Every finding on record at Glens Falls Center for Rehabilitation and Nursing

Based on record review and interviews conducted during survey, the facility failed to ensure the resident's right to be free from abuse and exploitation for one (Resident #24) of five residents reviewed. Specifically, on 04/10/2024, Certified Nurse Aide #1 used their cell phone to record Resident #24 in a state of undress while Certified Nurse Aide #2 provided care to the resident. Using the reasonable person concept, this caused psychosocial harm to Resident #24 that was not Immediate Jeopardy. This is being issued as past noncompliance as there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement at the time of this survey. Findings Include: Facility policy and procedure titled, Abuse Prohibition Policy and Procedures, last revised 07/18/2025, documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. Mental/Emotional abuse is the use of verbal and nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. It also includes abuse that is facilitated or enabled through the use of technology such as smart phones or other personal electronic devices and cameras that demean or humiliates the resident regardless of whether the resident provided consent or the resident's cognitive status. Facility policy and procedure titled, Cell Phone Use, last revised October 2019, documented the use of any non-company issued personal electronic device, such as cellular phones, is prohibited in resident areas. It further stated inappropriate use of a cellular phone included videoing residents and sharing Health Information Portability and Accountability Act protected information via unsecured networks such as text message. Staff using cell phones in resident areas will be subject to disciplinary action, up to and including termination. Resident #24 was admitted to the facility with the diagnoses of mild major depressive disorder (when a person experiences a first-time, short-of severe bout of clinical depression lasting at least two weeks), generalized anxiety disorder (a mental health disorder defined by extreme worry about everyday things like work, health, or money) and type two diabetes mellitus with diabetic neuropathy (nerve damage caused by long-term high blood sugar). The Minimum Data Set (a resident assessment tool) dated 04/05/2024 documented the resident could make themselves understood, could understand others, and had severe cognitive impairment. Facility Investigation Form signed and dated 05/22/2024 documented the date of the incident as 04/10/2024 with the facility being made aware on 05/12/2024. On 05/12/2024 around 12:50 PM, Director of Nursing #2 was sent a video on their cell phone from Certified Nurse Aide #1's cell phone with a message stating it was unacceptable to record residents. The video displayed Resident #24 undressed receiving patient care. The video was date stamped 04/10/2024 around 4:10 PM to 4:15 PM. Another staff member, Certified Nurse Aide # 2, was in the video frame with their back to the camera and was assisting Resident #24 on the toilet. Director of Nursing #2 went to the facility and called Administrator #3 to discuss the employee. Certified Nurse Aide #1 denied sending the video and stated the number listed as sending the video was their old phone which was being used by their significant other. Certified Nurse Aide #1 was immediately terminated and escorted out of the building by the nursing supervisor.A nursing progress noted dated 05/13/2024 documented the interdisciplinary team met for the following reasons: resident related. The team met to discuss the resident. The resident was at their baseline with no complaints, no changes in condition. During an interview on 08/07/2026 at 10:27 AM, Certified Nurse Aide #3 stated they remembered finding out about an incident that occurred around Mother's Day of 2024 in which Resident #24 was recorded during the provision of care. They stated the staff were upset regarding the recording and stated, you can't do that, you're not supposed to record people. It's a big no-no. They stated the staff were upset because Resident #24 had special needs, and they should not have been recorded. During an interview on 08/07/2026 at 10:32 AM, Licensed Practical Nurse #1 stated they were aware of this incident and the recording of Resident #24 being sent to Director of Nursing #2. They stated Certified Nurse Aide #1 was terminated. They stated Resident #24 should not have been recorded, especially when in the bathroom, and there was a respect level to have for residents. They stated staff were upset by this incident. The Certified Nurse Aide #3 and Licensed Practical Nurse #1's interviews indicate that facility staff not involved in the incident were made aware of it. Certified Nurse Aide #3 stated Resident #24 had special needs. Using the reasonable person concept, Resident #24 would have considered the facility to be their home, where there was an expectation that they were safe, had privacy, and would be treated with respect and dignity. The resident would have trusted and relied on facility staff to meet their needs. Resident #24 was vulnerable and the potential psychosocial outcome the deficiency may have had on a reasonable person in the resident's position include feelings of negative self-worth, mortification, anxiety, frustration, sadness, and negative impacts to mood, activities of daily living, ability to sleep, and ability to allow care to be provided. During an interview on 08/12/2026 at 9:50 AM, Assistant Director of Nursing #1 recalled this incident and stated at that time, they were either a cart nurse or the nursing supervisor. They stated Certified Nurse Aide #1 took pictures of Resident #24 in the restroom and Certified Nurse Aide #1 was terminated. They stated this should not have been possible to happen and staff were very upset because Resident #24 was at the facility for a long time and the staff loved them. They stated they had been in healthcare for a long time and were never in a building where something like this took place. They stated they did not understand how someone could do that to another person and it bothered them that this incident happened.During a phone interview on 08/06/2026 at 2:38 PM, Director of Nursing #2 stated on Mother's Day of 2024, they were sent a video on their cell phone in which Certified Nurse Aide #1 was recording Resident #24 while Certified Nurse Aide #2 was assisting the resident with getting dressed. Resident #24's top was off and Certified Nurse Aide #2 did not know that they were being recorded. They stated it was not a good video. They stated they spoke with Administrator #3 about the video. They went to the facility to investigate the incident and ended up terminating the employee that made the video. During a phone interview on 08/10/2026 at 1:31 PM, Administrator #3 stated the incident during this timeframe with Resident #24 may have involved a staff member recording or taking a photograph of Resident #24, but it was an accusation and they did not have solid proof as they did not see the video. The Administrator stated they could not recall the specifics as it was a long time ago. They stated they knew they had to start education with the staff right away to do their due diligence. They could not recall the outcome for Certified Nurse Aide #1. During a phone interview on 08/12/2026 at 11:50 AM, Medical Director #1 stated they could not recall this incident with Resident #24. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement at the time of this survey:The facility completed an investigation for this incident which stated deficient practice was corrected upon finding by Director of Nursing #2. Interviews were completed with alert and oriented residents on the same unit as Resident #24 and the residents confirmed there were no concerns of a similar nature. Employee Counseling/Corrective Action Form for Certified Nurse Aide #1 dated 05/12/2024 documented Certified Nurse Aide #1 had their phone present during patient care. Resolution was immediate termination.Comprehensive Care plan with focus Resident is at risk for misappropriation, neglect, abuse, exploitation related to cognitive status/cognitive impairment was initiated on 05/13/2024.In-service attendance record with topics including Health Insurance Portability and Accountability Act, cell phone use, resident's rights education completed in May2024 for 110 employees from nursing, rehabilitation, housekeeping, laundry, dietary, social work, reception, administration, and activities department. 10 New York Code of Rules and Regulations 415.4(b)(1)(i)

