Every finding on record at Good Shepherd-Fairview Home Inc

Based on observation, record review, and interview during the recertification survey conducted 7/29/2025-8/1/2025, the facility did not develop care plans that describe the resident's medical, nursing, physical, mental and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences for (4) of four (4) residents (Residents #65, #4, #8, and #5) reviewed. Specifically, Resident #65 and #4's care plan did not include the use of anticoagulant (blood thinner) medication. Resident #8's care plan did not include the use of diabetic medications and Resident #5's care plan did not include the use of antihypertensive medications. Findings include: The facility policy, Comprehensive Care Plan, revised 7/2019, documented each discipline was responsible for the initiation and augmentation of problems with correlating goals and approaches to address care areas, to support the highest quality of care. Interdisciplinary team members were expected to have analyzed each triggered care area assessment related to their discipline and would have made care planning decisions based on their professional judgment. The care manager was responsible for collaboration with the interdisciplinary team, gathered input from the resident and direct care staff, and would have entered the information into the care plan. 1) Resident #65 had diagnoses including atrial fibrillation (irregular heartbeat), and coronary artery disease. The 7/29/2025 Minimum Data Set assessment documented the resident's cognition was intact, required minimal assistance for most activities of daily living, and was to be discharged home following rehabilitation. The physician orders dated 7/25/2025 through 8/31/2025 documented Eliquis (anticoagulation/blood thinner) 5 milligrams two times a day for an irregular heartbeat. The admission history and physical dated 7/29/2025 Medical Doctor #6 documented the resident had a significant cardiac history which Included atrial fibrillation, coronary artery disease, history of cardiac stent placements and implanted cardiac defibrillator. The resident was to have continued all cardiac medications including, aspirin and Eliquis and continued with iron supplementation related to the resident's anemia. The comprehensive care plan initiated 7/29/2025, documented the resident was at risk for falls. Interventions included education the resident on fall risks. The comprehensive care plan did not include the resident's use of anticoagulant medication. The undated care card did not include any documentation related to the resident's use of anticoagulant medication. During an observation and interview on 7/29/2025 at 2:51 PM, Resident #65 stated they had spontaneous nose bleeds as a result of having been on a blood thinner. During an interview on 8/1/2025 at 10:05 AM, Certified Nurse Aide #16 stated would have known if a resident had been on blood thinners by looking at the care card in the computer and by morning report. They had not been aware of resident #65 having been on a blood thinner. They had not witnessed the resident having had a nosebleed however stated they would have reported it to the nurse as soon as it happened. During an interview on 8/1/2025 at 10:25 AM, Licensed Practical Nurse #15 stated they had not been aware of any nosebleeds that resident #65 may have had. The certified nurse aides would have let us know if there was any significant incident such as a bleed. The resident was on blood thinners and the certified nurse aides would know that by looking at the electronic care card. Licensed Practical Nurse #15 reviewed the resident's medical record and stated the resident did not have care plan regarding anticoagulation use. The information contained on the care card came from the care plan. During an interview on 8/1/2025 at 3:10 PM Licensed Practical Nurse Unit Manager #14 stated they were responsible for initiating care plans. If the care plan had been missing pertinent content, the care card would not have had the information either. All nursing staff were educated on the complications related to blood thinners and the importance of observations of the resident. They did not know why there was no anticoagulation care plan developed for Resident #65. 2) Resident #4 had a diagnosis including anemia, hypertension, atrial fibrillation and a left hip fracture. The 6/2025, Minimum Data Set documented the resident had a moderate cognitive impairment, used both a walker and a wheelchair, required a moderate amount of assistance with most activities of daily living, and received anticoagulant medication. The undated certified nurse aide care card identified the resident was a fall risk. There was no information related to anticoagulation. A progress note on 6/23/2025 by Nurse Practitioner #12 documented the resident had returned to the facility following an unwitnessed fall with a head strike the previous day. Testing revealed no acute cranial hemorrhage or skull fracture. The resident was evaluated upon their return to the facility, and the staff had been updated on the plan of care and instructed to continue safety interventions. The comprehensive care plan last revised on 6/25/2025 identified the resident was a high risk for falls and they were unaware of their safety needs. There was no documentation within the care plan indicating that the resident had been receiving anticoagulant therapy. The physician's order on 7/25/2025 documented the resident was to continue to receive Apixaban (blood thinner) 2.5 milligram tablets twice daily for anticoagulation. During an interview on 8/11/2025 at 4:04 PM the Director of Nursing stated the managers would have been responsible to have initiated and updated the care plans. The supervisors would have also updated them as needed. The care plans would have been reviewed every quarter, every new problem, every medication change, or every time there had been a gradual dose reduction. There should be a care plan for anticoagulation medications because the resident would have been monitored for bruising or bleeding. It was the expectation to have a care plan for diabetic as well as any hypertensive medication. Director of Nursing stated if the resident had been treated for something it would have been on the care plan. The care was what directed the residents care and informed the staff on how to care for that resident. 3) Resident #5 had diagnoses including hypertension, peripheral vascular disease (narrowed or blocked blood vessels in limbs), and dementia with other behavioral disturbance. The 5/25/2025 Minimum Data Set documented the resident was severely cognitively impaired, had behaviors, rejected care, and had a diagnosis of hypertension. The resident had no documented care plan related to their diagnosis of hypertension or their hypertensive medications. The 5/29/2025 physicians orders documented the resident received one tablet of 2.5 milligrams of Amlodipine Besylate by mouth one time a day for hypertension and two tablets of 75 milligrams of irbesartan one time a day for hypertension. The irbesartan was to be held if the resident's systolic blood pressure was less than 130. The July 2025 Medication Administration Record documented the resident received their medication as ordered for the month of July. During an interview on 8/1/2025 at 1:45 PM, Licensed Practical Nurse #11 stated residents on hypertension medication were to have their blood pressure and pulse monitored. There were also orders with specific parameters regarding the blood pressure medication they received. The resident's care plan for their hypertension had all of their symptoms the resident experiences so the staff knew what to look for in a hypertensive episode. During an interview on 8/1/2025 at 1:57 PM, Licensed Practical Nurse Unit Manager #14 stated residents on hypertensive medications had cardiac care plans related to their hypertension and medication. Resident #5 did not have a cardiac care plan, and they should have one. The care plan must have been missed. During an interview on 8/1/2024 at 4:04 PM, the Director of Nursing stated the Nurse Managers were responsible for initiating and updating care plans. Care plans were reviewed quarterly at minimum but also with medication changes and new problems. Residents who were on hypertensive medications should have a cardiac care plan. If the resident was being treated for something, there should be a care plan in place to tell staff how to care for that resident. 10NYCRR 415.11(c)(2)(iii)

Based on observation, interview, and record review during the recertification survey conducted 7/29/2025 to 8/1/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infection for one (1) of two (2) residents (Resident #5) reviewed. Specifically, Resident #5's enhanced barrier precautions were not followed, and wound care was completed without appropriate hand hygiene, clean supplies, and precautions to prevent contamination of the wound. Additionally, Licensed Practical Nurse #15 did not perform hand hygiene consistently during their medication administration between residents.Findings included: The facility policy Enhanced Barrier Precautions, revised 11/2024, documented enhanced barrier precautions were utilized to prevent the spread of multidrug-resistant organisms to residents. Gowns and gloves were to be utilized during high contact resident care activities when contact precautions did not apply. Examples of high contact resident care activities included wound care. Enhanced barrier precautions were indicated for residents with wounds when contact precautions did not apply and remained in place until the resolution of the wound. Staff are trained prior to caring for residents on enhanced barrier precautions and signs were posted at the resident's room indicating the type of precautions and personal protective equipment required.The facility policy Medication Administration-General Guidelines, effective 4/2022, documented hand hygiene must be performed before and after medication administration.Wound Care:Resident #5 had diagnoses including peripheral vascular disease (narrowed or blocked blood vessels in limbs) and hypertension. The 5/25/2025 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, had one unstageable pressure injury, and one veinous or arterial ulcer.The Comprehensive Care Plan initiated 6/28/2021, updated7/29/2025, documented the resident had potential for skin breakdown related to hypertension, impaired cognition, and impaired mobility. The resident had a left second toe peripheral vascular wound that opened 1/26/2025, a deep tissue injury to the right posterior heel that occurred on 1/27/2025 and was on enhanced barrier precautions related to a chronic wound.The 6/25/2025 physician's order documented to apply skin prep to the left second toe every day shift for a vascular wound.The 7/16/2025 physician's order documented to cleanse the right posterior heel with wound wash, apply Adaptic dressing to wound base and cover with Optiform once daily every dayshift for wound care.The 7/29/2025 physician's order documented the resident was on enhanced barrier precautions for chronic wounds.During a wound care observation on 7/31/2025 at 10:00 AM, Licensed Practical Nurse #21 wrote the order for Resident #5's wound care on a sticky note then obtained the wound care supplies from the treatment cart in the medication room without performing hand hygiene or gloving. The treatment supplies included a skin prep packet, unpackaged gauze squares, a package of Adaptic non-adhesive dressing, a bottle of wound wash dated 7/1/2025, an optifoam heel protector, tape and an unpackaged gauze roll. All supplies were set on top of the unprotected treatment cart surface while they grabbed gloves which were placed in the pocket of the licensed practical nurses' uniform top. The supplies were carried to the resident's room with an ungloved hand and set down on an unprotected and uncleaned nightstand. The unpacked gauze was directly touching the nightstand, and the scissors were on top of the sticky note also placed on the nightstand. Licensed Practical Nurse #21 washed their hands in the bathroom and then kneeled in front of the resident while they were sitting in their wheelchair and took the resident's sock off their right foot. Licensed Practical Nurse #21 then put gloves on, moved the paper towels they had obtained from the bathroom and the wound care supplies and placed them on a chair behind them. The paper towels were then moved to the floor under the resident's heel with the wound care supplies remaining on the chair. Licensed Practical Nurse #12 removed the resident's previous dressing from their heel and then lifted the heel to look at the resident's wound. They did not change their gloves or sanitize their hands after removing the dirty dressing. They grabbed the unwrapped gauze square and sprayed it with wound wash and held it against the wound. All other wound care supplies (the package of Adaptic with scissors on top and unpacked gauze wrap) were then placed on the floor without a barrier next to the paper towels under the resident's foot and the pile of the previous dirty dressing. Licensed Practical Nurse #21 then cut the multi-use Adaptic square with uncleaned scissors, placed the rest of the Adaptic dressing back in its package, placed the scissors directly onto the uncleaned chair behind them, and applied the cut Adaptic piece to the resident's wound, applied Optifoam heel protector and then wrapped with the unpackaged gauze roll. The gauze roll was then cut to length with uncleaned scissors. Licensed Practical Nurse #21 put the resident's sock and slipper back on without removing or changing their gloves or performing hand hygiene. The resident's left slipper and sock were removed, and skin prep was applied to the resident's left second toe, then their sock and shoe replaced without Licensed Practical Nurse #21 changing their gloves or performing hand hygiene. Licensed Practical Nurse #21 then threw all the used/dirty supplies away, removed their gloves, put the uncleaned scissors into their uniform top pocket, and brought the resident out to the common area with the bottle of wound wash and multi-use Adaptic package in the hand. They then put the wound wash and Adaptic package back into the treatment cart in the medication room then went to the common area to wash their hands. They had not put on personal protective equipment per the resident's enhanced barrier precaution at all during the wound care.During an interview on 7/31/2025 at 10:14 AM, Licensed Practical Nurse #21 stated the process for providing wound care was to check the order, gather the supplies, wash their hands, put on gloves, then perform the treatment. Residents who had wounds were on enhanced barrier precautions as the resident was at risk of higher levels of infection. Enhanced Barrier Precautions meant gowns, gloves, and masks needed to be worn when in the room. They forgot the resident was on Enhanced Barrier Precautions when the performed the resident's wound care. Wound care items should not be placed on uncleaned surfaces or surfaces without a barrier. They should not have placed the wound care supplies on the non-sanitized bedside table, chair, or floor. They should have changed their gloves and sanitized their hands after removing the soiled dressing and putting on the new dressing. They did not know why they did not. They should have sanitized their hands after wound care prior to returning the multiuse items to the clean treatment cart.During an interview on 8/1/2025 at 10:24 AM, Licensed Practical Nurse Unit Manager #14 stated if a resident was on Enhanced Barrier Precautions the staff should be wearing a gown and gloves for wound care. Wound care supplies should not be placed on an uncleaned, uncovered surface or on the floor. Multiuse Adaptic dressing should not be cut with uncleaned scissors and hand hygiene and glove changing should be performed in-between removing the soiled dressing and placing the new dressing. Gloves should be changed and hand hygiene performed after removing a resident's shoes and socks prior to doing wound care. Hand hygiene should also be performed prior to bringing multiuse wound care supplies back to the treatment cart.During an interview on 8/01/2025 at 2:47 PM, the Infection Preventionist stated when a resident was on enhanced barrier precautions their name tag on their door was flipped to the orange side, a personal protective equipment cart was placed in their room and the precaution sign was hung up. The resident and their family were also educated on why they were on it and what to do. A resident with wounds would be put on enhanced barrier precautions. Staff should be putting on gowns and gloves to care for a resident with an open wound as they are in direct contact with the area the resident was placed on precautions for. All staff were just recently educated within 2025 on enhanced barrier precautions and the nurses had competencies done on infection control and precautions. Gloves should be changed, and hand hygiene should be performed after removing the old dressing before applying the new one. Wound care supplies should not be placed on unclean surfaces, there should always be a barrier, and the surfaces should be wiped down. Wound care items should not be placed on the floor. Uncleaned scissors should not be used to cut multiuse Adaptic dressings.Hand Hygiene during Medication Administration:During a medication administration observation from 12:41 PM to 1:52 PM, Licensed Practical Nurse #15 administered medications to Residents #36, 39, 47, 66, and 67 without performing hand hygiene between residents.During an interview on 7/30/2025 at 2:06 PM, Licensed Practical Nurse #15 stated they did not remember to wash their hands between residents during medication administration. They stated they often got into a rush and forget to perform hand hygiene. During an interview on 8/01/2025 at 2:47 PM, the Infection Preventionist stated hand hygiene should be performed during medication administration. The licensed practical nurses should at least be wearing gloves for each administration and using hand sanitizer between each resident.10 NYCRR 415.19

