Every finding on record at Golden Gate Rehabilitation & Health Care Center

Based on observation, interview, and record review conducted during the Recertification Survey from 05/21/2024 to 05/29/2024 , the facility did not ensure that food was served at an appetizing temperature during meal service. This was evident for 2 of 2 units (Units 4 and 5) observed during dining observation. Specifically, food served during lunch meal service were not maintained at palatable and appetizing temperatures. The findings are: The facility policy titled Serving/Feeding the Resident with revision date of 02/22/2024 documented the objective of the policy was to serve attractive and nutritious meals and ensure the residents consume adequate food and fluids. The Meal Delivery / Tray Pass schedule with revision date of 03/13/2024 documented lunch tray pass for Units 4 and 5 starts at 11:45 AM. 1. Resident #25 was admitted to the facility with diagnosis of Heart Failure, Diabetes Mellitus and Hyperlipidemia. The Minimum Data Set assessment dated [DATE] documented Resident was cognitively intact. During an interview conducted on 05/21/2024 at 10:54 AM, Resident #25 stated their breakfast were always cold and lunch were served lukewarm. 2. Resident #415 was admitted to the facility with diagnosis of Osteoarthritis, Atrial Fibrillation and Gastro-esophageal Reflux Disease. The Minimum Data Set assessment dated [DATE] documented Resident was cognitively intact. During an interview conducted on 05/21/2024 at 11:03 AM, Resident #415 stated hot foods were delivered at lukewarm temperature most of the time and sometimes hot food were cold. 3. Resident #19 was admitted to the facility with diagnosis of Diabetes Mellitus, Hypertension and Hyperlipidemia. The Minimum Data Set assessment dated [DATE] documented Resident had moderately impaired cognition. On 05/21/2024 at 12:11 PM, Resident #19 was observed in their room and stated they were waiting for their lunch. On 05/24/2024 at 11:06 AM, test trays for Units 4 and 5 were requested. The meal carts arrived, and distribution of the tray service continued until 11:29 AM on Unit 5. On 05/24/2024 at 11:29 AM, the food temperatures on the test trays were checked and revealed the following: crusted fish at 112 degrees Fahrenheit, potato-garlic mashed potato at 117.5 degrees Fahrenheit, and fresh cut green beans at 108 degrees Fahrenheit. Puree diet tray tested puree fish at 136.4 degrees Fahrenheit, mashed potato 131.9 degrees Fahrenheit, puree vegetable at 131 degrees Fahrenheit, and milk at 55 degrees Fahrenheit. On 05/24/2024 at 12:02 PM, a test tray was conducted on Unit 4. Temperatures revealed the following: crusted fish at 122 degrees Fahrenheit, mashed potatoes at 138 degrees Fahrenheit, green beans at 128 degrees Fahrenheit and milk at 54 degrees Fahrenheit. On 05/29/2024 at 10:30 AM, Food Service Director was interviewed and stated the temperatures were not appropriate at the time of service when temperature checks were done on 05/24/2024. They stated ideal temperature for hot foods should be around 150-155 degrees Fahrenheit. The Food Service Director stated the temperature issue was identified in the past. They stated they have been using disposable ware for meal service. Therefore, it had been vital to deliver the meals as quickly as possible. On 05/29/2024 at 12:10 PM, the Administrator stated they recognized the problem and stated they already have a plan to implement a new food service system. The food presentation and temperatures will greatly improve and will dignify resident's dining experience. 10 NYCRR 415.14(d)(1)(2)

Based on record review and interviews conducted during the Recertification Survey from 05/21/2024 to 05/29/2024, the facility did not ensure the Minimum Data Set assessments accurately reflected the resident's status. This was evident for 2 (Resident #90 and #212) of 38 total sampled residents. Specifically, 1.) Resident #90's Minimum Data Set assessment did not accurately document the resident acquired pressure sores in the facility, and 2.) Resident #212's Minimum Data Assessment assessment documented the resident was discharged to the hospital. The findings are: The facility policy titled Minimum Data Set 3.0 assessment dated ,d+[DATE] documented the assessment must reflect the current status of the resident. 1) Resident #90 had diagnoses of Anemia and Hypertension. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #90 had 2 wounds that were present upon the resident's admission to the facility. Medical wounds notes Dated 02/20/2024 documented Resident #90's left heel pressure ulcer and right heel pressure ulcer were facility acquired. There was no documented evidence the Minimum Data Set 3.0 dated 4/19/2024 accurately documented Resident #90's pressure ulcers as facility acquired. On 05/24/2024 at 02:40 PM, an interview was conducted with the Minimum Data Set Coordinator who stated they reviewed documentation to determine a resident's skin condition when filling out the Minimum Data Set 3.0 assessment. Resident #90's pressure ulcers were not documented as facility acquired due to a coding error. 45351 2) Resident #212 had diagnoses of Diabetes Mellitus and Bipolar Disorder. The discharge Minimum Data Set assessment dated [DATE] documented Resident #212 was discharged to an acute hospital. The Medical Doctor Note dated 02/29/2024 documented Resident #212 was discharged against medical advice. On 05/23/2024 at 12:14 PM, the Minimum Data Set Coordinator was interviewed and stated Resident #212 should have been coded as being discharged against medical advice on their Minimum Data Set 3.0 assessment dated [DATE]. 10 NYCRR 415.11(b)

Based on interview and record review conducted during the Recertification and Complaint Survey (NY00333382) from 05/21/2024 to 05/29/2024, the facility did not ensure services provided by the facility met professional standards of quality. This was evident for 1 of 1 resident reviewed for drugs and medication. Specifically, Resident #215 had Bacitracin allergy. Review of Resident's treatment administration record revealed that Bacitracin was administered from 02/24/2024 to 02/29/2024. The findings are: A facility policy titled Review of Medication Profile and Plan of Care dated 10/2013 documented consultant pharmacist will review each resident's physician's orders and pharmaceutical plan of care. The Pharmacist will evaluate the need to discontinue any medication due to allergy, drug interaction or inconsistency of therapy to diagnosis. Resident #215 was admitted to the facility with diagnoses of Heart Failure, Cerebrovascular Accident, and Malignant Neoplasm of the Colon. The Minimum Data Set, dated dated dated [DATE] documented Resident #215 had severe impairment in cognition. A nurse's notes dated 02/23/2024 at 10:25 PM documented Resident #215 was noted with a small cut on the right heel during shower, treatment rendered. A physician's order by Nurse Practitioner #3 dated 02/23/2024 documented apply Bacitracin and Band-Aid to right heel once daily until healed. The physician's order form documented Resident #215 had allergy to Bacitracin. A review of Resident #215's treatment administration record showed documentation that Bacitracin was administered from 02/24/2024 to 02/29/2024. During an interview on 05/28/2024 at 11:45 AM, Nurse Practitioner #3 stated they did not remember prescribing any medication for Resident #215. During an interview on 05/29/2024 at 11:37 AM, Registered Nurse #2 stated it was the responsibility of the licensed nurse, prescribing physician, and pharmacy to check if a resident had allergy to any medication prior to prescribing or administering the medications. During an interview on 05/29/2024 at 12:28 PM, Registered Nurse #17, who was the Staff Educator, stated the electronic medical record gives an alert on resident allergies, these alerts are visible to the licensed nurses. They stated licensed nurses were supposed to check the resident's allergy bracelet, the physician's order, and the allergy section on the electronic medical record prior to administering the medication. During an interview on 05/29/2024 at 10:59 AM, Pharmacy Consultant #3 stated resident allergies to any medication were coded in the electronic medical record and the pharmacist will be able to see the alert and would contact the facility immediately. They stated treatment orders for in-house stock are not sent to the pharmacy, but the facility should have been alerted because allergies were listed in the resident's electronic medical record. During an interview on 05/28/2024 at 11:51 AM, the Assistant Director of Nursing stated the physician, and the pharmacist were supposed to check for resident allergies on each physician's treatment order. 10 NYCRR 415.11 (c)(3)(i)

Based on record review and staff interview conducted during the Recertification Survey conducted from 05/21/2024 to 05/29/2024, the facility failed to address an irregularity identified by the pharmacist during Medication Regimen Review. This was evident for 1 (Resident # 67) of 5 residents reviewed for Unnecessary Medications out of a total sample of 38 residents. Specifically, Divalproex (a mood stabilizer) serum level was recommended for Resident #67 by the Consultant Pharmacist during Drug Regimen Review. The recommendation was not addressed. The findings are: The facility's policy titled Drug Regimen Review - Monthly Policy with revision date of 03/2024 documented the consultant pharmacist shall identify, document, and report possible medication irregularities for review and action by the attending physician, where appropriate. The attending physician or licensed designee shall respond to the Drug Regimen Review within 30 days or more promptly whenever possible. Resident #67 had diagnoses of Schizophrenia, Type 2 Diabetes Mellitus, and Parkinsonism. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #67 had moderately impaired cognition. A physician's order for Divalproex 125 milligram tablet, give one tablet by oral route twice daily was renewed on 01/29/2024. Divalproex was initially ordered on 09/23/2022. The Medication Administration Record from 09/2022 through 05/2024 documented that Resident #67 was administered Divalproex as ordered by the physician. A Medication Regimen Review by Pharmacy Consultant #2 dated 02/23/2023 documented Resident #67 was currently receiving Divalproex. Unable to locate recent serum level in chart. Recommended 2 weeks after start then every 6 months thereafter. Please consider ordering. The physician documented agree; will do and signed the review on 02/24/2023. The same recommendation was made by Pharmacy Consultant #2 on 10/25/2022. A review of the physician's order and laboratory reports from 09/23/2022 through 05/24/2024 revealed no documented evidence that Divalproex serum level was ordered and obtained. During an interview on 05/28/2024 at 12:46 PM, Pharmacy Consultant #2 stated they made the recommendation to obtain Divalproex serum level on 02/23/2023. They stated they made the recommendation twice but was not addressed. During an interview on 05/28/2024 at 11:08 AM, Attending Physician #1 stated Resident #67 had been on Divalproex since 09/2022. They stated the consultant pharmacist recommended Divalproex serum level and it should have been ordered. During an interview on 05/28/2024 at 12:09 PM, Nurse Practitioner #1 stated Resident #67 had been on Divalproex since 09/2022. They stated there had been no order to check the Divalproex serum level for Resident #67. Nurse Practitioner #1 stated the Divalproex serum level should be checked at least once a year to monitor for toxicity. During an interview on 05/28/2024 at 12:37 PM, the Assistant Director of Nursing stated the Drug Regimen Review recommendations were given to the medical providers to address. They stated the medical providers put in the orders for laboratory requests. During an interview on 05/28/2024 at 3:41 PM, the Medical Director stated Drug Regimen Reviews were placed in medical providers mailbox for them to review. The Medical Director stated it was pointless to obtain the serum level for Divalproex since the medication was for mood. 10 NYCRR 415.18(c)(2)

Based on observations, record review, and interview conducted during the Recertification Survey from 05/21/2024 to 05/29/2024, the facility did not ensure that infection control practices were maintained. This was evident in 1 of 4 floors (3rd Floor) observed for the Dining Task and Infection Control. Specifically, Transporter #1 did not perform hand hygiene while assisting multiple residents in the dining room. The findings are: The facility policy titled Infection Control Handwashing, Proper Hand Washing Technique with revision date of 01/2024 documented it was the policy of the facility to promote and enforce hand washing as set forth by the Guidelines of the Centers of Disease Control and Prevention. The policy documented personnel should always wash their hands, even when gloves are used. If running water and soap are not available, hand antisepsis may be accomplished with alcohol based hand rubs. It is mandatory to wash hands between handling individual resident; before and after resident contact; before donning and after removing disposable gloves; during performance of normal duties including handling food trays; before, during, and after meal preparation; and after touching garbage. During an observation on 05/21/2024 from 11:58 AM - 12:36 PM, Transporter #1 assisted Residents #99, #32, #96, #52, and #113 with hand hygiene. Transporter #1 changed their gloves between each resident but failed to perform hand hygiene after removing and donning new gloves. Transporter #1 was observed with gloved hands disposed food in a trash bin then proceeded to open the water, fruit cup and juice, and cut meat for Resident #16, their gloved hands touched the Resident's mashed potato on the tray. Transporter #1 entered the pantry, disposed an item in the trash bin, then got water for Resident #147, pick up a piece of plastic on the floor, gave tray to Resident #114 and assisted with opening and placing utensils on the food, opened egg salad container and canned fruit with the same gloves on. On 05/21/2024 at 12:50 PM, the Transporter was interviewed and stated they cleaned residents' hands before meal and distributed meal trays. They stated they did everything right and that they changed their gloves and sanitized their hands once. On 05/29/2024 at 01:22 PM, Licensed Practical Nurse #3 was interviewed and stated they monitor staff for hand hygiene. They stated staff must perform hand hygiene between residents. Licensed Practical Nurse #3 stated staff may sanitize their hands up to 2 times and after that must wash their hands. On 05/29/2024 at 01:38 PM, Registered Nurse #9, who was the Registered Nurse Supervisor, was interviewed and stated staff should practice hand hygiene, and should either wash or sanitize their hands after taking their gloves off so they do not spread germs from the garbage to the residents. On 05/29/2024 at 02:28 PM, the Assistant Director of Nursing was interviewed and stated staff must practice hand hygiene before residents' meals, after contact with residents, after touching the trash. 415.19 (b)(4)

Based on observation, interviews, and record review conducted during an Abbreviated Survey (NY00313864), the facility did not ensure that an alleged violation involving abuse was reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator or the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities). This was evident for 1 out of 4 residents (Resident #1) sampled for abuse. Specifically, Resident #1 reported to Licensed Practical Nurse (LPN) #1 on 04/01/2023 at 10:00 PM that Certified Nursing Assistant (CNA) #1 yelled at and shoved Resident #1 on 04/01/2023 on the night shift. The facility did not report the alleged violation of abuse within two hours to New York State Department of Health (NYSDOH). The facility reported the alleged abuse on 04/02/2023 at 10:37 PM. The findings are The facility Policy and Procedure entitled Abuse Prevention with revised date 03/01/2022 states that all alleged violations must be immediately reported to the Administrator and no later than two hours to other officials (including to the State Survey Agency) after the allegation is made, if the events that caused the allegation involves abuse or result in serious bodily injury; the alleged violations must be reported no later than 24 hours to the State Survey Agency if the events that caused the allegation does not involve abuse and do not result in serious bodily injury. Resident #1 was admitted to the facility with diagnoses including Post Ischemic Stroke, Insomnia, and Diabetes. The Minimum Data Set (MDS, a resident assessment tool) dated 03/18/2023 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and a score of 15/15 indicating cognition intact. A Nurse's note dated 04/01/2023 at 10:46 PM, written by Registered Nurse Supervisor (RNS) #1, documented that Resident #1 made an accusation against CNA #1 who worked last night. Resident #1 said that CNA #1 was mean to Resident #1 and that CNA #1 turned and pushed Resident #1. CNA #1 also told Resident #1 to Go ahead and die. The Director of Nursing (DON) was notified, and an investigation was initiated. CNA #1 was removed from duty pending investigation and the police was called. An Investigation Summary Report dated 04/01/2023 documented that Resident #1 reported to LPN #1 on 04/01/2023 at 10:00 PM that CNA #1 (from the night shift) yelled at and shoved Resident #1 while CNA #1 was turning Resident #1 in bed. Resident #1 also stated that CNA #1 was mean and was verbally abusive to Resident #1. The Nursing Supervisor was notified immediately. Resident #1 was assessed and there was no visible injury. Facility concluded that abuse did not occur. An email communication Webform Submission from the Nursing Home Facility Incident Report documented that the facility submitted the Incident Report on 04/02/2023 at 10:37 PM. During an interview on 10/19/23 at 1:39 PM, the DON stated that they investigated the allegation and is also responsible for reporting incidents to NYSDOH. The DON stated that they reported the incident to NYSDOH on 04/02/2023 within 24 hours because Resident #1 did not sustain any injury. The DON stated that they misinterpreted the requirement noting that all allegations of abuse must be reported to NYSDOH immediately but not later than 2 hours after the allegation is made. 10 NYC RR 415.4(b)

