablet by mouth one time a day for Hypertension; and -Tylenol Oral Tablet 325 milligram (Acetaminophen) Give 2 tablets by mouth two times a day for pain. Licensed Practical Nurse #6, Unit 2 West's medication nurse, was observed administering medications on 4/29/2024 at 12:02 PM. Licensed Practical Nurse #6 stated they were still administering the 9:00 AM medications and there are three (Resident #126, #131, and #32) more residents remaining who still need their 9:00 AM medications administered. Licensed Practical Nurse #6 stated they were late with administering medications because they were the only nurse for 39 residents today (4/29/2024). Licensed Practical Nurse #6 stated they did not inform their supervisor that they were late with medications, they were just trying to finish up. A review of the Medication Administration Audit Report (a report indicating medication administration time) for 4/29/2024 for Resident #126 revealed that Licensed Practical Nurse #6 documented the 9:00 AM medications were administered at 12:27 PM. Registered Nurse #4, Unit 2 West's Supervisor, was interviewed on 5/2/2024 at 7:58 AM and stated they were a new supervisor and were not sure what the medication nurse should do if they (the medication nurse) were late with the medication administration. Registered Nurse #4 stated I assume the medication nurse has to reach out to the supervisor to let me know they need help. 1b) An example of one of the eleven residents affected on Unit 1 [NAME] in the Glengariff building: Resident #151 was admitted with diagnoses including Non-Alzheimer's Dementia, Cerebrovascular Accident, and Hypertension. The 6/1/2023 quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 5, indicating the resident had severe cognitive impairment. Resident #151's physician orders as of 4/30/2024 included the following medications due for 9:00 AM administration: -B-Complex Oral Capsule, give one capsule by mouth one time a day for Anemia. -Calcium-Vitamin D Tablet 600-200 milligrams, give one tablet by mouth one time a day for supplementation. -Eliquis oral tablet 2.5 milligrams, give one tablet by mouth two times a day for Anticoagulant. -Furosemide (Diuretic) tablet 20 milligrams, give one tablet by mouth one time a day. -Lisinopril tablet 40 milligrams, give one tablet by mouth one time a day for Hypertension. -Metoprolol Succinate Extended Release, 25 milligrams, give three tablets by mouth one time a day for Hypertension. -Potassium Chloride extended-release tablet, 10 milliequivalents, give one tablet by mouth one time a day for a supplement. Licensed Practical Nurse #1, Unit 1 [NAME] Medication Nurse, was observed on 4/30/2024 at 11:12 AM administering the 9:00 AM medications. Licensed Practical Nurse #1 stated they were still administering the 9:00 Medications and there were 11 residents (Resident #134, Resident #151, Resident #331, Resident #82, Resident #34, Resident #92, Resident #95, Resident #8, Resident #46, Resident #157, Resident #178) that still needed to get their 9:00 AM medications. Licensed Practical Nurse #1 stated there are 37 residents on the unit and it is very time-consuming for one nurse to administer all the medications. Licensed Practical Nurse #1 stated they did not ask for help. A review of the Medication Administration Audit Report (a report indicating medication administration time) for 4/30/2024 for Resident #151 revealed that the 9:00 AM medications were administered at 11:56 AM by Licensed Practical Nurse #1. Registered Nurse #2, Unit 1 [NAME] Supervisor, was interviewed on 5/2/2024 at 8:07 AM. Registered Nurse #2 stated when a medication nurse is late with the medication administration, they should have reached out to the supervisor for assistance. The Director of Nursing Services was interviewed on 5/2/2024 at 2:20 PM and stated the nurses have one hour before and one hour after the ordered administration time to administer the medications. The nurses should have requested help from the supervisor if they were running late with their medication administration. The Medical Director was interviewed on 5/7/2024 at 8:44 AM and stated if the nurses are late in administering medications, they should ask for help. Generally, the nurses should stick to the time frame of when the medications are due as per the nursing policy. There are certain medications, like antibiotics, that are critical and need to be given on time. 49245 2) The facility policy and procedure titled, Storage of Controlled Substances last revised on 12/22/2022 documented that all controlled substance medications must be stored in a metal, double-locked, double-door stationary cabinet, in a locked medication room. Only one authorized medication nurse may have possession of the keys. When the keys are transferred to an on-coming medication nurse, a shift-to-shift count of narcotics will be performed and documented. When medications are to be administered during the medication pass, the container (e.g., blister pack) may be removed from the double-locked cabinet and stored in the narcotic lock box within the medication cart. Upon completion of the medication pass, the medication container must be immediately returned to the stationary, double-door, double-locked cabinet. Resident #538 was admitted with Diagnoses of the right foot Amputation, Sepsis, and Congestive Heart Failure. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated that Resident #538 had intact cognition. Resident #538 received scheduled pain medication. A Physician's order dated 4/10/2024 documented to administer Oxycodone Hydrochloride (a type of analgesic controlled substance medication to treat moderate to severe pain) 10 milligrams, give one tablet by mouth every four hours as needed for severe pain for seven days. The order was completed on 4/17/2024. A Comprehensive Care Plan (CCP) dated 4/11/2024 documented that Resident #538 had amputation of the right foot. The intervention included analgesics as ordered by the Physician. Monitor and document for any side effects and effectiveness of the medications. A Physician's order dated 4/30/3024 documented to administer Oxycodone Hydrochloride 5 milligrams, give one tablet by mouth every six hours for Pain. The Medication Storage room on Unit 1 was observed with Registered Nurse #1 on 5/3/2024 at 10:23 AM. An Oxycodone 10 milligram blister pack, that was labeled with Resident #538's name, was observed inside the double-locked narcotic cabinet. A Controlled Medication Administration Record form was attached to the blister pack. The Controlled Medication Administration Record form documented a zero balance as of 5/1/2024 at 7:34 PM; however, the medication blister pack was observed with one tablet remaining. Registered Nurse #1 was interviewed on 5/3/2024 at 10:40 AM. Stated that the oxycodone 10 milligrams was discontinued on 4/29/2024 and the remaining tablet in the blister pack was put in the double-locked narcotic box. Resident #538 has an active order for Oxycodone Hydrochloride 5 milligrams one tablet every six hours for pain which was administered to Resident #538 on 5/1/2024 at 7:34 PM by Licensed Practical Nurse #7. Registered Nurse #1 stated that Licensed Practical Nurse #7 erroneously documented on both 5 milligrams and the discontinued 10-milligram Oxycodone Controlled Medication Administration Record form instead of the 5 milligrams Oxycodone Controlled Medication Administration Record form. Licensed Practical Nurse #7 was interviewed on 5/3/2024 at 11:00 AM and stated they administered Oxycodone 5 milligrams for Resident #538 as per the Physician's order on 5/1/2024 at 7:34 PM. Licensed Practical Nurse #7 stated they mistakenly documented the same entry on both the discontinued 10-milligram Controlled Medication Administration Record form and the active 5-milligram Controlled Medication Administration Record form. The Director of Nursing Services was interviewed on 5/3/2024 at 11:15 AM. Stated that discontinued controlled medications should be brought to the Nursing Office and should not be stored on the units and all controlled medications that are stored on the unit should be counted every shift by the nurse. The Director of Nursing Services stated there are times when a discontinued controlled medication is kept in the unit's medication storage room in a double-locked box if it is the weekend or if the Nursing Office is closed. 10 NYCRR 415.18(a)(b)(1)(2)(3)