Based on observation, record review, and interview during the recertification survey conducted 9/9/2024-9/16/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (1) of one (1) resident (Resident #8) reviewed. Specifically, Resident #8's diabetes mellitus diagnoses was incorrect in the resident's electronic medical record and was incorrectly coded in their Minimum Data Set, their morning insulin sliding scale order was not updated timely per the Endocrinologist's recommendation, the resident had a low blood sugar outside their sliding scale parameters with no documented notification to the provider, did not have maximum parameters on their sliding scales on when to notify the provider, and did not have a person-centered diabetic management care plan. Additionally, the resident did not have the recommended diabetic eye exam scheduled. The facility policy, Emergency Procedure Hyperglycemia, effective 4/2022, documented the nurse was to perform a finger stick and determine the blood sugar level with the glucometer. The nurse was to check for sliding scale insulin orders/parameters, follow the orders as written, and notify the registered nurse, nurse practitioner, and the physician would determine if 9-1-1 needed to be called. The nurse was to prepare the insulin per the medical provider's order and secure vital signs as soon as possible and every 10-15 minutes until stable.The facility policy, Interdisciplinary Comprehensive Care Plan, effective 4/2022, a comprehensive care plan must be completed within the first 7 days after admission that include person-centered, measurable objectives and timetables to meet resident's medical, nursing, mental, and psychosocial needs. Members of the interdisciplinary team were to update the comprehensive care plan as needed and review on no less than a quarterly basis.Incorrect diagnosis and Minimum Data Set coding and Care plan: Resident #8's electronic medical record documented the resident had diagnoses including Type 2 diabetes mellitus with hyperglycemia (high blood sugar), Type 2 diabetes mellitus with diabetic neuropathy (nerve damage), and hypertension (high blood pressure). The 7/10/2025 Minimum Data Set documented the resident was cognitively intact, the resident had Type 2 diabetes mellitus and received daily insulin with changes.There was no documented diabetes mellitus plan of care.The 4/17/2025 Endocrinology Office Note by Nurse Practitioner #3 documented Resident #8 had been diagnosed with Type 1 diabetes following pancreatitis in 2006.The 6/18/2025 Physician's Progress Note by Medical Provider #6 documented the resident had a diagnosis of Type 1 Diabetes Mellitus. During an interview on 8/01/2025 at 10:24 AM Licensed Practical Nurse Unit Manager #14 stated the resident was a Type 1 diabetic, the resident should have a diabetic/insulin care plan. The resident did not have one, it must have been missed.During an interview on 8/1/2024 at 4:04 PM, the Director of Nursing stated the Nurse Managers were responsible for initiating and updating care plans. Care plans were reviewed quarterly at minimum but also with medication changes and new problems. Residents who were diabetic and on insulin should have a care plan to reflect that. Care plans direct a resident's care to let staff know how to care for the resident.Diabetic eye care follow up:The 4/17/2025 Endocrinology Office Note by Nurse Practitioner #3 documented they recommended the resident have an updated diabetic eye exam as part of their plan of care for the management of their Type 1 Diabetes Mellitus.The 4/17/2025 After Visit Summary from Endocrinology documented Nurse Practitioner #4 recommend that the resident have a yearly diabetic eye exam and request the facility to assist to schedule.There was no documented evidence a diabetic eye exam was completed or scheduled for the resident.During an interview on 8/1/2025 at 11:07 AM, Unit Secretary #13 stated they had not scheduled a diabetic eye exam for Resident #8. They were unaware of the recommendation from the Endocrinologist on 4/17/2025. They had not seen it when they reviewed the paperwork.Timely sliding scale order change:The 5/28/2025 physician's order Humalog subcutaneous injection per sliding scale: if the resident's blood sugar was 90 - 160 = inject 8 units subcutaneously; 161 - 200 = 10 units; 201 - 250 = 12 units; 251 - 300 = 12 units; 301+ = 14 units at 7:00 AM. The order was discontinued on 7/7/2025.On 7/1/2025, Nurse Practitioner #3 from the Endocrinologist office reviewed the blood sugar logs for Resident #8 and noted the blood sugars before lunch were elevated and the Nurse Practitioner recommended increasing the sliding scale insulin at breakfast by 2 units. On 7/2/2025, a new morning sliding scale was faxed to the facility that included Humalog insulin for blood sugar 90 - 160 = inject 10 units subcutaneously; 161 - 200 = 12 units; 201 - 250 = 14 units; 251 - 300 = 14 units; 301+ = 16 units.There was no documented evidence the recommended new sliding scale from the endocrinologist office was addressed until 7/8/2025. The resident's morning blood sugars following breakfast prior to lunch between 7/2/2025 to 7/7/2025 were:- on 7/1/2025: 363- on 7/2/2025: 239- 7/3/2025: 169- on 7/4/2025: 338- on 7/5/2025: 280- on 7/6/2025: 478- on 7/7/2025: 329The 7/8/2025 physician's order documented the resident used Humalog subcutaneous injection per sliding scale at 7:00 AM: if the resident's blood sugar was 90 - 160 = inject 10 units subcutaneously; 161 - 200 = 12 units; 201 - 250 = 14 units; 251 - 300 = 14 units; 301+ = 16 units.During an interview on 8/1/2025 at 9:45 AM, Unit Secretary #13 stated when a resident came back from a consult or a consult from an outside provider, the consult paperwork came to the nursing station hub, Licensed Practical Nurse Unit Manager #14 reviewed it and then Unit Secretary #13 scanned it into the chart. If the consult paperwork contained orders, Licensed Practical Nurse Unit Manager #14 reviewed it and then informed the providers of the orders. If Licensed Practical Nurse Unit Manager #14 was not there, the Director of Nursing reviewed the consults.During an interview on 8/01/2025 at 10:24 AM Licensed Practical Nurse Unit Manager #14 stated when consults come back from appointments with residents or were faxed over, they reviewed the consult. If there were orders, they reviewed them with the provider within 24 hours. On 7/2/2025, they were aware there was a lot of back and forth with the Endocrinologist regarding Resident #8. There was no documentation of contact with the Endocrinologist office or them not receiving the expected sliding scale change on 7/2/2025.During a phone interview on 8/1/2025 at 12:18 PM, Licensed Practical Nurse #4 from the Endocrinologist office stated the facility had called on 7/7/2025 to inform them they had not received the new insulin sliding scale for Resident #8's morning blood sugar check. Licensed Practical Nurse #4 stated the facility had been anticipating the new orders as they had to call the facility to obtain their fax number. During a phone interview on 8/01/2025 at 3:14 PM, Medical Provider #6 stated if the facility staff were aware Endocrinology was sending over new orders for a sliding scale and they did not receive it that day, they should call that day to follow up on not receiving the orders.No parameters for physician notification:The resident's Humalog insulin orders did not contain parameters to instruct the administrating nurse when to notify the provider for blood sugar that were low, high or outside the sliding scale range. The July Medication Administration record documented:- on 7/21/2025 at the 7:00 AM blood sugar check, the resident had a blood sugar level of 72. The resident's insulin was held for being outside parameters. There was no documented evidence the provider was made aware, or steps were taken for the resident's low blood sugar.- on 7/6/2025 at 12:00 PM, 7/9/2025 at 12:00 PM and 5:00 PM, 7/10/2025 at 12:00 PM, 7/23/2025 at 12:00 PM, and 7/27/2025 at 12:00 PM the resident had blood sugars of 400 and over with no documentation of notification to the provider or steps taken except to provide the 301+ insulin coverage from the sliding scale.During an interview on 8/1/2025 at 9:32 AM, Licensed Practical Nurse #11 stated if a resident was on a sliding scale of insulin for diabetes mellitus and a resident's blood sugar were outside the numbers on the sliding scale you had to notify the provider. On 7/21/2025 when Resident #8's blood sugar level was 72, they notified the Nurse Practitioner #12 who was rounding on the floor. They were also supposed to give orange juice if a resident's blood sugar was below 100. They had not documented notifying Nurse Practitioner #12 or that they gave the resident orange juice. There were no additional orders for the resident besides giving orange juice to Resident #8. If the resident's sugar was low, the resident had their own designated glucagon in the medication cart, but they would need an order for when to administer it. During an interview on 8/01/2025 at 10:24 AM Licensed Practical Nurse Unit Manager #14 stated a resident who was on a sliding scale for insulin whose blood sugars were outside of the sliding scale the nurse was to notify the provider and themselves as the Unit Manager. It should be documented if the provider was notified. They were unaware Resident #8 had a blood sugar of 72 on 7/21/2025 and it was something they should have been aware of. Resident #8 did not have an order to notify the provider if their blood sugar reached above a certain number; it was based on clinical judgement. If Resident #8 had a blood sugar of 458, the provider should have been notified.During a phone interview on 8/01/2025 at 3:14 PM, Medical Provider #6 stated if a resident was on sliding scale insulin orders, there was supposed to be parameters for when the nursing staff were to call the physician. If it was above a certain number, they were to call a physician. They believed for the facility it was if the resident's blood sugar was above 300 or 350. They were unaware of what the facility's protocol was for at which low threshold the nursing staff was to notify the physician. They expected a sliding scale order to have parameters for when to call the provider. They were unaware Resident #8 had four sliding scales that did not have parameters and there should be. They stated if a resident had a blood sugar of 478, the facility staff should notify a provider as the resident might need more insulin.10NYCRR 415.12