Based on interviews and record review conducted during an abbreviated survey (NY00303546), the facility failed to complete a discharge summary for a discharged resident. This was evident for 1 of 4 residents (Resident #2) reviewed for discharge. Specifically, Resident #2 was discharged home on 09/24/2022. There was no documented evidence of a discharge summary detailing a summary of the resident's stay that includes, but not limited to diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. The findings are: The facility's undated Policy and Procedure entitled Discharge/Transfer Procedures states that the physician with the input with the other members of the interdisciplinary team will assess the resident's care requirements for the need to be transferred or discharged . Resident #2 was admitted to the facility with diagnoses including Ataxic gait, Unspecified fall, and Pain in left knee. The Minimum Data Set (MDS) dated [DATE] documented that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 09/15 identified the resident's cognitive pattern as moderately impaired. Resident #2 requires one-person physical assist with bed mobility, transfer, personal hygiene, toilet use, dressing, locomotion, and one-person physical assist for eating. A Nursing Progress Note 09/20/2022 at 10:19 AM, by Registered Nurse Supervisor (RN #1), documented Care Plan meeting done with team and Resident #2. Resident #2 requesting discharge home but willing to stay to complete rehab to attain independence. Per Resident #2 they have a glucometer and can do their own fasting sugar (SF) and injections as Resident #2 was doing it in the past. Resident #2 to be re-evaluated by Rehab on Friday for possible discharge home on Saturday. A Transfer/Discharge Notice dated 09/22/2022 documented that the Resident #2 was notified that the discharge will take place on 09/24/2022. Resident #2 's health has improved sufficiently and that the notice was issued in compliance with Resident #2 's request. A Discharge Instructions dated 09/24/2022 was signed by Resident #2. The Discharge Instructions had information that include a referral for a Registered Nurse, Physical Therapy and Home Health Aide services including Home Care Agency name and telephone number. The form also had instructions that were provided by Social Services, Physical Therapy, and Nursing. A Social Work Progress Notes dated 09/29/2022 at 10:32 AM, written by Social Worker (SW #1), documented Discharge Note: Resident #2 was initially admitted to this facility on 09/06/2022 for Short Term Rehab and was discharged home on 09/24/2022. Resident #2 was referred for home care Visiting Nursing Agency (VNA) of [NAME] Island (SI), prescriptions sent to pharmacy at Resident #2's request. Resident #2 left with all belongings. A follow up call made, and Resident #2 is adjusting well to being at home, no issues/concerns verbalized. A review of Resident #2's medical record revealed that there was no documented evidence that Resident #2 was evaluated and medically cleared for discharge by a physician prior to Resident #2 discharged home. There was no documented evidence of a final discharge summary. There was no documented evidence of a Physician's Order to discharge Resident #2 home. During an interview on 10/19/2023 at 4:30 PM, the Assistant Director of Nursing (ADON) stated that if a resident is being discharged on the weekend, the Nurse Practitioner or Medical Doctor on call will write a script and the primary physician will write a discharge summary. During telephone interview on 10/19/2023 at 4:38 PM, the Medical Director, who was also Resident #2's primary physician, stated that the resident's primary physician is responsible for evaluating the resident prior to discharge. The Medical Director also stated that the discharge plans should be discussed in a care plan meeting with the Resident and family. The Medical Director stated that they do not recall evaluating Resident #2 prior to discharge and was not sure if the discharge summary contains a recapitulation of Resident #2's stay at the facility. The Medical Director does not recall if a final discharge summary for Resident #2 was completed. During a telephone interview on 10/20/2023 at 10:36 AM, the Nurse Practitioner (NP) who signed the discharge script for Resident #2, stated that the attending physician should have evaluated Resident #2 prior to discharge. The NP also stated that they just signed the scripts for the residents who are being discharged on the weekends to ensure that the residents receive their medications. The NP stated that they are not responsible for writing a discharge summary for Resident #2. 415.11(d)(1)(2)

Based on observation, record review and staff interviews conducted during the Recertification/Complaint/Extended survey (NY 457, NY 720 & NY 488), 01/31/2022 through 02/11/2022, and 02/23/2022 through 03/03/2022, the facility failed to ensure residents remained free from abuse and neglect. This was evident for 3 (Resident #24, Resident #367, and Resident #203) of 10 residents reviewed. Specifically: 1). On 05/21/2020 at 6:05AM, Licensed Practical Nurse (LPN #1) witnessed Resident #24 being punched in the right thigh area by Certified Nursing Assistant (CNA) #1. CNA #1 was suspended and later returned to work (direct resident care) on 05/27/2020 and was assigned to the unit on which Resident #24 resided. 2). On 10/28/2020 at 07:30PM, LPN #2 witnessed Resident #367 being punched on the right arm by CNA #2. While CNA #2 was in the process of exiting Resident #367's room, CNA #2 threw a pillow that hit Resident #367 on the face. Resident #367 was observed with slight redness with dry yellow drainage to corner of the right eye and was later observed with bruise on the right hand. 3). On 02/03/2022, during the 7:00AM to 3:00PM shift, CNA #4 did not provide Activity of Daily Living (ADL) care to Resident #203. This resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood for serious, injury, serious harm, serious impairment, or death to all residents. Serious adverse outcome is likely to occur if the facility fails to immediately remove staff accused of abuse or neglect from direct resident care. The Findings Include but are not limited to: The facility's Policy and Procedure entitled Protection of Residents dated 07/2010 documented that During Abuse Investigation, as soon as someone is identified as suspected of abuse, neglect, or mistreatment, the employee may be immediately removed from duty or have duties reassigned pending completion of an investigation. The facility will ensure that the complainant will not have any direct contact with the individual identified. Review of the facility policy Prohibition of Abuse, Neglect, Mistreatment and the Misappropriation of Resident Property revised 7/2010 documents that residents of Golden Gate Rehabilitation and Health Care Center shall not be subjected to abuse, neglect or mistreatment by anyone, including but not limited to facility employees, medical staff, other residents, visitors, consultants, volunteers, and staff of other agencies servicing the facility. The facility's Policy and Procedure entitled Identification of Abuse, Neglect, Mistreatment, and Misappropriation of Property dated 07/2010 documented that abuse means the willful infliction of injury with resulting physical harm, pain, or mental anguish. The policy further documented that Physical Abuse includes hitting, pinching, and kicking. Review of the facility policy Training of Staff in the Prevention, Identification, Investigation, and Reporting of Abuse, Neglect, Mistreatment and Misappropriation of Resident Property revised 7/2010 documents that each new employee will receive a full explanation of regulations including resident abuse, neglect and how it relates to every day working situations. 1. Resident #24 Resident #24 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set (MDS, a resident assessment tool) dated 05/05/2020 documented Resident #24 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and score of 03/15 indicating severely impaired cognition. Resident #24 required supervision with setup help only for most areas of ADLs. Review of the Facility's Physical Abuse Allegations Investigation Report dated 05/26/2020 documented that on 05/21/2020 at about 6:05 AM, LPN #1 heard commotion coming from Resident #24's room. LPN #1 entered the room and observed CNA #1 hit Resident #24 on the right thigh twice with a closed fist. LPN #1 yelled out I saw you. CNA #1 proceeded to complete care that was being provided. LPN #1 remained in the room and later informed the supervisor. An investigation was initiated, and the Police were called. LPN #1 looked at Resident #24's right thigh area and there was no redness or visible injury. The nurse manager and the Medical Doctor (MD) assessed the resident and there was no visible injury to the right thigh area. Resident #24 was observed with discoloration to the left finger. CNA #1 reported that Resident #24 was resistive to care and kicked CNA #1 who instinctively pushed back on Resident #24's right leg to prevent being struck. The facility investigation concluded although LPN #1 was an eyewitness to an actual physical encounter between Resident #24 and CNA #1, it is questionable if this interaction was actual abuse or an instinctive response by CNA #1. There were no findings of abuse or assault by the police. Both LPN #1 and CNA #1 were re-educated on abuse. A Nursing Progress Note dated 05/21/2020 documented that the unit nurse (LPN #1) reported that they had observed Resident #24 being ''punched with closed fist twice in upper right thigh by CNA. Body assessment was done, and no visible injury was noted to the area. CNA #1 was instructed to leave the unit and wait downstairs. The Police were called and responded. A Medical Progress Note dated 05/21/2020 documented that Resident #24 alleged to have been punched by aide into Right thigh. Appears to have no recollection and appears to be at baseline. No acute distress noted. No injury noted to right thigh. Multiple attempts were made to contact CNA #1, but all were unsuccessful. LPN #1 is no longer employed at the facility. An attempt was made to contact LPN #1, but the phone number was disconnected. During an interview on 01/31/2022 at 03:15 PM, the Director of Nursing (DON) stated that he/she was not familiar with the case related to Resident #24 since they were not the DON at the time of the incident. The DON stated that if the investigation reveals that abuse has occurred or that the witness was credible, without any motive to provide false information, the alleged abuser would immediately be terminated. During an interview on 02/11/2022 at 11:59 AM, the Administrator stated that CNA #1 was immediately suspended pending the investigation outcome. The Administrator stated that CNA #1 had worked in the facility for about [AGE] years with no prior history of abuse. The Administrator stated that they believe that CNA #1 was acting in self-defense due to Resident #24 being combative. The Administrator stated that regarding the contact, the facility could not determine if this was an open fist or a closed fist. The Administrator stated, despite LPN #1 being a credible witness, abuse could not definitively be determined, so CNA #1 was re-instated and able to work with residents in the facility. A review of CNA #1's personnel file revealed that CNA #1 was suspended from 05/23/2020 to 05/25/2020, disciplined, and was reinstated on 05/27/2020 and continued to provide direct resident care on the same unit. 2. Resident #367 Resident #367 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #367 had a BIMS score of 06/15 indicating severely impaired cognition. The resident required extensive assistance with one-person physical assist for most areas of ADLs. Review of the Facility's Investigation Summary Report for Occurrence dated 10/28/2020 documented that LPN #2 observed CNA #2 punching Resident #367 on the right arm. Resident #367 was trying to kick CNA #2 and CNA #2 pushed the resident's feet away towards the resident's face. LPN #2 immediately intervened. CNA #2 left the room, but on the way out threw a pillow that hit Resident #367 on the face. Resident #367 had slight redness to the right eye and a bruise noted on the top of the right hand. CNA #2 reported that LPN #2 asked them to assist Resident #367 and the resident was kicking and punching CNA #2. CNA #2 reported that the nurse entered the room and asked CNA #2 to be patient and nice. CNA #2 proceeded to leave the room and noticed that a pillow was on the floor. CNA #2 picked up the pillow and threw it on the bed. The Police were contacted. The investigation concluded that it was reasonable to conclude that there was an altercation between CNA #2 and Resident #367. CNA #2 agreed with most of what LPN #2 stated other than punching Resident #367. There was no reasonable cause to believe that LPN #2 would lie. CNA #2 was counseled and reeducated. A Nursing Progress Note dated 10/28/2020 documented that at approximately 7:30PM the nurse stated that CNA #2 was abusing Resident #367. Resident #367 stated that CNA #2 threw a pillow at me. No injury was noted, just slight redness with yellow dry drainage to corner of Right eye. The resident denied any pain. A Nursing Progress Note dated 10/29/2020 documented status post [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medical Progress Note dated 10/30/2020 documented that Resident #367 had a very superficial bruise noted right hand. A review of CNA #2's personnel file revealed that CNA #2 resigned on 11/02/2020. During an interview on 01/31/2022 at 03:13 PM, CNA #2 stated that he/she was sitting close to the nursing station when LPN #2 told him/her that Resident #367's legs were hanging off the bed and that he/she should help the resident. CNA #2 stated that when he/she attempted to reposition Resident #367, the resident began to kick him/her. CNA #2 stated he/she was trapped between the wall and the bed and was trying to get away from Resident #367 so he/she would not be kicked. CNA #2 stated that he/she yelled help, help. CNA #2 stated that he/she ran out of the room as soon as LPN #2 entered the room. CNA #2 stated that while running out of the room, the pillow fell from the bed, and he/she picked up the pillow and threw it back on the bed. CNA #2 stated that the pillow might have hit Resident #367. CNA #2 stated that he/she did not hit or punch Resident #367. LPN #2 is no longer employed by the facility. Multiple attempts were made to contact LPN #2, but all were unsuccessful. During an interview on 01/31/2022 at 03:15 PM, the Director of Nursing (DON) stated that he/she was not familiar with the cases related to Resident #24 and Resident #367 since they were not the DON at the time of the incident. The DON stated that if the investigation reveals that abuse has occurred or that the witness is credible, without any motive to provide false information, the alleged abuser would immediately be terminated. During an interview on 02/11/2022 at 11:59 AM, the Administrator stated that regarding the incident with Resident #367, CNA #2 was immediately suspended pending investigation. The Administrator stated that despite it not being documented in the investigation, CNA #2 was informed that the facility was looking towards termination. The Administrator stated that CNA #2 immediately resigned on their own. A review of CNA #2's personnel file revealed that CNA #2 resigned on 11/02/2020. 3. Resident #203 Resident #203 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented that Resident #203 had a BIMS score of 15/15 associated with intact cognition. The MDS also documented Resident #203 had clear speech and was able to understand others and be understood. The Facility's Incident Report submitted to the NYS Department of Health on 02/04/2022 revealed that Assistant Director of Nursing (ADON) received a verbal report from psychologist (PsyD) that Resident #203 had complained to PsyD that he/she had been neglected on 02/03/2022 as he/she had not received any care from any CNA. ADON #1 discovered on 02/03/2022 that CNA #4 had not entered Resident #203's room from 7:00AM and 3:00PM. CNA #4 stated to ADON #1 that he/she must have mistakenly omitted Resident #203's room number on the assignment sheet when he/she wrote down the residents for the day. CNA #4, when asked by ADON #1 about the fact that all CNA #4's administration records were completed for the day as though all care was provided, stated that he/she must have overlooked and thought he/she was documenting on someone else. It was further revealed that CNA #4 did not provide some ADL care to residents #178, #40 and #183, and failed to provide the Floor Ambulation Program (FAP) to #38, #75, #15, #40, and #203. A Physician's Orders, for Resident #203, dated 03/12/2021 documented orders for CNA Care, Floor Ambulation Program (FAP) 200 feet with RW and stand by assist without wheelchair follow, Toilet Use (extensive assistance with one person assist), Turning and positioning (7am, 9am, 11am, 1pm) during the 7AM-3PM shift. Review of the Resident CNA Accountability Record and Resident CNA Documentation History dated 02/03/2022, indicated that CNA #4 provided care to Resident #203 on 02/03/2022 as evident by CNA #4's initials in the following care areas: CNA #4 documented in the care areas on the forms that he/she provided care from 1:00PM-3:00PM, (FAP) 200 feet for 30 minutes, Toilet Use (extensive assistance with one person assist), turned and positioned Resident #203 at 7:00AM, 9:00AM, 11:00AM, and 1:00PM during the 7AM-3PM shift. During an interview on 02/28/2022 at 03:06 PM, Resident #203 stated that CNA #4 just did not come in at all that day, he/she just didn't come in at all. Resident #203 stated that he/she did not experience any psychosocial aftermath from the incident and that he/she was more concerned about the other residents who were not able to speak for themselves. During an interview with DON #1 on 02/28/22 at 04:25 PM, DON #1 stated that CNA #4 was new. DON #1 stated that on 02/03/2022, it appeared that CNA #4 was studying. DON #1 stated that he/she felt confident that CNA #4 was now performing his/her job, and that CNA #4 understands that if he/she does not do their job he/she will be terminated. During a telephone interview on 03/01/2022 at 10:18 AM, CNA #4 stated that on that day (02/03/2022) he/she came in late, around 8:25AM and the supervisor instructed him/her to write done the names of the residents. CNA #4 stated that he/she forgot to write down Resident #203's room number. CNA #4 stated that he/she provided care to everyone else on his/her assignment. CNA #4 stated that Resident #203's room door was closed most of the day and that he/she did not go into the room. CNA #4 stated that he/she did not provide care to Resident #203 because he/she (CNA #4) was not feeling well. During an interview on 03/01/2022 at 01:59 PM, LPN #1 stated that Resident #203 handles a lot of care by themselves and that he/she did not observe that anything was wrong with Resident #203. LPN #1 stated that around 1:50PM, he/she observed that another resident (#183) had not been changed. LPN #1 stated that he/she paged CNA #4 and instructed CNA #4 to go and change Resident #183. LPN #1 stated that other staff members told him/her that CNA #4 was in the day room on a break and that CNA #4 spent a lot of the day in the day room. LPN #1 stated at around 2:00PM, the Psych MD notified him/her that Resident #203 complained about not receiving care for the day. LPN #1 stated that he/she asked CNA #4 about the residents that were not changed or showered, and CNA #4 stated that he/she provided care. LPN #1 stated that he/she would normally have notified the supervisor, but that the supervisor was out on leave. During an interview on 03/01/2022 at 2:28 PM, Assistant Director of Nursing (ADON) #1 stated that he/she received a phone call from Resident #203's Psych MD who stated that during a session with Resident #203, the resident reported that no one took care of him/her that day (02/03/2022). ADON #1 stated that CNA #4 stated that he/she was not aware that he/she had the residents. ADON #1 stated that CNA #4 documented that he/she provided care to all residents. ADON #1 stated that the nurses reported that CNA #4 had not been doing his/her work. ADON #1 stated that he/she had a long conversation with CNA #4 regarding not providing care to the residents. ADON #1 stated that CNA #4 reported that he/she was just clicking on everything. ADON #1 stated that CNA #4 was suspended for one day. Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified on 03/01/2022 at 7:47PM. The facility submitted a removal plan that was reviewed and accepted by NYS DOH on 03/01/2022 at 11:00PM. 415.4(b)(1)(i)