Based on record review and interviews during the Recertification Survey and Extended Survey (NY 00321997) initiated on 4/29/2024 and completed on 5/7/2024 the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. This was identified for two (Resident #151 and Resident #82) of three residents reviewed for Abuse. Specifically, Resident #151 and Resident #82 were involved in a resident-to-resident altercation on 8/11/2023, in which Resident #151 was allegedly pushed by Resident #82 and fell to the floor. The incident of resident to resident altercation was not reported to the New York State Department of Health until three days after the incident, on 8/14/2023. The finding is: The facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised 5/3/2024, documented to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within the timeframes required by federal requirements. Establish and implement a quality assurance and performance improvement review and analysis of reports, allegations, or findings of abuse, neglect, mistreatment, or misappropriation of property. Resident #151 was admitted with diagnoses including Non-Alzheimer's Dementia, Cerebrovascular Accident, and Hypertension. The 6/1/2023 quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 5, indicating the resident had severe cognitive impairment. Resident #82 was admitted with diagnoses including Schizophrenia, Peripheral Vascular Disease, and Anxiety Disorder. The 7/20/2023 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A nursing progress note written by Registered Nurse #1 (supervisor) on 8/11/2023 at 6:30 PM for Resident #151 documented an Accident and Incident Note. The resident was heard shouting for help. When checked, the resident was found lying on the floor, pushing their upper body with bilateral elbows. The resident claimed they were pushed by the resident next door (Resident #82) who wanted to use the toilet while Resident #151 was still inside the bathroom. The resident complained of pain in the lower back and claimed that they hit their head slightly on the floor. The resident was assessed for any visible injury. Placed back in their wheelchair via two-person assist. Referred to the primary physician. Tylenol was given by the medication nurse. Bilateral hip and lumbar X-rays were ordered. A nursing progress note written by Registered Nurse #1, the nursing supervisor, on 8/11/2023 at 6:30 PM for Resident #82 documented that at 6:30 PM the resident was seen inside the shared toilet, appeared mad and was pointing a finger at Resident #151 who was found on the floor. Resident #151 alleged that Resident #82 pushed them. According to Resident #82, they were using the bathroom first when Resident #151 went inside to get a tissue. Resident #82 also alleged that Resident #151 pushed them first and that Resident #82 just pushed Resident #151 back out of the toilet causing Resident #151 to fall. The New York State Department of Health complaint intake revealed that the incident was received on 8/14/2023 at 12:10 PM. A physician's progress note dated 8/15/2023 documented X-rays for Resident #151 were reviewed. The findings were chronic without any acute fractures. A psychiatrist consults for Resident #82 dated 8/15/2023 documented the resident pushed another resident. The resident had a history of Schizoaffective disorder. The resident has involuntary movements and is not aware of it. The resident blames the other resident for taking toilet paper from the bathroom and not leaving for this resident. On 4/29/2024 Resident #151 and Resident #82's rooms were observed. Both residents reside on Unit 1 West. The resident rooms are adjacent to each other and there is a shared bathroom. The residents still reside in the same rooms/beds as they did on 8/11/2023. On 4/29/2024 at 11:24 AM Resident #151 was interviewed. Resident #151 stated they did not get hurt when they were pushed, but I was scared for sure. This resident was observed ambulating independently in their room. On 4/30/2024 at 12:49 PM Resident #82 was interviewed. Resident #82 stated they did not remember the incident. On 5/2/2024 at 11:57 AM Registered Nurse #1 was interviewed. Registered Nurse #1 stated they were the supervisor on the 3:00 PM-11:00 PM shift when the 8/11/2023 incident occurred. When they arrived at the unit, Resident #151 was on the floor and claimed they were pushed by Resident #82. Registered Nurse #1 stated there were no incidents between the two residents prior to the 8/11/2023 incident. On 5/2/2024 at 12:50 PM Resident #134, the resident who witnessed the incident, was interviewed. Resident #134 stated Resident #151 was in the bathroom first and was coming out when Resident #82 came into the bathroom from the other room and pushed Resident #151. Resident #151 fell right in front of Resident #134's bed. Resident #134 stated they did not know of any previous incidents between the two residents. On 5/3/2024 at 8:54 AM Certified Nursing Assistant #1, who was assigned to Resident #151 on 8/11/2024 during the 3:00 PM-11:00 PM shift, was interviewed. Certified Nursing Assistant #1 stated Resident #82 was very quiet; we did not know how this incident happened; everyone was surprised. Certified Nursing Assistant #1 did not observe any issues between the two residents. Assistant Director of Nursing #2, the Risk Manager was interviewed on 5/3/2024 at 11:11 AM. Assistant Director of Nursing #2 stated they were not employed at the facility when the 8/11/2023 incident occurred. The 8/11/2023 incident was reportable and should have been reported to the New York State Department of Health within 2 hours. Two residents pushing each other could be a willful act, which is why the incident between Resident #82 and Resident #151 should have been reported within 2 hours. The Director of Nursing Services was interviewed on 5/3/2024 at 1:20 PM and stated the incident on 8/11/2023 between the two residents should have been reported to the New York State Department of Health within two hours. The Director of Nursing Services stated they were involved in the investigation and concluded there was no abuse, neglect, or mistreatment. 10 NYCRR415.4 (b) (1) (ii)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00337626) initiated on 4/29/2024 and completed on 5/7/2024, the facility did not immediately notify the resident's Designated Representative when there was a significant change in the resident's physical status. This was identified for one (Resident #140) of one resident reviewed for Notification of Change. Specifically, on 3/17/2024 Resident #140 fell and hit their head on a radiator and was identified to have sustained a scalp laceration. Subsequently, the resident was transferred to the hospital for evaluation on 3/17/2024. There was no documented evidence that the resident's designated representative was notified of the resident's fall and the resident's transfer to the hospital until 3/19/2024. The finding is: The facility's policy titled, Notification of Change created in 12/2021 and revised in 12/2023 documented to notify the resident, their attending physician, and the resident representative of changes in the resident's condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in an injury including an injury of unknown origin, and when it is necessary to transfer the resident to a hospital or treatment center; except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Resident #140 had diagnoses that included Dementia with Psychotic Disturbance, Anxiety Disorder, and Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 0 which indicated the resident had severe cognitive impairment. An Accident and Incident report dated 3/17/2024 documented that Resident #140 fell and hit their head on the corner of a radiator. The report also documented Resident #140 had a skin laceration on the top of their head and they were transferred to the hospital for evaluation. A Nursing Progress Note dated 3/17/2024 documented Resident #140 was noted with a laceration to their head. The Medical Doctor was notified, and the resident was transported to the hospital for further evaluation. A review of the medical record indicated there was no documented evidence that Resident #140's designated representative was immediately notified of the resident's fall or the resident's transfer to the hospital on 3/17/2024. An Electronic Medical Record Investigation Report documented Resident #140's designated representative was notified on 3/19/2024 (two days later) that Resident #140 had a scalp laceration because of a fall and was sent to the hospital on 3/17/2024. The Designated Representative was interviewed on 5/1/2024 at 4:47 PM and stated they were not notified of the resident's fall or their hospitalization on either 3/17/2024 or 3/19/2024. The Designative Representative stated they became aware of Resident #140's injury when they visited Resident #140 on 3/26/2024 The Designated Representative stated they did not receive a voice message from the facility, and they did not have a missed call from the facility on 3/17/2024 or 3/19/2024. Assistant Director of Nursing #2, the Risk Manager, was interviewed on 5/7/2024 at 5:02 PM. Assistant Director of Nursing #2 stated it is the Registered Nurse Supervisor's responsibility to ensure the resident's designated representative is notified of an injury or hospital transfer and to ensure the communication with the resident's designated representative is documented in the resident's medical record. The Registered Nurse Supervisor who was responsible for notifying Resident #140's designated representative on 3/17/2024 was not available for an interview. The Director of Nursing was interviewed on 5/7/2024 at 5:30 PM and stated the Registered Nurse Supervisors are responsible for notifying the resident's designated representatives when a resident has an injury and is transferred to the hospital. The Director of Nursing Services stated that the staff must document the date and the time in the resident's medical record when the resident's designated representative was notified. 10 NYCRR 415.3(f)(2)(ii)(d)