Based on record review, observations, and interviews during the recertification survey conducted 7/29/2025 - 8/1/2025, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one (1) of two (2) residents reviewed (Resident #5). Specifically, Resident #5 had a pressure ulcer that was not reclassified to its proper stage once opened and they did not have their ordered protective dressing applied to their hand as ordered to maintain skin integrity. Additionally, the resident's privacy was not maintained during wound care. The facility policy, Skin-Wound Assessment and Care, effective 4/2022, documented the interdisciplinary team were to minimize pressure and risk factors to the resident's skin and ensure adequate hydration and nutrition to maintain skin integrity. A pressure ulcer means an ulcer and/or necrotic tissue overlaying a bony prominence that had been subjected to pressure, friction, or sheer. The nurse would observe the resident for skin care needs, including preventative measures. Preventative measures as recommended in the [National Pressure Ulcer Advisory Panel] prevention and treatment of pressure ulcer guidelines on any resident at risk for skin breakdown.The Minimum Data Set 3.0 Resident Assessment Instrument Manual, effective 10/2024, documented a deep tissue injury was defined as a purple or maroon area of discolored intact skin due to damage of underlying soft tissue. Once deep tissue injury has opened to an ulcer, the ulcer was to be reclassified into the appropriate stage.Resident #5 had diagnoses including peripheral vascular disease (narrowed or blocked blood vessels in limbs), dementia with other behavioral disturbance, and hypertension. The 5/25/2025 Minimum Data Set documented the resident was severely cognitively impaired, had an impairment to both left and right upper and lower extremities, was at risk for developing pressure ulcers, and had one unstageable pressure injury that presented as a deep tissue injury.The Comprehensive Care Plan initiated 6/28/2021, updated 7/29/2025, documented the resident had potential for skin breakdown related to hypertension, impaired cognition, impaired mobility. The resident had a left second toe peripheral vascular wound that opened 1/26/2025, a deep tissue injury to the right posterior heel that occurred on 1/27/2025, was on enhanced barrier precautions related to a chronic wound and was ordered to have a small Allevyn Ag Gentle Border Adhesive dressing to right palm for preventative. The 2/10/2025 Physician's order documented to apply small Allevyn Ag Gentle Border Adhesive dressing to the right palm once every other day and as needed for preventative.The 7/16/2025 Physician's order documented to cleanse the right posterior heel with wound wash, apply Adaptic dressing to wound base and cover with Optiform once daily every dayshift for wound care.The 6/18/2025 Skin and Wound note by Registered Nurse #17 documented the resident was followed for a deep tissue injury to the right posterior heel and a peripheral vascular wound to the left second toe. The deep pressure injury to the right posterior heel measured 0.5 centimeters by 1 centimeter. It had an odor but no drainage, undermining, or sinus tract. The wound base was pale with a red peri-wound, and a well-defined wound edge. The treatment to the right posterior heel was changed on 6/12/2025 to cleanse area with wound cleanser, pat dry, apply iodosorb on a dry 2 by 2-inch pad, and apply to the wound base. Cover the area with a heel cup and secure with conforming gauze to be changed every day and as needed.The 7/16/2025 Skin and Wound note by Registered Nurse #17 documented the deep tissue injury to the right posterior heel measured 0.9 centimeters by 1.2 centimeters by 0.1 centimeters. There was a scant amount of serous (clear watery fluid) with no odor, undermining, or sinus tract. The wound base was 50 percent red and 50% tendon.The 7/23/22025 Skin and Wound note by Registered Nurse #17 documented the deep tissue injury to the right posterior heel measured 0.7 centimeters by 1 centimeter by 0.1 centimeter. There was a scant amount of serous drainage with no odor, undermining, or sinus tract. The wound base was 80 percent glistening white tendon and 20 percent red. The peri-wound was pink and the wound edge well defined.During observations on 7/29/2025 at 3:17 PM, 7/30/2025 at 1:14 PM, 7/31/2025 at 8:21 AM and 1:34 PM, and 8/1/2025 at 9:29 AM the resident's fingers on their right hand were curled in toward the palm and the resident did not have a small Allevyn Ag Gentle Border Adhesive dressing applied.During a wound care observation on 7/31/2025 at 10:08 AM, the resident's wound was a circular wound on the resident's lateral heel approximately the size of a dime with red edges with the tendon line visible with the rest of the wound bed reddish pink with a slightly wet appearance. The door to the resident's room also remained open during wound care and their privacy was not maintained.During an interview on 7/31/2025 at 10:14 AM, Licensed Practical Nurse #21 stated they typically provided privacy such as closing the door or drawing the curtain to provide privacy during wound care for a resident. Resident #5 was very temperamental and can get aggressive during care so they left the door open for if they needed assistance. The resident did not have a privacy curtain in their room since it was a private room. They should have closed the door for privacy. During an interview on 8/1/2025 at 9:32 AM, Licensed Practical Nurse #11 stated treatments and skin integrity intervention orders were documented on the Treatment Administration Record. A resident who had an order for a skin integrity intervention should have it in place as ordered. Resident #5 had an order for a small pad to their right palm ordered every other day and as needed. When they worked with the resident on 7/29/2025, the order was not due that day. The pad should be applied to the resident's hand if it was not there. During an interview on 8/1/2025 at 10:24 AM, Licensed Practical Nurse Unit Manager #14 stated a resident who had a skin integrity intervention ordered should have the device in place. Resident #5 had an order for a small adhesive pad to be applied to the hand to maintain skin integrity. The resident did refuse the pad on occasion, and it should be documented in the electronic medical record as a refusal. They weren't aware of any time the resident had removed the adhesive pad once it was applied. The pad was to relieve pressure on their right hand. They were unaware the adhesive pad had not been applied throughout the week. The resident's deep tissue injury was caused by rubbing from a pair of sneakers the resident had. The wound was considered a deep tissue injury and the staging of the wound was done by Register Nurse #17, who was the Wound Nurse. The deep tissue injury had opened opened up and the wound bed was visible. During an interview on 8/1/2025 at 12:44 PM, Registered Nurse #17 stated they did weekly wound rounds at the facility. They were responsible for staging the wounds if it was a facility acquired wound. If a deep pressure injury opened, they generally kept the classification as a deep tissue injury depending on what the wound base looked like. Resident #5's lateral heel wound was a pressure wound from socks and shoes. They were unsure if since the wound opened if it would still be considered a deep tissue injury but that was what it currently was called. 10NYCRR 415.12(c)(1)

Based on observations, record review, and interviews during the recertification survey conducted 7/29/2025 to 8/1/2025 the facility did not ensure a system of records and accounts of all controlled drugs was maintained for one (1) of two (2) nursing carts (Rehab Unit) reviewed. Specifically, the controlled substance accountability record was not accurately reconciled after the medication was administered to the resident for four residents.Findings include:The facility policy Controlled Medication Storage, effective 5/2018 documented controlled substances were subject to special handling, storage, disposal, and record keeping in accordance with federal, state, and other applicable laws and regulations. A controlled substance accountability record was prepared by the pharmacy/facility for controlled substance category medications including those in emergency supply. The following information was completed on the accountability form upon dispensing or receipt of controlled substance or use of controlled substance from the emergency supply: name of resident, prescription number, name/strength/dose form of the medication, date received, amount received, and name of person who received the medication supply.The facility policy Narcotic and Controlled Drugs Reconciliation/Count, effective 4/2022, documented it was the policy of the facility to reconcile all narcotic and controlled medications reconciliation/count during the shift or at the change of shift on each unit.The facility policy Medication Administration- General Guidelines, effective 4/2022, documented the licensed individual who administered the medication was to record the administration in the medication administration record at the time the medication was given and initial and date the blister pack for the dose administered.During an observation and interview on 7/30/2025 at 10:51 AM with Licensed Practical Nurse #15, four narcotic medications were given to residents and not signed out in the controlled substance accountability record in the nurses' cart for:- Resident #55 had a blister pack for an as needed dose of 10 milligrams of oxycodone that had 9 pills remaining. The count in the controlled substance accountability record was 10. Licensed Practical Nurse #15 stated the medication was given at 10:37 AM.- Resident #26 had a blister pack of 5 milligrams of oxycodone that had 10 pills remaining. The count in the controlled substance accountability record was 11. Licensed Practical Nurse #15 stated they signed for it in the medication administration record when it was given.- Resident #46 had a blister pack of tramadol/apap 37.5-325 milligrams that had two pills remaining. The count in the controlled substance accountability record was 3. The medication was signed for in the medication administration record.- Resident #64 had a blister pack for Percocet that had 13 pills remaining. The count in the controlled substance accountability record was 14. The medication was signed for in the medication administration record as an as needed dose at 9:59 AM.Licensed Practical Nurse #15 stated none of the narcotic medication they have given that morning had been signed out for in the narcotic reconciliation book. They normally signed out when they gave the narcotic medication, but they were very behind that morning. They should be signed for when given so it doesn't look like they took the medication.During an interview on 8/1/2025 at 11:14 AM, the Director of Nursing stated narcotic and controlled medications should be signed out in the narcotic reconciliation book at the time it was given. It was best practice to sign for the medication it was given so its not forgotten to be signed for. When a narcotic or controlled medication wasn't signed for, a concern for diversion of controlled substances occurs.10NYCRR 415.18

Based on observations and interviews during the recertification survey conducted 7/29/2025 to 8/1/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for one (1) of two (2) medication carts (Rehab Unit cart) and one (1) of one (1) medication rooms (Rehab Unit) reviewed. Specifically, the Rehab Unit medication cart had three multidose eye drops that were opened and expired. The Rehab Unit medication room had two single resident use medication vials that were unlabeled, there was expired flu vaccine in the medication fridge and a box of medications to be destroyed underneath the medication room sink. Additionally, the Rehab Unit medication cart was left unattended and out of sight of the licensed practical nurse during one observation.Findings include:The facility policy Medication Storage in the Facility, effective 5/2018, documented medications and biologicals would be stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply was to only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully able to administer medications. Medication carts, rooms, and medication supplies were to be locked when unattended. Medications labeled for individual residents were to be stored separately from the floor stock medications when not in the medication cart. Outdated, contaminated, or deteriorated medications and those in containers that have been cracked, soiled, or without secured closures were to be immediately removed from inventory, disposed of in accordance with procedures for medication disposal, and reordered from the pharmacy if there was an active order. Ophthalmic and multiple dose injection vials required an expiration shorter than the manufacturer's recommendation to ensure medication purity and potency. The nurse was to check the expiration date of a medication prior to administration and no expired medication would be administered to a resident.Medication Cart:During an observation and interview with Licensed Practical Nurse #15 on 7/30/2025 at 10:45 AM of the Rehab Unit medication cart there were three eye drop bottles: two bottles of latanoprost 0.005% dated 6/14/2025, one of which had a dose administered out of that morning and one bottle of dorzolamide solution 2% with an open date of 6/14/2025 that a dose was administered from that morning. Licensed Practical Nurse #15 stated eye drops were good for 30 days after opening. All three bottles were expired as they were opened 6/14/2025. They did not know why eye drops were supposed to be given within 30 days. They did not usually look at the open dates on the bottles of eye drops. They stated they were usually in a hurry and residents were not usually on the unit for more than 30 days.During an interview on 08/01/2025 at 11:14 AM, the Director of Nursing stated medication carts were checked at least monthly to ensure there were no expired medications in the cart. Eye drops were labeled on the day it was opened, they were good for 28 days, then they should be disposed of. Eye drops that were opened on 6/14/2025 should not have been given on 7/30/2025 because it was beyond the manufacturer's recommendations to be used after a set amount of time.Medication Room:During an observation and interview on 7/30/2025 at 11:06 AM of the Rehab Unit medication room there was:- two small vials of opened Lidocaine Hydrochloride 1% injection with an open date of 6/30/2025 mixed into the house stock medication bottle cabinet. They were not labeled with the resident's name.- a box of medications and cold packs that were to be destroyed per the Director of Nursing under the sink in the medication room along with a bag full of file folders with paperwork, an empty basin, and an organization tray.- a tube of Secura Protective Cream in the treatment cart that expired 4/2025 that was opened and used.- lying on a layer of water along the top shelf in the medication fridge were vials of influenza vaccines and refrigerated medication bags. - a box of high dose influenza vaccine, unopened, that expired 6/2025. The Director of Nursing stated the lidocaine hydrochloride 1% vials were resident specific and could not be utilized for multiple residents. They were unsure why they were with the house stock of medications, and they should have been disposed of. The did not have a pharmacy label as they were likely pulled from the Omnicell emergency medication supply. They stated they did not use that brand of protective cream anymore and stated they were unaware of why it was in the treatment cart. Treatment carts should be checked monthly to make sure nothing was expired. The facility had not administered the influenza vaccine in months, and they did not know why there was expired vaccines in the fridge.Unattended and Unlocked Medication Cart:During an observation and interview on 7/30/2025 at 1:48 PM, Licensed Practical Nurse #15 left the medication cart open by a resident room unlocked and unattended as they went down the hallway and around the corner to retrieve a ginger ale. Licensed Practical Nurse #15 stated medication carts were to be locked so confused residents did not get into the cart.During a follow up interview on 7/30/2025 at 2:06 PM, Licensed Practical Nurse #15 stated they locked the medication cart when they out of sight of the cart. They should not have left the cart unlocked to go get a ginger ale and not in sight, but they were busy and forgot. The policy for locking the medication cart should be followed to keep people who wander from getting into the medication cart and getting harmed.10NYCRR 415.18(d)