Based on observation, record review and staff interviews conducted during a Recertification/Complaint/Extended survey (NY 457, NY 683 & NY 833) conducted from 02/23/2022 through 03/03/2022, the facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment and to prevent further potential abuse, neglect, exploitation, or mistreatment. This was evident for 3 (Resident #24, Resident #10, and Resident #192) out of 10 residents reviewed. Specifically: 1). On 05/21/2020 at 6:05AM, Licensed Practical Nurse (LPN #1) witnessed Resident #24 being punched in the right thigh area by Certified Nursing Assistant (CNA) #1. CNA #1 was suspended and later returned to work (direct resident care) on 05/27/2020 and was assigned to the unit on which Resident #24 resided. 2). On 02/22/2022, Resident #10 was observed with increased swelling and pain to the right elbow. An x-ray result dated 02/22/2022 documented that Resident #10 had an acute mildly displaced transverse fracture across the right distal humeral metadiaphysis (elbow). Resident #10 was transferred to the hospital on 02/22/2022. On 02/23/2022, in the morning, the Medical Director notified the Director of Nursing (DON) #1 that Resident #10 accused CNA #5 of abuse, potentially causing a fracture to the right elbow. The facility did not initiate an investigation on 02/22/2022 to ascertain how Resident #10 sustained the fracture and Resident #10 was not interviewed. CNA #5 continued to provide direct care to residents on the same unit while the investigation was pending. 3). On 02/23/2022 at 10:42 AM, Resident #192 reported that CNA #3 called him/her a fat little elephant every night between Midnight and 4:00 AM. While the investigation was pending, CNA #3 continued to work on the same unit providing direct resident care. This resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood for serious, injury, serious harm, serious impairment, or death to all residents. The pattern of failing to remove accused staff from direct care pending investigation puts residents at risk for continued potential abuse which could result in serious injury, harm, impairment, or death. Failure to thoroughly investigate and determine if abuse occurred puts residents at risk for continued abuse because the facility may not take appropriate corrective actions and monitor effectiveness to ensure there is not recurrence. The Findings Include, but are not limited to: The facility's Policy and Procedure entitled Protection of Residents dated 07/2010 documented that During Abuse Investigation, as soon as someone is identified as suspected of abuse, neglect, or mistreatment, the employee may be immediately removed from duty or have duties reassigned pending completion of an investigation. The facility will ensure that the complainant will not have any direct contact with the individual identified. 1. Resident #24 Resident #24 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set (MDS, a resident assessment tool) dated 05/05/2020 documented Resident #24 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) of 03/15 indicating severely impaired cognition. Resident #24 required supervision with setup help only for most areas of ADLs. Review of the Facility's Physical Abuse Allegations Investigation Report dated 05/26/2020 documented that on 05/21/2020 at about 6:05 AM, LPN #1 heard commotion coming from Resident #24's room. LPN #1 entered the room and observed CNA #1 hit Resident #24 on the right thigh twice with a closed fist. LPN #1 yelled out I saw you. CNA #1 proceeded to complete care that was being provided. LPN #1 remained in the room and later informed the supervisor. An investigation was initiated, and the Police were called. LPN #1 looked at Resident #24's right thigh area and there was no redness or visible injury. The nurse manager and the Medical Doctor (MD) assessed the resident and there was no visible injury to the right thigh area. Resident #24 was observed with discoloration to the left finger. CNA #1 reported that Resident #24 was resistive to care and kicked CNA #1 who instinctively pushed back on Resident #24's right leg to prevent being struck. The facility investigation concluded although LPN #1 was an eyewitness to an actual physical encounter between Resident #24 and CNA #1, it is questionable if this interaction was actual abuse or an instinctive response by CNA #1. There were no findings of abuse or assault by the police. Both LPN #1 and CNA #1 were re-educated on abuse. A Nursing Progress Note dated 05/21/2020 documented that the unit nurse (LPN #1) reported that they had observed Resident #24 being ''punched with closed fist twice in upper right thigh by CNA. Body assessment was done, and no visible injury was noted to the area. CNA #1 was instructed to leave the unit and wait downstairs. The Police were called and responded. A review of CNA #1's personnel file revealed that CNA #1 was suspended from 05/23/2020 to 05/25/2020 and disciplined for allegation of physical abuse. CNA #1 was reinstated on 05/27/2020 and continued to provide direct resident care on the same unit that Resident #24 resided on. It also documented that CNA #1 retired on 12/31/2020. During an interview on 01/31/2022 at 03:15 PM, the Director of Nursing (DON) #1 stated if the investigation reveals that abuse has occurred or that the witness is credible and without any motive to provide false information, the alleged abuser would immediately be terminated. During an interview on 02/11/2022 at 11:59 AM, the Administrator stated that CNA #1 was immediately suspended pending the investigation outcome. The Administrator stated that they believe that CNA #1 was acting in self-defense due to Resident #24 being combative. The Administrator stated that regarding the contact, the facility could not determine if this was an open fist or a closed fist. The Administrator stated that LPN #1 was a credible witness, however, abuse could not definitively be determined, so CNA #1 was re-instated and able to work with residents in the facility. 2. Resident #10 Resident #10 was initially admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #10 had a BIMS score of 14/15 indicating intact cognition. Resident #10 required extensive assistance with one-person physical assist for most areas of ADLs. The Facility's Accident/Incident Investigation Report - Summary dated 02/27/2022 documented that Resident #10 was diagnosed with [CONDITION(S)] of the right elbow since 02/08/2022 and was treated with antibiotic. On 02/22/2022, Resident #10 was noted with increased swelling and pain to the site. RNS #4 evaluated the resident and notified the Medical Doctor who ordered x-ray. An X-Ray of the Right elbow was done on 02/22/2022 and revealed a fracture to the right elbow and Resident #10 was transferred to the hospital. On 02/23/2022 the Medical Director reported to the DON that Resident #10, while at the hospital, had stated to staff that he/she was abused at the facility. Resident #10 claimed that CNA #5 had twisted their arm behind their back and hurt him/her. The CNA who worked with the resident was identified (CNA #5). CNA #5 was interviewed and described CNA's interaction with the resident on that day. CNA #5 stated that the resident was guarding his/her right elbow, both elbows are very contracted, and resident does not allow staff to properly clean around the area. CNA #5 stated that he/she was providing care with nurse on that day and did not touch the resident's elbow and did not manipulate the arm in any way other than just cleaning the hand. Resident #10 would not allow it otherwise. The nurse who assisted CNA #5 was identified as LPN #4. The LPN was interviewed and confirmed the statement of CNA #5. The investigation concluded that there is no reasonable cause to believe that any alleged resident abuse, neglect, or mistreatment regarding this resident had occurred. A Nursing Note Progress Note dated 02/22/2022 documented that Resident #10 complained of right shoulder pain. An x-ray was ordered for right shoulder, arm, and elbow. A Nursing Progress Note dated 02/22/2022 documented that x-ray of Resident #10's right shoulder and right elbow revealed acute mildly displaced transverse fracture across the distal humeral metadiaphysis with severe [CONDITION(S)]. Resident #10 has severe pain to right elbow area. The Nurse practitioner (NP) ordered to send the resident to the hospital. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 03/01/2022 at 11:46 AM, DON #1 and the Administrator stated that Resident #10 had a fracture, and that CNA #5 was identified as the staff who took care of the resident. DON #1 and Administrator stated that local law enforcement was not called, and CNA #5 was not removed from the schedule and was not reassigned to other duties. During an interview on 03/01/2022 at 02:58 PM, CNA #5 stated that if a resident is resistive to care, they step away and inform their supervisor, they do not continue to provide care. CNA #5 stated that if a resident has contractures, they start dressing them on the non-contracted side first. CNA #5 stated that Resident #10 had bilateral contractures - clothing could be put onto the left side and then draped over the right side due to severe contractures. CNA #5 stated that Resident #10's right arm is contracted close to the resident's chest. CNA #5 stated that Resident #10 would frequently resist care - never forced to receive care. CNA #5 stated that they would step away, inform the supervisor and re-attempt later. CNA #5 stated that on 02/22/2022 they assisted LPN #4 in providing treatment #10. CNA #5 stated that he/she held Resident #10's wrist - pulling the arm open slightly 1-2 inches (CNA re-enacted) so that LPN #4 could do the treatment to the resident's antecubital area. CNA #5 stated that LPN #4 instructed him/her to do this. CNA #5 stated that Resident #10 did not scream during this interaction. CNA #5 stated that this was the only time CNA #5 assisted LPN #4 in doing this procedure. CNA #5 stated that Resident #10 had no reaction at the time. During an interview on 03/02/2022 at 12:02 PM, LPN #4 stated that on 02/22/2022 they had to do a treatment on Resident #10 during which they had to pour saline on the antecubital area of the right arm then wipe it dry with gauze. LPN #4 stated that they asked CNA #5 to assist and hold Resident #10's right arm in place so that arm doesn't move - and saline doesn't get everywhere. LPN #4 stated that CNA #5 held Resident #10's right arm by the elbow area. LPN #4 stated that CNA #5 was not instructed to pull Resident #10's arm and at no point did CNA #5 do such a thing. LPN #4 stated that for residents that are contracted, they would never pull their extremities or asked a CNA to pull the residents extremities. During an interview on 03/02/2022 at 02:45 PM, MD #1 stated that they examined Resident #10 (does not recall dates) and the was observed with some minor swelling to the right elbow, thinking that it was due to lymphatic drainage and then later decided that they will give antibiotics for [CONDITION(S)]. MD #1 stated that they do not recall what instructions they gave to staff regarding cleaning the antecubital area. MD #1 stated that staff should not pull Resident #10's right arm away from the body to clean since it can theoretically cause a pathological fracture, due to Resident #10's comorbidities. During an interview on 03/02/2022 at 02:57 PM, MD #2 stated that they followed Resident #10 while the resident was in the hospital. MD #2 stated that after reading the X-Ray results in the hospital, it was noted that Resident #10 had a fracture of the distal humerus. MD #2 stated that the X-Ray report does not indicate that this was a pathological fracture. MD #2 stated that they are not sure how staff should clean the antecubital area and that this was not being done at the hospital. MD #2 stated that pulling the arm to clean the antecubital area can cause a fracture on Resident #10. During an interview on 03/02/2022 at 03:40 PM, RNS #4 stated that Resident #10 had bilateral upper extremity contractures, more significant on the right side. RNS #4 stated that Resident #10 had slight range of motion on the left upper extremity (UE) and no range of motion on the Right UE, except for the hand and fingers and tiny amount in the elbow. RNS #4 stated that for stability, someone would assist nurses in holding Resident #10's right UE while treatment is being performed. RNS #4 stated that Resident #10's arm was never pulled open for treatment. During an interview on 03/02/2022 at 04:08 PM, the DON #1 stated that they conducted the investigation for Resident #10 regarding the broken elbow. DON #1 stated at the time of the investigation, they did not interview Resident #10 since they were in the hospital. Resident #10 interview was still pending. DON #1 stated that local law enforcement was contacted on 03/02/2022 as a part of IJ Removal Plan. The DON stated that Resident #10's guardian was contacted on 03/02/2022 by the facility and follow up is pending. The DON stated that to perform the treatment to the Right antecubital area, two staff are required - a nurse and a CNA so that the nurse can get into the area to clean and treat. 3. Resident #192 Resident # 192 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 02/03/2022 documented that Resident #192 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 12/15 associated with moderately impaired cognition. The Facility's Investigation Findings Summary Report dated 02/27/2022, documented that Resident #192 reported to Registered Nurse Unit Manager, who was doing rounds with State Surveyor, on 02/23/2022 at 10:30AM, that someone referred to the resident as a fat little elephant every night between 12:00AM and 4:00AM. Resident #192 denied any physical abuse had occurred. The unit manager notified the DON and Director of Social Services about the allegation of abuse. The investigation immediately began by identifying the allegedly accused aide. Based on investigation findings, there is no reasonable cause to believe that a crime had occurred. On 02/25/2022, Department of Health Director of Nursing advised the facility to take further action. Was informed to ensure that proper steps for residents' safety and the following actions must be done immediately. Notify law enforcement in addition to education provided to allegedly accused staff and reporting to the DOH. Review of the facility's incident report revealed that CNA #3 was not removed from direct resident care pending the investigation outcome. Review of the 3rd Floor 11:00PM-7:00AM Night CNA Assignment dated 02/24/2022, revealed that CNA #3 was scheduled and worked on the night shift of 02/24/2022 and was scheduled to work on 02/25/2022 performing direct resident care. DON #1 removed CNA #3 from direct resident care after concerns were brought to their attention by the state survey agency. A Nursing Progress Note dated 02/23/2022 at 10:42 AM documented that Resident #192 reported that one of the workers called him/her a fat little elephant every night between 12:00AM and 4:00 AM. A Nursing Progress Note dated 02/24/2022 at 4:09 PM documented that the Director of Nursing interviewed Resident #192 and that the resident was consistent with his/her earlier statement. Resident #192 denied being fearful of the aide. A Social Service Progress Note dated 02/25/2022 at 5:39 PM documented that the Police were called, and officers arrived at the facility. Resident #192 was interviewed and stated that they were frightened by CNA #3 but that the worse was over. Resident # 192 told the Social Worker that CNA #3 was in the hallway last night, but there was no interaction. DON #1 removed CNA #3 from direct resident care on 02/25/2022. During an interview on 03/01/2022 at 10:30 AM, DON #1 stated that the nursing supervisor informed him/her that an investigation was initiated immediately. DON #1 stated that CNA #3 was identified, and Resident #192 was made safe. DON #1 stated that CNA #3 was off on 02/23/2022 but worked on 02/24/2022 during the night shift. DON #1 stated that Resident #192 was removed from CNA #3's assignment and that the CNA was instructed not to provide care to Resident #192 pending the outcome of the investigation. DON #1 reported that CNA #3 was removed from the schedule on 02/25/2022. Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified on 03/01/2022 at 7:47PM. The facility submitted a removal plan that was reviewed and accepted by NYS DOH on 03/01/2022 at 11:00PM. 415.4(b)(1)(i)