Based on observation and interviews conducted during the survey, the facility did not provide a homelike environment by not performing effective maintenance services on three (3) of three (3) resident wings. Specifically, several walls, doorways and sinks were in various states of disrepair. Findings include: During facility tours on 08/03/2026 through 08/07/26 between the hours of 09:00AM and 3:00PM the following items were identified to be in a state of disrepair. Walls and wallpaper in resident rooms 3, 8, 17 and 43 were identified to be in a state of disrepair. Hallway walls and doorways into resident's rooms in 3 of 3 resident wings showed signs of marking and damage consistently throughout the facility. Sinks in rooms 16 and 39 were found to be leaking with facility provided buckets placed underneath to catch the water. During an interview, on 08/6/2026 at 1:45PM, Administrator #1 stated, they are aware the facility is in need of physical plant repairs but without a maintenance team it is hard. Hopefully with the hiring of a new Director of Maintenance, they will be able to address these issues in a timely manner. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on record review and interviews conducted during a survey, the facility failed to report immediately, but not later than two hours after the allegation was made to officials, including the State Survey Agency, two incidents regarding allegations of abuse and exploitation for two (2) out of (2) incidents reviewed for reporting. Specifically, (a) an incident in which Certified Nurse Aide #1 used their cell phone to record Resident #24 in a state of undress while Certified Nurse Aide #2 provided care to the resident was not reported. (b) an incident with allegations that involved Resident #120 being removed from their room at night and sexually assaulted was not reported until 06/18/2026 at 3:09 PM when the facility indicated the time of notification of the incident was 06/18/2026 at 9:15 AM. Findings include: Facility policy and procedure titled, Abuse Prohibition Policy and Procedures last revised 07/18/2025 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients. The facility has designed and implemented processes which strive to ensure the prevention and reporting of suspected or alleged resident abuse, neglect, and mistreatment. It further documented the Administrator and Director of Nursing are responsible for investigating and reporting. A step under reporting procedure documented to notify the local law enforcement and appropriate State Agencies immediately (no later than two hours after allegation/suspected incident. Initiate process according to the Elder Justice Act and State-specific regulations. Resident #24 Resident #24 was admitted to the facility with the diagnoses of major depressive disorder, single episode, mild (when a person experiences a first-time, short-of severe bout of clinical depression lasting at least two weeks), generalized anxiety disorder (a mental health disorder defined by extreme worry about everyday things like work, health, or money) and type two (2) diabetes mellitus with diabetic neuropathy (nerve damage caused by long-term high blood sugar). The Minimum Data Set (an assessment tool) dated 04/05/2024 documented the resident could make themselves understood, could understand others, and had severe cognitive impairment. Facility Investigation Form dated 05/22/2024 documented date of incident 04/10/2024, notified 05/12/2024. On 05/12/2024 around 12:50 PM, Former Director of Nursing #1 was sent a video on their cell phone from Certified Nurse Aide #1's cell phone with the message along the lines of I think it's unacceptable to record residents. The video displayed Resident #24 during patient care. The video was date-stamped 04/10/2024 around 4:10-4:15 PM. Another staff member, Certified Nurse Aide # 2, was turned away from the video, assisting Resident #24 on the toilet. Former Director of Nursing #1 went to the facility and called Former Administrator #1 to discuss the employee. Certified Nurse Aide #1 denied sending the video and stated the number listed as sending the video was their old phone which was being used by their significant other. Certified Nurse Aide #1 was immediately terminated and escorted out of the building by the nursing supervisor. There was no documented evidence that this incident was reported by the facility in the Internet Quality Improvement and Evaluation System. During a phone interview on 08/06/2026 at 2:38 PM, Director of Nursing #2 stated they did not know if a report was made to the Department of Health regarding this incident, and if it was to be reported, it would be up to the administrator to report the incident. During a phone interview on 08/10/2026 at 1:31 PM, Administrator #3 stated they report any kind of abuse outlined in Appendix PP and they have two hours from the time they find out about the allegations to report it. They stated they were told by someone from the Attorney General's office who came to the facility to investigate the day after the event took place (they did not recall who the person was) that the Attorney General's office reported this event to the Department of Health. They stated at the time, they did not recall if Director of Nursing #2 reported this incident. Resident #120 Resident #120 was admitted to the facility with the diagnoses of unspecified dementia, unspecified severity (when a person shows signs of cognitive decline, but a sub-type or detail regarding progression is not stated), anxiety disorder, unspecified (when a person has signs of fear or worry that disrupt daily life, but symptoms do not match rules for a more specific diagnosis) and heart failure, unspecified ( when a person has a diagnosis of heart failure, but it is not stated whether it is acute, chronic, systolic, or diastolic). The Minimum Data Set (an assessment tool) dated 05/14/2026 documented the resident had the ability to make theirself understood, understand others, and had severe cognitive impairment. Facility Investigation Form dated 06/18/2026 documented on that date, the facility received a phone call from the Attorney General stating a family member reported that a resident with the first name of Resident 120 was being sexually assaulted at night. Nursing Home Investigative Report submitted to the Department of Health documented the date and time of incident was 06/18/2026 at 9:15 AM Review of the incident reported in the Internet Quality Improvement and Evaluation system documented this incident was reported on 06/18/2026 at 3:09 PM. It also documented there was only one resident with the first name of the reported resident in the facility. During a phone interview on 08/11/2026 at 12:13 PM, Administrator #2 stated they reported incidents of abuse online to the Department of Health and they thought the incidents needed to be reported within two to four hours. They could not recall if they reported this specific incident but stated an incident like this would have been reportable to the Department of Health. They also stated Assistant Administrator #1 may have reported the incident as they knew the building and the employees better than Administrator #2 and in an event like this, they would call on Assistant Administrator #1 for assistance. During an interview on 08/11/2026 at 12:25 PM, Assistant Administrator #1 stated an event with an allegation of abuse needed to be reported withing two hours of notification of the event. In this case, they were trying to find out the story by talking with the resident and their family member. They stated they knew they needed to report the incident, but they were reporting to their corporate leaders what they learned about the incident prior to reporting the incident. They stated involving corporate leaders was not always part of their protocol. 10 New York Codes, Rules, and Regulations 483.12(c)(1)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure residents were provided with food and drink that was palatable, flavorful, and at a safe and appetizing temperature. Specifically, (a) for Resident #39, food was not served at an appetizing temperature during a lunch meal on 08/06/2026 and they stated that food was cold and horrible; (b) temperatures of hot beverages were not being taken prior to being served to residents on 08/06/2026 by the activities department; (c) Residents #28 and #5 stated the food was not appetizing and/or hot foods were often cold on 08/03/2026 and 08/04/2026; (d) six residents during a resident council meeting on 08/04/2026 stated the food was subpar, bland, and cold. Findings include: Facility Policy titled, Dining Room Service, dated 01/2023, documented that effective equipment shall be provided and guidelines established to maintain food at appropriate and palatable temperatures during meal service. Food will be delivered promptly to assure quality. Meals will be served promptly to maintain adequate temperature and appearance. Facility Policy titled, Meal Service Process: Delivery, Set-Up, Assistance and Documentation, dated 12/15/2025, documented the facility provides a safe, nutritious, and person-centered meal service to residents in accordance with federal and state regulations, and current standards of practice. Meals will be served in a timely manner. Heated plates and insulated bowls and mugs may be utilized to maintain the appropriate temperature. Validate hot foods are hot (but not scalding temperature) and cold foods are cold. Facility Policy titled, Hot Beverage Service, revised 04/29/2026, documented the facility provides hot beverages (coffee, hot water, tea, hot chocolate) during meals, activities, and/or as requested in accordance with current standards of practice and in a safe manner that prevents the risk of resident injury and supports resident choice and dignity. The coffee brewer/hot water dispensing unit is located in either the main kitchen or nursing unit kitchen and will be utilized to prepare coffee/hot water according to the Manufacturer's Instruction for Use. Hot beverage temperatures will be measured and recorded by the Dining Services Supervisor or assigned designee prior to transport from the main kitchen and/or the nursing unit kitchen. Document titled, Test Tray Evaluation, dated 04/21/2026, documented an informal test tray was completed in the main kitchen. The results included following items with temperatures measured as follows: pork was 115 degrees Fahrenheit, mashed potatoes were 125 degrees Fahrenheit, and oriental vegetables were 115 degrees Fahrenheit. The test tray evaluation documented that the overall meal did not maintain temperature. Notes from the food committee meeting held on dated 03/10/2026, documented that residents said food has been cold a couple of times. The document included that they talked to the cooks about this concern to ensure temperatures are good and food was not cooked early. Residents stated baked potatoes needed to be cooked longer. On 05/26/2026, documented that the residents in attendance stated the food was cold. They also stated that the baked potatoes needed to be cooked for a longer time. Resident #39 Resident #39 was admitted to the facility with diagnoses of chronic kidney disease stage three (a disease when kidneys have mild to moderate damage and are less able to filter waste and fluid out of the blood), type two diabetes mellitus (a chronic condition that happens when a person has persistently high blood sugar levels), and major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). The Minimum Data Set (an assessment tool) dated 06/12/2026, documented the resident understood others, was able to be understood, and was cognitively intact. During an observation on 08/06/2026 at 11:58 AM, Resident #39's lunch meal was delivered and contained the following items with temperatures measured as follows: Cranberry juice was 57.7 degrees Fahrenheit, creamer was 68 degrees Fahrenheit, cottage cheese was 56.3 degrees Fahrenheit, pears were 73.2 degrees Fahrenheit, coffee was 144.8 degrees Fahrenheit, butter was 77.5 degrees Fahrenheit, baked potato was 175.8 degrees Fahrenheit, turkey with gravy was 104.1 degrees Fahrenheit, spinach was 111.5 degrees Fahrenheit, and salt and pepper were on the lunch meal tray. After tasting the food and drinks, the temperature of the turkey with gravy and spinach were lukewarm to slightly cool. During an interview on 08/03/2026 at 11:31 AM, Resident #39 stated the food at the facility was horrible and gross. Resident #39 stated that hot foods were not really that hot. Resident #39 provided an example. They stated that they were served a hot salad that was meant to be cold and cold lasagna that was meant to be hot in the past. During an observation on 08/06/2026 at 10:25 AM, Activities Aide #1 was observed passing out hot beverages on the units. Activities Aide #1 was not taking temperatures of the hot beverages before serving them to the residents. During an interview on 08/06/2026 at 10:25 AM, Activities Aide #1 stated they do not take temperatures of the hot drinks. During an interview on 08/11/2026 at 9:28 AM, Food Service Manager #1 stated the kitchen does not prepare coffee for the activities department to distribute to the units. The activities department has their own coffee maker, and they prepare their own coffee. The activities department has a thermometer to take temperatures of the coffee before they served it to residents. During an interview on 08/11/2026 at 9:47 AM, Registered Nurse #1 stated the activities department does not have temperature logs that they maintained prior to today. During an interview on 08/10/2026 at 3:54 PM, Director of Nursing #1 stated they doid not know of any thermometers on the units for staff to take temperatures of the foods and beverages. Resident #28 Resident #28 was admitted to the facility with diagnoses of type two diabetes mellitus (a chronic condition that happens when a person has persistently high blood sugar levels), hypertension (high blood pressure), and chronic kidney disease stage three B (a disease when kidneys have moderate to severe loss of kidney function and are less able to filter waste and fluid out of the blood). The Minimum Data Set, dated [DATE], documented the resident understood others, was able to be understood, and was cognitively intact. During an interview on 08/03/2026 at 12:29 PM, Resident #28 stated hot foods were are usually cold, and the food served at the facility was not appetizing. Resident #5 Resident #5 was admitted to the facility with diagnoses of heart failure (a chronic condition where the heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), type two diabetes mellitus (a chronic condition that happens when a person has persistently high blood sugar levels), and chronic obstructive pulmonary disease (narrowing of airways in the lungs making it difficult to breathe). The Minimum Data Set, dated [DATE], documented the resident understood others, was able to be understood, and was cognitively intact. During an interview on 08/04/2026 at 11:29 AM, Resident #5 stated the food served at the facility was bland, unappetizing, and they doid not want to eat it. Resident #5 stated they needed to ask for snacks. During a surveyor-led resident council meeting on 08/04/2026 at 10:07 AM, six out of six residents stated and agreed that the food was subpar, bland, and cold. They stated the food had no taste; however, part of the reason is because a lot of people cannot tolerate spices. During an interview on 08/06/2026 at 11:58 AM, Certified Nursing Aide #4 stated there were mixed reviews from the residents regarding the food served at the facility. Certified Nursing Aide #4 stated a lot of residents loved the food and a lot of residents hated the food. Certified Nursing Aide #4 stated that most of the complaints from the residents are that they [NAME] being served a lot of the same food items especially turkey. If a resident disliked the food, they would offer the resident an alternative. They stated they have not received complaints about undesirable food temperatures from residents. Certified Nursing Aide #4 stated if a resident had complaints about undesirable food temperatures, they would go to the kitchen and ask for a new tray. During an interview on 08/07/2026 at 11:10 AM, Certified Nursing Aide #5 stated that some residents loved the food at the facility, and some residents do not care for it. Certified Nursing Aide #5 stated that most of the food complaints from the resident are about the food being bland. They stated they have not heard about undesirable food temperature complaints from residents in quite a while. During an interview on 08/07/2026 at 11:28 AM, Food Service Manager #1 stated they have a food committee meeting monthly where they discussed menu changes. They stated if residents brought up food concerns during the food committee meeting, they would fix them. They stated that there [NAME] some residents that stated they dido not like the food at the facility and others who stated they loved it. Food Service Manager #1 stated that the residents stated they enjoyed the new menu since new items were added. Food Service Manager #1 stated trays were being delivered faster after speaking with nursing staff regarding complaints of undesirable food temperatures. They stated that it had been a few months since they received complaints about undesirable food temperatures. Food Service Manager #1 stated the kitchen staff ensured they turned on the hot cart earlier and plates were heated up to help with the undesirable food temperature complaints. Food Service Manager #1 stated they educated the kitchen staff about waiting to put meal trays on the cart to preserve heat. They stated they would follow up with the residents about the changes they made to help with the food complaints they received. During an interview on 08/10/2026 at 11:07 AM, Administrator #1 stated they have heard good things about the food in the facility from the residents. Administrator #1 stated they would address food concerns with the dietary director. Administrator #1 stated if there were concerns regarding temperatures of foods, they would conduct a test tray. They stated they were not sure if there were any test trays conducted within the past couple of months. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)

Based on observation, record review and interviews during the recertification survey from [DATE] to [DATE], the facility did not ensure safe and appropriate labeling and storage of all medications for 1 of 3 units for medication labeling and storage. Specifically, the medication cart B located on the South Unit contained an expired bottle of Oyster Shell Calcium 500 Milligram tablet; 4 insulin Kwik pens were not labeled with expiration dates after opening; and 1 Ipratropium bromide nasal spray, 1 Fluticasone nasal spray, 1 bottle of Geri-Lanta; 2 bottles of Tussin stock medications, and 1 antifungal cream were not labeled in accordance with facility policy. This was evidenced by: The facility Medication Administration Policy, dated ,d+[DATE], documented the expiration date on the medication label would be checked prior to administering. When opening a multi-dose container, the date would be recorded on the container, and referred to pharmacy guidance for expiration of opened medications. The facility Medication Storage Policy, dated ,d+[DATE], documented that expired, discontinued and/or contaminated medications would be removed from the medication storage areas and disposed of in accordance with facility policy. During an observation of medication cart B on the South Unit on [DATE] at 10:02 AM, there was: - A stock medication for Oyster Shell Calcium 500 Milligram tablet that was labeled with an expiration date of ,d+[DATE] (not discarded); - Three types of insulin Kwik pens (Basaglar, Victoza, and glargine) not labeled with an open or expiration date after opening; - One insulin Lispro Kwik pen labeled with an open date, but no label of an expiration date after opening; - Two bottles of nasal spray (Fluticasone nasal spray, and Ipratropium bromide nasal spray) not labeled with an open and or expiration date after opening; - One bottle of Geri-Lanta, 2 bottles of Tussin stock medications, and 1 INZO antifungal cream not labeled with an open and or expiration date after opening. During an observation on [DATE] at 11:00 AM, the following opened medications were noted on Resident #34's overbed table: Deep Sea Nasal Spray; Ipratropium bromide nasal spray and Trelegy inhaler. All three medications were not labeled with neither an opened date nor an expiration date after opening. During an interview on [DATE] at 10:02 AM, Licensed Practical Nurse #7 stated they would check expiration dates prior to administering medications and that insulin Kwik pens were used up very quickly and likely used before expiration dates. When asked, Licensed Practical Nurse #7 did not verbalize what the expiration dates were for the insulin Kwik pens. During an interview on [DATE] at 11:30 AM, the Director of Nursing deferred to the South Unit Manager, stating that they - the Director of Nursing - was newly appointed to their position. During an interview on [DATE] at 11:30 AM, the South Unit Manager stated insulin Kwik pens expired 28 days after opening unless otherwise indicated by the manufacturer, and that nursing staff received training on medication administration upon hire and annually thereafter. 10 NYCRR 415.18(d)