Based on observations, record review, and interviews during the recertification survey conducted 7/29/2025-8/1/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one (1) of two (2) kitchenette areas. Specifically, the 3rd floor kitchenette contained staff food items that were not properly stored, undated food items in the refrigerator, dishes were not dried properly after washing, and the air conditioning vent had debris on it.Findings include:The facility policy Unit Pantries effective 12/2024 documented dietary would check all unit pantry refrigerators and cupboards daily and discard items that were not labeled, not dated, expired, or items opened not sealed or covered properly. Unit refrigerators in the pantry were for resident items only and staff should not consume or store products in the resident refrigerators.The facility policy Sanitary Conditions effective 12/2024 documented storage areas including cupboards, shelves, and drawers were to be kept dry and clean from debris.During an observation of the 3rd floor kitchenette on 7/31/2025 between 10:38 AM and 11:04 AM:- 1 opened 16-ounce energy drink was in the refrigerator.- 17 individual 2-ounce dressing cups with lids were undated in the refrigerator.- 37 various 4-ounce and 6-ounce juice cups were stacked inside the cupboard and wet. There was a wet spot on the shelf where the cups were stacked.- 27 insulated plate domes and bottoms were stacked and wet.- the air conditioning vent near the steam table had debris on it.During an interview on 7/31/2025 at 11:04 AM, Food Service Worker #19 stated they did not see the cups stacked in the cupboard but there was a wet spot where they were stacked. They did the dishes and did not check to make sure they were dry. The 27 insulated plate domes and bottoms were also stacked wet. During an interview on 7/31/2025 at 11:22 AM, the Food Service Director stated maintenance should have been cleaning the air vents in the kitchenette monthly to prevent the potential for physical contamination of food items while food was being served. It was the responsibility of the server during meals to ensure dishes were dry before bringing them upstairs. If dishes were stacked wet, it could have potentially led to bacterial growth. The refrigerators in the kitchenettes were for the residents. Facility staff should not have put their personal items in the resident refrigerator because they had their own breakroom and if the food item was opened it could have led to cross contamination.During a follow up interview on 8/1/2025 at 4:00 PM, the Food Service Director stated they did not date items on the production sheet. They knew they needed 17 salad dressings, they were prepped that day, and they used a full gallon of ranch dressing each day, but they expected thing to be dated.10NYCRR 415.14(h)

Based on observations and interviews during the recent recertification survey conducted 7/29/2025-8/1/2025 the facility did not ensure the results of the most recent survey and the corresponding plan of correction were readily accessible to residents and their representatives, as required. Findings include:The facility policy Resident Rights, revised in April 2022, documented the residents/family members/responsible party of resident's rights by posting within the facility, information to provide access to any representative or governmental agent as outline in federal and state code, legal or other services. During a Resident Council meeting on 7/30/2025 at 11:26 AM, the residents in attendance were unaware of the location of a copy of the most recent Statement of Deficiencies (Form CMS 2567) or Plan of Correction.During an observation on 7/30/2025, the main lobby had no visible information indicating the detailed availability of past survey information. Upon inspection, the survey binder was discovered in the lobby on top of a shelf, under a plant with random unrelated papers placed on top. The folder contained the results of complaint surveys from 2024.During an interview on 8/1/2025, front desk Receptionist #5 stated they did know the location of the folder that contained the state survey results. They were not aware the results were required to have been readily accessible to all residents and families. During an interview on 8/1/2025 at 4:25 PM, the Administrator stated they were responsible for the placement of the survey results. The binder should have been placed where the residents could have accessed them. 10 NYCRR S 415.3(c)(1)(v)