Based on record review and interviews conducted during the Abbreviated survey (NY 320) completed on 4/19/2022, the Facility did not ensure residents rights to be free from sexual abuse. This was identified for 2 (Resident #1 and # 2) of 4 residents reviewed for abuse. Specifically, Certified Nursing Assistant (CNA) #1 inappropriately touched Resident #1 and Resident #2 while providing routine care. This resulted in actual psychosocial harm to Resident #2 that was not an immediate jeopardy. The Findings are: The Abuse policy dated 2/22/2021 documented that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation, and misappropriation of property. Residents will not be subjected to abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, contractors, and staff from other agencies, family members, legal guardians, resident representatives, friends, or other individuals. The Policy definition of sexual abuse was the non -consenting contact of any kind and included but was not limited to sexual harassment, sexual coercion, or sexual assault. 1) Resident#1 was admitted to the Facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated on 3/5/2022 documented the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating intact cognition. The MDS further documented that Resident#1 required extensive assistance with one person for dressing, extensive assistance with two persons for personal hygiene, two-person assistance for toileting, extensive assistance with two persons for bed mobility, and total dependence of two persons assistance for transfer. The MDS further documented that Resident #1 was always incontinent with bowel and bladder. A nursing progress note dated 3/5/2022 at 12:34 PM documented that Resident#1 was observed with increased confusion from baseline on admission. The Primary Care Physician ordered to transfer Resident#1 to Hospital for evaluation and emergency [CONDITION(S)] on 3/5/2022. The Facility Occurrence Investigation initiated on 3/8/2022 documented Resident#1's family notified the Facility on 3/8/2022 that Resident#1 reported that during care on 3/5/2022, their assigned male CNA, stuck their finger in Resident#1's rectum. The Occurrence Investigation report dated 3/8/2022 documented that the Facility started an investigation upon Resident#1's family member's notification about CNA#1. The Facility conducted an interview with all residents (7) assigned to CNA#1 on 3/5/2022. During the investigation Resident#2 was identified with the same sexual abuse allegation that CNA#1 inserted their finger in Resident#2's rectum. Attempts were made to contact Resident#2 for an interview but was unsuccessful. 2) Resident#2 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment initiated on 2/7/2022 documented the resident's Brief Interview for Mental Status (BIMS) score was 14 indicates intact cognition. The resident required extensive assistance with two people for bed mobility, transfer, and toileting. Resident#2 required extensive assistance of one staff member for personal hygiene. The Occurrence Investigation Summary completed on 3/10/2022 documented the investigation concluded that CNA#1 did not completely admit that the allegations were truthful. However, Resident#1 and Resident#2, whose BIMS scores were between 14-15, came forward having the same allegations and based on CNA#1 statement that 'CNA#1 may have stuck up their finger to Resident#2 buttocks , through this investigation, the Facility believes that possible abuse may have occurred. CNA#1 had been terminated from employment at the Facility. Resident#2 was interviewed on 3/17/2022 at 11:30 AM and stated on 3/5/2022 in the morning, CNA#1 came into their room to provide personal hygiene. Resident#2 stated CNA#1 turned off the lights and placed a hot wet towel between their legs while laying down on their back. Resident#2 stated CNA#1 began to massage between their legs and inner thighs. Resident#2 stated that no caregiver had ever done that type of a care before. Resident#2 stated that CNA#1 placed a hot towel on their chest. Resident#2 stated that CNA#1 continued to massage between their legs and thighs and slowly moved to their buttocks. Resident#2 stated CNA#1 separated their butt cheeks and started massaging the buttocks and rectum area. Resident#2 stated that CNA#1 asked permission to put some A and D ointment on their finger to grease their body. Resident#2 stated they permitted CNA#1 since they did not think anything of it. Resident#2 stated that CNA#1 massaged Resident#2's back with the ointment. Resident#2 stated CNA#1 then put the ointment on their rectum area and inserted their finger inside their rectum. Resident#2 stated that after 6 to 8 seconds they realized this care was not part of a bed bath, and they had pain. Resident#2 stated they informed CNA#1 they had pain, and CNA#1 stopped and took their finger out. Resident#2 stated that CNA#1 completed their bed bath and helped them get dressed. Resident#2 further stated they were surprised and tried to comprehend what happened. Resident#2 stated they have a family, and they could not face their family due to the shame of the incident. Resident #2 was observed during the interview crying with tears dripping from their cheeks and shaking. Resident#2 was observed grabbing the wheelchair armrests and squeezing them. Resident#2 was observed making a fist and waving their hands and stated, this should have not happened. Resident#2 stated they are ashamed. Resident#2 stated it was their fault this happened, and they should have protected themselves. Resident#2 stated they were ashamed and embarrassed to report the incident to the Facility until they were interviewed. The Director of Nursing (DNS) was interviewed on 3/17/2022 at 9:40 AM stated they received a call on 3/8/2022 at approximately 11:00 AM from Resident#1's family member to report a sexual abuse allegation that occurred on 3/5/2022 during 7:00 AM to 3 PM shift, involving CNA#1 and Resident#1. The DNS stated that CNA#1 was interviewed and was sent home around 11:05 AM on 3/8/2022. The DNS further stated that CNA #1 was instructed not to return to work until the sexual allegation investigation was completed. The DNS stated that CNA#1 admitted that they may have put their finger in Resident #2 rectum. The DNS further stated that the Director of Social Worker (SW#1) interviewed seven (7) residents assigned to CNA#1 on 3/5/2022 from 7:00 AM to 3:00 PM hours. During investigation and interviews of 7 residents who were assigned to CNA#1 on 3/5/2022 morning, Resident#2 was identified with the same allegation. The Director of Social Work (SW#1) was interviewed on 3/17/2022 at 11:23 AM and stated they were made aware of the sexual abuse allegation by the DNS on 3/8/2022 at 11 AM. SW#1 further stated that the DNS initiated the investigation for this allegation on 3/8/2022 at 11:00 AM. SW#1 further stated that Resident#1 did not notify any staff regarding the sexual abuse allegation. SW#1 stated they interviewed seven residents, and Resident#2 was identified as having a similar sexual allegation. SW#1 stated that during the interview with Resident#2, they appeared uncomfortable, shy, and reserved. SW#1 stated that Resident#2 stated that CNA#1 placed a hot towel on their chest. CNA#1 continued to massage between their legs and thighs and slowly move to their buttocks. Resident#2 stated that CNA#1 separated their butt cheeks and started massaging the buttocks and rectum area. Resident#2 stated that CNA#1 asked permission to put some A and D ointment on their finger to grease their body. Resident#2 stated they permitted CNA#1 since they did not think anything of it. Resident#2 stated that CNA#1 massaged Resident#2 back with the ointment. Resident#2 stated CNA#1 put the ointment on their rectum area and inserted their finger inside their rectum. SW#1 stated they notified the Psychologist#1 and SW#2 regarding the sexual abuse allegation to initiate a consult with Resident#2. Registered Nurse (RN) RN#1 was interviewed on 3/19/2022 at 5:31 PM and stated that on 3/8/2022, the DNS directed RN#1 to perform a complete body assessment of Resident #2 as part of a sexual abuse investigation. RN#1 stated they found no skin changes, [CONDITION(S)], bruises, or redness on Resident#2's body or rectum area. RN#1 stated that the resident reported that CNA#1 put their finger in their rectum. RN#1 stated that Resident#2 appeared to be upset. CNA#1 Personnel files revealed CNA#1 was an Agency employee contracted by the Facility. CNA#1 was in-service by the Facility on Sexual Harassment Policy and Procedure on 12/22/2021 prior to working at the Facility. CNA#1 was interviewed on 3/21/2022 and stated they had been CNA since December 2021, and this Facility was their first CNA job. CNA# 1 further stated their regular shift was 11:00 PM to 7:00 AM, but they often work 7:00 AM to 3:00 PM as a floater CNA to help the Facility. CNA#1 stated they were assigned to Resident#1's care on 3/5/2022 on the 7 AM to 3 PM shift. CNA#1 stated that on 3/5/2022 morning, they made hot wet towels to take care of Resident#1's skin during a bed bath. CNA#1 stated Resident#1 did not like body massages on their buttocks because Resident#1 had a wound on their buttocks. CNA#1 stated they stopped massaging Resident#1 inner buttocks after Resident#1 informed CNA#1 they had pain to their buttocks. CNA#1 stated they completed the