Every finding on record at Gowanda Rehabilitation and Nursing Center

Based on observation, interview and record review conducted during survey, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (Resident #1) of five residents reviewed. Specifically, the facility failed to provide Resident #1 with their medically prescribed diet, resulting in an avoidable choking accident. Subsequently, Resident #1 expired. This resulted in harm that is Immediate Jeopardy and Substandard Quality of Care to Resident #1's health and safety.The findings include:The facility policy and procedure titled Food Consistencies reviewed 01/2026 documented the facility was committed to ensuring that all residents receive meals that are prepared and served in accordance with their assessed needs, prescribed diets, and physician or speech-language pathologist recommendations. The facility shall provide each resident with a diet that meets daily nutritional and special dietary needs, including appropriate food texture modifications to prevent complications such as aspiration (taking foreign matter into the lungs), choking, or malnutrition.The facility policy and procedure titled The Dining Experience reviewed 03/2026 documented nursing staff will provide ongoing supervision and monitoring of residents during meal service to ensure a safe dining environment. All residents, including those who are independent with eating, will be observed for any signs of difficulty such as choking, coughing, swallowing concerns, or changes in condition requiring intervention. Any identified concerns will be promptly addressed and communicated to the interdisciplinary team for further evaluation as indicated.Review of the job description for Unit Helper, dated 01/10/2022, documented Unit Helpers/Resident Assistants assist independent residents with their meal set up, pass out and pick up resident trays at mealtime on unit, assist with serving meals in the dining room, and maintain safety needs of residents.Review of the undated job description Certified Nursing Assistant documented functions included assists or feeds residents as indicated, serves water and nourishment, serves and collects trays, observes residents and notes physical condition, attitude, reactions, appetites and reports changes or unusual findings.Resident #1 had diagnoses which included profound intellectual disabilities (the most severe level of intellectual developmental disorder), dysphagia (difficulty swallowing), and congenital rubella syndrome (when the German measles pass to a developing baby). The Minimum Data Set (a resident assessment tool) dated 03/22/2026 documented Resident #1 rarely/never understands others, was not assessed if they could make themselves understood, and was severely cognitively impaired. Additionally, the Minimum Data Set documented, Resident #1 held food in their mouth/cheeks or had residual food in their mouth after meals. On admission and while a resident of the facility, Resident #1 required a mechanically altered diet.Review of the Nutritional Comprehensive assessment dated [DATE] revealed Resident #1 was alert to self only, had a diet order of mechanical soft texture, and utilized their hands to eat and shoveled food in their mouth.Review of the Speech Language Pathologist Evaluation and Plan of Treatment dated 03/17/2026 revealed Resident #1 had a rapid rate of intake with large bite sizes, mild oral residue between bites with attempts to take additional bites before clearing.Review of the Comprehensive Care Plan, revised on 03/18/2026, revealed Resident #1 had a potential for alteration in swallowing related to diagnosis of dysphagia and diet of mechanical soft. Interventions included standard feeding precautions: upright all meals, observe for signs and symptoms of aspiration, diet per speech language pathologist recommendations.Review of the Kardex (guide used by staff to provide care) dated 03/28/2026 revealed Resident #1's diet was mechanical soft and required moderate assist (staff assists using less than half the effort) while eating with a small/maroon spoon to limit intake portion.Review of the Medication Review Report dated 03/28/2026 revealed Resident #1 had an order for a mechanical soft texture diet starting on 03/16/2026.Review of the meal ticket dated 03/28/2026 revealed Resident #1's diet order was mechanical soft.Review of the Nursing Progress Note dated 03/28/2026 by Registered Nurse Supervisor #1, revealed Resident Assistant #1 stated Resident #1 was choking at 5:25 PM. Upon entering the room, Resident #1 was breathing, and pulse was present, however they appeared to be in distress as their body was rigid, and they were coughing. Abdominal thrusts (a first-aid technique used to treat choking) were performed until