Based on observation and staff interviews during the recertification and abbreviated survey from [DATE] to [DATE], the facility did not store, prepare, distribute, or serve food in accordance with professional standards for food service safety in the central kitchen and 2 (South and East Units) of 3 nourishment rooms on resident units. Specifically, (a) in the main kitchen, the oven was soiled with food debris, the steamer was soiled, and the inside of the microwave was soiled; (b) in the South Unit nourishment room, the refrigerator gasket was soiled and had a large amount of dried liquid on top of the refrigerator; (c) and in the East Unit nourishment room, the freezer was soiled on the bottom interior and on the freezer door. This was evidenced by: During observations of the main kitchen and nourishment rooms on [DATE] at 9:40 AM, the oven in the main kitchen had food debris located within the appliance, the steamer had large liquid droplets of food and was soiled, and the inside of the microwave had several brown spots. The refrigerator in the South Unit nourishment room had a dirty gasket and a large amount of dried liquid on top of the appliance. The freezer in the East Unit nourishment room had long red streaks on the bottom interior and brown stains on the freezer door. The policy and procedure titled Cleaning Policy from Food and Nutrition Services, dated ,d+[DATE], documented that the nutrition and food services staff would maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written and comprehensive cleaning schedule. The policy further documented that all staff would be trained on the frequency of cleaning as necessary, a cleaning schedule would be posted for all cleaning tasks with staff initials for completeness, and all staff would be held accountable for the cleaning assignments. The policy and procedure titled Daily Cleaning of Nourishment Rooms, not dated, documented the policy's purpose to maintain high standards of hygiene and sanitation in nourishment rooms to ensure a safe and clean environment for storing and preparing food and beverages for residents. The policy further documented that the procedures for cleaning the nourishment rooms were to be done at least once every 24 hours, and to maintain a cleaning log for each room documenting the time, date, and staff member accomplishing the task. The Daily Cleaning Schedule dated from [DATE] to [DATE] documented the initials of staff members cleaning appliances and equipment in the kitchen area. Record review of each unit's Routine Cleaning Checklists for time period of [DATE] to [DATE] revealed the following: - For [NAME] and South Units: the nourishment rooms were cleaned daily. - For the East Unit: the nourishment room was cleaned three (3) out of the eleven (11) days. During an interview on [DATE] at 8:58 AM, the Housekeeping and Laundry Supervisor stated that all refrigerators and freezers should be cleaned daily and logged on the Daily Routine Cleaning Checklist. They stated that the refrigerator on the South Unit should not have a large amount of dried liquid on the top of the refrigerator and should have been cleaned before it got to that state. They further stated that housekeeping staff should have caught and cleaned the issues on the East Unit, and would not comment regarding the reason the Routine Cleaning Checklist on the East Unit did not include documentation that the cleaning had been done daily. During an interview on [DATE] at 8:23 AM, Housekeeper #1 for the South Unit stated they follow a daily checklist for their daily task; nourishment rooms were to be cleaned every day. They stated they threw out any expired food in the refrigerator and cleaned the refrigerator and freezer interior and exterior if dirty or soiled. They further stated they would not comment on the top of the appliance as they were short and could not see the top of the appliance. They stated that nourishment rooms are cleaned first and that housekeepers should only list the check of having completed the cleaning on the Daily Routine Cleaning Checklist if they cleaned the refrigerators. During an interview on [DATE] at 8:49 AM, Housekeeper #2 for the East Unit stated they had a daily checklist for their daily tasks and were responsible for cleaning all resident's rooms and common areas daily. They stated they cleand the nourishment rooms, threw out any old food, changed garbage, sanitized sinks and countertops, swept and mopped floors. They further stated that they were made aware of the cleaning policy when onboarding, signed off on cleaning the nourishment area on [DATE], and should have cleaned the freezer's interior when doing the nourishment room. They stated that they did not think about that area when cleaning. During an interview on [DATE] at 11:25 AM, the Dietary Director stated that the cooks were responsible for cleaning up after themselves and the appliances in the kitchen. They further stated that the kitchen cleaning policy was based on the facility cleaning policy, and there were no other policies related to specific kitchen cleaning. During an interview on [DATE] at 11:40 AM, Cook #1 stated that they would clean the areas of use when there was downtime; that the stove should be cleaned daily, and the steamer should be cleaned whenever any mess was created. They stated that they trained a staff member last week on cleaning the appliances, and that it did not fall on them - the Cook - to clean if they were busy preparing resident meals. They stated they were trained on the policy for proper cleaning procedures when the facility hired them several years ago. 10 NYCRR 415.14(h)

Based on observations, record reviews and staff interview during a Recertification Survey from 12/07/2023 to 12/18/2023, the facility did not ensure residents were assessed by the interdisciplinary team to determine a residents' ability to safely administer their own medications if clinically appropriate for 2 of 2 (Resident #'s 34 and 41) residents reviewed. Specifically, Resident #34's medications were observed on their overbed table on 12/12/2023, and Resident #41's bedtime medications were observed at their bedside on 12/07/2023; there was no documented evidence that Resident #'s 34 and 41 were assessed to determine their ability to safely self-administer medications, or for physician orders for self-administration of medications. This was evidenced by: The facility Medication Self-Administration Policy, dated 7/2019, documented staff and practitioner would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate for the resident upon request. Self-administered medications were to be stored in a safe and secure place that was not accessible by other residents. Resident #34 Resident #34 was admitted to the facility with diagnoses of heart failure, coronary artery disease and end stage renal disease. The Minimum Data Set (an assessment tool) dated 9/29/2023 documented the resident was understood by others and could understand others. A Brief Interview for Mental Status (a brief cognitive screening measure that focuses on orientation and short-term word recall) assessed the resident as cognitively intact for decisions of daily living. During an observation on 12/12/2023 at 11:00 AM, the following mediations were on Resident #34's overbed table: Deep Sea Nasal Spray, ipratropium bromide nasal spray, and Trelegy inhaler. Review of Resident #34's Comprehensive Care Plans, on 12/12/2023 at 11:30 AM, did not include documentation that Resident #34 was able to self-administer their medications (to perform self-medication). Review of Resident #34's medical record did not include documentation that the resident was assessed for their ability to self-medicate. Review of Resident #34's medical record did not include documentation from the resident's physician that the resident could self-administer their medications. During an on interview on 12/12/2023 at 11:00 AM, Resident #34 stated they had requested their medication to be left at the bedside so that they could take them as needed. Resident #34 stated that medications were often given late, and that they knew when to take medications that were left at the bedside. Resident #34 stated they had been self-medicating for several months. During an interview on 12/13/2023 at 1:00 PM, Resident #34 stated after their interview with the surveyor on 12/12/2023, the Unit Manager took all their medications from their bedside, and they were told the medication nurse would administer all their medications going forward. Resident #41 Resident #41 was admitted to the facility with diagnoses of status post cerebral vascular accident with hemiplegia (muscle weakness), peripheral vascular disease and end stage renal disease. The Minimum Data Set (an assessment tool), dated 9/13/2023, documented the resident was understood by others and could understand others. A Brief Interview for Mental Status assessed the resident as cognitively intact for decisions of daily living. The facility's policy and procedure titled, 'Medication Administration' and last revised on 12/2019 included documentation that residents may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, had determined that they had the decision-making capacity to do so safely. Review of the Comprehensive Care Plan for Resident #41 revealed it did not include a care plan addressing self-administration of medication. Physician orders dated 12/01/2023 documented: Evening medications ordered for Resident #41 as follows: 1. Rosuvastatin Calcium Oral 20 milligrams 1 tablet by mouth at bedtime, ordered on 09/07/2023. 2. Diazepam Oral tablet 5 milligrams 1 tablet by mouth at bedtime for insomnia, order on 3. MiraLAX Oral Powder 17 grams 1 scoop (Polyethylene Glycol by mouth two times a day, ordered on 09/07/2023. 4. Ranitidine 40 milligrams 1 tablet by mouth 1 time a day, ordered on 09/07/2023. 5. Senna S tablet 8.6-50 milligram, 2 tablets by mouth two times a day, ordered on 9/07/2023. 6. Simethicone tablet Chewable 80 milligram 1 tablet three times a day, ordered on 12/13/2023. Evening medications documented on Electronic Administration Admission Record for 12/2023 as follows: 1. Rosuvastatin Calcium Oral 20 milligrams 1 tablet by mouth at bedtime, ordered on 09/07/2023. 2. Diazepam Oral tablet 5 milligrams 1 tablet by mouth at bedtime for insomnia, order on 3. MiraLAX Oral Powder 17 grams 1 scoop (Polyethylene Glycol by mouth two times a day, ordered on 09/07/2023. 4. Ranitidine 40 milligrams 1 tablet by mouth 1 time a day, ordered on 09/07/2023. 5. Senna S tablet 8.6-50 milligram, 2 tablets by mouth two times a day, ordered on 9/7/2023. 6. Simethicone tablet Chewable 80 milligram 1 tablet three times a day, ordered on 12/13/2023. A progress note dated 12/12/2023 and written by the Director of Nursing documented that Licensed Practical Nurse #1 reported they had not observed Resident #41 take their medication. During an interview on 12/08/2023 at 4:15 PM, Resident #41 stated that on the evening shift on 12/07/2023, Licensed Practical Nurse #1 delivered the evening medications in a medication cup and left them at the bedside. During an interview on 12/12/2023 at 12:01 PM, Licensed Practical Nurse #8 stated they had been made aware that Resident #41's pills had been left bedside on the evening shift on 12/07/2023. They stated Resident #41 was not care planned or assessed to self-medicate. During an interview on 12/12/2023 at 12:14 PM, Licensed Practical Nurse Unit Manager #2 stated that medications should not be left bedside, that Resident #41 was not assessed and was not care planned for self-administration of medication, and that there had not been interdisciplinary team meetings regarding approval for the resident to self-administer their medications. During an interview on 12/12/2023 at 12:34 PM, Registered Nurse Supervisor #1 stated they had been made aware that on 12/07/2023 around 10:00 PM that Licensed Practical Nurse #1 left Resident #41's medication at their bedside. Registered Nurse Supervisor #1 stated Resident #41 had not been assessed for the ability to self-administer their medication. During an interview on 12/12/2023 at 12:51 PM, the Director of Nursing stated they had been made aware of on 12/08/2023 that Licensed Practical Nurse #1 left Resident #41 medication bedside, and that Resident #41 was not assessed for the ability to self-administer their medication. The Director of Nursing stated they were unable to find an assessment that Resident #41 was able to self-administer their medications, and the Comprehensive Care Plan for Resident #41 did not include a plan for the resident to self-administer medication. During an interview on 12/12/2023 at 4:25 PM, Director of Nursing #2 stated that staff did not report that medications were found at the bedside recently, and was not aware of any residents in the facility that had been assessed to self-administer medications. Director of Nursing #2 further stated that an in-service was initiated on 12/11/2023 to reeducate nurses, which included medications were to never to be left at the bedside and the nurse should not leave the room until they see the resident take the medication brought to them otherwise that would be considered a form of self-administration of medication. During an interview on 12/13/2023 at 11:37 AM, the Medical Director stated none of the residents in the facility were assessed to self-administer medication. The Medical Director stated they were unaware that medications had been left at bedside, and if the facility decided this to be a preferred method for medication administration, it would require the resident to be assessed for their ability and to document in a Comprehensive Care Plan to ensure that orders for medication administration were followed. Monitoring would be required by the nurses, and nurses would still be responsible to inform the Medical Director of any concerns. During a telephone interview on 12/14/2023 at 9:35 AM, Licensed Practical Nurse #1 stated they left Resident #41's medication bedside on 12/07/2023 approximately between 7 PM and 9 PM. Licensed Practical Nurse #1 stated the resident was not assessed to perform self-administration for their medications and that they should not have left the medications for the resident. 10NYCRR 415.3 (e)(1)(vi)