perineal hygiene task and put Resident#1's clothes on. CNA#1 stated that Resident#2 did not have a sore on their buttocks. CNA #1 stated they started to grease Resident#2 buttocks and their rectum area. CNA#1 stated that they applied ointment to lubricate Resident#2 rectum to help Resident#2 dry skin around their rectum. CNA#1 stated giving a hot wet towel massage and greasing Resident#2's skin would make the Resident feel better. CNA#1 stated they used ointment as a lubricant to massage Resident#2 rectum to release the dry skin. CNA#1 stated they pulled their finger out of Resident#2 buttocks after the resident informed them, they had pain. CNA#1 stated they applied grease to all residents' skins, including their buttocks and rectum since dry skin makes residents' bowel movements pass harder and more complex. The Administrator was interviewed on 3/21/2022 at 2:21 PM and stated they were in the building on 3/8/2022 around 6:00 PM. They stated they informed the Staffing Agency about the sexual abuse allegation and that CNA# 1 was terminated. Psychologist #1 was interviewed on 4/12/2022 at 2:01 PM and stated that prior to Resident#2 discharge from the facility they had a therapeutic session regarding Resident#2 sexual abuse trauma. Psychologist #1 stated that during the therapeutic session, Resident#2 started crying and told the Psychologist they did not how they would face their family members after the sexual abuse. Psychologist #1 stated that Resident#2 was very upset and cried throughout the session. Psychologist #1 stated that Resident#2 would be affected by this sexual abuse trauma for the rest of their life. CNA #1 was re-interviewed on 4/19/2022 at 12:39 PM and stated the Facility did not instruct CNA#1 to insert their finger into Resident#1 and Resident#2's rectum. CNA#1's description of the rectum was the entire buttocks, including the opening area where the feces came from. CNA#1 stated that sexual abuse was having sex or touching someone without their permission. CNA#1 further stated, God and Angels helped me taking care of Residents and helped my days and nights go smooth, easy, and fast. CNA#1 stated, God gave me a mission to help people. They had a special gift of knowledge to take care of people, and they can utilize it to assist residents in alleviating their bowel movements. 415.4(b)

Based on observations, interviews, and record review, during an abbreviated survey (complaint ID #NY 375) the facility failed to have an effective system in place to identify a potential hazardous environment, and failed to provide adequate supervision to each resident to prevent an avoidable accident. Specifically, the facility did not have a system in place to ensure windows accessible to residents in each of two second floor resident lounges were secured to prevent an avoidable accident for one (Resident #1) and potential for accidents for 10 other ambulatory residents with dementia. Additionally, the facility did not have a system in place that identified designated persons or frequency to supervise residents while they were in the lounge. Specifically, Resident #1 was able to independently opened a second story slider window without difficulty and fell out the window resulting in multiple traumatic injuries, and later died in the hospital. This resulted in actual harm for Resident #1 and potential for serious harm for 10 residents that is Immediate Jeopardy and substandard Quality of Care. This resulted in actual harm for Resident #1 and potential for serious harm for 10 residents that is Immediate Jeopardy and substandard Quality of Care. The facility made modifications to the operation of the windows restricting opening the window beyond 6 inches. The facility developed policies and procedures to ensure daily preventative maintenance for window operations. Immediate Jeopardy was removed on [DATE], prior to the onsite abbreviated survey. The findings are: Facility video camera surveillance of the 2 East day room (#28) and patio (#20) date stamped [DATE] revealed the following: 4:01 PM - Resident #1 was observed sitting in his wheelchair in front of the television. 4:01 PM - Two Recreation Leader (RL) staff members ( as identified by the Director of Nursing(DON)) left the day room. No staff remained in the room. 4:05 PM - Resident #1 stood up from the wheelchair and walked to the window closest to him and was touching the window. 4:09 PM - Resident #1 walked over to the opposite side of the room and opened a sliding window. The window appeared to be open as wide as the width of resident's upper body. Resident #1 was moving the sliding window to the right then to the left, without difficulty. 4:13 PM - Resident #1 was observed sitting on the window sill for approximately six minutes with the window wide open. 4:19 PM - Resident #1 leaned his upper body outside of the window. 4:20 PM - Resident #1 fell to the ground floor patio. No staff members were present in the lounge from 4:01 PM to 4:20 PM. Nine other residents were present in the day room. Resident #2 was observed ambulating independently in and out of the day room, including in front of the opened window, during this time. The Director of Plant Engineering (DPE) was interviewed on [DATE] at 1:17 PM and stated that all the windows in the building were sliders that dated back to the 1970's. The DPE stated that, about 3 years ago, all windows were retrofitted with specific Hex Head screws to be used as stoppers because the screws that were in place were not effective to keep the windows from being opened greater than 6 inches. The DPE went to look at the window on the night of the incident, after the police concluded their investigation, and the DPE could not locate the bottom Hex Head screw. The DPE stated that the windows were checked at least yearly but that the findings were not documented. The DPE also stated that the facility did not have a policy for preventative window maintenance prior to the event on [DATE]. Room Check Logs dated [DATE] lacked documented evidence that the day room (lounge) window stops were evaluated for preventative maintenance, safety or function. The undated facility Policy and Procedure titled Preventative Maintenance lacked documented evidence that parameters for window openings were designated or that window function, maintenance, or surveillance was addressed. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS-an assessment tool) dated [DATE] documented the resident was cognitively intact, required extensive assistance of one person with ambulation and used a wheelchair for mobility. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) dated [DATE], documented the resident required limited assistance of one person for ambulation and transfers. The Admission Fall Risk assessment dated [DATE] documented the resident was at high risk for falls. The CCP for Risk for Falls and Injury dated [DATE] included Dementia, history of falls and limited mobility as risk factors and documented to anticipate the resident's needs in relation to ADLs, maintain safe environment, notify MD (Physician) of behavioral changes, observe for changes in ambulation and transfer, and provide reality orientation. The Exit Seeking/Wandering Evaluation assessment dated [DATE], documented the resident could physically move about on his own, was oriented to place, did not make statements about going home and had no behavior or history of wandering behaviors. The CCP for Risk for Elopement dated [DATE], documented Resident #1 was at risk for elopement from unit/facility. The interventions included to monitor resident's whereabouts and redirect behavior as needed. The Visual/Bedside Kardex Report (a Certified Nursing Assistant (CNA) guide for the care of the resident and tool for documentation of care provided) for the period from [DATE] - [DATE] documented the resident was on safety checks which included fall precautions and placement of ID band every shift. It was noted that Resident #1 was at risk for fall. There was no documented evidence that checks were completed on five out of 10 evening (3:00 PM - 11:00 PM) shifts. The Accident/Incident Report dated [DATE] and timed 4:24 PM, and the Facility Investigation Summary dated [DATE], documented Resident #1 was last seen watching TV in the day room (second floor lounge) on [DATE] at approximately 4:00 PM and fell from the second story window. The facility investigation further documented that as per the investigation and statements, when the activities were over, as per the customary routine; the staff began to bring residents out of the day room who were at risk for falls and place them in the hallway near the nursing station. The residents remained in the day room were considered safe in the room and monitoring was done by the unit staff while preparing residents for dinner. On or about approximately 4:10 PM, the resident (#1) was noted to get up from his wheelchair and walk first to the left then to the right towards the window. The resident then seized the opportunity to push open the window, kick the screen and climb out the window which resulted in fall. The facility concluded there was no evidence to support abuse, neglect, or mistreatment; the resident acted in his normal and customary manner, had no change in his condition or behavioral symptoms