Based on observation, interviews and record review conducted during the Recertification/Complaint/Extended survey (N 683) conducted from 02/23/2022 through 03/03/2022, the facility failed to report immediately, but not later than 2 hours after forming a reasonable suspicion of a crime, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. This was evident for 1 (Resident #10) of 12 residents reviewed. Specifically, on 02/23/2022, in the morning, the Medical Director notified the Director of Nursing (DON) #1 that Resident #10 accused Certified Nursing Assistant (CNA) #5 of abuse, potentially causing a fracture to the right elbow. The allegation of alleged abuse was not reported to local law enforcement agencies. This resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood for serious, injury, serious harm, serious impairment, or death to all residents. The facility failure to consistently report reasonable suspicions of crimes against residents to law enforcement puts the residents at risk for serious harm, impairment, or death if the crimes are not addressed and acted upon as needed. The Findings Include: The facility's Policy and Procedure entitled Reporting/Response of Alleged Abuse with revised date 07/2010, documented that the Administrator, after consultation with the Administrative Investigating team determines if abuse, neglect, mistreatment, or misappropriation of property has occurred. The policy further documents the actions to be taken if there is reasonable cause that abuse, neglect, mistreatment has occurred: report to New York State Office of Health Systems Management ([NAME]) or Central Office or State Health Department's Hotline. The policy documented that all alleged violations and all substantial incidents will also be reported to all other agencies as required. Resident #10 was initially admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 02/08/2022 documented that Resident #10 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) of 14/15 indicating with intact cognition. The Facility's Accident/Incident Investigation Report - Summary dated 02/27/2022 documented that Resident #10 was diagnosed with [CONDITION(S)] of the right elbow since 02/08/2022 and was treated with antibiotic. On 02/22/2022, Resident #10 was noted with increased swelling and pain to the site. RNS #4 evaluated the resident and notified the Medical Doctor who ordered x-ray. An X-Ray of the Right elbow was done on 02/22/2022 and revealed a fracture to the right elbow and Resident #10 was transferred to the hospital. On 02/23/2022 the Medical Director reported to the DON that Resident #10, while at the hospital, had stated to staff that he/she was abused at the facility. Resident #10 reported that CNA #5 had twisted their arm behind their back and hurt him/her. The CNA who worked with the resident was identified (CNA #5). CNA #5 was interviewed and described CNA's interaction with the resident on that day. CNA #5 stated that the resident was guarding his/her right elbow, both elbows are very contracted, and resident does not allow staff to properly clean around the area. CNA #5 stated that he/she was providing care with nurse on that day and did not touch the resident's elbow and did not manipulate the arm in any way other than just cleaning the hand. Resident #10 would not allow it otherwise. The nurse who assisted CNA #5 was identified as LPN #4. The LPN was interviewed and confirmed the statement of CNA #5. The investigation concluded that there is no reasonable cause to believe that any alleged resident abuse, neglect, or mistreatment regarding this resident had occurred. Review of the facility's investigation revealed that the facility's Medical Director and DON #1 became aware of the alleged abuse allegation on 02/23/2022 and did not report the allegations to law enforcement. A Nursing Note Progress Note dated 02/22/2022 documented that Resident #10 complained of right shoulder pain. An x-ray was ordered for right shoulder, arm, and elbow. A Nursing Progress Note dated 02/22/2022 documented that x-ray of Resident #10's right shoulder and right elbow revealed acute mildly displaced transverse fracture across the distal humeral metadiaphysis with severe [CONDITION(S)]. Resident #10 has severe pain to right elbow area. The Nurse practitioner (NP) ordered to send the resident to the hospital. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 03/01/2022 at 11:46 AM, DON #1 and the Administrator stated that Resident #10 had a fracture, and that CNA #5 was identified as the staff who took care of the resident. DON #1 and the Administrator stated that local law enforcement was not called, and CNA #5 was not removed from the schedule. Stated that CNA #5 continued to do direct resident care. During an interview on 03/01/2022 at 02:58 PM, CNA #5 stated that if a resident is resistive to care, they step away and inform their supervisor, they do not continue to provide care. CNA #5 stated that if a resident has contractures, they start dressing them on the non-contracted side first. CNA #5 stated that Resident #10 had bilateral contractures - clothing could be put onto the left side and then draped over the right side due to severe contractures. CNA #5 stated that Resident #10's right arm is contracted close to the resident's chest. CNA #5 stated that Resident #10 would frequently resist care - never forced to receive care. CNA #5 stated that they would step away, inform the supervisor and re-attempt later. CNA #5 stated that on 02/22/2022 they assisted LPN #4 in providing treatment #10. CNA #5 stated that he/she held Resident #10's wrist - pulling the arm open slightly 1-2 inches (CNA re-enacted) so that LPN #4 could do the treatment to the resident's antecubital area. CNA #5 stated that LPN #4 instructed him/her to do this. CNA #5 stated that Resident #10 did not scream during this interaction. CNA #5 stated that this was the only time CNA #5 assisted LPN #4 in doing this procedure. CNA #5 stated that Resident #10 had no reaction at the time. During telephone interview on 03/02/2022 at 11:03 PM, Resident #10 stated that staff have always been rough with him/her and their roommate. Resident #10 stated that on 02/22/2022 (does not recall the time) CNA #5 and LPN # 4 came to the room to clean Resident #10's right arm. Resident #10 stated that CNA #5 lifted their right arm so that the nurse could clean it and at that point Resident #10 stated that he/she heard a crack in the bone. Resident #10 stated that CNA #5 also twisted their left arm behind their back, however, could not elaborate as to why CNA #5 did this or the exact date and time that it occurred. Resident #10 stated that CNA #5 has anger management problems and yells at the residents when he/she gets mad. During an interview on 03/02/2022 at 12:02 PM, LPN #4 stated that on 02/22/2022 they had to do a treatment on Resident #10 during which they had to pour saline on the antecubital area of the right arm then wipe it dry with gauze. LPN #4 stated that they asked CNA #5 to assist and hold Resident #10's right arm in place so that arm doesn't move - and saline doesn't get everywhere. LPN #4 stated that CNA #5 held Resident #10's right arm by the elbow area. LPN #4 stated that CNA #5 was not instructed to pull Resident #10's arm and at no point did CNA #5 do such a thing. LPN #4 stated that for residents that are contracted, they would never pull their extremities or asked a CNA to pull the residents extremities. During an interview on 03/02/2022 at 02:45 PM, MD #1 stated that they examined Resident #10 (does not recall dates) and the was observed with some minor swelling to the right elbow, thinking that it was due to lymphatic drainage and then later decided that they will give antibiotics for [CONDITION(S)]. MD #1 stated that they do not recall what instructions they gave to staff regarding cleaning the antecubital area. MD #1 stated that staff should not pull Resident #10's right arm away from the body to clean since it can theoretically cause a pathological fracture, due to Resident #10's comorbidities. Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified on 03/01/2022 at 7:47PM The facility submitted a removal plan that was reviewed and accepted by NYS DOH on 03/01/2022 at 11:00PM. 415.4(b)(1)(i)