Based on record review and staff interviews during the recertification survey and abbreviated survey (Case #NY00320404) from 12/07/2023 to 12/18/2023, the facility did not report an injury of unknown origin for 1 (Resident #110) of 7 residents reviewed. Specifically, Resident #110 had a distal fibula fracture (broken calf bone) diagnosed on [DATE] after an x-ray was ordered by their physician in response to a complaint of ankle pain on 7/10/2023. The facility did not report the fracture to the State Survey Agency. This was evidenced by: The Resident Abuse Policy and Procedure, dated 2/2019, documented the following: Notify the local law enforcement and appropriate State Agency(s) immediately (no later than 2 hours after allegation/identification of allegation). Resident #110 was admitted to the facility with diagnoses of chronic kidney disease, morbid obesity, and diabetes. The Minimum Data Set (an assessment tool) dated 7/6/2023 documented the resident was assessed as having intact cognition, able to make self-understood and was able to understand others. Review of Physician Progress notes dated 7/10/2023 documented the resident reported a new onset of ankle pain, and an x-ray was ordered. Review of a radiology report dated 7/11/2023 documented Resident #110 had a distal fibula fracture (broken calf bone) with early signs of healing, slight lateral displacement, and swelling. Review of the consultation form dated 7/20/2023 documented Resident #110 was evaluated by an orthopedist (doctors who focus on caring for your bones, joints, ligaments, nerves, and tendons). The report documented an old healing fracture and significant osteoarthritis (degeneration of joint cartilage and the underlying bone) of the ankle and foot. A review of the resident's medical record from 7/6/2023 through 7/27/2023 revealed it did not include documentation that a report was submitted to appropriate agencies. During an interview on 12/12/2023 at 09:28 AM, the Administrator stated there were no incidents and accidents files for Resident #110 from June 2023 to July 2023. During an interview on 12/14/2023 at 01:51 PM, the Assistant Director of Nursing and Director of Nursing stated Resident #110 acquired an injury of unknown origin. They stated that they had up to two (2) hours to report any unknown injury or suspected abuse, and they misunderstood the injury's nature and believed it may have been a previous injury since the x-ray documented the fracture was healing. They stated the injury should have been reported appropriately. NYCRR 483.12(c)(1)A

Based on record review and staff interviews during the recertification survey and abbreviated survey (Case #NY00320404) from 12/07/2023 to 12/18/2023, the facility did not investigate all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, and mistreatment, including injuries of unknown source for 1 (Resident #110) of 7 residents reviewed. Specifically, the facility did not initiate an investigation to determine the root cause of a distal fibula fracture (broken calf bone) discovered on 7/11/2023 after an x-ray was performed for Resident #110's complaint of ankle pain. This was evidenced by: The Resident Abuse Policy and Procedure dated 2/2019 documented the all allegations of suspected neglect, abuse, mistreatment, or any injury of unknown origin were to be promptly and thoroughly investigated by facility management. Resident #110 was admitted to the facility with diagnoses of chronic kidney disease, morbid obesity, and diabetes. The Minimum Data Set (an assessment tool) dated 7/6/2023 documented the resident could be understood and could understand and was cognitively intact. Physician Progress notes dated 7/10/2023 documented the resident reported a new onset of ankle pain, and an x-ray was ordered. Review of the resident's medical record from 7/6/2023 to 7/27/2023 did not include documentation of an investigation regarding the resident's injury of unknown origin. Review of the radiology report dated 7/11/2023 documented Resident #110 had a distal fibula fracture (broken calf bone) with early signs of healing, slight lateral displacement, and swelling. Review of the consultation form dated 7/20/2023 documented Resident #110 was evaluated by an orthopedist (doctors who focus on caring for your bones, joints, ligaments, nerves, and tendons--tissue that connects bones and joints). The report documented an old healing fracture and significant osteoarthritis (degeneration of joint cartilage and the underlying bone) of the ankle and foot. During an interview on 12/12/2023 at 09:28 AM, the Administrator stated there were no incidents and accidents files for Resident #110 from June 2023 to July 2023. During an interview on 12/14/2023 at 01:51 PM, the Assistant Director of Nursing and Director of Nursing stated Resident #110 acquired an injury of unknown origin. They indicated they misunderstood the injury's nature and believed it may have been a previous injury since the x-ray documented the fracture was healing. They stated they did not complete an investigation and should have, and that staff are educated on abuse, neglect, and investigations during orientation, annually, and as needed. NYCRR 483.12(c)(1)A

Based on observations, record review, and staff interviews during a recertification survey from 12/07/2023 to 12/18/2023, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences, for 1 of 1 (Resident #10) residents reviewed for dialysis. Specifically, the facility did not ensure nursing consistently completed, reviewed, and logged dialysis communication sheets for Resident # 10 between 11/08/2023 and 12/11/2023. This was evidenced by: Resident #10 was admitted to the facility on [DATE] with the diagnoses of end-stage renal disease and right foot ulcer with methicillin-resistant staphylococcus aureus (known as MRSA, a group of gram-positive bacteria that is a cause of staph infection with resistance to some antibiotics). The Minimum Data Set (assessment tool) dated 9/22/2023 documented the resident could be understood and could understand others. The policy and procedure titled, Dialysis, dated 5/2019, documented that a communications log would be used to establish open communication with the resident's dialysis center by completing the Dialysis Communication Form. Before the resident left, the facility would fill out the form, including all resident vital signs for the day and any pertinent resident information. Upon the resident's return from the dialysis session, the nurse would review the communication book for any information on the resident's vital signs and treatment issues. A comprehensive care plan for Resident #10 titled, Dialysis and dated 9/11/2023 documented to use the communications book to relay information to and from dialysis. A physician order dated 9/11/2023 documented Resident #10 was to receive dialysis three (3) times a week on Monday, Wednesday, and Friday; vital signs were to be completed before and after dialysis treatment. A review of Resdient #10's Dialysis Communication Book revealed the following: - Communication Sheets dated 11/15/2023, 11/17/2023, 11/23/2023, 11/27/2023, 11/29/2023, 12/01/2023, and 12/04/2023 did not include documentation of vital signs and weights from dialysis center. - Dialysis sheets dated 11/8/2023, 11/10/2023, and 11/13/2023 were missing from the Dialysis Communication Book. During record review on 12/12/2023, the progress notes for Resident #10 dated 11/8/2023 to 12/04/2023 did not include documentation of communication between the facility and the dialysis center regarding Resident #10's dialysis care. During an interview on 12/12/2023 at 12:09 PM, Registered Nurse #1 stated the resident had a dialysis communication book with pre- and post-dialysis weights. Weights were also performed on a weekly basis. If a resident was to refuse dialysis, the resident would contact the dialysis center and nursing staff would notify the primary care physician and nephrologist (a doctor who specializes in kidney care and treating diseases of the kidneys). Registered Nurse #1 furhter stated that training on how to care for dialysis residents was provided during general nurse orientation. During an interview on 12/12/2023 at 12:30 PM, the Registered Nurse Unit Manager stated they had located the missing dialysis sheets dated 11/8/2023, 11/10/2023 and 11/13/2023; and that the sheets were located stuffed in Resident's wheelchair carry-on bag. On 12/12/2023 at 12:30 PM, review of Resdient #10's located dialysis sheets for the dates 11/8/2023, 11/10/2023 and 11/13/2023 revealed they did not include documentation of vital signs and weights from the dialysis center. 10NYCRR415.12

Based on record review and interviews during an abbreviated survey (Case #s NY00272083, NY00276329, NY00305531, and NY00311480), the facility did not ensure it maintained complete medical records for 3 (Resident #s 1, 2, and 3) of 6 residents reviewed for Certified Nursing Assistant (CNA) documentation of care provided. Specifically, the facility did not ensure CNAs consistently documented the care provided to Resident #s 1, 2, and #3 on every shift. This was evidenced by: The Policy and Procedure titled Charting and Documentation- CNA created 3/2020, documented all services provided to the resident, or any changes in the resident's medical or mental conditions, shall be documented in the resident's medical record. The procedure documented CNAs encouraged to document care as close to completion of task as possible, if not, must be documented by end of shift. Resident #1 Resident #1 was admitted to the facility with diagnoses of diabetes with skin ulcer, chronic obstructive pulmonary disease, and anxiety disorder. The Minimum Data Set (MDS- an assessment tool) dated 12/16/2022, documented the resident was cognitively intact, could be understood, and could understand others. The document titled Activities of Daily Living (ADL) Late Loss Look Back Report dated 2/20/2023- 2/26/2023, documented on 2/21/2023, only the evening shift CNAs documented the resident's care and on 2/22/2023 the night shift did not document any care provided to the resident. On 2/23/2023, there was no documentation of the resident's care by the day, night, or evening shifts. The evening shift was the only shift on 2/24/2023 that documented care provided to the resident. The day shift on 2/25/2023 did not document the provision of any resident care. On 2/26/2023, the evening or night shift CNAs did not document any care was provided to the resident. Resident #2 Resident #2 was admitted to the facility with diagnoses of a stroke, atrial fibrillation (an abnormal heart rhythm that can cause blood clots), and heart failure. The MDS dated [DATE], documented the resident had severe cognitive impairment, was sometimes understood, and could sometimes understand others. The document titled ADL Late Loss Look Back Report dated 2/20/2023- 2/26/2023, documented on 2/21/2023, only the evening shift CNAs documented the resident's care and on 2/22/2023 the night shift did not document any care provided to the resident. On 2/23/2023, the was no documentation of the resident's care by the day, night, or evening shifts. The evening shift was the only shift on 2/24/2023 that documented care provided to the resident. The day shift on 2/25/2023 did not document the provision of any resident care. On 2/26/2023, the evening or night shift CNAs did not document any care was provided to the resident. Resident #3 Resident #3 was admitted to the facility with diagnoses of cerebral infarction, seizures, and paralysis of their left side resulting from the stroke. The MDS dated [DATE], documented the resident had moderate cognitive impairment, could be understood, and could understand others. The document titled ADL Late Loss Look Back Report dated 3/16/2023- 3/22/2023, had no CNA documentation from day, evening, or night shifts of care provided to the resident. On 3/17/2023, the evening shift did not document any care provided. There was no care documented on 3/18/2023 and 3/19/2023 by the day, evening, or night shift CNAs. On 3/22/2023, only the day shift CNAs documented care provided. During an interview on 3/22/2023 at 1:47 PM, Licensed Practical Nurse Manager #1 (LPNM) stated they were unable to determine which CNA provided care to the residents on the 2/23/2023 night shift because there was no documentation of the care they provided to any of the residents on the unit. The LPNM stated it was an ongoing issue at the facility. They stated it was very important for the CNAs to document resident care because that was how other staff knew what was done. They stated the CNAs can either stay late to complete their documentation or do it prior to their next shift. During an interview on 3/22/2023 at 2:27 PM, the Director of Nursing (DON) stated the CNAs were supposed to document the care they provided to the residents every shift. That included ADL status such as bed mobility, transfers, toileting, ambulation, wheelchair mobility, personal hygiene, etc. 10 NYCRR 415.22(a)(1-4)