and that the resident was under adequate supervision. The Unit 2 East Assignment Sheets dated [DATE] for the 7:00AM-3:00PM and 3:00PM -11:00PM lacked documented evidence staff were assigned to supervise the residents in the day rooms. The Administrator (ADM) was interviewed on [DATE] at 2:06 PM and stated that she was notified on [DATE] by the Director of Nursing (DON) about the incident, she spoke with staff and reviewed the video and her conclusion was that the resident was trying to go out the window and she thought he kicked out the screen. The ADM stated that there was a general maintenance policy in place prior to the incident that did not include window surveillance or preventative maintenance. The ADM stated that the maintenance department conducted annual checks on the windows which was completed in [DATE]. The findings were documented in the log book. Licensed Practical Nurse (LPN) # 4 was interviewed on [DATE] at 2:36 PM and stated that Resident #1 had dementia, some confusion and could ambulate with the assistance of one person. LPN #4 stated that the resident had no physical, verbal or non-compliant behaviors. LPN #4 stated that there were no formal assigned day room checks by the CNAs prior to the incident and that the CNAs would discuss and decide amongst themselves what time each of them would go into the lounge. LPN #4 stated that the last time she saw Resident #1 on [DATE] was about 2:45 PM; he was in the day room with the recreation staff. CNA #1, assigned to the 3:00 PM-11:00 PM shift, was interviewed by phone on [DATE] at 12:01 PM and stated that the resident was alert, quiet, and required the assistance of one person with walking because he was unstable while standing. CNA #1 stated she was not aware that the resident was at risk for falls and that the resident did not have any alarm devices to indicate that he was at risk for falls or elopement. CNA #1 stated that the resident had not displayed any behaviors such as trying to stand unassisted or wheel himself out of the lounge or verbalize that he wanted to leave. CNA #1 stated that, on the evening of the incident, she saw Resident #1 about 3:00 PM; he was in the lounge with the activity staff. She thought the next time she saw him was about 4:00 PM after the recreation staff left. CNA #1 stated that residents were allowed to stay in the lounge without staff present because the staff were familiar with the residents, knew their behaviors, and were aware of the residents that liked to remain in the lounge until dinner. She stated Resident #1 was allowed to sit in the lounge because he did not have any behaviors that would indicate he needed more monitoring/supervision. Residents that were not stable and were at risk for falls, were placed at the nurses' station for the nurse to monitor. CNA #1 stated that before the incident, staff would go every 30 minutes to the lounge and check on the residents, to peak and look to make sure everyone was okay. CNA #1 stated that there was no written assignment as to who would go to the lounge and when. The CNAs worked it out among themselves. CNA #1 also stated she did not recall if the windows were open that evening but knew that they were only supposed to be open a little bit. The Director of Nursing (DON) was interviewed on [DATE] at 1:47 PM and 5:45 PM and stated that the CNAs were not required or assigned to stay in the lounge throughout the shift and that resident's that were not at high risk for falls could come and go as they pleased. The staff brought the high-risk residents with behaviors to the nurses' station to be monitored by the nurse. The DON stated that even though Resident #1 was a high risk for falls he did not have any behaviors that indicated he needed to be monitored closely. The DON also stated that the other residents in the video were allowed to remain in the lounge without staff presence because they liked to stay in there before dinner and were not at high risk for falls. The 3:00 PM-11:00 PM shift Licensed Practical Nurse (LPN) #5 was interviewed on [DATE] at 5:15 PM and stated that Resident #1 was quiet, did not have any behaviors like trying to stand, and did not verbalize he wanted to leave. She stated that she did not go back in the lounge that day and did not see Resident #1. At about 4:20 PM, she was alerted by a CNA that a resident fell out of the window. LPN #5 stated that there was no schedule for the CNAs to check or supervise the day room for resident safety. The 7:00 AM-3:00 PM Registered Nurse Supervisor (RNS#1) was interviewed on [DATE] at 12:00 PM and stated the CNAs were not assigned to go and stay in the dayroom/lounge just that they had to check the area periodically which was part of their daily task. Residents that can stay in the lounge were not at high risk for falls and do not generally have behaviors. RNS #1 stated when the CNAs documented that they completed safety check on their residents that meant that residents were not a danger to themselves or others, had not had a change in behavior, and were on the unit. CNA #2, assigned to the 3:00 PM-11:00 PM shift, was interviewed on [DATE] at 2:10 PM and stated that she had worked the evening when Resident #1 fell . When she came on shift she did the head count before 4:00 PM and found Resident #1 in the lounge watching TV. She stated that the CNAs usually went back and checked the lounge room every 30 minutes and that there was no specific time assigned and that they were not assigned to sit in the lounge. CNA #2 stated that some residents stayed in the lounge until dinner time. RNS #3 was interviewed by phone on [DATE]at 2:50 PM and stated that she worked the 7:00 AM-7:00 PM shift and was on duty the day of the incident. After 4:00 PM, one of the CNAs (could not recall name) came to the nursing office and told her that someone fell through the window from the second floor. She saw Resident #1 lying on the patio directly under the window, with a pool of blood around his head; he was gasping for air. RNS #3 immediately instructed staff to call 911 and get towels. She provided oxygen (at a high concentration) to the resident. She did not move him and applied pressure to his head and then he was taken to the hospital by the ambulance. RNS #3 stated that she believed that staff must remain in the lounge with the residents because it was a dementia unit and that residents with dementia were at higher risk for accidents and elopements and cannot make appropriate decisions. She stated that staff were supposed to go to the day room after the RLs left. RNS #3 stated that she started to collect statements and found out that no one was in the room at the time when Resident #1 opened the window. CNA #3, a 3:00 PM - 11:00 PM shift CNA, was interviewed on [DATE] at 3:45 PM and stated that she worked on [DATE] and when she came in she did rounds between 3:00 and 4:00PM and did a head count of all the residents to make sure they were all accounted for. She saw Resident #1 sitting in lounge watching television. She stated there was a RL in there at that time and that she left about 4:00PM. CNA #3 stated that the staff were not assigned to stay in the lounge with the residents and that they know which residents have to be moved to the nursing station to be monitored and which residents can stay in the lounge. She stated that residents that walked or wheeled themselves back and forth could come and go into the lounge. She stated until that day she did not know Resident #1 could walk. She stated she never saw the resident self-ambulate or verbalize he wanted to leave. CNA #3 stated she did not recall seeing the windows open in the lounge when she did the head count and if she noticed the window opened she did not know if she would report it but she would have definitely closed it and checked on the residents. CNA #3 reiterated that they go to check the lounge periodically but were not assigned to sit in the lounge with the residents. 483.25(d)