Based on observation, interviews and record review conducted during the Recertification/Complaint/Extended survey (NY 457, NY 488, NY 720, NY 433, NY 683, and NY 833) conducted from 02/23/2022 through 03/04/2022 the facility failed to report all alleged violations involving abuse, neglect, including injuries of unknown source, immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury. This was evident for 5 out of 10 residents reviewed for Abuse, Neglect, and Mistreatment (Resident #24, Resident #367, Resident #211, Resident #10, and Resident #192). Specifically: 1. On 05/21/2020 at 6:05AM, Licensed Practical Nurse (LPN #1) witnessed Resident #24 being punched in the right thigh area by Certified Nursing Assistant (CNA) #1. The facility reported this to The New York State Department of Health (NYSDOH) on 05/22/2020 at 03:20 PM. 2. On 10/28/2020 at 07:30PM, LPN #2 witnessed Resident #367 being punched on the right arm by CNA #2. While CNA #2 was in the process of exiting Resident #367's room, CNA #2 threw a pillow that hit Resident #367 on the face. Resident #367 was observed with slight redness with dry yellow drainage to corner of the right eye and was later observed with bruise on the right hand. The facility reported this to the NYSDOH on 10/29/2020 at 04:42 PM. 3. On 02/22/2022, (time not documented) Resident #10 was observed with increased swelling and pain to the right elbow. An x-ray result dated 02/22/2022 documented that Resident #10 had an acute mildly displaced transverse fracture across the right distal humeral metadiaphysis (elbow). Resident #10 was transferred to the hospital on 02/22/2022. On 02/23/2022, in the morning, the Medical Director notified the Director of Nursing (DON) #1 that Resident #10 accused CNA #5 of abuse, potentially causing a fracture to the right elbow. This allegation of abuse was reported to NYSDOH on 2/23/2022 at 7:05 PM. 4. On 02/12/2022, Resident #211's child reported that Resident #211 was abused by a staff member between 6pm and 7pm. The facility reported this to the NYSDOH on 02/17/2022 at 08:41 PM. 5. On 02/23/2022 at 10:42 AM, Resident #192 reported that CNA #3 called him/her a fat little elephant every night between Midnight and 4:00 AM to the state agent (SA) who immediately informed the facility. The facility reported this to the NYSDOH on 02/25/2022 at 07:05 PM after being directed to do so by the NYSDOH. The findings include but are not limited to: A review of the facility policy dated 07/2010 titled Reporting/Response of Alleged Abuse documented that The Administrator, after consultation with the Administrative Investigating team determines if abuse, neglect, mistreatment or misappropriation of property has occurred. The policy further documents that actions to be taken if there is reasonable cause that abuse, neglect, mistreatment has occurred: report to New York State Office of Health Systems Management ([NAME]) or Central Office or State Health Department's Hotline. The policy documents that all alleged and all substantial incidents will also be reported to all other agencies as required. 1) Resident #24 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #24 had severely impaired cognition. The MDS further documented Resident #24 required supervision with setup help only for most areas of Activities for Daily Living (ADLs). The Physical Abuse Allegations Investigation Report dated 05/26/2020 documented that on 05/21/2020 at about 6:05 AM, the LPN #1 heard commotion coming from Resident #24's room. LPN #1 entered the room and observed CNA #1 hit Resident #24 on the right thigh twice with a closed fist. LPN #1 yelled out I saw you. CNA #1 proceeded to complete care that was being provided. LPN #1 remained in the room and later informed the supervisor. An investigation was initiated, and the Police were called. LPN #1 looked at Resident #24's right thigh area and there was no redness or visible injury. The nurse manager and the Medical Doctor (MD) assessed the resident and there was no visible injury to the right thigh area. Resident #24 was observed with discoloration to the left finger. CNA #1 reported that Resident #24 was resistive to care and kicked CNA #1 who instinctively pushed back on Resident #24's right leg to prevent being struck. The facility investigation concluded although LPN #1 was an eyewitness to an actual physical encounter between Resident #24 and CNA #1, it is questionable if this interaction was actual abuse or an instinctive response by CNA #1. There were no findings of abuse or assault by the police. Both LPN #1 and CNA #1 were re-educated on abuse. A Nursing Progress Note dated 05/21/2020 documented that the unit nurse (LPN #1) reported that they had observed Resident #24 being ''punched with closed fist twice in upper right thigh by CNA. Body assessment was done, and no visible injury was noted to the area. CNA #1 was instructed to leave the unit and wait downstairs. The Police were called and responded. A Medical Progress Note dated 05/21/2020 documented that Resident #24 alleged to have been punched by aide into Right thigh. Appears to have no recollection and appears to be at baseline. No acute distress noted. No injury noted to right thigh. Review of the HERDS submission report revealed that the facility reported this to The New York State Department of Health (NYSDOH) on 05/22/2020 at 03:20 PM. This allegation of physical abuse was not reported to NYSDOH within 2 hours. Multiple attempts were made to contact CNA #1, but all were unsuccessful. LPN #1 is no longer employed at the facility. An attempt was made to contact LPN #1, but the phone number was disconnected. During an interview on 01/31/2022 at 03:15 PM, the Director of Nursing (DON) stated that he/she was not familiar with the case related to Resident #24 since they were not the DON at the time of the incident. 2) Resident #367 was initially admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #367 had a Brief Interview of Mental Status (BIMS) score of 6/15, indicating severely impaired cognition. The resident required extensive assistance with one-person physical assist for most areas of ADLs. The Investigation Summary Report for Occurrence dated 10/28/2020 documented LPN #2 observed CNA #2 punching Resident #367 on the right arm. Resident #367 was trying to kick CNA #2 and CNA #2 pushed the resident's feet away towards the resident's face. LPN #2 immediately intervened. CNA #2 left the room, but on the way out threw a pillow that hit Resident #367 on the face. Resident #367 had slight redness to the right eye and a bruise noted on the top of the right hand. CNA #2 reported that LPN #2 asked them to assist Resident #367 and the resident was kicking and punching CNA #2. CNA #2 reported that the nurse entered the room and asked CNA #2 to be patient and nice. CNA #2 proceeded to leave the room and noticed that a pillow was on the floor. CNA #2 picked up the pillow and threw it on the bed. The Police were contacted. The investigation concluded that it was reasonable to conclude that there was an altercation between CNA #2 and Resident #367. CNA #2 agreed with most of what LPN #2 stated other than punching Resident #367. There was no reasonable cause to believe that LPN #2 would lie. CNA #2 was counseled and reeducated. A Nursing Progress Note dated 10/28/2020 documented that at approximately 7:30PM the nurse stated that CNA #2 was abusing Resident #367. Resident #367 stated that CNA #2 threw a pillow at me. No injury was noted, just slight redness with yellow dry drainage to corner of Right eye. The resident denied any pain. A Nursing Progress Note dated 10/29/2020 documented status post [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the HERDS submission report revealed that the facility reported this to the NYSDOH on 10/29/2020 at 04:42 PM. This allegation of Physical abuse was not reported to NYSDOH within 2 hours. During an interview on 01/31/2022 at 03:13 PM, CNA #2 stated that he/she was sitting close to the nursing station when LPN #2 told him/her that Resident #367's legs were hanging off the bed and that he/she should help the resident. CNA #2 stated that when he/she attempted to repositioned Resident #367, the resident began to kick him/her. CNA #2 stated he/she was trapped between the wall and the bed and was trying to get away from Resident #367 so he/she would not be kicked. CNA #2 stated that he/she yelled help, help. CNA #2 stated that he/she ran out of the room as soon as LPN #2 entered the room. CNA #2 stated that while running out of the room, the pillow fell from the bed, and he/she picked up the pillow and threw it back on the bed. CNA #2 stated that the pillow might have hit Resident #367. CNA #2 stated that he/she did not hit or punch Resident #367. LPN #2 is no longer employed by the facility. Multiple attempts were made to contact LPN #2, but all were unsuccessful. During an interview on 01/31/2022 at 03:15 PM, the Director of Nursing (DON) #1 stated that he/she was not familiar with the cases related to Resident #24 and Resident #367 since they were not the DON at the time of the incident. During an interview with on 02/25/2022 at 04:20 PM, DON #1 stated that either the Assistant Director of Nursing of the DON are responsible for submitting cases to the NYSDOH (HERDS) system. DON #1 stated that cases that involve abuse and result in serious injury are reported with in 2 hours, cases without serious injury are reported within 24 hours. 3) Resident #10 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #10 had a BIMS score of 14/15, indicating intact cognition. Resident #10 required extensive assistance with one-person physical assist for most areas of ADLs. The Accident/Incident Investigation Report - Summary dated 02/27/2022 documented Resident #10 was diagnosed with [CONDITION(S)] of the right elbow since 02/08/2022 and was treated with antibiotic. On 02/22/2022, Resident #10 was noted with increased swelling and pain to the site. RNS #4 evaluated the resident and notified the Medical Doctor who ordered x-ray which in turn resulted in right elbow fracture. An X-Ray of the Right elbow was done on 02/22/2022 and revealed a fracture to the right elbow and Resident #10 was transferred to the hospital. The next morning, on 02/23/2022 (time unknown) the Medical Director reported to the DON that Resident #10, while at the hospital, had stated to staff that he/she was abused at the facility. Resident #10 claimed that CNA #5 twisted their arm behind their back and hurt him/her. The CNA who worked with the resident was identified (CNA #5). CNA #5 was interviewed and described CNA's interaction with the resident on that day. CNA #5 stated that the resident was guarding his/her right elbow, both elbows are very contracted, and resident does not allow staff to properly clean around the area. CNA #5 stated that he/she was providing care with nurse on that day and did not touch the resident's elbow and did not manipulate the arm in any way other than just cleaning the hand. Resident #10 would not allow it otherwise. The nurse who assisted CNA #5 was identified as LPN #4. The LPN was interviewed and confirmed the statement of CNA #5. The investigation concluded that there is no reasonable cause to believe that any alleged resident abuse, neglect, or mistreatment regarding this resident had occurred. A Nursing Note Progress Note dated 02/22/2022 documented that Resident #10 complained of right shoulder pain. An x-ray was ordered for right shoulder, arm, and elbow. A Nursing Progress Note dated 02/22/2022 documented that x-ray of Resident #10's right shoulder and right elbow revealed acute mildly displaced transverse fracture across the distal humeral metadiaphysis with severe [CONDITION(S)]. Resident #10 has severe pain to right elbow area. The Nurse practitioner (NP) ordered to send the resident to the hospital. A Patient Report dated 02/22/2022, revealed that an x-ray of Resident #10's right shoulder was done and documented acute displaced transverse fracture across the distal humeral metadiaphysis and severe [CONDITION(S)]. There was no documented evidence in the medical record that Resident #10 had any accident or injury prior to the injury being identified on 2/22/2022. There was no documented evidence in the medical record that the facility interviewed the resident and/or staff about the possible cause of the injury on 2/22/2022. Review of the HERDS submission report revealed that the facility reported this to the NYSDOH on 02/23/2022 at 07:05 PM. This serious injury of unknown origin was not reported to NYSDOH within 2 hours on 2/22/2022 when the fracture was identified. Once the facility became aware of the allegation of abuse connected to the injury, the facility still did not report the allegation to NYSDOH within 2 hours. During telephone interview on 03/02/2022 at 11:03 PM, Resident #10 stated that staff have always been rough with him/her and their roommate. Resident #10 stated that on 02/22/2022 (does not recall the time) CNA #5 and LPN # 4 came to the room to clean Resident #10's right arm. Resident #10 stated that CNA #5 lifted their right arm so that the nurse could clean it and at that point Resident #10 stated that he/she heard a crack in the bone. Resident #10 stated that CNA #5 also twisted their left arm behind their back, however, could not elaborate as to why CNA #5 did this or the exact date and time that it occurred. Resident #10 stated that CNA #5 has anger management problems and yells at the residents when he/she gets mad. During an interview on 03/01/2022 at 02:58 PM, CNA #5 stated that if a resident is resistive to care, they step away and inform their supervisor, they do not continue to provide care. CNA #5 stated that if a resident has contractures, they start dressing them on the non-contracted side first. CNA #5 stated that Resident #10 had bilateral contractures - clothing could be put onto the left side and then draped over the right side due to severe contractures. CNA #5 stated that Resident #10's right arm is contracted close to the resident's chest. CNA #5 stated that Resident #10 would frequently resist care - never forced to receive care. CNA #5 stated that they would step away, inform the supervisor and re-attempt later. CNA #5 stated that on 02/22/2022 they assisted LPN #4 in providing treatment #10. CNA #5 stated that he/she held Resident #10's wrist - pulling the arm open slightly 1-2 inches (CNA re-enacted) so that LPN #4 could do the treatment to the resident's antecubital area. CNA #5 stated that LPN #4 instructed him/her to do this. CNA #5 stated that Resident #10 did not scream during this interaction. CNA #5 stated that this was the only time CNA #5 assisted LPN #4 in doing this procedure. CNA #5 stated that Resident #10 had no reaction at the time. During an interview on 03/02/2022 at 12:02 PM, LPN #4 stated that on 02/22/2022 they had to do a treatment on Resident #10 during which they had to pour saline on the antecubital area of the right arm then wipe it dry with gauze. LPN #4 stated that they asked CNA #5 to assist and hold Resident #10's right arm in place so that arm doesn't move - and saline doesn't get everywhere. LPN #4 stated that CNA #5 held Resident #10's right arm by the elbow area. LPN #4 stated that CNA #5 was not instructed to pull Resident #10's arm and at no point did CNA #5 do such a thing. LPN #4 stated that for residents that are contracted, they would never pull their extremities or asked a CNA to pull the residents extremities. During an interview on 03/02/2022 at 04:08 PM The DON #1 stated that they conducted the investigation for Resident #10 regarding the broken elbow. The DON stated that local law enforcement was contacted on 03/02/2022 as a part of IJ Removal Plan. The DON could not state why the case was not submitted to the NYSDOH within 2 hours of receiving the allegation. The DON stated that I am new in this role and was not familiar with all the regulation. 4) Resident #192 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 192 cognition as moderately impaired with a Brief Interview for Mental Status a (BIMS) score of 12. Resident # 192 requires extensive assistance of one person for personal hygiene. During an interview on 02/23/2022 at 10:15 AM, Resident #192 reported Certified Nursing Assistant # 3 (CNA) # 3 verbally abused them at approximately 4:30 AM on 02/23/2022. The Surveyor reported the allegations to the Nursing Supervisor immediately as the resident had not reported the incident. A Nurse's Progress Note dated 02/23/2022 at 10:42 AM documented that Resident # 192 reported one of the workers calls me a fat little elephant every night between 12 midnight and 4:00 AM. The resident denied any physical abuse the social worker and Administration were notified. A review of the facility records revealed as of 02/25/2022 at 4:20 PM, the allegation had not been reported to NYSDOH. This allegation of verbal abuse was not reported to NYS DOH within 2 hours. A Social Service Progress Note dated 02/25/2022 at 5:39 PM documented as per Department of Health (DOH) surveyor advice, the Police were called, and Officers arrived at the facility. The Officers interviewed Resident # 192. The Officers informed Resident # 192 the occurrence was not a crime but inappropriate. A review of the facility Investigation Findings Summary dated 02/27/2022 revealed Law Enforcement was informed on 02/25/2022. The Director of Social Services called the Police Precinct and reported the allegation as per the advice of the Department of Health. The facility reported the incident to NYSDOH via the HERDS system on 02/25/2022 at 8:09 PM after being directed at 5:45 PM by State Agency. During an interview on 03/03/2022 at 12:22 PM, the Nursing Supervisor stated that administration was notified immediately. Social service, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) were informed of the allegation immediately on 02/23/2022 at around 10:30 AM. During an interview on 03/01/2022 at 10:30 AM, the Director of Nursing (DON) stated the nursing supervisor informed them of the alleged abuse allegation on 02/23/2022 at approximately 10:30 AM. The DON initiated an investigation immediately and concluded that a crime did not occur. The case was not reported to NYSDOH because they did not see the severity and did not see severe injury or serious harm. The incident was reported to NYSDOH on 02/25/2022 at 8:09 PM after being directed by State Agency. 415.4(b)(1)(i)

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that each resident or resident representative was offered the opportunity to participate in reviewing and revising of the comprehensive care plan. Specifically, cognitively intact residents were not invited to quarterly care plan meetings. This was evident for 4 of 4 residents reviewed for Care Planning Participation out of 44 sampled residents (Resident #200, 185, 110, and 203). The findings are: The facility's policy and procedure titled Comprehensive Care Planning (CCP) dated 10/01/2016 documented both the resident and the resident representative are vital members of Comprehensive Care Planning and will therefore be invited to participate in the Comprehensive Care Plan meetings for all comprehensive assessments, including special review. 1) Resident #200 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 200 cognition as intact with a brief Interview for Mental Status (BIMS) score of 15. A Quarterly Care Plan Meeting Note dated 02/17/2021, 11/17/2021, and 02/16/2022 contained no documented evidence Resident # 200 was invited to the quarterly care meeting. An Annual Plan Meeting Note dated 08/18/2021 had no documented evidence Resident #200 was invited to the annual care plan meeting. There were no documentation of the people who attended the Annual Care Plan Meeting. There was no documented evidence in the medical record that Resident # 200 was invited to the care plan meetings held on 02/17/2021, 02/18/2021, 11/17/2021, and 02/16/2022. During an interview on 02/23/2022 at 1:57 PM, Resident # 200 stated they were not invited to participate in any care plan meetings. During an interview on 03/02/2022 at 12:04 PM, the Director of Social Service stated care plan meetings are done initially after admission, quarterly, annual, and significant change. The residents and or families are invited to the initial, significant change and the annual care plan meeting. Residents and or families are not invited to the quarterly meeting. It has always been the facility policy not to invite residents and families to the quarterly care plan meeting. During an interview on 03/03/2022 at 3:31 PM, the Director of Nursing stated that residents are invited to the initial, quarterly, annual, and significant change care plan meeting. They are supposed to invite residents and family to all care plan meetings 2) Resident # 185 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Assessment Minimum Data Set (MDS) assessment dated [DATE] identified Resident #185 cognition as severely impaired with a brief Interview for Mental Status (BIMS) score of 99. The MDS further documented Resident #185 was short- and long-term memory impaired. A Quarterly Care Plan Meeting Notes dated 1/6/21, 2/3/21, 5/19/21, 7/7/21, 10/13/21, 2/10/22 contained no documented evidence Resident #185 nor the resident's representative /attended or were invited to quarterly care plan meetings. There was no documented evidence in the medical record that Resident # 185 nor their resident representative were invited to the care plan meetings held on 1/6/21, 2/3/21, 5/19/21, 7/7/21, 10/13/21 and 2/10/22. 3) Resident # 110 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Assessment Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 110 cognition as intact with a brief Interview for Mental Status (BIMS) score of 15. The Quarterly Care Plan Meeting Notes dated 4/22/21, 7/22/21, 10/21/21, 2/10/22 had no documented evidence Resident #110 nor the resident representative attended or were invited to the quarterly care meeting. On 2/23/22 at 10:55 AM, an interview with Resident #110 was conducted. Resident #110 stated they were not invited to any of the quarterly meetings to discuss their overall health status and they have voiced their concerns to the staff, but were ignored. On 03/03/22 at 12:56 PM, an interview with the Director of Social Service (DSS) was conducted. DSS stated they provide care plan meetings to all residents with their representative initially after admission, annually or any significant change. The residents and residents' family are not invited to the quarterly care plan meeting as it has been the facility policy not to give residents and representatives a quarterly care plan meeting. On 03/03/22 at 1:30 PM, an interview with the Director of Nursing (DON) was conducted. DON stated that all residents and resident's representative are entitled to received initial, admission, quarterly, annual, significant change and special care plan meetings. The facility staff are supposed to invite all residents and resident's representatives to all care plan meetings, and if they decline to attend, it must be documented in the chart as evidence that they were invited and declined. 4) Resident #203 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS dated [DATE], documented that Resident #203 had a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The resident and family participated in the assessment, and Resident #203 had no guardian or legally authorized representative. The MDS further documented Resident #203 had clear speech and was able to understand others and be understood. The Social Services Cognitive Loss 3.0 Care plan effective date 10/1/2020 documented the resident presents with a cognitive score of 15 on BIMS, daily decision making is independent and his ability to express ideas and wants and consider both verbal and non-verbal expression is understood. Care plan interventions were resident will participate in decision making process through next review and will verbalize needs to staff. The Care Plan Meeting reports dated 1/19/2021, 3/30/21, 6/3/21 and 9/2/21 contained no documented evidence Resident #203 was invited or attended the CCP meeting held by the interdisciplinary team. There was no documented evidence that Resident #203 attended or was invited to any quarterly care plan meetings in progress notes, assessments, or care plans meeting log from 09/28/20-3/2/22. On 2/23/22 at 01:52 PM, Resident #203 was interviewed and stated they were not involved in care planning. On 03/02/22 at 12:28 PM, the Director of Social Services (DSS) was interviewed. The DSS stated care planning is done for new admissions, annual, significant change, and quarterly. The DSS stated residents and their family/designated representatives are invited to join the team for new admission, annual and significant change care plan meetings, but they are not invited to the quarterly meetings. Social Services oversees the care plan meeting invites. DSS stated they have a letter and keep track that way and make phone calls. 415.11(c)(2) (i-iii)