Based on record review and interviews, the facility did not ensure the resident had the right to be free from abuse. The facility must not use verbal abuse for 1 resident (Resident #1) of 6 residents reviewed for verbal abuse during an abbreviated survey (Case #s NY00272083, NY00276329, NY00305531, and NY00311480). Specifically, the facility did not ensure Certified Nursing Aide (CNA) #s 1 and 2 did not verbally abuse Resident #1 when during a verbal altercation with the resident, both CNAs called the resident a cracker (Webster's Dictionary defines the word cracker as offensive when used as an insulting and contemptuous term for a poor, white usually Southern person). Resident #1 stated in an interview that to them, cracker meant scumbag (Webster's Dictionary defines scumbag as a dirty or despicable person). This was evidenced by: The Policy and Procedure titled Abuse last revised 12/2022, documented the facility prohibits the abuse of residents. Verbal abuse is defined as oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident to describe the resident regardless of their age, ability to comprehend, or disability. Resident #1 Resident #1 was admitted to the facility with diagnoses of diabetes with skin ulcer, major depression, and anxiety disorder. The Minimum Data Set (MDS-an assessment tool) dated 12/16/2022, documented the resident was cognitively intact, could be understood, and could understand others. The Comprehensive Care Plan for At Risk for Feelings of Victimization related to Actual Event of Abuse, updated on 2/23/2023, documented to refer the resident for psychiatric and psychological evaluation and ongoing services if indicated, and remove the resident from abusive situation. A written statement dated 2/23/2023, documented the Transportation Coordinator (TC) arrived to work at 6:00 AM and at 6:05 AM, they heard Resident #1 in the main hall screaming. When the TC went to the resident, they were covered in medicated powder in their hair, eyebrows, eyes, and their shirt. The resident stated CNA #s 1 and 2 were doing care on their roommate and when they heard them crying, they asked the CNAs to be easy with their roommate. The CNAs then started calling Resident #1 cracker, rotten tooth, etc., and they said something back to the CNAs. The CNAs opened Resident #1's privacy curtain, squeezed a bottle of medicated powder and sprayed it all over the resident. A Psychiatric Nurse Practitioner (PNP) visit note dated 2/23/2023 at 2:15 PM, documented Resident #2 stated 2 staff (CNA #s 1 and 2) had verbally and physically assaulted them at 5:30 AM on 2/23/2023. The resident was shaking during the visit and stated they were feeling nervous because of the incident. It documented the resident's insight was good. The resident appeared unstable at the present time. A Psychologist's Note dated 2/24/2023 at 11:45 AM, documented Resident #1 was seen as a follow up to an abuse allegation. The resident stated 2 staff members (CNA #s 1 and 2) began verbally abusing them, calling them names, and then sprayed medicated powder on their eyes, face, and table. The resident stated the CNAs obstructed them from leaving the room to seek help. The resident stated CNA #1 was not a staff member; they were no longer an employee at the facility. The Psychologist documented the resident had lingering trauma, anger, and sadness and was crying as they reported the event. A Psychologist's Note dated 3/1/2023, documented the resident remained with elevated distress (from the 2/23/2023 incident). Resident #1 stated they were going to be meeting with the State today (3/1/2023) regarding the allegations of abuse. The resident had ongoing trauma and continued to process the incident. The resident stated feeling attacked had highlighted their sense of disability and lack of capacity to ambulate or defend themselves. The resident was sobbing. During an interview on 3/21/2023 at 9:45 AM, Resident #1 stated CNA #'s 1 and 2 were providing care to their roommate (on the 2/23/2023 night shift) and they heard the resident scream like they were in pain. The resident asked what they were doing to their roommate, and they told them it was none of their business. They stated then CNA #1 sprayed powder in their face and called them a cracker, a crack head, and a comment about their bad teeth, which the resident stated they were very self-conscious of. The 2 CNAs left the room and held the door shut so they could not exit. During an interview on 3/21/2023 at 11:50 AM, the Purchasing Coordinator stated (on 2/23/2023) Resident #1 told them the CNAs called them a white cracker. During an interview on 3/21/2023 1:50 PM, Registered Nurse Supervisor #1 (RNS) stated (on 2/23/2023 after 5:00 AM) they heard Resident #1 yelling in the hallway. It sounded different from their usual yelling; it sounded like fear. They were crying. The resident had powder on their face. The RNS stated the resident told them CNA #s 1 and 2 had thrown powder in their face and were calling them names. They stated the CNAs held their room door closed so they could not get out. RNS #1 stated the incident was traumatic for the resident. This was their home, and they were attacked in their home. During an interview on 3/21/2023 at 2:59 PM, CNA #2 stated Resident #1 called them the n word (a racial slur) and they told the resident they could not talk to them that way. They stated they called the resident a cracker after the resident called them the n word. CNA #2 stated CNA #1 and the resident were going back and forth with racial slurs. They stated CNA #1 called the resident a cracker. During an interview on 3/22/2023 at 11:20 AM, CNA #1 stated Resident #1 was throwing racial slurs at CNA #2 and them. They stated they called the resident a cracker because the resident called them the n word. CNA #1 stated Resident #1 said they did not care if they were making racial slurs to them and CNA #1 stated neither did they, so they called the resident a cracker. When CNA #1 was asked what they should have done when a resident was agitated, they stated they did exactly what they needed to do by insulting the resident and it was the right thing to do. They stated CNA #2 called the resident a cracker because the resident had called CNA #2 the n word. During a subsequent interview on 3/22/2023 at 1:18 PM, Resident #1 stated cracker meant scumbag (Webster's Dictionary defines scumbag as a dirty or despicable person). The resident stated it was upsetting at the time of the incident and they were not a scumbag. During an interview on 3/23/2023 at 8:40 AM, the Medical Director stated they examined Resident #1 the morning of the incident (2/23/2023). The resident was upset but had the presence of mind to tell them what happened. They were emotionally hurt, embarrassed and insulted. They talked about the name calling. The resident was referencing being called cracker by the CNAs (#s 1 and 2) and they told the resident they smelled. The Medical Director stated the resident felt helpless. Usually, the resident had a happier demeanor, but was down and upset at the time of their exam. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: -Implemented an audit completed by the receptionist on the day and evening shifts and licensed nursing staff on the night shift that ensures all staff that entered the building were verified current and in good standing related to employment. The Audit was started on 2/24/2023 and will end on 5/30/2023. - 100% of staff were reeducated on abuse and neglect. -The facility posted notices at the front entrance and back entrance where the time clock is that no terminated employees were to be allowed in the building without Administrator authorization. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (Case #s NY00311480, NY00305531, NY00276329, and NY00272083), the facility did not ensure in response to allegations of abuse, the facility must prevent further potential abuse for 1 (Resident #1) of 6 residents reviewed for abuse. Specifically, the facility did not ensure they prevented further abuse when Certified Nursing Assistant #1 (CNA), whose employment at the facility had been terminated on 2/14/2023 for workplace violence, was not told to leave the facility on the night of 2/23/2023 as soon as staff were aware CNA #1 was in the facility. This resulted in CNA #1 allegedly throwing powder in Resident #1's face, allegedly holding the resident's room door shut so they could not exit, and the use of derogatory language directed at Resident #1. This was evidenced by: The Policy and Procedure titled Abuse last revised 12/2022, documented the facility prohibits abuse of residents. If the suspected perpetrator is a visitor, the Chief Executive Officer will ensure the visitor does not have access to the resident, pending investigation, or visit unsupervised until the circumstances can be determined. Resident #1 Resident #1 was admitted to the facility with diagnoses of diabetes with skin ulcer, major depression, and anxiety disorder. The Minimum Data Set (MDS- an assessment tool) dated 12/16/2022, documented the resident was cognitively intact, could be understood, and could understand others. The document titled Investigation Form dated 2/23/2023, documented CNA #2 let CNA #1 (who had been terminated from employment at the facility) into the facility and allowed them to assist them in their job duties on the overnight shift on 2/23/2023. CNA #s 1 and 2 were in Resident #1's room providing care to their roommate, and they commented to the CNAs they were not providing adequate care to their roommate. At 5:50 AM (on 2/23/2023), CNA #1 pulled back Resident #1's curtain and threw medicated powder into Resident #1's eyes. Both CNAs exited the room and held the door shut so Resident #1 could not exit the room. A Nursing Clinical Evaluation dated 2/23/2023 at 9:57 AM, documented the following; at 6:00 AM, Resident #1 reported to staff that their roommate was screaming and crying because they thought CNA #1 and CNA #2 were rough with their roommate and told them they had to be careful with them. That was when CNA #1 opened their privacy curtain and threw their roommate's medicated powder in their face and on their bed. Resident #1 then started screaming because the powder hurt their eyes. The resident got into their wheelchair and tried to go out of the room to yell at CNA #1 and CNA #2, but the 2 CNAs were holding the door closed from outside of the room, preventing them from exiting. A Physician Progress Note dated 2/23/2023 at 10:21 AM, documented Resident #1 was examined by the Medical Director. They documented the resident got into a verbal altercation with CNA #1 and CNA #2 who were caring for their roommate. It resulted in medicated body powder being thrown on Resident #1. The resident stated their eyes felt a bit hazy and stung off and on. The resident was visibly upset and tearful. It documented the resident would be seen this date by ophthalmology (an eye doctor) to rule out corneal abrasion (a scratch on the clear outer part of the eye). During an interview on 3/21/2023 at 9:45 AM, Resident #1 stated there was a CNA (CNA #1) that was not supposed to be in the building during the night shift on 2/23/2023 because they had been fired. During an interview on 3/21/2023 at 3:29 PM, Licensed Practical Nurse (LPN) #2 stated they saw CNA #1 in the building sitting at the nurses' station on Resident #1's unit next to another CNA and RNS #1. They stated RNS #1 was sitting next to CNA #1 chatting with them at the time. LPN #2 stated CNA #1 was there the entire night. During an interview on 3/23/2023 at 9:36 AM, the Administrator stated they were called at 6:45 AM on 3/23/2023 by the Transportation Coordinator (TC) who reported the incident. The Administrator stated they asked if the 2 individuals (CNA #1 and CNA #2) were in the building and the TC stated they were, under supervision. The Administrator requested they be escorted from the building, and they called the police. The Administrator stated the theory was that CNA #2 let CNA #1 into the building, but nobody knew for sure. During an interview on 3/21/2023 at 1:36 PM, CNA #4 stated CNA #1 had been terminated and they thought maybe they had been rehired. RNS #1 asked them if CNA #1 was supposed to be there. During an interview on 3/21/2023 at 2:24 PM, Licensed Practical Nurse Manager (LPNM) #1 stated CNA #1 was not supposed to be in the facility. The CNA had been fired about a week prior to the incident. LPNM #1 stated they thought CNA #2 snuck CNA #1 in through the back door. During an interview on 3/21/2023 at 2:59 PM, CNA #2 stated CNA #1 told them they had a text message to come to the building. CNA #2 stated they did not let CNA #1 into the building, but then stated they could not remember if they had let CNA #1 into the building. CNA #2 stated they did not tell anyone CNA #1 was in the building. They stated everyone knew CNA #1 was in the building. During an interview on 3/22/2023 at 2:27 PM, the Director of Nursing (DON) stated they were called and notified that the 2/23/2023 incident had occurred prior to 7:00 AM. They went to the facility and were very upset to learn that CNA #1 was in the building. The DON stated they were told by the TC that CNA #2 let CNA #1 into the building. 10 NYCRR 415.4(b)(3)

Based on observation, record review, and interviews during the recertification survey dated 10/24/2022 through 11/1/2022, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and 2 of 3 nourishment kitchens. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) exceeded that required by the manufacturer; one food temperature thermometer was not in calibration; the can opener and holder, slicer, edge of reach-in refrigerator door, and ceiling in dishwashing machine room in the main kitchen and the microwave oven and refrigerator in the West Unit nourishment kitchen were soiled with food particles or splatters; and the kitchen janitor closet wall and South Unit nourishment room wall required repair. This is evidenced as follows: During observations on 10/24/2022 at 10:11 AM, in the main kitchen, one food temperature thermometer was found not in calibration at 37 F when tested in a standard ice-bath method; the can opener and holder, slicer, edge of reach-in refrigerator door, and ceiling in dishwashing machine room were soiled with food particles or splatters; and the janitor closet had a 3-foot by 1.5-foot section where the wall was crumbling and had holes. During observations on 10/24/2022 at 11:29 AM, the microwave oven and refrigerator in the West Unit nourishment kitchen were soiled with food particles, and a 3-foot by 2-foot section of gypsum board wall was missing on the wall behind the ice machine in the South Unit nourishment kitchen. During observations on 10/28/2022 at 09:43 AM, the concentration of QAC used in the final, sanitizing rinse sink was 500 parts per million (ppm) when measured at 70 degrees Fahrenheit (F). The label titled Greenex Quaternary Sanitizer (label not dated) instruct that the QAC sanitizing range is to be between 200 ppm and 400 ppm During an interview on 10/28/2022 at 9:43 AM, the Food Service Manager stated the automatic pre-mix for the sanitizer does not work and will contact the vendor to have it repaired. During an interview on 10/28/2022 at 9:46 AM, the Administrator stated the Food Service Manager will be contacted to correct the issues with manual sanitizing, cleaning, and thermometer calibration, and maintenance will be contacted to correct the issues with the walls. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.85, 14-1.110, 14-1.112, 14-1.171