Based on staff interviews and record review during an abbreviated and partial extended survey it was determined that the administration failed to ensure that there was a system in place to ensure that each resident reached and maintained the highest practicable physical, mental and psychosocial well-being for one (Resident #1) of 9 residents reviewed for quality of care. Specifically, the Administration failed to develop and implement policies and procedures for CPR (cardiopulmonary resuscitation) and aspiration precautions; failed to ensure staff were knowledgeable of when to initiate CPR; and failed to identify system failures related to the supervision of residents at risk for aspiration. In addition, the Administration failed to conduct a thorough investigation to determine the root cause of an incident. This resulted in actual harm to Resident #1 and the potential for a pattern of serious harm that is Immediate Jeopardy for 87 residents. Complaint Number: NY 963 Cross References: F 309 - Provide Care for Highest Well-being F 501 - Medical Director F 520 - Quality Assessment & Assurance The findings are: The undated Policy and Procedure on Swallowing Precautions for Dysphagia Patients/Residents (PPSPD) documented that nurses will assess residents at risk for aspiration on admission. Patients/residents with dysphagia are at high risk for aspiration. The PPSPD documented that a resident's ability to swallow will be noted upon admission, reassessed as indicated and through a facility universal identifier will be identifiable on resident identification bracelet. The Policy and Procedure on Automated External Defibrillator (AED) dated ,[DATE] documented that the initial protocol for the unconscious victim is to assess the resident for unresponsiveness, call Doctor White on overhead announcement, call 911, assess breathing and if warranted perform CPR (cardiopulmonary resuscitation) until AED arrives. The Policy and Procedure for Doctor White dated ,[DATE] documented that any personnel who finds a person in apparent cardiopulmonary arrest must stay with the victim and summon help by whatever means are available. In order to summon the Doctor White team an announcement will be made three times over the intercom system. The Doctor White Team shall adhere to the current Advanced Cardiac Life Support (ACLS) guidelines. There was no documented evidence of facility staff training in ACLS. An interview was conducted with the Attending Physician (AP) on [DATE] at 2:19 PM. The AP stated that he only followed Resident #1 for medical care in the facility and is not aware of a cause of death. Resident #1 did not want a DNR and should have been responded to as a "full code." He ordered aspiration precautions for the resident, who should have been supervised while eating. "That should be routine." An interview was conducted with the In-Service Coordinator (ISC) on [DATE] at 2:29 PM. The ISC stated that nursing staff is in-serviced upon hire and yearly regarding the Doctor White and AED policies. "There is no specific CPR policy but we follow the standards of the American Heart Association using C.A.B. (circulation, airway, breathing)." A resident should be assessed for unresponsiveness, presence of a pulse and breathing before a Doctor White is called. The ISC stated that there is no specific responsibility assigned during a Doctor White and all nurses should respond. The Staff is trained on how to use the AED, following the prompts of the machine. The ISC stated that there is no specific monitoring regarding aspiration precautions but "every discipline is taught not to just give fluids without first checking with a nurse." An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:01 AM. The DON stated that she is not aware of a need to investigate the circumstances surrounding Resident #1's death. There is no specific policy on CPR. All nurses should respond to a Doctor White and "everyone kind of takes a job." The DON further stated that there is no specific documentation tool or requirements for CPR. An interview was conducted with the Administrator on [DATE] at 11:14 AM. The Administrator stated that he was made aware of Resident #1's death on the following day at morning report. The Administrator further stated he is not aware of any concerns regarding the resident's care; therefore, he has not taken any measures of correction. 10 NYCRR 415.26

Based on staff interviews and record review during an abbreviated and partial extended survey the Medical Director failed to ensure that the facility provided care to meet the needs of residents for one (Resident #1) of 9 residents reviewed for quality of care. Specifically, the Medical Director failed to ensure that policies and procedures were developed and implemented to supervise residents with aspiration precautions and to provide timely CPR (cardiopulmonary resuscitation) for residents without DNR (Do Not Resuscitate) orders. This failure resulted in actual harm to Resident #1 and the potential for a pattern of serious harm that is Immediate Jeopardy. Complaint Number: NY 963 Cross References: F 309 - Provide Care for Highest Well-being F 490 - Administration F 520 - Quality Assessment & Assurance The findings are: The undated Policy and Procedure on Swallowing Precautions for Dysphagia Patients/Residents (PPSPD) documented that nurses will assess residents at risk for aspiration on admission. Patients/residents with dysphagia are at high risk for aspiration. The PPSPD documented that a resident's ability to swallow will be noted upon admission, reassessed as indicated and through a facility universal identifier will be identifiable on resident identification bracelet. The Policy and Procedure on Automated External Defibrillator (AED) dated ,[DATE] documented that the initial protocol for the unconscious victim is to assess the resident for unresponsiveness, call Doctor White on overhead announcement, call 911, assess breathing and if warranted perform CPR (cardiopulmonary resuscitation) until AED arrives. The Policy and Procedure for Doctor White dated ,[DATE] documented that any personnel who finds a person in apparent cardiopulmonary arrest must stay with the victim and summon help by whatever means are available. In order to summon the Doctor White team an announcement will be made three times over the intercom system. The Doctor White Team shall adhere to the current Advanced Cardiac Life Support (ACLS) guidelines. There was no documented evidence of facility staff training in ACLS. An interview was conducted with the Attending Physician (AP) on [DATE] at 2:19 PM. The AP stated that Resident #1 did not want a DNR and should have been responded to as a "full code." The AP ordered aspiration precautions for the resident, who should have been supervised while eating. He further stated, "That should be routine." An interview was conducted with the In-Service Coordinator (ISC) on [DATE] at 2:29 PM. The ISC stated that nursing staff is in-serviced upon hire and yearly regarding the Doctor White and AED (automated external defibrillator a portable electronic device that automatically [DIAGNOSES REDACTED]. "There is no specific CPR policy but we follow the standards of the American Heart Association using C.A.B. (circulation, airway, breathing)." A resident should be assessed for unresponsiveness, presence of a pulse and breathing before a Doctor White is called. The ISC stated that there is no specific responsibility assigned during a Doctor White and all nurses should respond. The staff is trained on how to use the AED, following the prompts of the machine. The ISC also stated that there is no specific monitoring for aspiration precautions but "every discipline is taught not to just give fluids without first checking with a nurse." An interview was conducted with the Medical Director (MD) on [DATE] at 3:33 PM. The MD stated that he does not know who Resident #1 was and is not aware of any concerns or investigations regarding the resident. He is not sure what policies are in effect regarding CPR. The MD further stated that he does not know of a policy in effect regarding aspiration precautions but "regardless, any patient on aspiration precautions should always be supervised when eating." An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:01 AM. The DON stated that she is not aware of a need to investigate the circumstances surrounding Resident #1's death. There is no specific CPR policy. All nurses should respond to a Doctor White and "everyone kind of takes a job." The DON further stated that there is no specific documentation tool or requirements for CPR. 10 NYCRR 415.15 (a)

Based on staff interviews and record review during an abbreviated and partial extended survey the facility failed to ensure that the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being were provided to one (Resident #1) of nine residents reviewed for quality of care. Specifically, supervision was not provided during meals to Resident #1, who was on aspiration precautions. In addition, CPR (cardiopulmonary resuscitation) was not provided timely. Subsequently, the resident was transferred to the hospital, where he was pronounced dead. The facility failed to develop and implement policies and procedures for the supervision and monitoring of residents with aspiration precautions and CPR. Key staff were not knowledgeable of when to initiate CPR and when to apply the AED (automated external defibrillator, a portable electronic device that automatically [DIAGNOSES REDACTED]. This resulted in actual harm to Resident #1 and the potential for a pattern of serious harm that is Immediate Jeopardy and Substandard Quality of Care for 87 residents without Do Not Resuscitate (DNR) orders, 10 of whom were on aspiration precautions. Complaint Number: NY 963 The findings are: The undated Policy and Procedure on Swallowing Precautions for Dysphagia Patients/Residents (PPSPD) documented that nurses will assess residents at risk for aspiration on admission. Patients/residents with dysphagia are at high risk for aspiration. The PPSPD documented that a resident's ability to swallow will be noted upon admission, reassessed as indicated and through a facility universal identifier will be identifiable on resident identification bracelet. The Policy and Procedure on Automated External Defibrillator (AED) dated ,[DATE] documented that the initial protocol for the unconscious victim is to assess the resident for unresponsiveness, call Doctor White on overhead announcement, call 911, assess breathing and if warranted perform CPR (cardiopulmonary resuscitation) until AED arrives. The Policy and Procedure