Based on record review and interviews during the abbreviated survey (NY00368765), the facility failed to ensure the residents' environment remained free of accident hazards for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1's care plan documented to remove the walker from their room when not in use. Subsequently, the resident fell from bed, their neck became entangled on the basket attached to their walker, and they were found without a pulse or respirations and expired. This resulted in Immediate Jeopardy past non-compliance, to Resident #1. Findings include: The facility policy, Accident/Incident Prevention and Risk Management, revised ,d+[DATE], documented each resident would receive adequate supervision and assistive devices to prevent accidents and the residents' environment would be managed to be free of accident hazards. Fall and elopement risk evaluations were completed within the electronic record upon admission, quarterly, annually and with any significant changes. The resident's care plan would be initiated and/or updated to reflect and address these and other injury risk factors with appropriate interventions as determined by the Interdisciplinary Team. The undated facility policy, Updating of Resident Care Plans, documented it was essential that each resident's care plan reflect the current status of the resident and the necessary interventions to meet their needs. Care plans were to be reviewed and updated regarding the resident's progress toward any stated goal. This was the responsibility of each member of the Interdisciplinary Team to complete before the meeting. Care Plans needed to be updated whenever the resident developed an acute illness or experiences another new event which could impact the resident's overall status: any updates should be reflected in the resident's Kardex (care instructions) for staff's immediate reference for care of the resident. The resident's Kardex would be considered part of the care plan. Resident #1 had diagnoses including dementia. The [DATE] Minimum Data Set assessment (an assessment tool) documented the resident had severely impaired cognition, required substantial/maximal assistance with rolling left to right, was dependent with transfers, and utilized a walker and a wheelchair. The Comprehensive Care Plan documented: - On [DATE], the resident was at risk of falling and required partial/moderate assistance of 1 with a two-wheel walker, and the walker was to be left at the nursing station when the resident was not ambulating with staff. - On [DATE], the resident was dependent on 2 staff for transfers using a mechanical sit-to-stand lift. The resident had an ambulation program to walk to and from all meals and was dependent on 2 staff using a rolling walker, gait belt, and a wheelchair to follow. - On [DATE], the resident was non-ambulatory and dependent with assistance of one (1) staff for wheelchair mobility. The intervention to ambulate to all meals using a rolling walker was discontinued. The intervention to store the walker at the nursing station when not in use remained on the care plan. A [DATE] Occupational Therapist #7's evaluation and plan of treatment documented the resident was evaluated for a decline in ability to perform functional activities. They had a history of falls, was a fall risk, and used a 2 wheeled walker prior to onset of their current condition. The resident had generalized weakness, deconditioning, decline in functioning, increased dependence on caregiver, pain, and cognitive deficits, resulting in the need for skilled occupational therapy. There was no documented evidence regarding the resident's current use of a walker. A [DATE] at 4:30 AM Incident Report completed by Registered Nurse Supervisor #2 documented the resident was found on the floor between the bed and the nightstand. The resident stated they were trying to get out of bed. They sustained a hematoma (collection of blood) to their forehead and an abrasion to the right knee. Predisposing environmental factors included furniture and poor lighting. There was no further documentation related to the furniture. There was no documented evidence the care plan was reviewed or revised with interventions to address environmental hazards. The [DATE] Physical Therapy Assistant #5 progress note documented they attempted ambulation with the resident. The resident stood with the rolling walker with moderate assistance of 3, the resident was leaning back and to the right. The undated Kardex documented the resident utilized a sit to stand mechanical lift with 2 staff assistance for transfers. The resident had a basket for their walker. The Kardex did not contain documentation the resident utilized a walker for transfers or ambulation or the intervention (from the care plan) the walker was to be stored at the nursing station when not in use. A [DATE] at 12:29 AM Licensed Practical Nurse #3 progress note documented the resident was in bed upon start of shift (night shift, 11:00 PM-7:00 AM) where they remained. The resident appeared to be resting comfortably in bed with all safety measures in place. A [DATE] at 1:04 AM Incident Report initiated by Registered Nurse Supervisor #2 documented they were called to the resident's room at 1:04 AM by Certified Nurse Aide #8. The resident was found between their bed and recliner with their neck on the wire basket of their walker, their right knee on the ground, and their left leg against the bed. The resident had no pulse and was not breathing. The resident was wearing non-skid socks and pressure relieving boots. The resident had a pressure mark on their neck, a skin tear on the left arm, bruising on their knees, and was incontinent of stool. The on-call nurse practitioner was called, who then notified the coroner and the local police, who in turn completed assessments on site. Predisposing factors included poor lighting, confusion, impaired memory, recent illness, and the resident ambulated without assistance. Certified Nurse Aide #1's statement documented they found the resident off their bed, with their neck caught on their walker basket. The Investigative Summary, unsigned and undated, documented the resident was care planned as dependent for transfers and bed mobility, was non-ambulatory, and their walker was to be stored at the nurse's station when not in use. On [DATE], the coroner contacted the facility and reported the resident had an active cardiac event at the time of their passing. The coroner concluded the resident's neck came to rest on the walker basket and the positional pressure on the carotid artery potentially contributed to their death. The cause of death was determined to be strangulation. During a telephone interview on [DATE] at 2:15 PM, Certified Nurse Aide #1 stated they were not aware the resident's walker should have been stored at the nursing station because it was not on the Kardex. They typically saw the walker in the resident's room at night when they worked. The night they found the resident, the walker was folded up and the wire basket attached to the walker was facing out (not against the wall). The walker was sandwiched between the bed and recliner. During a telephone interview on [DATE] at 9:26 AM, Coroner #4 stated when they arrived at the facility on [DATE] the resident was still warm and flaccid (limp). Based on autopsy, the resident was in the process of having a heart attack that was a coronary dissection (tearing of a coronary artery). They could not say if the heart attack happened first and then the resident fell on the walker or if the resident fell first and subsequently had a heart attack. The imprint on the neck from the walker basket was very evident. They stated the resident did not fall from a high distance to cause the mark; the mark was more from pressure. They presumed strangulation was the immediate cause of death and the contributing factor was the heart attack. During a telephone interview on [DATE] at 9:30 AM, Registered Nurse Supervisor #2 stated the resident attempted to get out of bed unassisted and transferred on their own in the past. They were not sure why the resident had a walker in their room and stated the resident worked with therapy with the walker. The resident was dependent for transfers. During an interview on [DATE] at 10:38 AM, the Director of Nursing stated it was best practice to check the Kardex at the time of the care plan review. The Nurse Manager was responsible for completing the care plan review at the time the Minimum Data Set assessment was scheduled. If nursing staff added a new intervention to the care plan, they were responsible for ensuring the intervention was transferred to the Kardex. There was no second check process to ensure interventions were carried over the to the Kardex. During a telephone interview on [DATE] at 3:33 PM, Occupational Therapist #7 stated prior to the resident's hospitalization , they implemented an ambulation program for the resident using a rolling walker. When the resident returned from the hospital on [DATE], they could no longer ambulate. Occupational Therapist #7 stated they discontinued the ambulation goal because they did not want staff ambulating the resident. Occupational Therapist #7 stated they typically notified as many staff as they could upon discontinuing a goal and they could not recall who they spoke with. There was no process in place to determine who was responsible for removing the resident's walker once a goal was discontinued. They were not aware the walker was not removed from the resident's room. They used a walker from the therapy department on [DATE] and did not use the walker in the resident's room. During an interview on [DATE] at 4:15 PM, Licensed Practical Nurse Manager #6 stated they were responsible for initiating, updating, and reviewing care plans. When there was an incident and the Interdisciplinary Team made recommendations, the Licensed Practical Nurse Manager added those to care plans. At the quarterly Care Conferences from ,d+[DATE] to ,d+[DATE], they did not compare the Care Plan against the Kardex. When adding interventions to the Kardex, they needed to choose a category (like safety or elimination); if that step was left out, the intervention would not transfer to the Kardex, and the system did not alert anyone the transfer failed. Licensed Practical Nurse Manager #6 stated near the end of their stay, the resident no longer ambulated with staff but continued to ambulate with therapy. They stated the walker should have been removed from the resident's room when the ambulation goal was discontinued in [DATE]. The resident's Care Conference Attendance Sheets documented Licensed Practical Nurse Manager #6 signed they were in attendance on [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 1:10 PM, the Administrator stated they determined there was a care plan violation on [DATE] when the Interdisciplinary Team reviewed the incident and found the Kardex did not match the Care Plan. The care plan violation contributed to the incident. They were not aware Licensed Practical Nurse Manager #6 was not comparing the Care Plan against the Kardex prior to the incident, as they were expected to. During a telephone interview on [DATE] at 1:03 PM, the Medical Director stated they expected the Care Plan and Kardex to match so the certified nurse aides were aware of interventions. They stated the walker should have been removed from the resident's room when staff were no longer using it. The Medical Director stated the resident died from strangulation. -------------------------------------------------------------------------------------- Immediate Jeopardy past non-compliance was identified, and the Administrator notified on [DATE] at 1:58 PM. The facility provided verification the following corrective actions were completed: - On [DATE], Licensed Practical Nurse Manager #6 was retrained on Updating Resident Care Plans. - On [DATE], all licensed nursing staff were retrained on Updating Resident Care Plans. - On [DATE], staff education sign in sheets were reviewed and compared to current staff list and no discrepancies were identified. - All resident Care Plans/Kardex's were audited on [DATE] to ensure all interventions were accounted for. The Director of Nursing continued to audit five resident records weekly to ensure compliance. 10NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interview during the recertification and abbreviated (NY00329838)surveys conducted 1/16/2024- 1/19/2024, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to the installation of bed rails for 5 of 5 residents (Residents #1, #24, #25, #27 and #38) reviewed. Specifically, for Residents #1, #24, #25, #27 and #38 there was no documented evidence the risks and benefits of bed rails were explained to the residents or their representatives or that consents were obtained prior to bed rail installation. Additionally, on 12/13/2023, Resident #24 was found sitting on the floor next to their bed with their left arm entrapped in the bed rail resulting in abrasions to their abdomen. Findings include: The facility policy Physical Restraints, reviewed 4/21/2022, documented physical restraints were any manual method or physical mechanical device, material or equipment attached or adjacent to the resident's body that the individual could not remove easily. This included bed assist rails. The procedure for physical restraints included: - The interdisciplinary team would determine with the resident and health care proxy input if a device constituted a restraint or an enabler for the resident and examined the risks and benefits. - The team would continue to monitor/evaluate the use of restraints and attempt to minimize/reduce the use of restraints as part of its evaluation process. - Documentation of effectiveness of enabler restraints would be reflected in the care plan and medical record. 1) Resident #24 had diagnoses including unspecified dementia without behavioral disturbance and chronic obstructive pulmonary disease (lung disease). The 11/17/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, had upper extremity impairment on one side, rolled to the left and to the right with partial/moderate assistance, and a bed rail was not used. The comprehensive care plan initiated on 10/31/2023 documented the resident had bilateral assist rails to promote independence in bed mobility. Interventions included complete bed rail determination evaluation per facility policy and educate resident and family on appropriate use of assist rails. The resident's Restrictive Device form, effective date 10/31/2023, documented: - The resident was alert but had decreased safety awareness. - Interventions attempted to date were assist rail, and the resident could purposefully release the device upon request. - Under restrictive devices necessary it was checked no. - The date of consent by the health care proxy for the device and the date of most current order and/or review by the medical provider at the bottom of the form were blank. The form was signed by licensed practical nurse supervisor #6 on 10/31/2023. The resident's Bed Rail Determination form, effective date 11/15/2023, documented: - The resident required assist rails for bed mobility and/or transfers. - The resident was not reaching out or up as they were turned from side to side, so a screen from therapy was not required. - The recommendation from therapy and nursing was the resident required the use of assist rails for repositioning of self and preparation of transfers. - The plan was reviewed by the interdisciplinary team, and it was recommended to continue the current plan of care. - The form was signed by licensed practical nurse supervisor #6 on 11/16/2023. The 12/13/2023 resident's care instructions documented under bed mobility: bilateral assist rails. A 12/13/2023 facility investigation documented at 12:25 AM Resident #24 was found sitting on the floor next to their bed with their left arm caught between the assist rail and the mattress/bed frame. The resident was laughing and stated they wanted to play on the floor. The resident's arm was removed from between the assist rail and mattress by registered nurse #11. Registered nurse #11 assessed the resident who was found to have red marks on their left arm from the assist rail and an abrasion to their left upper abdomen where it rubbed against the bed frame. First aid was administered. The resident was transferred back to their bed via a mechanical lift. The medical provider on-call and family were notified. The care plan was reviewed, and therapy was notified with a request for a bed rail determination evaluation. The Bed Rail Determination form effective 12/13/2023 at 8:17 AM documented: - The resident required assist rails for bed mobility and/or transfers. - The resident was reaching out or up as they were turned from side to side, so a screen from therapy was required. - The recommendation from therapy was assist rails to assist with repositioning and to improve independence with bed mobility tasks. - The plan was reviewed by the interdisciplinary team, and they agreed. - The form was signed by the Director of Nursing on 1/16/2024. During an observation on 1/16/2024 at 1:30 PM the resident was lying in their bed with their lunch tray in front of them. The bed was in high position with bilateral bed assist rails. The resident was looking at the ceiling and mumbling nonsensical words. They were unable to answer any questions regarding their bilateral bed assist rails. There was no documented evidence that the risks and benefits of bed rails was completed with the resident or the resident's representative, or that informed consent was obtained prior to the installation of the assist rails. 2) Resident #25 had diagnoses including vascular dementia with other behavioral disturbances and cerebral infarction (stroke). The 12/6/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, had lower extremity impairment on one side, rolled to the left and to the right with partial/moderate assistance, and a bed rail was not used. The comprehensive care plan initiated on 9/27/2021 and revised on 10/27/2023 documented the resident had bilateral assist rails to promote independence in bed mobility. Interventions included complete bed rail determination evaluation per facility policy and educate resident and family on appropriate use of assist rails. The resident's Restrictive Device form, effective date 12/6/2023, documented: - The resident was alert but had impaired memory, decreased safety awareness, and wandered. - Interventions attempted were increased supervision and interventions attempted to date were assist rail. - - The resident could purposefully release the device upon request. - Under restrictive devices necessary it was checked no. - The date of consent by the health care proxy for the device and the date of most current order and/or review by the medical provider at the bottom of the form were blank. The form was signed by licensed practical nurse supervisor #6 on 12/7/2023. The resident's Bed Rail Determination form, effective 12/15/2023, documented: - The resident required assist rails for bed mobility and/or transfers. - The resident was not reaching out or up as they were turned from side to side, so a screen from therapy was not required. - The recommendation from therapy and nursing was to continue to utilize assist rails to assist with bed mobility and repositioning. - The plan, reviewed by the interdisciplinary team, was to continue the current plan of care. - The form was signed by licensed practical nurse supervisor #6 on 12/7/2023. The resident's care instructions as of 1/18/2024, documented bed mobility: bilateral assist rails. During an observation on 1/18/2024 at 9:18 AM, the resident was sitting in their room in a recliner drinking a beverage. Bilateral bed assist rails were on the bed. The resident was not able to answer any questions about their bilateral bed assist rails. There was no documented evidence that the risks and benefits of bed rails was completed with the resident or the resident's representative, or that informed consent was obtained prior to the installation of the assist rails. 3) Resident #1 had diagnoses including dementia and cerebral infarction (stroke). The 10/12/2023 Minimum Data Set assessment documented the resident had intact cognition, had no lower or upper body impairments, rolled to the left and to the right with substantial/maximal assistance, and a bed rail was not used. The comprehensive care plan initiated on 11/24/2020 and revised on 12/9/2023 documented the resident had bilateral assist rails to promote independence in bed mobility. Interventions included complete bed rail determination evaluation per facility policy and educate resident and family on appropriate use of assist rails. The resident's Restrictive Device form, effective 1/12/2024, documented: - The resident was alert but had decreased safety awareness. - Interventions attempted to date were assist rail. - The resident could purposefully release the device upon request. - Under restrictive devices necessary it was checked no. - The date of consent by the health care proxy for the device and the date of most current order and/or review by the medical provider at the bottom of the form were blank. - The form was signed by licensed practical nurse supervisor #6 on 1/12/2024. The resident's Bed Rail Determination form, effective date 1/12/2024, documented: - The resident required assist rails for bed mobility and/or transfers. - The resident was not reaching out or up as they were turned from side to side, so a screen from therapy was not required. - The recommendation from therapy and nursing was the resident continued to utilize bed rails to assist with bed mobility. - The plan, reviewed by the interdisciplinary team, was to continue current plan of care. - The form was signed by licensed practical nurse supervisor #6 on 1/12/2024. The resident's care instructions as of 1/18/2024, documented bed mobility: bilateral assist rails. During an observation on 1/18/2024 at 9:33 AM the resident was in bed eating their breakfast. Bilateral assist rails were on the bed. The resident stated they used the bilateral assist rails on their bed and grabbed onto them when they were being washed or turned. They could not state if they or their family representative had had the risks or benefits of the assist rails explained prior to their installation on the bed. There was no documented evidence that the risks and benefits of bed rails was completed with the resident or the resident's representative, or that informed consent was obtained prior to the installation of the bed assist rails. During an interview on 1/17/2024 at 2:15 PM, certified nurse aide #12 stated Resident #24 used the assist rails for mobility and turning during care. The resident had requested the assist rails be pulled down all the way, but they told the resident they could not do that as they were only to be used for mobility assistance and not as a bed rail to keep them in bed. They were not aware of any incidents involving the resident becoming entrapped in the assist rails. During an interview on 1/17/2024 at 2:31 PM, social worker #13 stated Resident #24 did use their bed assist rails. They recalled the 12/13/2023 incident involving the bed assist rails as it was discussed in the interdisciplinary team meeting on 12/13/2023.They discussed what interventions were in place and if the care plan was followed. They notified the resident's representative about the incident. The resident could have erratic behaviors and sometimes could be more aware of what was going on than other days. They were not aware of any risk/benefit meetings or informed consent needed for the bed assist rails and thought maybe the Director of Social Work or the Director of Nursing would have more knowledge about this topic. During an interview on 1/18/2024 at 10:01 AM licensed practical nurse supervisor #6 stated all new admissions were screened by therapy for bed assist rails using the bed rail determination form. It was discussed during the interdisciplinary team meeting, and when it was decided by the team a resident needed the bed assist rails, it would be documented at the bottom of the bed rail determination form. It would also be documented in the comprehensive care plan by either therapy or the registered nurse. They were not aware of any interventions trialed for Resident #24 before they received their bilateral bed assist rails. Possible interventions prior to bed assist rails being installed could be a scoop mattress or having another staff person assist with turning and repositioning. The risks of using bed assist rails could be entanglement, injury, or suffocation. They were aware of the 12/13/2023 incident involving the bed assist rails and Resident #24. During the interdisciplinary team meeting they had asked therapy to assess the resident and they felt the resident still needed the bed assist rails. They were not aware of any risk/benefit meetings involving bed assist rails or if there was any informed consent by the resident or the resident's representative. They reviewed the 10/31/2023 restrictive device form for Resident #24 and stated they filled it out. They noticed at the bottom of the evaluation that the informed consent section and medical provider section were blank. They stated it looked like they did not complete the form but was not sure what staff was responsible for obtaining informed consent. Licensed practical nurse supervisor #6 then looked at the restrictive device form for Residents #1 and #25 and stated the informed consent and medical provider sections were blank for those two residents as well. During an interview on 1/18/2024 at 10:31 AM the Director of Social Work stated it was a team decision for a resident to be able to use bed assist rails. Therapy did the initial bed rail determination evaluation. They did recall the interdisciplinary team meeting on 12/13/2023 regarding Resident #24's incident with the bed assist rails. They did not know what staff was responsible for the risk/benefit meeting regarding bed assist rails, and they were not aware of the restrictive device form that contained the informed consent and medical provider sections to be addressed. During an interview on 1/18/2024 at 10:58 AM, the Director of Nursing stated therapy did a screen on all new admissions and then it would be discussed during the interdisciplinary team meeting. It was a team decision for a resident to use bed assist rails. The care plan for bed assist rails needed to be individualized for the resident. The intervention for educating the resident and family on bed assist rails would be discussed during admission, along with other things the resident needed to be oriented on. They did not think the education on the bed assist rails was the risk/benefit meeting, it was just being oriented to the bed assist rails. The risk of bed assist rails was entrapment, and injuries such as bumps and skin tears. Since they did not consider the bed assist rails restraints, they thought the only form needed was the bed rail determination form. When the incident involving Resident #24 on 12/13/2023 was discussed during the interdisciplinary meeting, it was recommended by therapy the resident continue with the bilateral bed assist rails. When they reviewed the 10/31/2023 restrictive device form for Resident #24, they noticed that the informed consent and medical provider sections were blank. They were not sure who was responsible for completing that section. During an interview on 1/19/2024 at 8:58 AM, the Director of Therapy stated they wrote the note on the 12/15/2023 bed rail determination form for Resident #24 to continue with the bilateral bed assist rails after the 12/13/2023 incident. It was determined the resident could safely use the bed assist rails during care with toileting and hygiene as they could follow commands. They stated the resident would not be able to release the bed assist rails (as documented on the resident's 10/31/2023 restrictive device form). A staff person standing next to the bed would have to release their bed assist rail. Resident #1 needed the bed assist rails for offloading and for sitting on the edge of the bed to use the stand lift. Resident #25 used their bed assist rails for bed mobility. Residents #1 and #25 could not release their bed assist rails. They thought of the bed assist rails as enabling devices rather than restraints. 10 NYCRR 415.12(h)(1)(2) 48632