Based on observation, record reviews, and interviews conducted during the Recertification/Complaint survey, the facility did not ensure that Minimum Data Set (MDS) 3.0 assessments were completed accurately to reflect the resident's status. Specifically, Resident's use of oxygen therapy was not coded on the latest Quarterly MDS. This was evident for 1 of 1 resident reviewed for respiratory therapy out of a total investigation sample of 44 residents. (Resident #134). The findings are: The facility Policy on Minimum Data Set (MDS) Completion dated 10/01/2019, last revised 10/4/2021 documented All MDS assessments are maintained electronically with electronic signatures to assure accurate and timely completion of the MDS 3.0 and to fulfill Federal regulations. Resident #134 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), Assessment Reference dated 01/19/2022 documented the resident has intact cognitive status. The MDS further documented the resident required extensive assistance of staff for most Activities of Daily Living (ADL). The assessment did not include oxygen therapy as a treatment received in the last 14 days. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Oxygen at 2-4 liter per minute via NC (Nasal cannula). The Comprehensive Care Plan (CCP) for Respiratory: Oxygen Use/Neb dated 11/22/2021 documented the resident required use of oxygen due to episodes of shortness of breath. CCP goals included: -Resident will have oxygen saturation (pulse oximeter reading) within normal limits. Interventions included: - Assess for pain and discomfort with breathing, check proper placement of oxygen tubing: not too tight nor too loose, prevent irritation or pressure from developing caused by oxygen tubing, monitor vital signs every shift, provide oxygen as ordered by MD, pulse oximetry as ordered by MD, and report to MD if below normal limits. The facility did not ensure the MDS assessment accurately reflected the resident's status. On 02/23/2022 at 12:01 PM, 02/24/2022 between 08:42 and 01:00 PM, 02/25/2022 between 9:39 AM and 01:00 PM, Resident #134 was observed in the room, with continuous oxygen on from oxygen concentrator, via Nasal Canula. Nebulizer tubing observed placed on the nightstand. The resident was interviewed and stated that the oxygen is used every time to assist in breathing better. 03/01/22 at 10:38 AM an interview was conducted with Certified Nursing Assistant (CNA) #12). CNA #12 stated the resident has been on continuous oxygen since they began taking care of the resident. On 03/01/22 at 11:01 AM, an interview was conducted with Unit Manager - Registered Nurse (RN) #2. RN #2 stated the resident is on continuous oxygen therapy for [CONDITION(S)] and has been on oxygen prior transfer to the hospital last November, and the order was renewed when resident returned from the hospital on 11/22/2021. RN#2 stated they did not realize that oxygen therapy was not coded on the current MDS. On 03/02/22 at 01:20 PM, an interview was conducted with the Registered Nurse MDS assessor (RN#3). RN#3 stated each portion of assessment is completed by reviewing nursing and medical progress notes, reviewing Medication Administration/Treatment Records, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #3 stated that the coding for Resident #134's use of oxygen therapy was missed on the current MDS, and it will be modified. On 03/02/22 at 01:28 PM, an interview was conducted with the MDS Coordinator. MDSC stated the skills and qualifications of the staff that assess relevant care areas to complete the resident assessments comprise of Interdisciplinary Team (IDT) members of Registered Nurse, Registered Dietician, Licensed Social Worker, Activity Director and Rehab Director. RN/MDSC stated each of the members have to be a graduate in their fields and have proper clinical assessment skills, both learned in school and from the experience - knowledge based. MDSC stated the resident is supposed to be physically assessed by the assessor when completing the MDS. There is also a review the progress notes and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDSC further stated that the accuracy of the MDS assessment is the responsibility of the staff completing and signing each of the section completed. The MDS Coordinator is supposed to monitor for the completion and timely submission of the assessment. MDSC stated that the error of not coding the oxygen therapy for Resident #134 in the current MDS is an oversight which will be modified. 415.11(b)

Based on record observation, record review, and staff interviews conducted during the recertification survey, the facility did not ensure that needed services, care, and equipment are provided to ensure that residents with limited range of motion and mobility maintain or improve function the residents' clinical condition. Specifically, 1) A resident was not provided with the bilateral wrist brace at bedtime as ordered to improve the resident's contractures, and 2) A resident was not provided with the splint device ordered to improve resident's contractures. This was evident for 2 out of 4 residents reviewed for Limited Range of Motion (Residents #106 and # 200) out of a total sample of 44 residents. The Findings Include: The facility policy and procedure titled AFOs, Splints, Orthoses, Prostheses dated 09/2021 documented all AFOs, Splints, Orthoses, Prostheses that the Rehabilitation Department issues will be issued after the therapist assess the resident and recommend the appropriate device. The policy further documented the nursing department will take responsibility for the daily application/removal of the device. The nurse manager will ensure that the information is entered in the CNA Accountability record. 1) Resident #106 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #106 was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 9. Resident # 106 was dependent on staff for all Activities of Daily Living (ADLs). Section O of has no indication of Range of motion of splints. M On 02/23/2022 at 10:45 AM, on 02/24/2022 at 10:29 AM, and on 02/25/2022 at 10:23 AM Resident #106 was observed lying in bed, noted with contracture to the bilateral wrist. Resident #106 had no wrist brace in place. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Musculoskeletal Disorder Bilateral Wrist Splint Care Plan was initiated on 06/09/2018. The interventions include bilateral wrist braces to be applied at bedtime and removed while in the wheelchair. The revised care plan dated 02/10/2022 documented to continue the current care plan. A review of the Treatment Admiration Record dated 02/01-02/28/2022 has no documented evidence that a bilateral wrist brace was applied at bedtime. A review of the Certified Nursing Assistant (CNA) Record dated 02/01-02/28/2022 has no documented evidence that bilateral wrist brace was applied at bedtime. A review of the CNA Nursing Instruction did not contain information on a bilateral wrist brace. During an interview on 03/02/2022 at 11:30 AM, Resident # 106 stated that he had not been wearing the wrist brace at bedtime. During an interview on 03/02/2022 at 12:50 PM, the Certified Nursing Assistant # 5 (CNA# 5) stated that Resident # 106 is usually in bed sleeping in the morning. CNA # 5 has not seen Resident # 106 wearing the bilateral wrist braces. There was one wrist brace at the bedside. The supervisor was informed. During an interview on 03/03/2022 at 12:29 PM, the Registered Nurse Supervisor (RNS) stated Resident #106 has as order for a bilateral wrist brace while in bed. The order for the brace is supposed to be entered in the CNA Accountability for the CNAs to see and document. The RNS stated the order is not in the CNA Accountability. The RNS was supposed to enter the order in the CNA Accountability and ensure that the CNAs are documenting it. During an interview on 03/02/22 at 11:49 AM, the Director of Rehab stated Resident # 106 should have a bilateral wrist brace at bedtime and be removed when out of bed in a wheelchair so they can use the hands. 2) Resident # 200 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #200 had intact cognition. The resident required extensive assistance in all activities of daily living. Section O had no indication of Range of Motion (ROM) or splints devices. On 02/23/2022 at 2:08 PM, 02/24/2022 at 9:38 AM, and 02/25/2022 at 10:30 AM, Resident #200 was observed was out of bed in a wheelchair. The left arm was flaccid; no splint was noted. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the CNA Accountability Record and Treatment Administration Record dated 02/01-02/28/2022 revealed no documented evidence a left resting hand splint was applied. A review of the CNA Nursing Instruction has no documented evidence for a left arm splint. There was no documented evidence that a care plan was in place for the left-hand splint. During an interview on 03/02/2022 at 11:34 AM, the Certified Nursing Assistant (CNA #11) stated that Resident # 200 has splint for the left arm but did not see it in the room. During an interview on 03/02/2022 at 11:38 AM, the Director of Rehab (DR) stated that Resident #200 has left [CONDITION(S)], that is why the resident has the order for the splint to prevent contractures. The splint is applied to the left arm when out of bed. Resident # 200 was not wearing the split. The splint was in a chair behind the door in the resident's room. The DR has applied the splint on Resident # 200 left arm. During an interview on 03/03/22 at 12:39 PM, the Registered Nurse Supervisor #1 (RNS #1) stated that Resident #200 has a splint for the left arm, and it was supposed to be in the CNA Accountability so that the CNAs will see that the resident needs a splint. The RN Supervisor is responsible for updating the CNA Accountability, but it was not done. During an interview on 03/03/2022 at 3:44 PM, the Director of Nursing (DON) said that the RN Supervisor is responsible for entering the splint in the care plan and the CNA Nursing Instruction. The unit nurse was supposed to enter it in the Treatment Administration Records. The nurses and the RN Supervisor ensure that the splint is applied as ordered. 415.12 (e)(2).

Based on observation, interviews, and record review conducted during the recertification survey, the facility did not ensure that all medications and biologicals were labeled in accordance with currently accepted pharmaceutical principles and practices. Specifically, three metered dose inhalers and two bottles of ophthalmic solution were not labelled with the opening date. This was evident for 1 of 4 carts on 1 of 4 units observed for medication and storage labeling (3rd floor). The findings are: The facility policy titled Medication / Clinical Supplies & Equipment Management dated 9/2012 documented the nursing department will maintain all prescription and over the counter (OTC) medications, treatment supplies and other clinical equipment's that are stored in designated storage areas on the unit (i.e., cart, cabinet, refrigerator, closet or box) as secure, clean and orderly with appropriate packaging and labeling to identify directions and expiration date. All expired and discontinued medications will be removed from the storage area for return to the pharmacy or resident (when appropriate) or off unit storage, disposal, or destruction. All licensed nurses are responsible for the ongoing maintenance and the management of medications clinical supplies, and equipment stored in designated storage areas on the unit. The licensed nurse responsible for medication/ treatment administration will maintain the medication/treatment cart as clean and orderly and replenish supply (i.e., medications, gauze, tape, etc.) and remove any unused, discontinued or expired medications / supplies during each shift worked. On 03/01/22 at 09:59 AM, the 3rd floor unit medication cart was observed with the Registered Nurse (RN #3). Three open metered dose inhalers ([MEDICATION(S)] [MEDICATION(S)] [MEDICATION(S)] Inhalation Powder 220 Mcg, Fluticason Propionate and Salmeterol Inhalation Powder USP 250 mcg / 50 mcg, [MEDICATION(S)] 62.5 mcg 25 mcg / actuation powder) and two open bottles of ophthalmic solution ([MEDICATION(S)] ([MEDICATION(S)] and one [MEDICATION(S)] ophthalmic solution) were not labelled with the open date. [MEDICATION(S)] ([MEDICATION(S)] and [MEDICATION(S)] ophthalmic solution) 0.02 %, 0.005% for topical ophthalmic use- The manufacturers insert how supplied/ storage and handling documented after opening the product may be kept at 2 degree Celsius to 25 degrees Celsius for up to 6 weeks. If after opening the product is kept refrigerated at 2 degrees Celsius to 8 degrees Celsius then the product can be used until the expiration date stamped on the bottle. [MEDICATION(S)] [MEDICATION(S)] [MEDICATION(S)] Inhalation Powder 220 Mcg per actuation- The manufacturers insert supplied/ storage and handling documented to discard the inhaler 45 days after opening the foil pouch or when dose counter reads 00, whichever comes first. [MEDICATION(S)] Propionate and Salmeterol, inhalation powder for oral inhalation- The manufacturers insert supplied/ storage and handling documented [MEDICATION(S)] propionate and salmeterol inhalation powder should be stored inside the unopened moisture protective foil pouch and only removed from the pouch immediately before initial use. Discard [MEDICATION(S)] Propionate and Salmeterol inhalation powder 1 month after opening the foil pouch or when the counter reads 0. Anore Ellipta ([MEDICATION(S)] and vilanterol inhalation powder) for oral inhalation use- The manufacturers Insert storage instruction documented to safely throw away [MEDICATION(S)] in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. On 03/01/22 at 09:59 AM, an interview with RN #3 was conducted. RN#3 stated that he/she is not a regular on the unit and is currently being assign as a float nurse who works per diem. RN #3 added that he/she does not know why the inhalers and eyedrops were not dated the proper way to ensure all medications such as inhalers and eyedrops are stored and discarded properly. RN #3 stated that she/he was in-serviced about medication storage and handling and noticed that the inhalers and eyedrops were not dated as they should be. On 03/01/22 at 10:23 AM, an interview with the 3rd floor RN Manager, RN #4, was conducted. RN #4 stated all eyedrops and inhalers should be dated properly when opened. RN #4 stated whoever opened the inhalers and eyedrops wrote the designated resident's information but failed to date the medication. As per RN #4, all nurses are well aware that inhalers and eyedrops should be dated upon opening for storage and handling purposes. The nurses should have followed the medication insert instructions. On 03/01/22 at 5:30 PM , an interview with the Director of Nursing (DON) was conducted. The DON stated that he/she does not know why the nursing staff on the unit failed to date the inhaler and eyedrops once opened. The DON added that all inhalers and eyedrops should be dated due to the insert storage and handling instructions that needed to be followed. The DON added that all nurses were re in-serviced and educated of this information and still failed to follow. 415.18 (d)

Based on observations, record review, and interviews, during an Abbreviated survey (NY 775) conducted on 01/28/2022, the facility did not develop and implement a comprehensive person-centered care plan with measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs for each resident. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1 was identified as having allergies to mushrooms, shellfish containing products, [MEDICATION(S)], Contrast [MEDICATION(S)], [MEDICATION(S)], and sulfanilamide. An allergy care plan was not developed and implemented for Resident #1. On 06/11/2021, Resident #1 had an anaphylactic reaction after ingesting mushrooms served on Resident #1's dinner tray. Resident #1 was transferred to the hospital and was readmitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The findings are: The Policy and Procedure titled Allergy, dated 6/2021 documented that it is the facility's policy to obtain and record allergy information at the time of admission and to prevent future allergic reactions. The procedure includes obtaining information upon admission from the resident and recording allergy information in Minimum Data Set (MDS), in the resident's Care Plan, on front of the medical record cover, in nursing's admissions notes. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 06/03/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 15/15 (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). Resident #1 required limited assistance with eating. Review of the Hospital Patient Review Instrument (PRI) dated 04/07/2021 documented that Resident #1 had an allergy to mushrooms, [MEDICATION(S)], contrast, [MEDICATION(S)], [MEDICATION(S)], sulfa drugs, and seafood. Review of Resident #1's Allergy Record dated 04/11/2021, revealed that Resident #1 had allergies to mushrooms, [MEDICATION(S)], Contrast [MEDICATION(S)], [MEDICATION(S)], and sulfanilamide. Review of an Admission Nutrition Assessment note dated 04/12/2021 documented that Resident #1 had Food allergies/intolerances: Non-Known Food Allergy (NKFA). Review of Resident #1's Comprehensive Care Plans (CCP) revealed there was no person-centered care plan with interventions addressing Resident #1's allergies to food and medication. A Physician's Progress Note dated 06/11/2021 at 05:23 PM documented that Resident #1 was observed with acute onset of Shortness of Breath (SOB). Resident #1 complained that he/she was given mushrooms when he/she was allergic to them. Resident #1 was gagging and had SOB. Resident #1 was afebrile, Blood Pressure (BP) 136/97, Heart Rate (HR) 80 - 82, Oxygen 99%. The vital signs (VS) were repeated post-Solumedrol 40 mg, [MEDICATION(S)] treatment, Blood Pressure (BP) 153/98, Heart Rate 102, Respiration (RR) 30, Oxygen 92-99%. Resident #1 was on oxygen 5 Liter/min, anxious, lungs shallow with no wheeze nor stridor noted. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 will be transferred to the emergency room (ER) for observation. A Hospital Patient Discharge Instruction dated 06/12/2021 documented an Anaphylactoid reaction secondary to mushroom. During an interview on 01/28/2022 at 12:34 PM, Registered Nurse (RN) #1 stated that he/she is responsible for developing the care plans for Resident #1's allergies. RN #1 stated that he/she was aware that Resident #1 had multiple allergies, and that a care plan for food and medications allergies should have been developed. 415.11(c)(1)