Based on record review and interviews during the recertification survey dated 10/24/2022 through 11/1/2022, the facility did not ensure the appropriate discharge information was documented in the resident's record for one (1) (Resident #109) of two (2) residents reviewed for transfer/discharge. Specifically, for Resident #109, the facility did not ensure the resident's record included documentation regarding the resident's discharge from the facility and did not ensure that when upon request the facility submitted an Against Medical Advice (AMA) form signed by Resident #109, the record included documentation the resident received education on what it meant to leave the facility Against Medical Advice (AMA), documentation regarding when or how the resident left the facility or documentation of notifications made when the resident left the facility. The findings include: Resident #109: Resident # 109 was admitted to the facility with diagnoses which included acute and chronic respiratory failure, idiopathic pulmonary fibrosis and severe protein-calorie malnutrition. The Minimum Data Set (MDS, an assessment tool) dated 7/27/2021, documented the resident was cognitively intact, could be understood and could understand others. The Policy and Procedure (P&P) titled Discharge-Against Medical Advice last revised April 2020 documented that residents who are cognitively intact, and residents with cognitive impairment who have a resident representative making their decisions for them, have the right to choose to leave the facility against medical advice. The facility must provide education to the resident (or representative where applicable) on the risks/ ramifications of leaving the facility against medical advice. The resident (or representative where applicable) will complete an Against Medical Advice (AMA) form when choose to leave AMA. When a resident or resident representative requests to leave AMA, the physician, Director of Nursing (DON) and administrator will be made aware. The nurse will explain the risks/ ramifications of leaving AMA, which may include but is not limited to the resident not receiving medications/ prescriptions from the facility, not receiving durable medical equipment and not receiving home care services. The nurse should document in the resident's medical record the provision of this education and the acceptance/understanding by the resident/ resident representative. Review of the resident record did not include documentation of Resident #109's discharge. The last clinical note documented on 9/3/2022 detailed the resident's condition, goals and progress in therapy. On 10/31/2022 at 11:17 AM, the Assistant Administrator (AA) provided an AMA form dated 9/4/22 signed by Resident #109 and the nurse supervisor as a witness. Written on the form was due to health insurance not paying as of 9/3/22. Review of the resident record did not include documentation detailing whether education was provided to the resident, why the resident elected to leave AMA, when the resident left the facility, how the resident left the facility or notifications of the physician and interdisciplinary team. During an interview on 10/31/2022 at 11:20 AM, the Director of Nursing (DON) stated there should be documentation entered into the record when a resident discharges from the facility AMA. They stated when a resident stated they want to leave the facility AMA, education should be provided to the resident so that the resident knows what they are signing and what it means for them. They stated, we want to make sure that the resident is aware all of the cons associated with them leaving AMA. They stated they had looked at Resident #109's record and found no documentation of the resident's discharge. They stated, all we know is that the AMA form was signed by the resident and the nurse supervisor beyond that there is no documentation that education was provided. During an interview on 10/31/2022 at 11:42 AM, Licensed Practical Nurse (LPN) #1 stated if a resident decided to leave the facility AMA, they would provide education to the resident on the risks associated with leaving AMA, would have the resident sign an AMA form and would sign the form themselves as a witness. LPN #1 stated they would notify the physician and document in the resident's chart that education was provided to the resident, the time that they left the facility and the mode of leaving the facility (with a family member, taxi, etc). 10 NYCRR415.3(h)(1)(ii)(a)(b)

Based on record review and interview conducted during the recertification survey dated 10/24/2022 through 11/1/2022, the facility did not ensure the development of comprehensive person-centered care plans, that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 2 (Resident #s 259 and #361) of 22 residents reviewed for comprehensive care plans (CCP). Specifically, for Resident #259, the facility did not ensure a CCP was developed to address the resident's activities of daily living (ADLs) and for Resident #361, did not ensure a CCP was developed to address the resident's pain management. This is Evidenced By: The Policy and Procedure (P&P) titled Care Plans - Comprehensive last revised 10/2019, documented the Interdisciplinary Team (IDT), in conjunction with the resident and their family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Resident #259: Resident #259 was admitted to the facility with diagnoses of dementia, type 2 diabetes mellitus with diabetic chronic kidney disease, and paroxysmal atrial fibrillation. The Minimum Data Set (MDS- an assessment tool) dated 3/5/2021, documented the resident had severe cognitive impairment, could be understood and could understand others. The MDS dated [DATE], documented the resident was frequently incontinent of the bladder and bowel and required extensive two-person assistance for bed mobility, total dependence with two-person physical assistance for transfers and toilet use, and extensive one person assistance with eating, dressing and personal hygiene. The Comprehensive Care Plan did not include a care plan to address the resident's activities of daily living. During an interview on 10/31/2022 at 12:45 PM, the Director of Nursing (DON) stated the comprehensive care plans were started on admission through the development of the baseline care plan. The baseline care plan was used for up to 14 days, then the comprehensive care plan replaced the baseline care plan. The care plan should address the needs and preferences of the resident. During an interview on 11/1/2022 at 1:33 PM, the Administrator stated they conducted a root cause analysis and found there was only one staff member updating the care plans and they were not being completed or updated in a timely manner. Resident #361: Resident #361 was admitted with the diagnoses of fracture of unspecified part of neck of right femur, unilateral primary osteoarthritis right knee and post-polio syndrome. The Minimum Data Set (MDS- an assessment tool) dated 10/1/2022, documented the resident had moderately impaired cognition, could be understood and could understand others. A Physician's Order dated 9/7/2022 documented a pain evaluation was to be done every shift and recorded on a 0-10 pain scale. A Physician's Order dated 9/7/2022 documented diclofenac sodium external gel 1% (a nonsteroidal anti-inflammatory drug used to relieve joint pain from arthritis) to be applied to right knee topically four times a day for pain and arthritis. A Physician's Order dated 9/7/2022 documented acetaminophen extra strength oral tablet 500 milligram (mg) give 2 tablets by mouth three times a day for pain. A Physician's Order dated 9/8/2022 documented lidocaine external patch 4% (a local anesthetic) to be applied to right knee topically one time a day for pain. A Physician's Order dated 9/21/2022 documented oxycodone (a narcotic pain reliever) 5 mg tablet give 2.5 mg by mouth every 8 hours as needed (PRN) for pain. A document titled RN: Baseline Care Plan dated 9/7/2022 documented the resident's pain was present on the admission assessment. The Comprehensive Care Plan did not include a care plan to address the resident's pain management. During an interview on 10/28/2022 at 10:48 AM, the Licensed Practical Nurse (LPN) #2 stated there should be a care plan for pain if a resident was being treated for pain. LPN #2 stated the registered nurses started care plans. During an interview on 10/31/2022 at 12:45 PM, the Director of Nursing (DON) stated the comprehensive care plans were started on admission through development of the baseline care plan. The baseline care plan was used for up to 14 days, then the comprehensive care plan replaced the baseline care plan. The care plan should address the needs and preferences of the resident. If the resident was in pain on admission, a pain or comfort care plan should be initiated. If a resident was on a routine medication for pain, then a pain or comfort care plan should be in place. The pain or comfort care plan would include any non-pharmacological interventions as well. During an interview on 11/1/2022 at 1:33 PM, the Administrator stated that they conducted a root cause analysis and found that there was only one staff member updating the care plans and they were not being completed or updated in a timely manner. 10 NYCRR415.11(c)(1)