Based on observation, interview, and record review during the recertification survey conducted 1/16/2024- 1/19/2024, the facility did not ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional standards and included the expiration date when applicable for 1 of 2 medication carts units (Unit 2 Long Hall medication cart) reviewed. Specifically, the Unit 2 Long Hall medication cart had 1 bottle of aspirin that was expired, 2 bottles of aspirin that did not have an expiration date listed, 1 multi-dose insulin pen that was not labeled with a resident name or an opened date, and 1 multi-dose insulin pen that was opened more than 28 days. Findings include: The facility policy Medication Storage in the Facility dated 2011 documented that stock medications would be kept separately from individually patient labeled medications. Outdated medications would be immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy if a current order exists. The facility Insulin Injection Administration policy revised 4/20/2022 documented the insulin pen should be labeled with resident identifiers, date opened and expiration date. Key points were to follow manufacturer's instructions and check their expiration date. The Basaglar KwikPen and Lantus Solostar manufacturer inserts documented the pens could be stored opened at room temperature for 28 days. During an observation and interview on 1/17/2024 at 9:54 AM, licensed practical nurse #4 opened the Unit 2 Long Hall medication cart top drawer which contained three bottles of aspirin. One bottle of enteric coated 325 milligram aspirin had an expiration date of 10/2023; and one bottle of 325 milligram and one bottle of 81 milligram aspirin did include a manufacturer expiration date. The third drawer of the medication cart contained one Lantus Solostar Insulin pen (a disposable single-patient prefilled insulin pen) without a resident identification label or opened or expiration dates; and one Basaglar KwikPen (a disposable single-patient prefilled insulin pen) was marked with an opened date of 12/15. Licensed practical nurse #4 stated that expired medications should be discarded as they were likely not as effective past the expiration date. Upon first use an insulin pen, the opened date should be written on the yellow sticker as this was the only way they could determine the expiration date per manufacturer recommendations. The Basaglar KwikPen was expired as the manufacturer instructions documented they were good for 28 days once opened. They stated if the Lantus pen did not have a label, they could not determine which resident it belonged to. During an interview on 1/19/2024 at 10:01 AM, licensed practical nurse #5 stated medication nurses were responsible for stocking the medication carts, verifying resident labeled medications matched their orders, and expiration dates were valid, prior to administering them. They were unaware of any facility process to check the carts. The resident specific insulin pens should be labeled with the resident name and when they were first opened as they were only good for 28 days after opening. Unlabeled or expired medications should be discarded and replaced. Insulin was for the intended resident as labeled and without a label they could not be sure who it was for. Expired medications should be discarded. During an interview on 1/19/2024 at 10:12 AM, licensed practical nurse Supervisor #6 stated the medication nurse was expected to check the medications in the medication room and their cart daily for expiration dates. They should also check for correct resident labeling prior to administering. Items that were not labelled or labelled incorrectly should be discarded. There were no checklists for going through the carts or medication rooms verifying expiration dates or resident labels. During an interview on 1/19/2024 at 12:23 PM, Director of Nursing #7 stated the facility did not have an auditing tool for medication storage. They expected the medication nurse to review the resident medication labels and assure the open dates were written on them. Unlabeled or expired medications should be discarded, and new medications obtained from the medication storage room. Efficacy of the medication could be decreased when used past the expiration date. 10NYCRR 483.45 (g)(h)

Based on record review, observation, and interview during the recertification survey conducted [DATE]-[DATE], the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (the main kitchen) reviewed. Specifically, the main kitchen dish machine area walls were unclean; the ceiling tile metal grid was rusty; and there were expired and undated bread products. Findings include: An undated facility policy Procedures: Walls, Kitchen-Cleaning documented the procedure frequency as needed and the time required was 15 minutes per each 10 foot x 10 foot wall section. The undated facility Food Storage Guidelines documented bread on a shelf was to be discarded after 4 days, and rolls were to be discarded after the package date. The following observations were made in the main kitchen on [DATE] from 9:20 AM-10:50 AM: - the dish machine area walls were unclean, and the ceiling tile grid was rusty; - there was a loaf of club wheat bread that had a best by date of [DATE]; and - the bread shelf in the main kitchen preparation area had two undated loaves of rye bread, two undated bags of bagels, 1 undated package of English muffins, 1 undated package of hamburger buns, 2 undated croissants in a bag, and 1 undated package of dinner rolls. During an interview on [DATE] at 12:47 PM, the Food Service Director stated that the night porter was responsible for cleaning the dish machine area from top to bottom and they assumed that the walls were also being cleaned. They stated ceiling grids were starting to rust and that this rust could fall onto items on the clean side of the dish machine area. The Food Service Director verified that the club wheat bread had a best by date of [DATE]. They stated that and the undated bread items found in the main kitchen should have had a pull date, and if an item had been removed from its original package the pull by date should have been transferred to that new package. The Food Service Director stated that it was important to ensure food was properly labeled so the items would not get stale or loose integrity. 10NYCRR 415.14(h)

Based on record review and interview during the abbreviated survey (NY00319839), the facility did not ensure residents were protected from further potential abuse while an investigation was in process for 1 of 3 residents reviewed (Residents #1). Specifically, Resident #1 reported an allegation of abuse against certified nurse aide (CNA) #1 and CNA #1 was not immediately removed from having access to residents while the investigation was in progress. Findings include: The 7/2023 facility policy Resident Abuse, Neglect, Mistreatment and Misappropriation documented residents were to be free from abuse and are to be protected from staff, volunteers and/or contractors. In response to allegations of abuse, the facility must be notified immediately but no later than 2 hours after the allegation was made. The registered nurse supervisors (RNS)/House Charge, Unit Managers, department Managers and/or Administration will immediately begin to investigate when it is brought to their attention that there is an allegation of resident abuse. The Administrator, Director of Nursing (DON), and RNS/House Charge will take steps immediately to ensure resident(s) are protected. A physical assessment is done and an evaluation of whether the alleged victim feels safe. If the alleged perpetrator is facility staff, removal of the alleged perpetrator's access to the victim and other residents by suspension if necessary. Resident #1 had diagnoses including multiple fractures sustained during falls and congestive heart failure (CHF). The 5/17/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and they had no memory problems or behaviors. The resident required extensive assistance of one staff person for most activities of daily living (ADL) and was frequently incontinent. The 5/15/2023 comprehensive care plan (CCP) documented the resident had an ADL self-care deficit due to diagnoses and required extensive assistance of one person for ADLs. The resident had a trauma history due to family losses and interventions included to develop a trusting relationship, be patient, allow the resident to express themselves, respond to their needs, and when anxious, redirect the resident's attention. The resident had a potential for a mood problem due to situational mood stressors, medical status, recent hospitalization , and skilled nursing facility placement. Staff were to monitor and report any mood symptoms. The 7/9/2023 at 9:00 PM, Quality Assurance Resident/Incident Investigation Report, initiated by RNS/House Charge #3 on 7/10/2023, documented: - RNS/House Charge #3 was called to the resident's room by the resident on 7/9/2023 at 9:00 PM. The resident stated several nights ago, during the middle of the night, a CNA of the opposite gender answered their call light to take them to the bathroom and touched them inappropriately on their breasts. They did not want anyone else to know about the incident. They assured the resident they were safe and told them they would follow-up and to let the Supervisors know if they saw the accused CNA. - RNS/House Charge #3 reported this allegation to the DON on 7/10/2023. - This was an allegation and there were no witnesses and the resident was alert and oriented. - RNS/House Charge #3 completed a head-to-toe assessment and no injuries were found. The resident had no pain or discomfort. - Staff were to allow the resident to express their feelings and their mood was to be monitored. Statements obtained by the facility as part of the investigation included: - CNA #2's statement dated 7/12/2023 documented on 7/8/2023 at 7:30 PM, the resident made a statement to them about a CNA groping them. CNA #2 asked if they wanted to talk to the Supervisor and the resident said no. CNA #2 then stated they needed to report the allegation to their Supervisor and the resident said that was okay. CNA #2 told RNS/House Charge #3 that Resident #1 wanted to talk to them and RNS/House Charge #3 went into the resident's room. - RNS//House Charge #3's statement dated 7/9/2023 at 9 PM documented the resident stated they brought the incident forward because they did not want the same thing to happen to another resident. The resident demonstrated how the CNA placed their hands in a circular motion on their breasts. The resident stated they did not say anything to the CNA at the time of the incident because they were shocked but now they know they should have told someone sooner. They did not want others to know about the incident but RNS/House Charge #3 told them they had to notify the social worker the next day and the resident agreed. The resident reported the incident happened several nights ago around 2 AM or 3 AM and gave a physical description of the accused CNA. - RNS/House Charge #3 wrote a second statement dated 7/12/2023, which documented on the evening of 7/8/2023, they were not aware of the incident. On that evening, they went into the resident's room but did not recall the resident saying anything about the incident. - CNA #1's verbal statement provided via telephone to the Administrator, DON, and social worker #4, dated 7/10/2023 at 4:00 PM, documented they were aware of the alleged complaint as another CNA told them about it when they reported to work on 7/8/2023 at 11 PM. They stated at that time, the other CNA said they should stay out of Resident #1's room as the resident said they were groped by a CNA. CNA #1 switched Resident #1's assignment with a different CNA but did go into Resident #1's room on last rounds and checked the resident for incontinence by pulling the sheet back and putting a gloved hand over their brief checking for saturation and the blue line indicating wetness. CNA #1 denied touching Resident #1 inappropriately. The undated Investigation Summary, completed by the Administrator, documented: - the exact date of the alleged sexual abuse incident was unknown but it was reported on 7/9/2023 at 9:00 PM. RNS/House Charge #3 assessed the resident at that time. - The DON was notified of the allegation on 7/10/2023 at 2:00 PM and the Administrator was notified on 7/10/2023 at 2:30 PM. Upon notification to the DON, a full investigation was initiated. - The unit schedule was reviewed and CNA #1 was the only CNA who worked who met the physical description given by the resident. CNA #1 was removed from the schedule and interviewed. CNA #1 denied touching Resident #1 inappropriately. CNA #1 stated another CNA informed them at the beginning of CNA #1's shift on 7/8/2023 that they should switch Resident #1 from their group as the resident reported to them during their evening shift, that a male CNA groped them. - CNA #2 reported to RNS/House Charge #3 on 7/8/2023 that Resident #1 wanted to speak with them but did not say what it was about. When RNS/House Charge #3 spoke with the resident that evening, they did not report the incident. - The conclusion was the facility was unable to substantiate the allegation of sexual abuse or any other abuse and education was to be provided to all staff on the facility's Resident Abuse, Neglect and Mistreatment policy. The agency weekly timesheet noted CNA #1 worked at the facility on 7/7/2023 and 7/8/2023 on the night shift from 11:00 PM to 7:00 AM and on 7/9/2023 from 2:40 PM through 7:12 AM on 07/10/2023. During a phone interview on 7/17/2023 at 3:38 PM, CNA #1 stated after their shift on 7/10/2023, they were told through a phone call not to return to this facility. They did not write a statement abotu the allegation but was questioned over the phone. CNA #1 stated the allegations against them were untrue and they denied touching the resident inappropriately. During an interview on 7/18/2023 at 9:05 AM, the DON stated they were told of the alleged sexual abuse incident on 7/10/2023 at 2:29 PM by RNS/House Charge #3 who told them that on 7/9/2023 at 9:05 PM, Resident #1 told them about being touched inappropriately and RNS/House Charge #3 told the DON they thought their concern was a social worker thing. The DON stated they told RNS/House Charge #3 that they should have called the DON on 7/9/2023 when the allegation was made. The DON did not know of the resident telling CNA #2 about the groping until after the investigation was initiated. When the DON became aware of the allegation, CNA #1 was suspended and had not worked since. During a phone interview on 7/18/2023 at 9:30 AM, RNS/House Charge #3 stated: - on 7/9/2023 when they were going by the resident's room, the resident asked to see them and stated they wanted to talk about something embarrassing. - The resident said several nights ago, in the middle of the night, when they were taken to the bathroom, they were touched inappropriately and the resident demonstrated how both breasts were touched by CNA #1. - The resident said they were okay and they did not want anyone to get in trouble and they were telling this to the RN because they did not want this to happen to someone else. - They assessed the resident and told them they were safe and staff was watching them. - The resident gave a physical description of the CNA and RNS/House Charge #3 checked the schedules and there were no CNAs of the opposite gender assigned that evening or the next night. - The resident said it was okay for RNS/House Charge #3 to tell the social worker about the incident the next day and that was done. - On 7/10/2023 around 2 PM, the social worker did not answer their phone and they did not want to leave a message, so they called the DON. They were told by the DON to start an incident report and write a statement. - The DON and Administrator told them that even if the resident told them not to tell anyone, they should have started the incident report the night they became aware of the allegation. - The evening before the resident reported the allegation to them on 7/8/2023, CNA #2 did tell them Resident #1 wanted to see them. They went to see them, but the resident said nothing about the incident. They did not find out the resident had told CNA #2 on 7/8/2023 about the inappropriate touching until after the DON got them together around 7/11/2023. During an interview on 7/18/2023 at 12:11 PM, Resident #1 stated they were bad at remembering dates, but they were flabbergasted when the CNA touched them inappropriately. They gave a physical description of the accused CNA and reported their breasts were touched and the CNA moved their hands in a circular motion. The resident stated the CNA thought it was funny and laughed. Halfway through the interview, the resident's family member became part of the interview. This family member stated the resident told them they did not want to say anything because they thought they would get kicked out of the nursing home if they made a fuss. The resient confirmed they said this to their family member. During a phone interview on 7/18/2023 at 1:30 PM, CNA #2 stated on 7/8/2023 they took care of Resident #1 and when they were getting them ready for bed the resident said someone groped them. The resident did not want anyone to know about it. CNA #2 stated they told the resident they had to tell the Supervisor and the resient agreed. CNA #2 told RNS/House Charge #3 that Resident #1 wanted to talk to them and the RN did go speak to Resident #1 and it was this CNA's belief that the resident would tell them but that did not happen. CNA #2 denied talking to anyone about what the resident told them until 7/10/2023 when they were asked by the DON to write a statement. They found out the resident did not say anything to the RN when talking to that RN supervisor who asked them about some dates. 10 NYCRR 415.4(b)(3)