Based on observations, record review, and interviews, during the Abbreviated survey (NY 775) conducted on 01/28/2022, the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1 who had an allergy to mushroom, was served mushroom during the dinner on 06/11/2021. Resident #1 had an allergic reaction and was transferred to the hospital on 06/11/2021. Resident #1 was readmitted to the facility on [DATE] with diagnoses included Anaphylactoid reaction secondary to mushroom. The findings are: The facility's Policy and Procedure entitled Food Trucks dated 12/2017 documented instructions for unloading food trucks. The instruction revealed that the front entrée and soup are to be placed on the front cold tray, according to each ticket, the back entrée, and soup is to be placed on the back cold tray according to each ticket. One Aid should be in charge of unloading the trays from the food trucks in order not to miss match food items on the trays. The Policy entitled Meal Preparation for residents with allergies dated 06/2021 documented that it is the policy of the facility to ensure that residents with food allergies are kept safe both for their physical well-being and for their quality of life. The Policy and Procedure entitled Allergy, dated 06/2021 documented that it is the facility's policy to obtain and record allergy information at the time of admission and to prevent future allergic reactions. The procedure includes obtaining information upon admission from the resident and recording allergy information in Minimum Data Set, in the resident's Care Plan, on front of the medical record cover, and in the nursing's admissions notes. Review of the facility Investigation Summary dated 06/11/2021 documented that Resident #1 called Certified Nursing Assistant (CNA) #2 and complained that he/she was having an allergic reaction to the food that was served to him/her for a dinner. Registered Nurse (RN) #1 was informed immediately and observed Resident #1 with Shortness of Breath (SOB) and gagging. The Medical Director was present on the unit and evaluated Resident #1. Treatment was given. Resident #1 reported that he/she was given mushrooms to which he/she was allergic. Resident #1 was transferred to the Hospital via 911. Resident #1 returned to the facility on [DATE] at around 8:00 pm. Facility investigated revealed that there were several pieces of mushroom mixed with rice and food appeared to have been partially touched. The meal ticked on the tray was also checked and noted that the resident was to be served an egg sandwich and roll. Rice and chicken that was on the ticket were crossed out. The facility concluded that the incident was most likely caused by human error whereby the meal ticket notation (Chicken and vegetable medley) was crossed out with a single line and was not effective in alerting the CNA that chicken meal was not to be part of the resident's meal tray for that evening. There is no reasonable cause to believe that the incident was caused by abuse, neglect, or mistreatment. Resident #1 was admitted to the facility with diagnoses that include Asthma, [CONDITION(S)] [CONDITION(S)], multiple allergies to the medications, and mushrooms. The Minimum Data Set (MDS, a resident assessment tool) dated 06/03/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 15/15 (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). Resident #1 required limited assistance with eating. Review of the Hospital Patient Review Instrument (PRI) dated 04/07/2021 documented that Resident #1 had an allergy to mushrooms, [MEDICATION(S)], contrast, [MEDICATION(S)], [MEDICATION(S)], sulfa drugs, and seafood. Review of Resident #1's Allergy Record dated 04/11/2021, revealed that Resident #1 had allergies to mushrooms, [MEDICATION(S)], Contrast [MEDICATION(S)], [MEDICATION(S)], and sulfanilamide. Review of Resident #1's Face Sheet revealed that Resident #1 had allergies to mushrooms, shellfish containing products, [MEDICATION(S)], Contrast [MEDICATION(S)], [MEDICATION(S)], and sulfanilamide. Review of an Admission Nutrition Assessment note dated 04/12/2021 documented that Resident #1 had Food allergies/intolerances: Non-Known Food Allergy (NKFA). Review of Resident #1's Comprehensive Care Plan (CCP) for Nutrition dated 04/12/2021, revealed that there was no documentation regarding allergies. Review of Resident #1's Meal Ticket dated 06/11/2021, revealed documentation that Resident #1 had Allergic to Mushrooms. The meal ticket revealed that Resident #1 should have an Egg Sandwich and Roll Challah, not Chicken Cacciatore, Potato-Mashed, Vegetable Medley. A Physician's Progress Note dated 06/11/2021 at 05:23 PM documented that Resident #1 was observed with acute onset of Shortness of Breath (SOB). Resident #1 complained that he/she was given mushrooms when he/she was allergic to them. Resident #1 was gagging and had SOB. Resident #1 was afebrile, Blood Pressure (BP) 136/97, Heart Rate (HR) 80 - 82, Oxygen 99%. The vital signs (VS) were repeated post-Solumedrol 40 mg, [MEDICATION(S)] treatment, Blood Pressure (BP) 153/98, Heart Rate 102, Respiration (RR) 30, Oxygen 92-99%. Resident #1 was on oxygen 5 Liter/min, anxious, lungs shallow with no wheeze nor stridor noted. Diagnosis: Allergic Reaction to mushrooms. Resident #1 was allergic to Benadryl; given Solumedrol 40 mg Intramuscular (IM) STAT and [MEDICATION(S)] respiratory treatment given STAT. Resident #1 will be transferred to the emergency room (ER) for observation. A Physician's Progress Notes dated 06/11/2021 at 06:07 PM, documented that Resident #1 had complaints of nausea and Chest Pain. Resident #1's vital signs were stable - given persistent complaints. Decision made to transfer Resident #1 to the ER. The resident initially resisted. Resident #1 had waxing and waning mental status. O2 Saturation dropped to 62%. The resident was placed on a non-rebreather mask. The lungs with transmittable sounds. Anaphylactic reaction. [MEDICATION(S)] 0.3 mg used, 911 called and the resident was transferred to the ER A Nursing Note dated 06/11/2021 at 10:06 PM documented that the writer was called to Resident #1's room by Certified Nursing Assistant (CNA) around 4:45 PM, stating that Resident #1 was having an allergic reaction. Resident #1 was noted to be having SOB and gagging. Resident #1 stated that he/she had a mushroom, which he/she was allergic to. Resident #1 given [MEDICATION(S)] 2.5mg/3mL nebulizer treatment at 4:45PM. The resident was given [MEDICATION(S)] 0.3mg by MD and put on a non-rebreather mask as the resident's condition did not improve. 911 called. Resident sent to ER. VS: BP 153/98, PR 102, RR 30, Temperature 97.5, O2 Saturation 92-99%. A Physician's Order dated 06/11/2021 documented an order Solu-[MEDICATION(S)] 40 mg STAT for Anaphylactic reaction due to fruits and vegetables, and [MEDICATION(S)] Sulfate inhale 3 ml by nebulizer one dose. A Hospital Patient Discharge Instruction dated 06/12/2021 documented an Anaphylactoid reaction secondary to mushroom. A Physician Note dated 06/14/2021 at 07:47 PM documented Resident #1 was hospitalized for 1 day and was treated for [MEDICATION(S)]. Impression/Diagnosis/Care Plan: [MEDICATION(S)] secondary to mushroom ingestion. As per ER record, the resident received solumedrol and Benadryl; to avoid known allergens. During an interview on 01/28/2022 at 1:20 PM, CNA #2 stated that he/she distributed meal trays to the residents. CNA #2 stated that he/she opened the kitchen track and there was a ticket on the tray with Resident #1's information. There was also a plate with the meal and sandwich. CNA #2 stated that he/she does not recall seeing allergy indication on Resident #1's meal ticket. CNA #2 stated that he/she read the meal ticket and compared it with what was on the plate and delivered the meal tray to Resident #1. CNA #2 stated that about an hour after the tray was served, he/she was told that Resident #1 had an allergic reaction. During an interview on 01/28/2022 at 1:35 PM, the Medical Doctor/ Director (MD) stated that he/she was on the unit when Resident #1 had an allergic reaction. The MD stated that he/she examined Resident #1 and the resident tongue was not swollen, no wheezing and no stridor. MD stated that it was more of a panic attack. The MD stated that first he/she administered steroid Intramuscular shot and staff monitored the resident. The MD stated that the steroid shot did not improve Resident #1's condition and the resident oxygen dropped. The MD stated that he/she administered an [MEDICATION(S)]. The MD stated that Resident 1 became [CONDITION(S)] and more nervous and 911 was called and the resident was to the hospital. The MD stated that Resident #1 refused Benadryl stating that Resident #1 was allergic to Benadryl but that the resident received Benadryl via Intravenous route in the ER. The hospital kept the resident on observation overnight and transferred Resident #1 back to the facility in the morning (06/12/2021). The MD stated that Resident #1 stated that the resident moved the mushrooms away with the fork and ate the food. During an interview on 1/28/2022 at 3:00 PM, the Director of Nursing (DON) stated that CNA #2 should have checked the ticket and food on the plate before giving it to Resident #1. The DON stated that the kitchen should not have send the wrong food for Resident #1. The DON stated that when track comes to the unit, the assigned CNA should open the hot section, the cold section, read what the ticket says, and put the food on the tray according to the ticket. The DON stated that the mushrooms were not visible because it was mixed with the vegetable. The DON stated that the Food Service Director who worked on the day of the incident has retired. During an interview on 02/07/2022 at 12:00 PM, the Food Service Supervisor (FSS) stated that his/her responsibility is to run the residents' tickets, oversee the tray line and make sure that the meal on the tray matches the ticket. The FSS stated that he/she supervises breakfast and launch and that the Director of Food Service supervises dinner. Surveyor was not able to interview Food Service Director who worked on 06/11/2021 and was responsible for ensuring that the correct food was on Resident #1's meal ticket and food track. The Food Service Director retired and whereabouts unknown. 415.14(d)(4)

Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that a residents' dignity was maintained. Specifically, two residents one female and one male complained that they were not given notice that they would be residing in rooms with a bathroom shared by the opposite sex/gender. Resident #208 complained to the State Agency Surveyor (SA) that the male residents have walked in while she was using the bathroom. Furthermore the facility does not provide signs informing residents to knock prior to entering shared bathrooms in an effort to maintain privacy and dignity of the residents in adjoining rooms. This was evident for 2 out of 36 sampled residents. (Resident #208, Resident #4) The findings are: The most recent Annual Minimum Data Set ((MDS) dated [DATE] documents that Resident #208 is a cognitively intact female and has a [DIAGNOSES REDACTED]. The resident is documented a requiring the limited assistance of one person for toileting, is always incontinent of bladder, and always continent of bowel. During an initial interview of Resident #208 on 06/20/19 at 10:58 AM, the resident stated that she is sharing a bathroom with 2 male residents in the adjoining room on the opposite side of the bathroom. The resident stated that she was told by facility staff that the 2 males in the adjoining room do not use the bathroom; however, Resident #208 has had disagreements with the other male residents regarding the frequency and the time required for her to use the bathroom. Resident #208 further stated that she has been walked in on by one of the male residents while she was using the bathroom. Resident #208 stated that she has informed the staff of this concern several times but there has been no resolution. During the interview in the resident's room, the SA did not observe any signs on the bathroom door indicating that the resident should knock before entering. Resident #208 also stated that she was not made aware that she would be sharing a bathroom with male residents until after they had already moved into the adjoining room. A Nursing assessment dated [DATE] documents that Resident #208 is able to move about with/without a device, is independently mobile, and is always continent of bowel and bladder. A Comprehensive Care Plan (CCP) related to Activities of Daily Living (ADL) dated 6/18/17 documents that the resident requires the assistance of 1 person to complete tasks such as toileting. There are no Social Work or Nursing Notes related to resident's concerns with using the shared bathroom. On 06/26/19 at 09:47 AM, an interview was conducted with one of the male residents (Resident #4) in the adjoining room that shares a bathroom with Resident #208. Resident #4 stated that he uses the bathroom independently and has had multiple occasions where he has tried to use the shared bathroom, but female resident #208 has been present in the bathroom at the time. The female resident has screamed as soon as he has opened the door to the shared bathroom. Resident #4 also stated that the staff has never discussed whether or not he would feel comfortable with sharing a bathroom with a female resident. Resident #4 has complained to staff about the cleanliness of the bathroom and had requested a room change approximately one month ago but stated that there have not been any improvements or changes made. Resident #4 also stated that he has witnessed his roommate, Resident #11, use the bathroom independently and also walk in on Resident #208 while she has been using the bathroom. During the interview with Resident #4, the SA observed that the door to the shared bathroom did not have any signs that directs the resident to knock before entering the bathroom. The most recent quarterly MDS for Resident #4 is dated 6/2/19 and documents that the resident is cognitively intact and requires the limited assistance of 1 person for toileting. On 6/26/19 at 9:47 AM, Resident #11 declined to be interviewed regarding sharing the bathroom with Resident #208. The most recent quarterly MDS for Resident #11 is dated 3/17/19 and documents that the resident is cognitively intact and requires the limited assistance of 1 person for toileting. On 06/26/19 at 11:02 AM, an interview was conducted with, CNA #2 the Certified Nursing Assistant (CNA) for Resident #208. CNA #2 stated that she has worked on the unit for an extended period of time and is familiar with Resident #208 and her ADL status. Resident #208 requires limited assistance of 1 person to complete her ADL tasks. The resident is sometimes continent of her bladder and is always continent of her bowels. When CNA #2 is assisting the resident with toileting, she will help her to the toilet, then leave the resident on the toilet until she is done using it. Once the resident has finished using the toilet, the resident knows to ring the call bell and the CNA will assist her in cleaning herself and being transferred back to bed. The CNA #2 stated that she is not aware of any issues that the resident has had in sharing the bathroom with male residents. The CNA is not certain whether other male and female residents share bathrooms. She believes that there are rooms that have signs on the shared bathrooms instructing residents to knock before entering. An interview was conducted with CNA #3 on 06/26/19 at 11:12 AM. CNA #3 stated that she has worked on the unit for a few months and was recently assigned to Resident #4. CNA #3 stated that Resident #4 requires assistance with bathing, washing his back, and changing his sheets. The resident does not require any assistance with toileting, does not wear a diaper, and is continent of bowel and bladder. On this morning, CNA #3 was providing care for Resident #4 when he stated that he needed to use the bathroom. Resident #4 was able to get himself up and walk to the shared bathroom in order to use it without any assistance from the CNA. CNA #3 is also assigned to Resident #4's roommate, Resident #11. Resident #11 wears a diaper for episodes of incontinence, but also uses the shared bathroom. CNA #3 will offer assistance with toileting to Resident #11 and will usually wait for him to finish in the shared bathroom before assisting with cleaning and dressing him. CNA #3 has not heard of any concerns or confrontations between the residents who share the bathroom between the 2 adjoining rooms. On 06/26/19 at 03:26 PM, an interview was conducted with the Social Worker (SW) assigned to the unit. The SW stated that the residents have not mentioned to her that there was an issue with sharing a bathroom with an opposite sex. She stated that Resident #4 believes that he is being discharged to an Assisted Living Facility. There is no set discharge date for Resident #4 at this time. The SW believes that Resident #4 is becoming more cranky because of the time it is taking for him to be discharged from the facility. The SW stated that she believes it may be becoming an issue now because Resident #208 is an obese woman and Resident #4 is a man and they have different hygiene practices. Resident #208 may not be able to clean the toilet effectively. Both residents are alert and have strong personalities. Resident #208 was originally placed in her current room prior to Resident #4 and Resident #11 being moved into the adjoining room. The SW stated that there are more males and females that share bathrooms throughout the facility and that there are times that an issue will arise because of it. There are room change notes completed for the residents but they do no reflect whether the residents are made aware that they will be sharing a bathroom with the opposite sex. There is usually a sign placed on the bathroom door instructing the residents to knock before entering. If a resident is too cognitively impaired to understand the instructions to knock on the door before entering, then he/she will not be placed in a situation where they would need to share a bathroom with the opposite sex. Room changes are a a team decision made in morning report and SW opinion is taken into account. On 06/26/19 at 04:07 PM, an interview was conducted with Director of Social Work (DSW). The DSW stated that none of the residents involved (Resident #208, #4, or #11) have made any complaints about sharing a bathroom with the opposite sex. The residents were offered a room change but refused. The facility does not keep a list of residents who share bathrooms with the opposite sex. There is no checklist of conditions that would need to be present for residents of the opposite sex to be placed in situation where they would be required to share bathrooms. There is a discussion of a resident's physical capabilities and cognition prior to making room changes that would place a resident in room where they would need to share a bathroom with the opposite sex. Residents' behaviors are taken into account as well but not prior sexual abuse history. There is no documentation that reflects a resident's agreement with being in a situation where they will be sharing a bathroom with the opposite sex. The facility also does not have a policy and procedure related to shared bathrooms between residents of the opposite sex. 415.3(c)(1)(i)

Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that proper treatment and assistive devices to maintain vision were provided to a resident. Specifically, a resident who was evaluated for new eyeglasses did not receive new eyeglasses. This was true for 1 of 3 residents reviewed for vision/sensory care out of 36 sampled residents. (Resident #3) The findings are: The most recent Annual Minimum Data Set ((MDS) dated [DATE] documents that Resident #3 has moderately impaired cognition, adequate vision with no corrective lenses, and is diagnosed with [REDACTED]. On 06/20/19 at 12:52 PM, an interview was conducted with the resident's son. According to the resident's son, Resident #3 had been evaluated for new eyeglasses approximately 3 months ago. The Optometrist was at the facility a few weeks ago but did not deliver any new eyeglasses to Resident #3. The son had spoken to the nursing staff regarding this concern but did not receive any follow up information regarding the whereabouts of the new eyeglasses. An Optometry Consult dated 3/12/19 documents that Resident #3 is requesting new bifocals. The resident's vision is impaired and her lenses are currently scratched. The consult documents that bifocals had been ordered for the resident. A Comprehensive Care Plan (CCP) related to Optometry and dated 3/14/19 documents that the resident was seen by optometrist 3/12/19 and glasses were ordered. The CCP documents to provide ongoing assessment of the resident's vision impairment. A Nursing Note dated 3/12/19 documents that the resident was seen by optometry. On 06/26/19 at 12:00 PM, an initial interview with the Assistance Director of Nursing (ADNS) was conducted. The ADNS stated that normally any resident who received new eyeglasses would have a receipt for the eyeglasses in their medical chart. The ADNS then stated that she would need to look into the matter. A follow up interview was conducted with the ADNS on 06/27/19 at 11:01 AM. The ADNS stated that the resident did not receive the eyeglasses that were ordered for her in 3/2019. The Optometrist office was contacted by the facility and sent a letter today notifying the facility that there was a delay. The ADNS stated that normally the Optometrist fills out a consult paper with any recommendations for eyeglasses, treatment, and/or follow up and delivers a copy of the consult paper to the nursing office. The nursing office reviews the consult and then gives it to the nurse manager responsible for the unit. The nurse then writes a progress note related to the recommendations documented in the consult report. If there is a recommendation for new eyeglasses, the facility will end up reviewing the glasses for the resident within 2-4 weeks. The eyeglasses are shipped to the nursing office through the mail. The nursing office then documents what eyeglasses were received. The glasses are given to the nurse on the unit and then delivered to the resident. Resident #3's name was not included on the list in the nursing office of residents who received eyeglasses. The nurse managers on the unit are responsible for following up if there is a recommendation for glasses but they have not been received. There is no system for tracking recommendations for eyeglasses or when eyeglasses are ordered for residents. The ADNS stated that the nurse managers use their own personal tracking system to ensure that the resident receives their eyeglasses. The ADNS was not aware of a specific timeframe in which the nurse managers would follow up with the Optometrist's office. If the patient is cognitively intact, they will usually tell the staff if there is an issue with waiting for glasses. 415.12(3)(b)

Based on observation, record review and staff interviews during the recertification survey , the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments at each visit. Specifically, a resident diagnosed with [REDACTED]. There is no documented evidence that the physician assessed the trends of elevated blood sugars to ensure accurate monitoring of glucose levels. It was 10 months since the physician or designee ordered the Glycated hemoglobin ( HbAIc ) test (a test that measure the overall blood glucose control over a period of 60-120 days). The resident's most recent test was taken on 6/21/19 and the resident's results were elevated over normal parameters. This was evident for 1 out of 36 sampled residents. (Resident # 50) The facility policy on diabetes mellitus with revision dated 11/2018 states It is the policy of Golden Gate Rehabilitation and Health Care Center that to ensure every resident diagnosed with [REDACTED]. Item#2 of the policy directs that the attending medical doctor ( MD ) will evaluate, the resident upon admission and decide which method of monitoring glucose levels would be appropriate for that resident. Item #3 directs that any resident on medication, oral or injected will be monitored by blood work Glycated hemoglobin ( HbAIc ) as per MD order. Item #4 directs the MD will be notified if a resident's fingerstick is below 70 and above 250 unless parameters indicate otherwise. All results will be documented in the resident's electronic medical record. The finding is: Resident # 50 a [AGE] years old admitted to the facility with [DIAGNOSES REDACTED]. The minimum data set ( MDS ) 3.0 assessment dated [DATE] assessed the resident as alert , oriented to person, place and time with a brief interview for mental status (BIMS) score of 15. The resident is independent in most activities of daily living with supervision in eating. On 06/25/2019 at 10:45 AM, the resident was initially observed seated in a regular chair in front of his room . alert and conversant , appropriately dressed and well- groomed. He was seen and spoken too several times during the survey period and was seen seated in his wheelchair around the unit. The physician's orders [REDACTED]. Call medical doctor (MD ) if FSBS is below ( < ) 70 and greater than (>) 250 milligram per dilution (MG/DL). Review of the FSBS from 06/01/2019 to 06/23/2019 documented that the resident's FSBS were at the highest 436 and the lowest 256. This revealed elevated FSBS for both morning and night. The HbAIc was last done on 08/10/2018, that is 10 months to the current test which was conducted on 6/21/19. The reference for normal parameters is 4.0-6.0%. The tests results were as follows: 08/10/2018 -- 6.4 % 06/19/2018 -- 5.8 % 06/21/2019 -- 8.3 % According to the American Diabetic Association (ADA ) it is standard practice to have HbAIc done at least every 3-6 months for a person diagnosed with [REDACTED]. On 06/20/2019 at 1:00 PM NP #3 Nurse (Practitioner) was interviewed. She stated, I review the FSBS on a monthly basis. The HbAIc is ordered on a patient to patient basis. She stated that she would order one immediately. The resident's EMR (electronic medical record) revealed that FSBS were higher in the evening and at bedtime. The EMR also documented that there were instances that when notified of elevated FSBS the physician or NP ordered stat doses of insulin. However, it was not until NP was interviewed by the with the State Surveyor on 6/20/19 did the physician order [REDACTED]. On 06/20/2019 the [MEDICATION NAME] was increased to 20 units and [MEDICATION NAME] to 8 Units TID AC . Additionally blood test for comprehensive metabolic panel ( CMP ) and hemoglobin A1C was added to the new order. On 06/23/2019 the [MEDICATION NAME] was increased to 22 units. On 06/21/2019 at 3:00 PM and again on 06/26/2019 at 11:00 AM the resident's attending physician (Physician #2) was interviewed. Physician #2 stated that the ordering of HbAIc levels are done on a patient to patient basis. She further stated that she may order every 6 months or maybe a year. The physician did not provide reason for why levels were not ordered for this resident in almost a year. She stated that the resident was non compliant with his diet. She stated that the resident consistently orders food from outside. Physician #2 further stated that when the nurses calls her, or the NP about the elevated FSBS additional insulin is ordered. However, she stated that there, but there are times when they don't call to inform them about the elevated FSBS. When asked if the resident has been referred to an endocrinologist, she stated that she believed the resident was seen by one in the hospital. She has not referred the resident to Endocrinologist. The physician stated that she would review and adjust the resident's medication. 415.15 (b)(2) (iii)

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that residents do not develop pressure sores unless unavoidable. This was evidenced by 2 of the 4 sampled residents (Resident #1 and #2) Specifically, a resident (#1) readmitted to the facility with no pressure ulcers, developed a stage IV pressure ulcer 21 days later. Secondly, a resident (#2) noted with redness to the right lateral lower leg was not monitored until the wound deteriorated to a stage IV pressure ulcer approximately one month later. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID # NY 974, NY 174 The findings are: Resident #1 is a [AGE] year old female readmitted to the facility from the hospital on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 2.0 (an assessment tool) dated 11/27/2009, documented that the resident had moderately impaired cognitive skills for daily decision making with long and short term memory impairments. She was totally dependent on staff for all activities of daily living and was incontinent of both bowel and bladder. The facility's Nursing Admission assessment dated [DATE] documented that the resident's skin was intact. The Braden Scale (a tool for determining pressure ulcer risk) dated 1/15/10 documented that the resident has mild risk to develop pressure ulcers. The Nursing Progress Note dated 1/15/10 at 11:30 PM documented that, " Resident readmitted from Hospital at 7:00PM accompanied by relatives, body assessment done. No distress noted. No open area noted. Care rendered." The Medical Doctor's Progress Note dated 1/18/10, documented that, " Patient was hospitalized (hospital name) for 4 days and was treated for [REDACTED]." A Comprehensive Care Plan (CCP) effective 6/11/09 and reactivated on 1/22/10 documented that the resident is at risk for skin breakdown related to a Braden Scale Score of "15 mild risk". Interventions include body checks biweekly by nurse and CNA after showers, turning and positioning as recommended, pressure reducing mattress and skin protectant when performing perineal care. The resident's medical record contained no documentation of body checks biweekly by a nurse on the resident's shower days as indicated on the CCP. The Nursing Progress Note dated 2/6/10 at 5:15 PM and 11:30 PM documented that, the resident was noted with a sacral ulcer. "Resident had stage IV pressure ulcer on buttock measuring 4 cm x 3cm, no depth, odorless, no exudates, on brown clean bed, supervisor on duty notified ...Treatment done, cleansed with saline, applied Xeroform, and covered with dry clean dressing." A CCP for Skin Integrity effective 2/9/10 documented that the resident has a stage IV pressure ulcer to the sacrum. Interventions included apply treatment as ordered, provide air mattress and perform weekly wound rounds. The Licensed Practical Nurse (LPN) (3-11PM shift) was interviewed on 6/10/10 at 3:20PM. She stated that the assigned Certified Nursing Assistant (CNA) first saw the ulcer on 2/6/10 and reported it to her. The LPN informed the Registered Nurse Supervisor (RNS #2). The RNS #1 (RN) (3-11PM shift) was interviewed on 6/10/10 at 3:53PM. He stated that he did not observe any ulcers on the resident while doing the admission assessment on 1/15/10 and could not explain how and why the pressure sore was not observed and treated before it became a stage IV ulcer. He stated that after the admission he did not see the resident's skin because it was not his duty to do body checks thereafter. The Medical Director was interviewed on 6/11/10 at 10:30AM via telephone. She stated that the resident had no ulcer when she examined her on 1/18/10 and that the resident was [AGE] years old with fragile skin. The RNS #2 (3-11 PM shift) was interviewed on 6/14/10 at 10:00AM via telephone. He stated that he was told that the resident had a pressure ulcer and when he assessed the resident, the ulcer was a stage IV. The 7-3 PM assigned CNA was interviewed on 6/9/10 at 1:43PM and on 10/12/10 at 10:20AM. She stated that she provided care to the resident on many occasions and did not notice any pressure ulcers on the resident's body. Resident #2 is a [AGE] year old female initially admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 2.0 assessment dated [DATE], documented that the resident had severely impaired cognitive skills for daily decision making with long and short term memory impairments. She was totally dependent on staff for all activities of daily living and was incontinent of both bowel and bladder. A CCP for Skin Integrity effective 11/30/08 documented that the resident is at high risk for skin breakdown related to Braden Scale Score. Interventions include body checks biweekly by nurse and CNA after showers, turning and positioning as recommended, bilateral TED stockings ([MEDICAL CONDITION] Embolic Deterrent used to improve circulation and prevent blood clots) and pressure reducing cushion in wheelchair. An air mattress and heel booties were added on 2/21/09 and 8/27/09 respectively. The resident's medical record contained no documentation of body checks biweekly by a nurse on the resident's shower days and indicated on the CCP. A CCP for Skin Integrity effective 2/5/10 documented that on 2/4/10 the resident had a stage IV Pressure Ulcer to the right lower leg. Interventions include applying treatments as ordered, pad wheelchair and leg rests and assess for pain. The Nursing Progress Note dated 2/4/10 at 3:55PM documented " Late Entry for 2/3/10 3p-11p. Called to room by CNA to evaluate sore to right leg. Upon assessment, 3cm x 2cm stage IV pressure sore noted to the right lateral lower leg. Placed in communication book for MD to evaluate." The facility's investigation report dated 2/11/10 documented that on 2/05/10, it was reported at the Interdisciplinary Morning Report that the resident developed a stage IV pressure ulcer to the right posterior lateral lower leg. The written statement of an LPN (#2) dated 2/05/10 documented that in the beginning of January 2010, she was called by a CNA to look at the resident's leg. Upon examination, slight redness was noted to the posterior lateral lower right leg and the MD (medical doctor) was called to examine it. The MD ordered a pressure relief measure and further monitoring of the area. On 2/3/10, the LPN was called to the resident ' s room by another CNA and a 3cm x 2cm Stage IV Ulcer was noted to posterior lateral lower right leg. The investigation concluded that the LPN failed to document her observation in January and therefore investigation and treatments of the area were delayed and resulted in the deterioration of the wound. A review of the resident's medical record revealed [REDACTED]. The Director of Nursing (DON) was interviewed on 3/2/10 at 10:30AM and on 11/8/10 at 2:55 PM via telephone. She stated that Resident #2 has fragile skin and that all preventive measures were put in place to prevent skin breakdown. In January 2010 the LPN (#2) failed to document her observation of redness and immediate intervention was delayed. During body checks the CNA focus primarily on bony prominences. She stated considering that the wound was not on a bony area and the fact that the resident wears TED stockings, may explain why CNAs did not detect the deterioration of Resident # 2's wound earlier. When asked about the nurse doing biweekly body checks after showers as indicated on both resident's (#1 and #2) CCP, she stated that she would look for the documentation and forward it to the surveyor. The documentation received from the DON did not include evidence that the nurse and CNAs were doing skin checks together on shower days for both residents, prior to the discovery of the stage IV ulcers in February 2010. The MD was interviewed on 3/2/10 at 1:00PM. She stated that she was getting ready to leave the facility when she was called to examine Resident #2's leg in January 2010. She stated that she saw redness on the resident's calf area of the right leg. She ordered for the resident to continue using booties and to monitor the area. The MD forgot to document her findings. She stated that no one reported any changes to Resident #2's leg until 2/4/10 when it was a stage IV ulcer. The LPN # 2 (3-11PM shift) was interviewed on 5/13/10 at 4:45PM. She stated that when a reddened area was noticed on Resident #2's leg early in January she called the MD and relief measures with booties at all times was ordered. She stated that she forgot to document and report her observation for follow-up. The LPN stated that the CNA did not report the wound to her until 2/3/10 and that it had become a stage IV pressure ulcer at that point. She stated that staff on the other shifts also failed to observe the deterioration of the ulcer. The CNA (11-7AM shift) was interviewed on 7/19/10 at 2:40PM. She stated that it was part of her assignment to do body checks on Resident #2 before putting on her TED stockings at 6:00AM daily. She did not observe any openings on the resident's right leg. She stated that one day she saw a little speck of dry blood on the bed sheet but she did not report it. The LPN #3 (11-7AM shift) was interviewed on 7/19/10 at 3:38PM via the phone. She stated LPN # 2 reported to her in January 2010 that Resident #2 had redness to the back of her right leg due to possible pressure from wheel chair. The MD ordered that booties must always be put on the resident's leg in the morning when she is transferred out of bed. She stated that she relied on the CNAs to report any further changes to her. 415.12 (c) (2)