Based on record review and interviews during the abbreviated survey (Case #NY 919), the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) for 1 (Resident #1) of 3 residents reviewed for CPR. Specifically, for Resident #1, whose advance directive status was a full code, the facility failed to ensure cardiopulmonary resuscitation (CPR) was initiated on [DATE] by Licensed Practical Nurse (LPN) #1 who found the resident unresponsive at 3:40 AM. LPN #1 did not perform CPR because the resident was cold. The facility failed to initiate a Code Blue (emergency response) to summon additional help, failed to activate the 911 system, and failed to provide cardio-pulmonary resuscitation efforts for a resident who was a full code. This resulted in actual harm and had the likelihood for serious harm to the health and safety of all residents in the facility that was Immediate Jeopardy and Substandard Quality of Care. This was evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing admission evaluation dated [DATE], documented that they were oriented to person, place, and time, their cognition was intact, and their code status was full code. The facility policy titled Code Blue/Cardiopulmonary Resuscitation (CPR), last revised ,d+[DATE], documented when an individual was found either turning blue, unresponsive, not breathing normally, not breathing, having no pulse felt for 10 seconds, or choking, the staff member needed to stay with the resident, call for assistance, have staff members check for advanced directives, and call Code Blue. The first licensed nurse certified in CPR on the scene, or the physician, was the team leader, and would direct the code. The team leader would initiate CPR unless a known DNR order specifically prohibited CPR and/or external defibrillation. If the person's code status was unknown, it was important to confirm this prior to initiating CPR. The facility policy titled Resident Identification, dated [DATE], documented the facility adopted a photo and/or wristband identification system for resident identification to help ensure that medications and treatments were administered to the right residents. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan note dated [DATE] at 5:11 PM, documented Resident #1 had declared advanced directives allowing resuscitation, and stated a code status of full code. The Medical Order for Life Sustaining Treatment (MOLST) dated [DATE] at 9:30 AM, documented Resident #1 wanted CPR attempted if they had no pulse and were not breathing. The Comprehensive Care Plan (CCP) titled MOLST, dated [DATE], documented Resident #1 was a full code as per their wishes, and that the advanced directives would be filed in their medical chart. Progress notes in the electronic medical record (EMR) documented: -[DATE] at 4:42 AM, documented Resident #1 was found lying in bed without a pulse or respirations. CPR was not initiated, EMS was not called, and the resident's time of death was 4:00 AM. -[DATE] at 5:06 AM, documented RN #1 went to the unit after being informed that a resident had passed away. Upon entering the room, they observed a resident lying in bed without a pulse or respirations. Vital signs were taken, and no discernable signs of life were present. Telehealth, family, the Director of Nursing (DON), Assistant DON (ADON), and Unit Manager were informed. -[DATE] at 5:43 AM, documented at approximately 3:40 AM, Licensed Practical Nurse (LPN) #1 went into Resident #1's room and found them lying in bed; their eyes were closed, they were not breathing, and they had no pulse. The supervisor was notified. The facility Accident and Incident (A&I) report dated [DATE] at 4:00 AM, documented Resident #1 expired on [DATE] at 4:00 AM. A Code Blue was not called, their code status was not immediately confirmed, and CPR was not initiated; and the facility's Code Blue policy was not followed. The A&I report documented that LPN #1 believed that Resident #1 had been dead for a while because their body was cold to the touch, so CPR would have been ineffective. An undated witness statement by LPN #1, documented at approximately 4:00 AM, LPN #1 entered Resident #1's room and observed their chest was not moving, they could not feel a pulse, and they did not respond when their name was called. Since Resident #1 had no pulse, respirations, and felt cold to the touch, LPN #1 believed that Resident #1 had been dead for a while and felt that CPR would be ineffective; they did not know the resident's code status at this time. They left the resident's room and reported to Registered Nurse (RN) #1 that they had a deceased resident on their unit. During the time that RN #1 was on the unit, LPN #1 reviewed Resident #1's chart and discovered that they were a full code; they did not inform RN #1, and a Code Blue was not called. A witness statement by RN #1 dated [DATE], documented at approximately 3:50 AM on [DATE], LPN #1 informed RN #1 there was a deceased resident on the South Unit; no name was given. When RN #1 arrived on the South Unit, they followed LPN #1 to the Resident #1's room and assessed the deceased resident; there were no signs of life present. Since the only nameplate outside the deceased resident's room belonged to Resident #1's roommate, RN #1 identified Resident #1 as their roommate and they called the wrong family and told them that their family member had passed away. When they called the Telehealth service, LPN #1 overheard them use the incorrect resident name and corrected them; the Telehealth service informed RN #1 that Resident #1 was a full code. RN #1 asked LPN #1 if they were aware that Resident #1 was a full code, and they stated that they were aware; a Code Blue was never called. A corrective call was made to the family member of Resident #1's roommate that was called in error, and the correct family was notified regarding Resident #1's death. During an interview on [DATE] at 8:56 AM, RN #2 stated code status was documented in the EMR, in the orders, and in each resident's paper chart on their MOLST. In an emergency, staff refer to the MOLST form. If a resident was found unresponsive with no pulse or respirations, a Code Blue would be called, and CPR would be initiated after their code status was verified. They were not aware of any situation where CPR would not be initiated for residents who were a full code. During an interview on [DATE] at 9:23 AM, LPN #2 stated in an emergent situation, resident code status was verified according to their MOLST form, these were present in the residents' charts. If they found a resident unresponsive with no pulse or respirations, they would call a Code Blue, confirm their code status, and if they were a full code, CPR would be initiated. They were not aware of any situation where CPR would not be started if when a resident was a full code. During an interview on [DATE] at 11:07 AM, LPN #1 stated sometime between 3:00 AM - 4:00 AM on [DATE], they went to check on Resident #1 and their eyes were closed, they had no chest rise, and had no pulse. When they touched their body, it was cold, and they realized that the resident was dead. They left the room and notified the Supervisor; they were not aware of the resident's code status. LPN #1 stated that they knew that CPR worked when the body was warm, and since Resident #1 felt cold to the touch, they assumed they had been dead for a while. They stated that the facility policy when a resident was found unresponsive, was to confirm the resident's code status and initiate CPR if they were a full code. They were not aware of any exceptions in facility policy for not initiating CPR when a resident was a full code and had not been trained to not perform CPR when a resident was found unresponsive without a pulse or respirations and felt cold to the touch. During an interview on [DATE] at 11:32 AM, RN #1 stated in the morning of [DATE], LPN #1 called them and informed them that one of the residents on their unit had died ; no name was given, and they did not ask. When they arrived on the unit they did not check to confirm the resident's identity or check the resident's chart to confirm their code status. Since Resident #1 was recently admitted to the facility, they did not yet have a nameplate posted outside their room; only their roommate's name was present there. When RN #1 entered Resident #1's room, they identified Resident #1 as their roommate because they only saw one resident in the room since Resident #1's roommate had their curtain pulled around their bed at the time. They assessed Resident #1, found no signs of life, and called their roommate's family by mistake to let them know their family member had passed away. When they called the Telehealth provider, LPN #1 heard RN #1 identify Resident #1 by their roommate's name and corrected them; this was when the Telehealth provider informed RN #1 that Resident #1 was a full code. A call was made to Resident #1's roommate's family to inform them that this resident was not deceased , and the call earlier was made in error; this was followed by a call to Resident #1's family to inform them that this resident had passed away. The RN stated upon arrival on the unit, they should have reviewed the resident's chart and confirmed their code status. Additionally, prior to assessing the resident, they should have correctly identified the resident using the photo of the resident in the electronic medical record (EMR) in accordance with facility policy, not by the nameplate on the outside of the resident's room. During an interview on [DATE] at 3:10 PM, LPN #3 stated according to facility policy, accurate identification of residents involved verifying each resident's identity against their photo in the EMR prior to performing any procedures. During an interview on [DATE] at 12:14 PM, Medical Director (MD) #1 stated when staff found a resident unresponsive, they should call for help, call a Code Blue, and stay with the person until help arrives. Once support arrived, the resident's code status needed to be confirmed. When Resident #1 was found unresponsive without a pulse or respirations on [DATE], a Code Blue should have been called, and their code status should have been verified to determine if CPR was required. During an interview on [DATE] at 2:00 PM, the DON stated when a resident was found unresponsive with no pulse or respirations, a Code Blue should be called so a facility-wide response could be initiated. The resident's code status was then confirmed, and if they were a full code CPR would be initiated. It was not within LPN #1's scope of practice to make a clinical decision regarding whether to initiate CPR for Resident #1 without reviewing their advanced directives. When Resident #1 was identified as unresponsive with no pulse or respirations on [DATE], a Code Blue should have been called, their code status should have been verified, and CPR should have been initiated. Additionally, RN #1 should have correctly identified Resident #1 using their photo in the EMR. Using the nameplate outside of the resident's room to identify a resident was not facility policy and should not be done. The Assistant Administrator was informed of the Immediate Jeopardy and provided the Immediate Jeopardy Template on [DATE]. Based on the following corrective actions, the facility corrected the non-compliance as of [DATE] at 9:00 AM. (IJ past non Compliance indicates the facility had an IJ but the non-compliance was corrected prior to the survey staff entering the NH on [DATE]. A Statement of Deficiency will be issued but a Plan of Correction is not required given the facility had corrected the non-compliance). -The facility immediately investigated and reported the event to the NYSDOH on [DATE] at 8:29 PM. -Both staff were suspended immediately, RN #1 received individual re-education and returned to work on [DATE], and LPN #1 was terminated on [DATE]. -100% facility-wide education of all RN, LPN, & CNA staff on CODE BLUE response completed by [DATE]. 10 NYCRR 400.21

Based on record review and interviews during an abbreviated survey (Case #NY 919), the facility did not ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 resident (Resident #2) of 3 residents reviewed for pain management. Specifically, Resident #2 received a narcotic pain medication 20 times from 4/30/2021 through 5/14/2021 with no documented monitoring to determine the medication's effectiveness. Additionally, there was no Comprehensive Care Plan with goals and interventions to address Resident #2's pain. This was evidenced by: Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 5/5/2021, documented the resident had moderate cognitive impairment, could be understood, and could understand others. The Policy and Procedure titled Pain Management dated 7/2019, documented the Interdisciplinary Team (IDT) worked with the resident and significant others to establish a plan of care that would address the individual resident goals for comfort and function. It also documented to evaluate effectiveness of pain management intervention(s) within 30-60 minutes. The Baseline Care Plan dated 5/2/2021, documented the resident had pain but did not document the most recent pain level. The resident's MDS was dated 5/5/2021. The comprehensive care plan was not in place by 5/12/2021. The resident resided at the facility for 15 days and there was no comprehensive care plan developed to address the resident's pain, their goals, and interventions. The Admission assessment dated [DATE] at 2:00 PM, documented the resident was able to discuss pain, had complaints of current pain and signs and symptoms of pain were observed. It documented medications as needed (PRN) helped. The goal was that the resident would have no pain. Nurse's notes from 4/29/2021- 5/14/2021 did not document any pain evaluations or assessments. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On the 4/30/2021 day shift, Resident #2's pain level was 10 on the numeric pain scale (10 is severe pain). [MEDICATION(S)] (a narcotic pain medication) was administered at 8:47 AM. There was no documentation in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] The MAR for May 2021 documented Resident #2 was administered PRN (as needed) [MEDICATION(S)] for pain on 5/1, 5/2, 5/3, 5/4 (twice), 5/5, 5/6 (twice), 5/7, 5/8, 5/9 (three times), 5/10, 5/11 (twice), 5/12 (twice), and 5/14/2021. There was no documentation of follow-up monitoring for the effectiveness of the [MEDICATION(S)]. A nurse's note dated 5/14/2021 at 11:15 PM, documented Resident #2 went for a Medical Doctor (MD) appointment that morning and was sent to the hospital with concerns about pain control. During an interview on 10/7/2021 at 3:03 PM, Registered Nurse (RN) #1 stated that, to assess pain, they asked the resident the level of their pain based on a scale of 0-10 (0 is no pain, 10 is severe pain) or a pain scale with pictures of faces for residents with dementia. They asked what type of pain (such as throbbing, stabbing, constant) the resident had, and observed for physical signs of pain (such as grimacing). If the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 stated they were supposed to check on the resident half an hour after administration to assess the effectiveness of the medication. During an interview on 11/16/2021 at 2:32 PM, the Assistant Director of Nursing (ADON) stated the Pain Management Flowsheet was not a separate document in the resident record, but rather part of the Electronic Medical Record. The pre and post pain levels were supposed to be documented in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When a pain medication was administered, it was the nurse's responsibility to evaluate the effectiveness and document the resident's pain level. During an interview on 11/18/2021 at 1:37 PM, the Director of Nursing (DON) stated the nurses were supposed to re-evaluate a resident's pain level about 45 minutes to an hour following the administration of pain medication and document that level. The DON stated that, despite the baseline care plan, there should have been a comprehensive care plan put in place for acute issues a resident may have, such as pain or wound care. The DON stated there should have been a comprehensive care plan in place to address Resident #2's pain or alteration in comfort since they were using pain medication. 10 NYCRR 415.12

Based on record review and interviews during an abbreviated survey (Case #NY 642), the facility did not ensure residents were free of any significant medication errors for 1 (Resident #1) of 3 residents reviewed for medication errors. Specifically, Resident #1 was administered another resident's medications that included the significant medications including: antidepressants, insulin, a narcotic pain medication, a blood thinner, and cardiac medication. The resident was transferred to the emergency room for evaluation. This was evidenced by: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (an assessment tool) dated 5/21/2021, documented the resident had severe cognitive impairment, could be understood, and could understand others. The Policy and Procedure titled, Medication Administration dated 12/2019, documented medications were to be administered in a safe, timely manner, and as prescribed. Medications were to be administered in accordance with the orders. The individual administering the medication were to check the label three times to verify the right medication, right dosage, right time, and right route of administration before giving the medication. A Medical Provider Note dated 4/13/2021 at 1:22 PM, written by the Nurse Practitioner (NP) documented the resident was seen for sedation related to incorrect medication administration. Resident #1 received another resident's morning medications that included the following significant medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 did not receive their own prescribed medications. The resident was minimally responsive to sternal rub (painful stimulus using the knuckles with a closed fist on the breastbone of a person who was not alert), could move their head and open their eyes but could not stay awake or answer questions. The resident's breathing was shallow and irregular at times. The NP documented the resident had received many sedating medications that they were not used to taking and was in a stupor (unresponsiveness in which a person can be aroused only by vigorous, physical stimulation). A Nurse's Note dated 4/13/2021 at 5:51 PM, written by Licensed Practical Nurse (LPN) #2, documented that around 9:00 AM that morning, the resident was given an incorrect medication. Vital signs and blood sugar levels were taken every hour and were at baseline. The NP and family were notified, and the resident sent to the hospital. The Medical Doctor Orders dated 3/20/2021, documented Resident #1's regularly administered significant medications included: [MEDICATION(S)] and [MEDICATION(S)] (both for high blood pressure), [MEDICATION(S)] (for underactive [CONDITION(S)] gland), [MEDICATION(S)] (an antidepressant) and eye drops for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospital Discharge Summary dated 4/14/2021 at 10:35 AM, documented that Resident #1's discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/2/2021 at 9:48 AM, LPN #1 stated the resident whose medications LPN #1 administered to Resident #1 had a nickname that was the same as Resident #1's first name. The residents did not wear name bands and the two residents looked similar. LPN #1 stated when they returned to the medication cart, LPN #1 realized they had given Resident #1 the other resident's medications when LPN #1 looked Resident #1's MAR and then looked at the other resident. LPN #1 stated they had confused the 2 residents' identities. As soon as LPN #1 realized they administered the wrong medications to Resident #1, they immediately reported it to the Registered Nurse Supervisor and monitored Resident #1's vital signs and blood sugar. The Physician Assistant was in the building and came to examine Resident #1. During an interview on 7/13/2021 at 11:30 AM, the Administrator stated the amount of medication administered to the resident was significant, especially given Resident #1's advanced age, and was they were sent to the emergency room for evaluation. During an interview on 7/15/2021 at 2:11 PM, the Director of Nursing (DON) stated they had been alerted by the Licensed Practical Nurse Unit Manager on 4/13/2021 that LPN #1 had given another resident's medication to Resident #1. LPN #1 had self-reported the error as soon as they realized what had happened. There were medical providers in the building at the time of the incident, so the DON assessed the resident and alerted the doctor. Resident #1 was placed on hourly vital sign monitoring. As time went on, the NP thought the resident should be sent to the emergency room for evaluation. The resident whose medications were administered to Resident #1, used the same first name as a nickname and it was the same as Resident #1's first name. The resident's given name was on the Medication Administration Record and was different from Resident #1's name. 10 NYCRR 415.12(m)(2)