Based on observation and interview during the recertification survey conducted 9/7/21-9/9/21, the facility failed to ensure the New York State Department of Health (NYSDOH) was notified of a loss of service and was not in compliance with Federal, State, and Local Laws and Professional Standards. Specifically, NYSDOH was not notified of a loss of the commercial dish machine within the main kitchen according to the NYS DOH Nursing Home Incident Reporting Manual. Findings include: The NYSDOH Nursing Home Incident Reporting Manual last updated August 2016 documents the facility must report planned and unintentional concerns effecting kitchen sanitation. This section refers to situations that are planned, such as for evaluation or repair, as well as situations that are unplanned, unexpected or emergent in nature. At least one of the following elements must be present for an incident to be reportable to the NYSDOH: -Loss of service [MEDICATION(S)] or expected to last 4 or more hours. -There is no back-up system in place; or -The back-up system fails to work. -Planned or unexpected events that may affect resident care. An email dated 8/24/21, to the Director of Facilities and the Food Service Director, documented that the dish machine booster pump broke on 8/24/21, and that the facility was in discussion with a third-party vendor to replace the part. A third-party vendor price quote documented that the facility had been given a price quote for the replacement for the dish machine booster pump on 8/24/21. During an observation of the kitchen on 9/7/21 at 10:00 AM, and 9/8/21 at 12:00 PM, the dish machine was not working. The facility was observed using disposable cups, plates, and utensils. The 3 bay sink in the kitchen was being used to wash and sanitize pots, pans, and other dishware. During an interview on 9/7/21 at 4:30 PM, the Executive Director stated that the booster pump for the dish machine went down the week of 8/22/21, and it had not been working for greater than four hours. The Executive Director stated they did not personally report this as they were not onsite at the that time. They would have reported it if they had been present at the facility because if a broken dish machine was down for greater than four hours it was a facility reportable event. 2012 NFPA 101: 2.2 483.70 (b) 10NYCRR 400.2 incident reporting manual.

Based on observation and interview during the recertification survey conducted 9/7/21-9/9/21, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 kitchenette refrigerator (third-floor kitchenette) and 3 of 3 juice machines (second and third-floor kitchenette and main dining room juice machines). Specifically, the air temperature of the third-floor kitchenette refrigerator was not maintained at an appropriate temperature, and the juice within the second and third-floor kitchenette and main dining room juice machines was not maintained at appropriate temperatures. Findings include: 1. Third-Floor Kitchenette Refrigerator During an observation on 9/7/21 at 6:30 PM, the state thermometer was placed in the third-floor kitchenette refrigerator, the door to the refrigerator was opened and kept open for 30 seconds. The state thermometer temperature jumped from 43 Fahrenheit (F) to 56 F. During an observation on 9/8/21 at 9:15 AM, with the Food Service Director present, there was a poured glass of milk in the third-floor kitchenette refrigerator located about 1-inch away from the door. The temperature of the milk was measured at 47 F. During an interview on 9/8/21 at 10:35 AM, the Food Service Director stated they could not ensure that the items within the third-floor kitchenette refrigerator had maintained proper temperatures under 45 F and all food items within this refrigerator would need to be discarded. During an interview on 9/8/21 at 12:01 PM, the Food Service Director stated they were not aware of how many times the third-floor kitchenette refrigerator door was opened and closed in a day. They stated cold food items within refrigerators should be kept at 45 F or lower. During an interview on 9/9/21 at 1:08 PM, the dining room Supervisor stated they were surprised how fast the temperature inside the refrigerator jumped when the door was opened after the evening meal service, and suspected that the air temperature in the room played a significant role. 2. Juice Machines During an observation on 9/8/21 at 1:15 PM, the temperature of a glass of cranberry juice taken directly from the third-floor kitchenette refrigerator juice machine was measured at 51 F. During an interview on 9/8/21 at 1:15 PM, the dining room Supervisor stated that a vendor for the facility juice machines was at the facility last Friday (9/3) and checked all three of the facility's machines. The Supervisor stated to expedite production speed for food service, juice was taken from the juice machine and placed in the third-floor kitchenette refrigerator. The Supervisor stated they were not aware that the temperature of the juice from the machines was over 45 F. During an observation on 9/8/21 at 1:25 PM, the temperature of a glass of cranberry juice taken directly from the second-floor kitchenette refrigerator juice machine was measured at 50 F and the temperature of a glass of apple juice taken directly from the third-floor kitchenette refrigerator juice machine was measured at 48 F. During an observation on 9/8/21 at 1:30 PM, the temperature of a glass of cranberry juice taken directly from the main dining room juice machine was measured at 46 F. During an interview on 9/9/21 at 12:14 PM, the Food Service Director stated a third part vendor for the juice machines had told them that the temperatures of the juice should be between 39 F and 45 F. The Food Service Director stated it would be appropriate for juice in juice machines to be 45 F or lower. 10NYCRR 415.29

Based on observation, record review, and interview during the recertification survey conducted 9/7/21-9/9/21, the facility failed to ensure food and drinks were palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (9/7/21 dinner and 9/8/21 lunch) reviewed. Specifically, multiple food items including pulled pork, peaches in syrup, Jello, cranberry juice, and Caesar salad were not served at palatable temperatures. Additionally, a container of coleslaw was not held at a safe temperature in a kitchenette refrigerator. Findings include: During an observation on 9/7/21 at 6:00 PM, a dinner meal tray was delivered to the resident in room C2. Temperature and taste tests were conducted on the meal tray and the resident received a replacement. At 6:03 PM the following temperatures were measured: - pulled pork 128 Fahrenheit (F); -peaches in syrup 68 F; - Jello 63 F. The pulled pork was not warm or palatable. The peaches in syrup and the Jello were not cold or palatable. During an interview on 9/7/21 at 6:15 PM, the dining room Supervisor stated that the peaches and Jello were kept inside the third-floor kitchenette refrigerator prior to serving. The prepared food in the refrigerator would be discarded after the meal. During an observation on 9/7/21 at 6:25 PM, there was a prepared individual container of coleslaw inside the third-floor kitchenette refrigerator that was not used for the dinner meal. The temperature of the coleslaw was measured at 51 F using a state thermometer and 50 F using the facility thermometer. During an interview on 9/8/21 at 10:00 AM, the dining room Supervisor stated the cold items from dinner on 9/7/21 had come from the main kitchen walk-in cooler at 5:15 PM and placed in the third-floor kitchenette refrigerator. The Supervisor stated these items were not taken out of the refrigerator until about an hour later. There was no reason for the temperatures to be out of the required temperature range. The Supervisor stated the certified nurse aides (CNA) were not picking up dinner trays timely, so service was slower. The Supervisor stated they assumed the coleslaw that was temperature checked after the 9/7/21 dinner service had been kept in the refrigerator for the entire dinner service. They stated the peaches served on 9/7/21 were removed from a #10 can (approximately 3 quarts) then placed in the individual bowls and put in the main kitchen walk-in cooler on 9/6/21. The bowls of peaches would be brought to the third-floor kitchenette refrigerator prior to serving. During an observation on 9/8/21 at 12:51 PM, a lunch meal tray was delivered to the resident in room C3. Temperatures and taste tests were conducted on the tray and the resident received a replacement. At 12:55 PM, the temperature of the cranberry juice was measured at 49 F and the Caesar salad was measured at 51 F. The cranberry juice and Caesar salad were not cold or palatable. During an interview on 9/9/21 at 12:31 PM, the Food Service Director stated on 9/7/21 the peaches and Jello were placed on the meal tray prior delivery to the resident's room and the ambient air temperature in the room could affect the temperature of cold products. The Food Service Director stated cold food items should be served at 45 F or lower and hot foods should be served at 140 F or higher. The Director stated that the pulled pork temperature of 128 F was not acceptable. Also, the peaches at 63 F and the jello at 68 F, both cold food items, were not acceptable. The Director stated the temperature for the coleslaw in the third-floor kitchenette refrigerator during the 9/7/21 dinner meal was not acceptable at 50 F. The cranberry juice was not appropriate at 49 F. The Director stated it was hard to keep Caesar salad within temperature range and 51 F was not acceptable. During an interview on 9/9/21 at 12:45 PM, the Dining Room Supervisor stated that they were surprised with the temperature of the peaches and Jello. The Supervisor stated that the temperature of any cold item would increase when sitting out in a warm kitchenette. They stated cold food items should be served at 45 F or lower, and hot food items should be served at 135 F or higher. The cold and hot food item temperatures identified during the two test trays were not acceptable. 10NYCRR 415.14(d)(1)(2)