for Doctor White dated ,[DATE] documented that any personnel who finds a person in apparent cardiopulmonary arrest must stay with the victim and summon help by whatever means are available. In order to summon the Doctor White team an announcement will be made three times over the intercom system. The Doctor White Team shall adhere to the current Advanced Cardiac Life Support (ACLS) guidelines. There was no documented evidence of facility staff training in ACLS. Resident #1 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated [DATE] documented that the resident was assessed to be cognitively intact and did not have a swallowing disorder. The Hospital Patient Review Instrument dated [DATE] documented that Resident #1 required aspiration precautions. The Resident Face Sheet documented that Resident #1 was admitted to the facility on [DATE] and did not have any advance directives. The Nursing Admission/Assessment History (NAAH) dated [DATE] documented that Resident #1 had no prior eating problem prior to current illness. The NAAH lacked documented evidence of an assessment of the resident's eating abilities on admission to the facility. The Social Services Psychosocial assessment dated [DATE] documented that Resident #1's recent memory was impaired and remote memory intact. The resident had been educated about advance directives with options and choices discussed. The resident declined to sign a HCP (health care proxy). The Comprehensive Care Plan (CCP) for Eating Supervision effective [DATE] documented that Resident #1 required monitoring for choking/aspiration during meals. The CCP for Nutritional Status effective [DATE] documented that Resident #1 required aspiration precautions. The CCP for Dysphagia/Communication effective [DATE] documented that Resident #1 was at risk for aspiration. The Resident Nursing Instructions (RNI) (used by aides to provide resident care) dated [DATE] documented that Resident #1 had a medical alert of aspiration precautions and required supervision for eating. The Speech Therapy Evaluation & Plan of Treatment dated [DATE] documented that Resident #1 was assessed to have a risk factor for aspiration precautions and required close supervision for oral intake. The Social Services Progress Notes dated [DATE] documented that Resident #1's plan of care was reviewed. Education about advance directives has been reviewed with resident and designated representative. At present, the resident has no advance directives. The Speech Therapy Progress Notes dated [DATE] documented that Resident #1 was tolerating trials of whole solids. Diet upgrade to regular consistency solids. Continue thin liquids. Extra sauces/gravies to moisten foods. Aspiration precautions. The Dietary Progress Notes dated [DATE] documented a diet upgrade to consistent carbohydrate, NAS (no added salt) diet. Aspiration precautions. The physician's orders [REDACTED]." The Occupational Therapy Progress Notes dated [DATE] documented that Resident #1 was assessed to require "SBA (stand-by assistance) with set-up" for eating. The Nursing Progress Notes (NPN) dated [DATE] at 1:48 PM documented that Resident #1 was found unresponsive by the CNA (Certified Nursing Assistant) in patient's room. Dr. White, 911 called, CPR performed and patient's wife and daughter called. The Patient Transfer Form (PTF) dated [DATE] documented Resident #1's transfer to the hospital was due to being unresponsive. The Daily 24 hour Unit Report dated [DATE] documented that Resident #1 was on aspiration precautions; found unresponsive at 1:00 PM; fire department was called; resident transferred to the hospital. The NPN dated [DATE] at 2:40 PM documented that the ER (emergency room ) called. Patient passed away. Resident #1's medical record lacked documented evidence of an assessment of his physical condition when found unresponsive and during CPR. An interview was conducted with a 7:00 AM to 3:00 PM Licensed Practical Nurse (LPN #1) on [DATE] at 10:49 AM. LPN #1 stated that, on [DATE] around 1:00 PM, she was on a break and did not hear a Doctor White called overhead. When she returned to the unit, emergency services were on the floor and LPN #1 did not think there was anything for her to do. LPN #1 stated that, if a Doctor White is heard overhead "and you're available, then you (a nurse) would go to the scene; I think there's an AED in the crash cart but I've never seen it used." An interview was conducted with a 7:00 AM to 3:00 PM LPN #2 on [DATE] at 11:10 AM. LPN #2 stated that, when she returned from her break around 1:00 PM on [DATE], CNA #1 called her to Resident #1's room. She observed Resident #1 slumped over in his wheelchair, foaming at the mouth and could not obtain a pulse. LPN #2 left the room to get LPN #3, who was on the opposite end of the nursing unit. Both LPNs went into the resident's room and observed the resident unresponsive, not breathing. LPN #2 stated that she left the room to get oxygen while LPN #3 went to the nursing desk to call a Doctor White overhead. When LPN #2 returned to the resident's room, she instructed the aides to lift Resident #1 from the wheelchair into bed. The nursing supervisor arrived and went to get a back board to place under the resident's back. CPR was, then, started. She further stated, "The way I understand it is, if CPR is not effective, then you go to get the AED." She was unable to say where the AED is located. "I'm not quite sure; it (AED) wasn't used. When the paramedics came, they used theirs." An interview was conducted with a 7:00 AM to 3:00 PM CNA #1 on [DATE] at 12:28 PM. CNA #1 stated that on [DATE], she served Resident #1 his lunch tray in his room at approximately 12:15 PM. She removed the top of the tray and left the room to continue serving other residents. At approximately, 1:00 PM CNA #1 returned to the resident's room and found Resident #1 slumped over in his wheelchair; "he wasn't breathing. I ran out for the nurse." CNA #1 stated that she had cared for Resident #1 as the resident's regularly assigned aide and she always served the resident breakfast and lunch in his room and had never stayed with the resident. She stated that the resident's instructions (RNI) for eating said that the resident "only needed to be set-up." CNA #1 further stated, "I let him (Resident #1) eat alone; I don't remember hearing that it wasn't allowed." An interview was conducted with a 7:00 AM to 3:00 PM LPN #3 on [DATE] at 12:44 PM. LPN #3 stated that on [DATE] at around 1:00 PM, she was on the other end of the nursing unit when LPN #2 came down the hall calling for LPN #3 to come with her to a resident's room. LPN #3 followed LPN #2 into Resident #1's room and saw Resident #1 unresponsive in his wheelchair. LPN #3 stated that she left the room with LPN #2 and went to the nursing desk "I paged Doctor White and started transfer papers to send the resident to the hospital. I didn't go back to the room." LPN #3 stated that, if a resident is found unresponsive, a Doctor White is called and "hopefully other nurses will come with equipment. When they (other nurses) come, CPR is started." LPN #3 stated that she did not know when to apply the AED. "I've done other codes here. It's (AED) never been applied." An interview was conducted with a 7:00 AM to 3:00 PM Registered Nurse Supervisor (RNS #1) on [DATE] at 1:32 PM. RNS #1 stated that, a few minutes after 1:00 PM on [DATE], she responded to an overhead Doctor White page. When she arrived in the resident's room, RNS #1 observed Resident #1 lying on his back in bed, clammy, not breathing and without respirations. LPN #2 was standing at bedside in the room. CPR was not in progress; she left the room to get the crash cart and back board to put under the resident, returned to the room and started CPR on the resident. RNS #1 stated that there are no specific roles assigned to nursing staff during a Doctor White. "We try to make it a team effort. Everyone helps out; there is no mechanism of keeping track in a code. During a code there's no concept of time." Regarding the use of the AED, RNS #1 further stated, "During a code, CPR is done and if EMS (emergency medical services) doesn't arrive, then you would apply the AED. But, I can't say a time frame. It's really just nursing judgment." RNS #1 also stated that she documented in the progress notes that a Doctor White was called and CPR was performed. "That's all we (nursing staff) usually document; not the specifics." An interview was conducted with the daily 7:00 AM to 3:00 PM charge Registered Nurse (RN #1) on [DATE] at 10:52 AM. RN #1 stated that Resident #1 ate his meals in his room since the first week of admission to the facility because Resident #1 did not like eating in the dining room. The resident was on aspiration precautions but RN #1 did not know how the resident was supervised during eating. "He (Resident #1) didn ' t need assistance with eating." RN #1 further stated that she was not on duty when Resident #1 was found unresponsive but she has responded to a Doctor White in the past. When a Doctor White is called, "all nurses should respond and when you get there, we (nurses) figure out what's needed and start CPR. It's hard to say when CPR begins." An interview was conducted with a 7:00 AM to 3:00 PM RNS #2 on [DATE] at 11:04 AM. RNS #2 stated that she