Based on record review and interviews during an abbreviated survey (Case #NY 951), the facility did not ensure each resident was free from any physical restraint imposed for purposes of convenience, and not required to treat the resident's medical symptoms for 1 (Resident #3) of 3 residents reviewed. Specifically, Resident #3 was restrained in a chair with a sheet tied with a knot at the back of the chair in a manner that the resident was unable to untie the sheet. This was evidenced by: Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 2/26/2021, documented the resident had severe cognitive impairment, could sometimes be understood, and could sometimes understand others. The Policy and Procedure dated 2015, titled, Restraints, documented the facility would promote a restraint-free environment for all residents in accordance with State and Federal regulations and that residents had the right to be free from any physical restraint imposed for purposes of staff convenience and not required to treat the resident's medical symptoms. Bed sheets as restraints were prohibited. Review of the resident's record revealed there was no physician order identifying the medical symptom being treated with a restraint, nor an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility investigation summary dated 2/22/2021, documented that on 2/22/2021, the resident was found physically restrained in a wheelchair. CNA #1 stated the resident made many attempts to get out of the wheelchair, so CNA #1 wrapped a sheet around the resident and secured it behind the wheelchair to keep the resident seated. An undated statement written and signed by CNA #1, documented CNA #1 put a sheet around the resident to keep the resident safe because there was no other CNA on the unit and did not want the resident to fall. Another CNA and a nurse were present when CNA #1 tied the resident, and nothing was said. The undated CNA Kardex documented that when restless or agitated, staff were to offer to ambulate the resident, provide one on one (1:1) companionship, music, a baby doll, or the resident's comfortable chair with a blanket, and ensure the resident's safety was maintained. A Nurse's Note dated 2/22/2021 at 5:38 AM, written by LPN #3 documented Resident #1 was anxious and yelled out most of the night. The resident was up and out of the chair, staff were unable to leave resident alone due to resident's poor safety awareness. Because of the resident's restlessness, 1:1 supervision was needed from 1:00 AM- 4:30 AM. The resident fell asleep in the chair at the nurses' station at 4:45 AM. During an interview on 4/20/2021 at 7:25 PM, CNA #1 stated the night of the incident (2/21/2021 into 2/22/2021), CNA #4 left the shift early, and LPN #3 went to another unit to help with something. Resident #1 had been agitated throughout the shift and kept trying to climb over the sides of the chair. CNA #4 and LPN #3 both saw that CNA #1 was tying a sheet around the resident to prevent a fall out of the chair, but CNA #4 said nothing, and LPN #3 stated they didn't see anything, and not to tell anyone. After CNA #4 left and LPN #3 went to a different unit, CNA #2 was sent to relieve CNA #1 for a break. While CNA #1 was on break, CNA #2 must have discovered the resident had the sheet tied around the resident to the wheelchair. During an interview on 4/21/2021 at 9:44 AM, LPN #3 stated on the night shift of 2/21/2021 into 2/22/2021, they received a text message from CNA #2 that Resident #3 had a sheet tucked around them and the resident told the CNA it was tight. When LPN #3 arrived on the unit, the sheet had been loosened. The resident had been very agitated all shift and believed the CNA #1 just did it to keep the resident safe to prevent a fall with injury. During an interview on 4/28/2021 at 2:54 PM, CNA #2 stated they had gone to the resident's unit to relieve CNA #1 for a break because CNA #1 was alone on the unit. CNA #2 was sitting with the resident when the resident stated it was too tight, too tight. CNA #2 found that the sheet was tied around the back portion of the resident's chair. CNA #2 then untied it and notified the LPN Supervisor. During an interview on 5/3/2021 at 2:38 PM, CNA #4 stated Resident #1 was very combative, yelling, screaming, trying to hit the nurse and another CNA. CNA #4 witnessed CNA #1 tie the sheet around the resident, and that the unit nurse witnessed it as well. During an interview on 5/12/2021 at 1:05 PM, the Director of Nursing (DON) stated CNA #1 thought putting the sheet around the resident was allowable. The DON stated it was not allowable, and CNA #1 should have asked a nurse or other CNA to help. During an interview on 5/12/2021 at 1:41 PM, the Administrator stated CNA #1 should not have tied the sheet around Resident #1, and that an MD order was necessary to place a restraint on a resident. 10 NYCRR 415.4(a)(2-7)

Based on observation, record review and interviews during an abbreviated survey (Case #NY 112), the facility did not ensure each resident was free from abuse for 1 (Resident #1) of 4 residents reviewed. Specifically, the facility did not ensure Resident #1, who had severe cognitive impairment, was free from sexual abuse when she was assaulted by Resident #2 who was cognitively intact. Due to the resident's severe cognitive impairment and her inability to express her feelings, it was determined that actual harm occurred as a result of the assault, using the reasonable person concept referenced in Appendix Q of the State Operations Manual. This is evidenced by: Resident #1: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment tool) documented the resident had severe cognitive impairment, could usually make herself understood, and could usually understand others. Resident #2: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was cognitively intact, could usually be understood and could usually understand others. The Policy and Procedure for Abuse revised 2/2019, documented the facility prohibited the mistreatment, neglect, and abuse of residents and defined sexual abuse as including, but not limited to humiliation, harassment, coercion, and assault. The Comprehensive Care Plan (CCP) dated 10/23/18, documented the resident had long and short-term memory loss, and required the extensive assistance of one person for bed mobility. An Accident/Incident Report dated 8/26/19 at 10:50 AM, completed by the Director of Nursing (DON), documented Licensed Practical Nurse (LPN) #1 reported to her that she responded to Resident #1's room when she heard the resident yelling, Stop It!. When LPN #1 entered the room, Resident #2 was next to Resident #1. Resident #1's incontinence brief was unfastened and Resident #2 was fondling her genitals. A late entry Nurse's Note dated 8/28/19 at 9:08 AM, written by LPN #1, documented that on 8/26/19 at 10:30 AM, she heard Resident #1 yelling, Stop it. The LPN went to her room and witnessed Resident #2 sitting next to her bed in his wheelchair. His left hand was holding the sheet, and his right hand was in her incontinence brief with his index finger in her vagina. The LPN pushed him away and told him to get out. She covered Resident #1 with her blanket and yelled for help, then ran for help. The DON returned to the room with her and they completed an external genital exam, with no findings identified. Resident #1 pointed to her private area and stated, Ow. Afterward, the resident was her usual self. A Medical Provider Note dated 8/26/19 at 1:34 PM, written by a Physician's Assistant, documented she examined Resident #1 for signs of injury from the sexual assault. The resident was resting comfortably in bed and did not appear to recall the incident at all. A Nurse's Note date 8/26/19 at 2:54 PM, written by the Director of Nursing (DON), documented that, upon the immediate removal of Resident #2 from Resident #1's room, he was placed on 1:1 supervision. The DON completed a head-to-toe assessment of Resident #1 and found no bruises or marks on the resident. Resident #1 had no recollection of the event. A Medical Provider Note dated 8/28/19, written by the Psychiatric Nurse Practitioner, documented she evaluated Resident #1 following the 8/26/19 sexual assault incident. The assessment documented the resident's mood appeared stable, she was pleasantly confused, and appeared to have no recollection of the 8/26/19 incident. During an observation of a security video on 8/29/19 at 1:35 PM, Resident #2 approached Resident #1's room in his wheelchair on 8/26/19 at 10:20:45 AM and remained in the hallway looking from side to side. A resident who resided in the room next to Resident #1's room, came down the hallway and entered his own room. Resident #2 watched him until he entered his room, then he looked to the right and entered Resident #1's room at 10:22:03 AM. At 10:30:30 AM, he exited the room. At 10:52:11 AM, he re-entered Resident #2's room, again after looking both ways. LPN #1 entered Resident #1's room at 11:54 AM. The LPN left the resident's room at 11:54:44 AM. The LPN and the DON entered Resident #1's room at 11:55:55 AM. During an interview on 8/29/19 at 8:39 AM, the Registered Nurse Manager stated Resident #2 had been discharged from the facility. She stated as soon as the incident was discovered, the resident was placed on 1:1 supervision. A few hours later he was discharged from the facility. During an interview on 8/29/19 at 2:43 PM, the Social Worker (SW) stated that on 8/26/19 she was called to Resident #1's room. LPN #1 and the DON reported what had occurred and she told them they needed to call the police. She immediately placed Resident #2 on 1:1 supervision. She reported the incident to the Assistant Administrator and said the police needed to be called. During an interview on 8/29/19 at 3:30 PM, the Administrator stated that on 8/26/19 immediately following the incident, she ensured Resident #2 was on 1:1 supervision. The Sheriff's Department responded and started interviews with Administration. The Psychiatric Nurse Practitioner (NP), Sheriff's Deputy, the Administrator, and the DON were present. The NP stated Resident #2 was well aware of what he had done. When the Administrator interviewed the resident with the Sheriff's Deputy present, he readily admitted what he had done and showed no remorse. Then the Deputy interviewed the resident, read him his rights, and told Resident #2 he would be arraigned at a later date. During an interview on 8/30/19 at 10:17 AM, LPN #1 stated that on 8/26/19, she heard screaming coming from Resident #1's room. She was screaming and screeching, Stop it! Stop it! When she entered the room, she saw Resident #2 with his left hand holding the blanket up and his right index finger in Resident #1's vagina. She immediately told him to get away from her and pushed him away (he was in his wheelchair next to the resident's bed). She yelled for help and then went for help. The DON returned with her and assessed the resident from head to toe, and Resident #1 pointed to her vaginal area and stated, Ow! LPN #1 stated there were no visible injuries. During an interview on 9/3/19 at 12:47 PM, The Medical Doctor (MD) stated he last saw the Resident #1 on 5/16/19. The resident had severe cognitive impairment and had difficulty with word finding and could not answer questions about her health or symptoms she may have had. He was unable to have any sensible communication with her. Her speech was nonsensical and rambling. The MD stated that it was reasonable to believe that, had she been aware of what happened to her, she would be upset. He stated anybody who was more cognitively intact would have been upset by the incident. The MD also stated he had last seen Resident #2 on 6/19/19, and Resident #2 had no cognitive issues when he examined him. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this regulatory requirement at the time of this survey: - As soon as the incident was discovered, Resident #2 was placed on 1:1 supervision. - The Sheriff's Department issued an Order of no Contact against Resident #2. The SW immediately developed a plan for safe discharge, and Resident #2 was discharged from the facility. - Completed an audit of all potential victims on Resident #2's unit, to include interviews with all cognitively intact female residents and full body assessments of all cognitively impaired female residents. - On 8/27/19 all staff were trained on the abuse protocol and abuse reporting. 10 NYCRR 415.4(b)(1)(i)