Based on observation, interview, and record review during the recertification survey, the facility did not ensure each resident had the right to a dignified experience for 2 of 9 residents (Residents #13 and 32) reviewed for dining. Specifically, a certified nurse aide (CNA) was observed using a personal cell phone while feeding Resident #13 at her bed side. Resident #32 was fed in an undignified manner during a meal in the dining room. Findings include: The 2/15/16 Policy on Employee Use of Cell Phones or Other Signal Devices and Other Personal Electronic Devices documented cell phones are not to be in view or turned on at any time when the individual is engaged with residents or doing the work of a normal day. Cell phones may be used only during the employee's break or lunch period outside or in designated break rooms. Personnel who are in violation of this policy shall be disciplined for violation of work rules and neglect of duty. 1) Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 2/8/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required extensive assistance with eating. The 2/19/19 comprehensive care plan (CCP) documented the resident was totally dependent on staff for eating. The undated certified nurse aide (CNA) Kardex (care instructions) documented the resident was totally dependent on 1 staff for eating and to involve the resident in care approaches and preferences to decrease anxiety, agitation, and emotional upset. The 2/1/19 Speech-Language Pathologist (SLP) Evaluation and Plan of Treatment documented the resident had mild to moderate oral-pharyngeal-[MEDICAL CONDITION] dysphagia (difficulty swallowing) and became fatigued as intake continued. She was at risk of aspiration, required close supervision, was unable to feed herself, and required maximum assistance with eating. During an observation on 5/1/19 at 12:59 PM, the resident was in her room with her lunch tray and CNA #1. The CNA was observed sitting in a chair at the bedside, facing the resident, with her head down using her cell phone and was not interacting with the resident. During an interview on 5/1/19 at 2:52 PM, CNA #1 stated she was using her cell phone while assisting the resident at lunch. The CNA stated she should not have been using her phone. During an interview on 5/2/19 at 12:12 PM, registered nurse (RN) Unit Manager #2 stated when staff fed a resident, they should be speaking with the resident and continuing to encourage the resident to eat. Cell phones were not allowed outside of the break room and the CNA should not have been on her phone while feeding the resident. 2) Resident #32 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 3/28/19 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired and required extensive assistance with eating. The 4/9/19 comprehensive care plan (CCP) documented the resident was to be fed by staff. Dining observations on 4/30/19 included the following: -At 1:09 PM, CNA #3 mixed together two pureed food items on Resident #32's plate and fed the mixture to the resident; -At 1:10 PM, CNA #3 stood to help another resident, leaving Resident #32 unassisted; -At 1:15 PM, Resident #32 was not being assisted with her meal while CNA #3 picked up tray tickets from other residents who had finished their meals; -At 1:16 PM, the LPN approached the resident and asked if she was done eating. CNA #3 said the resident was still working on her meal; -At 1:17 PM, CNA #3 sat down to feed Resident #32; -At 1:26 PM, CNA #3 assisted another resident out of the dining room, leaving Resident #32 unassisted with her meal; -At 1:29 PM, CNA #3 resumed feeding Resident #32 while standing and marking tray tickets at the same time. She fed the resident three bites of pudding before sitting down. The CNA placed heaping amounts of pudding on the spoon and the resident was unable to accommodate the whole spoonful in her mouth; -At 1:33 PM, the resident had pudding residue on her upper lip and was unable to clear it with her tongue. CNA #3 provided the resident with 3 drinks while standing before walking away from the resident; -At 1:34 PM, CNA #3 walked away from Resident #32 and the resident continued with pudding residue on her upper lip; and -From 1:42 PM-1:55 PM, Resident #32 had pudding residue on her lips. During an interview on 5/2/19 at 11:50 AM, CNA #3 stated she kept an eye on all her assigned residents during meals. If she saw a resident had finished their meal, she would get their meal slip and write down the intake. She reported she had gotten up in the middle of the meal because Resident #32 did not eat quickly, and she knew she had time to take care of other assigned tasks. She stated at one point she recognized she was standing while feeding the resident and sat down. During an interview on 5/2/19 at 12:12 PM, registered nurse (RN) Unit Manager #2 stated staff should be speaking with the resident they were assisting, letting them know what items were being offered, and to continue to encourage the resident to eat as much nourishment as possible. The CNA should not have been getting up once the resident received her meal tray and should stay by the resident until the meal was completed. 10NYCRR 415.5(a)

Based on observation, interview, and record review during the recertification survey, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #55, #207, and #355) observed during medication administration. Specifically, the licensed practical nurse (LPN) did not perform hand hygiene during medication administration. Findings include: Than facility policy, Hand Hygiene, revised 2009, documented if hands were not visibly soiled, alcohol-based hand rub was to be used for all clinical situations where washing with soap and water was not indicated. The facility policy, Medication Administration - General Guidelines, dated 7/17/18, did not include protocol for hand hygiene during medication administration. The facility policy, Subcutaneous Medication Administration, dated 7/17/18 documented hand hygiene was to be performed before preparing the syringe for administration and upon completion of the injection. 1) Resident #207 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/22/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition. The 4/15/19 physician order [REDACTED].<55 beats per minute. 2) Resident #355 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 4/26/19 physician orders [REDACTED]. 3) Resident #55 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 4/26/19 physician orders [REDACTED]. On 5/1/19 at 8:32 AM, licensed practical nurse (LPN) #4 was observed in Resident #207's room checking her blood pressure with a manual blood pressure cuff. The LPN administered the resident's medications then exited the room with the blood pressure cuff. She returned to the medication cart and did not complete hand hygiene or clean the blood pressure cuff or stethoscope. LPN #4 then prepared Resident #355's medications for administration and took the medications, blood pressure cuff, and stethoscope into Resident #355's room. She manually checked Resident #355's blood pressure and administered the resident's medications. The LPN returned to the medication cart, did not complete hand hygiene or clean the blood pressure cuff or stethoscope. At 08:43 AM, LPN #4 prepared Resident #55's medications for administration and entered the resident's room. She moved Resident #55's overbed table to the side of the resident and gave the resident her pills. LPN #4 then applied gloves and administered an injection in Resident #55's abdomen. The LPN then went to the resident's bathroom and washed her hands. During an interview on 5/1/19 at 3:28 PM, LPN #4 stated she forgot to wash her hands because being observed made her nervous. She stated she was not aware she needed to clean the blood pressure cuff between residents. It was not something she did normally. During an interview on 5/1/19 at 3:31 PM, registered nurse (RN) Unit Manager #5 stated the LPNs were expected to wash their hands and clean any equipment after use and before using with another resident. During an interview on 5/2/19 at 12:51 PM, the Infection Control Nurse stated proper hand hygiene practices should be completed between every resident during a medication pass. The LPNs should use hand sanitizer or wash their hands between residents to prevent contamination of medications and prevent the spread of germs between residents and staff members. If she saw a LPN not performing hand hygiene between residents during a medication pass, she would stop the LPN before she went to the next resident. 10NYCRR 415.19(a)(1-3)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not promote care for residents in a manner and an environment that maintained or enhanced each resident's dignity for 2 of 14 residents (Residents #5 and 6) observed during meals. Specifically, Residents #5 and 6 waited between 40 and 71 minutes from their scheduled meal times before receiving their food. Findings include: The facility policy and procedure for meal times on Cameo Court (second floor), revised 7/12/2017, documented: - Breakfast: 7:30 AM. - Dinner: 12:30 PM. - Supper: 5:30 PM. 1) Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had moderate cognitive impairment, required extensive assistance of one person for locomotion on the unit and was independent with setup help only for eating. The comprehensive care plan (CCP) dated 9/20/2017 documented the resident had activities of daily living (ADL) self-care performance deficit related to [MEDICAL CONDITION]. He required a lipped plate, right-handed angled utensils and two-handled covered cups for hot liquids to maximize independence with eating. The resident was observed in his room: - On 11/14/2017 from 12:35 PM - 1:41 PM. At 12:35 PM the resident was in his recliner with an overbed table in front of him. His wife was seated next to him. At 12:50 PM the first meal trays were served to residents in the dining room. At 1:15 PM, the resident was still waiting for his tray and stated he usually had his tray by then and this day was an exception. At 1:32 PM the resident turned on his call light. CNA #6 answered the call light at 1:38 PM and asked if the resident needed help. The resident stated his wife was in the bathroom. At 1:41 PM the resident received his meal, waiting 71 minutes from the specified meal serving time. - On 11/15/2017 at 1:10 PM the resident turned on his call light. When staff answered the call light, the resident asked if they were going to bring him his lunch as he was hungry. At 1:17 PM the resident received his meal, waiting 47 minutes from the specified meal serving time. 2) Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive assistance of one person for locomotion on the unit and required limited assistance of one person for eating. The comprehensive care plan (CCP) dated 11/10/2017 documented the resident had activities of daily living (ADLs) self-care performance deficits related to dementia and limited mobility. She ate well once staff got her started and needed help with drinks. She was to wear a clothing protector when awaiting meals due to a history of attempting to remove her shirt. The resident was observed in the dining room: - On 11/14/2017 from 12:30 PM - 1:45 PM. At 12:30 PM the resident was sitting at the dining room table. The resident received her meal tray at 1:20 PM, waiting 50 minutes from the specified meal serving time, and did not receive staff assistance until 1:45 PM. - On 11/14/2017 from 5:20 PM - 6:10 PM. At 5:25 PM the resident was observed sitting at the dining room table. At 5:35 PM LPN #1 stated, Where are all my CNAs (certified nursing assistants)? I guess I will start serving. At 5:45 PM an unidentified staff member and the registered nurse (RN) Unit Manager #2 joined LPN #1 passing trays. At that time, 23 residents were seated at tables waiting for their meals. From 5:47 PM - 5:55 PM other residents could be heard stating, Where's my dinner?' and, I'm hungry. Two residents were stating they had to use the bathroom, and another resident was observed self-propelling out of the dining room. Resident #6 received her meal tray at 6:10 PM, waiting 40 minutes from the specified meal serving time. During an interview with CNA #6 on 11/14/2017 at 1:45 PM, he stated the nurses determined when the meal serving process started, and the residents who ate in their rooms were usually served last. He stated lunch was at 12:30 PM and if there was a change in meal times the nurses would put it in the computer. During an interview with food service worker #4 on 11/15/2017 at 1:23 PM, she stated one of the nurses was the staff who initiated the meal serving process. She stated the residents in the dining room were served before the residents who ate in their rooms unless staff told her otherwise. During an interview with the Director of Dietary Services on 11/16/2017 at 12:50 PM, she stated the food service workers were always ready with the meals but had to wait for nursing to let them know when they could start serving meals. She stated she was aware of the residents waiting a long time before receiving their meals and did not know where the unit staff were while the residents sat at the tables. She stated they used to have beverages on the table while residents waited for their meals, but it changed and it was not her decision. She stated there was no policy on the meal serving process other than the time meals. During an interview with LPN #1 on 11/16/2017 at 1:15 PM she stated either the CNAs or nurses would tell the food service workers when they could start serving meals and, Usually it is me. During an interview with RN #2 on 11/16/2017 at 1:40 PM, she stated the residents were served once there were four at a table. She stated either the CNAs or nurses could tell the food service workers they could start preparing trays. In regard to the long wait time for meals, she stated, We know it's an issue. 10NYCRR 415.5(a)

Based on observation, interview, and record review conducted during the recertification survey the facility did not ensure all drugs were stored in locked compartments for 1 of 1 resident (Resident #4) reviewed for medication storage. Specifically, Resident #4 was observed with prescription topical medications in her room that were not stored in a locked container. Findings include: The facility's medication administration general guidelines policy and procedure reviewed 6/3/2017 documented all topical medications used in treatments should be stored in the treatment cart. Resident #4 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The 10/26/2017 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required limited assist for her activities of daily living (ADLs). The comprehensive care plan (CCP) dated 10/19/2017 documented the resident had a potential for skin breakdown related to [DIAGNOSES REDACTED] (a type of cancer) with skin rashes. Physician orders [REDACTED]. A physician order [REDACTED]. There was no documented evidence the physician orders [REDACTED]. The following observations were made: -On 11/14/2017 at 5:30 PM, the Clobetasol, CeraVe, Econazole, Sarna, and Triamcinolone creams/lotions were on the overbed table in the resident's room. -On 11/15/2017 at 3:32 PM, the Clobetasol, Triamcinolone, Econazole, and CeraVe creams/lotions were on the overbed and chairside tables in the resident's room. -On 11/16/2017 at 9:55 AM, the Triamcinolone cream was on the chairside table in the resident's room. During an interview with registered nurse (RN) unit manager #8 on 11/16/2017 at 12:25 PM, she stated topical medications should be stored in the treatment cart and if the resident had an order to self-administer her medications, topical medications would be stored in the resident's locked bedside stand. The resident was being evaluated to determine her ability to self-administer her medications and until the evaluation was completed, the topical medications should be stored in the locked treatment cart. She stated the staff must have forgotten to lock the topical medications in the treatment cart. 10NYCRR 415.18(d)