knew Resident #1, who was at the facility for rehab. The resident required assistance for bathing, dressing and toileting but did not need assistance for eating. The resident was doing well and had a recent upgrade in diet, although was still on aspiration precautions. RNS #2, then, stated that Resident #1 ate independently in his room and she did not know of any supervision provided during eating. RNS #2 stated that if a resident is found unresponsive and is not a DNR, a Doctor White would be called by overhead page. "Can't say who will respond to a Doctor White. It's whoever can." When nursing staff arrives, CPR is started and "we work as a team to get what's needed for the resident." RNS#2 was unable to say who would begin CPR, obtain the crash cart or when to apply the AED. RNS #2 further stated that there are no specific documentation requirements for a Doctor White. An interview was conducted with an 11:00 PM to 7:00 AM CNA #2 on [DATE] at 11:57 AM. CNA #2 stated that she was usually assigned to Resident #1 during the night and had no problems with the resident. On occasion, Resident #1 had a drink or snack. "I just gave it to him." CNA #2 did not know if Resident #1 was on aspiration precautions. An interview was conducted with an 11:00 PM to 7:00 AM RNS #3 on [DATE] at 1:40 PM. RNS #3 stated that during the night shift she is usually the charge nurse for Unit 1 and the supervisor for the entire building. Resident #1 had quiet nights and was on aspiration precautions but RNS #3 is not aware of the resident ever consuming anything during the night. RNS #3 further stated that, if a resident is found unresponsive, "the first thing to do is go out and call a Doctor White. Nurses are supposed to come from every floor and building. Then, we'll do CPR." RNS #3 stated, "I've never seen the AED used. I think it's down in the nursing office." An interview was conducted with the Speech Therapist (ST) on [DATE] at 1:51 PM. The ST stated that Resident #1 was initially on a ground diet with aspiration precautions when the resident was admitted to the facility. The resident was progressing well in Speech Therapy and was tolerating whole food in clinical trials. The ST stated that she recommended an upgrade in diet to a regular solid consistency. Resident #1 remained on aspiration precautions. An interview was conducted with the Registered Dietician (RD) on [DATE] at 2:00 PM. The RD stated that Resident #1 was on a ground diet upon admission to the facility, but due to his progress with Speech Therapy, the resident was upgraded to a regular diet about a week before he died . The RD further stated that aspiration precautions never changed and the resident should have been supervised while eating. An interview was conducted with the Attending Physician (AP) on [DATE] at 2:19 PM. The AP stated that he only followed Resident #1 for medical care in the facility and is not aware of a cause of death. Resident #1 did not want a DNR and should have been responded to as a "full code." The AP stated that he ordered aspiration precautions for the resident, who should have been supervised while eating. "That should be routine." An interview was conducted with the In-Service Coordinator (ISC) on [DATE] at 2:29 PM. The ISC stated that nursing staff is in-serviced upon hire and yearly regarding the Doctor White and AED policies. "There is no specific CPR policy but we follow the standards of the American Heart Association using C.A.B. (circulation, airway, breathing)." A resident should be assessed for unresponsiveness, presence of a pulse and breathing before a Doctor White is called. There is no specific responsibility assigned during a Doctor White and all nurses should respond. The staff is trained on how to use the AED, following the prompts of the machine. The ISC stated that there is no specific monitoring for aspiration precautions but "every discipline is taught not to just give fluids without first checking with a nurse." An interview was conducted with the Medical Director (MD) on [DATE] at 3:33 PM. The MD stated that he does not know who Resident #1 was and is not aware of any concerns or investigations regarding the resident. He (MD) is not sure what policies are in effect regarding CPR and does not know of a policy in effect regarding aspiration precautions but "regardless, any patient on aspiration precautions should always be supervised when eating." An interview was conducted with the Director of Social Work (DSW) on [DATE] at 10:25 AM. The DSW stated that Resident #1's cognition was "on the cusp; impaired." Resident #1 was not a DNR. She stated that the facility does not keep a list of DNR residents on the sub-acute units. "Social work would normally spearhead a conversation regarding advance directives, but it is difficult on the sub-acute unit because residents get panicky." An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:01 AM. The DON stated that she is not aware of a need to investigate the circumstances surrounding Resident #1's death. There is no specific policy on CPR. All nurses should respond to a Doctor White and "everyone kind of takes a job." The DON further stated that there is no specific documentation tool or requirements for CPR. An interview was conducted with the Administrator on [DATE] at 11:14 AM. The Administrator stated that he was made aware of Resident #1's death on the following day at morning report. The Administrator further stated he is not aware of any concerns regarding the resident's care; therefore, he has not taken any measures of correction. 10 NYCRR 415.12

Based on record review and staff interviews conducted during an abbreviated and partial extended survey the facility failed to provide a quality assessment and assurance program that readily identified quality of care deficiencies. Specifically, the Quality Assessment and Assurance (QAA) Committee failed to review and evaluate the sequence of events preceding Resident #1's death on [DATE], to identify system failures and determine the root cause. The QAA Committee failed to ensure the development and implementation of policies and procedures for CPR (cardiopulmonary resuscitation), and the monitoring and supervision of residents at risk for aspiration. This resulted in no actual harm with the potential for a pattern of serious harm that is Immediate Jeopardy. Complaint Number: NY 963 Cross References: F 309 - Provide Care for Highest Well-being F 490 - Administration F 501 - Medical Director The findings are: There was no documented evidence of a specific policy for CPR or a policy that included supervision of residents on aspiration precautions. There was no documented evidence of an investigation into the expiration of Resident #1. An interview was conducted with the In-Service Coordinator (ISC) on [DATE] at 2:29 PM. The ISC stated that nursing staff is in-serviced upon hire and yearly regarding the Doctor White and AED policies. "There is no specific CPR policy but we follow the standards of the American Heart Association using C.A.B. (circulation, airway, breathing)." A resident should be assessed for unresponsiveness, presence of a pulse and breathing before a Doctor White is called. The ISC stated that there is no specific responsibility assigned during a Doctor White and all nurses should respond. The staff is trained on how to use the AED, following the prompts of the machine. The ISC stated that there is no specific monitoring for aspiration precautions but "every discipline is taught not to just give fluids without first checking with a nurse." An interview was conducted with the Medical Director (MD) on [DATE] at 3:33 PM. The MD stated that he does not know who Resident #1 was and is not aware of any concerns or investigations regarding the resident. He is not sure what policies are in effect regarding CPR. The MD further stated that he does not know of a policy in effect regarding aspiration precautions but "regardless, any patient on aspiration precautions should always be supervised when eating." An interview was conducted with the Director of Social Work (DSW) on [DATE] at 10:25 AM. The DSW stated that Resident #1's cognition was "on the cusp; impaired." Resident #1 was not a DNR. The facility does not keep a list of DNR residents on the sub-acute units. "Social work would normally spearhead a conversation regarding advance directives, but it is difficult on the sub-acute unit because residents get panicky." An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:01 AM. The DON stated that she is not aware of a need to investigate the circumstances surrounding Resident #1's death. There is no specific policy on CPR. All nurses should respond to a Doctor White and "everyone kind of takes a job." The DON further stated that there is no specific documentation tool or requirements for CPR. An interview was conducted with the Administrator on [DATE] at 11:14 AM. The Administrator stated that he was made aware of Resident #1's death on the following day at morning report. The facility's QA on DNR/CPR status is an ongoing internal education of staff to make sure Advance Directives are reviewed. The Administrator further stated he is not aware of any concerns regarding Resident #1's care; therefore, he has not taken any measures of correction. 10 NYCRR 415.27(a-c)