Resident #1 stopped breathing, no pulse was present, and they were unresponsive. Chest compressions with ventilation (an emergency life-saving technique to manually pump blood to the brain and organs while delivering oxygen to the lungs) were performed. The sheriff arrived and used a portable suction machine. Maneuvers were successful as breathing was facilitated and pulse present.Review of the Facility Investigation Summary dated 03/28/2026 revealed Certified Nurse Aide #1 stated to Licensed Practical Nurse #1 that Resident #1 did not eat much. Certified Nurse Aide #1 stated Licensed Practical Nurse #1 told them to try an alternative meal and that Resident #2 declined their meal tray. Certified Nurse Aide #1 offered Resident #1 an alternative item from Resident #2's meal tray which was sausage. Certified Nurse Aide #1 broke off a small bite size of sausage and Resident #1 tolerated it. Resident #1 appeared to like the taste of it. Certified Nurse Aide #1 gave a small piece of sausage to Resident #1 and Resident #1 was picking at the insides of the sausage and crumbling it. Resident #1 finished eating the sausage. Resident Assistant #1 entered Resident #1's room. Certified Nurse Aide #1 stated they heard Resident #1 make a weird noise. Resident Assistant #1 yelled out in the hallway that Resident #1 might be choking. Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 entered the room and began abdominal thrusts, knowing Resident #1 had just consumed food. Resident #1 lost pulse and respirations. Cardiopulmonary Resuscitation (CPR - an emergency procedure used when a heartbeat or breathing has stopped) was started. The sheriff arrived on scene and used a portable suction machine. The machine was inspected and there was a very small flat piece of what appeared to be shredded/crumbled sausage. The conclusion of the investigation documented that a licensed practical nurse observed the portable suction machine and stated the food particle measured one to two centimeters.Review of the County Sheriff Field Case Report dated 03/28/2026 revealed at approximately 5:30 PM they were dispatched to a choking call at the facility. Upon arrival at the scene, cardiopulmonary resuscitation was in progress. Resident #1 was unresponsive and not breathing. A portable suction machine was used to clear Resident #1 airway. The portable suction machine was successfully used to clear the airway of food. Resident #1's pulse was strong and steady and they resumed breathing. The Emergency Medical Service had arrived on scene and had taken over care. Resident #1 was moved to the ambulance via stretcher and transported to the hospital.Review of the Emergency Medical Service report dated 03/28/2026 revealed Resident #1's airway was partially obstructed and post choking, Resident #1 was almost back to baseline. Resident #1 then went into cardiac arrest (a sudden loss of heart function). The presumed cardiac arrest etiology was choking.Review of the hospital documentation dated 03/28/2026 revealed Resident #1 choked on some food and cardiopulmonary resuscitation was started; however, a suction device was used to clear food particles and Resident #1 resumed normal breathing. As Resident #1 was loaded into an ambulance for post resuscitation evaluation, they went into asystole (a form of cardiac arrest where the heart stops all electrical and mechanical activity). Cardiopulmonary resuscitation continued. Resident #1 expired on 03/28/2026 at 6:32 PM with diagnosis of cardiac arrest and other specified symptoms and signs involving the circulatory and respiratory systems - choking on food.Review of a Notice of Disciplinary Action form dated 03/30/2026 revealed Certified Nurse Aide #1 provided food to a resident with texture that was inconsistent to their care plan.Review of an untitled document dated 04/01/2026 revealed on 03/28/2026, Resident #1 was provided food by the staff without verifying their diet order first. The document was signed by Certified Nurse Aide #1.During a telephone interview on 05/19/2026 at 11:18 AM, Certified Nurse Aide #1stated on 03/28/2026, during the meal, they sat with Resident #1 who was mostly playing with their food and did not eat much. Certified Nurse Aide #1 stated they let Licensed Practical Nurse #1 know that Resident #1 did not eat their dinner. They stated Licensed Practical Nurse #1 told them that Resident #2 had ordered dinner from outside the facility and to try giving Resident #1 their facility meal instead. They stated that they had taken Resident #1 to where the trays were and gave them a piece of sausage from Resident #2's tray. Resident #1 seemed to like the sausage. They stated that Resident #1 held a piece of sausage and was breaking off pieces. Certified Nurse Aide #1 stated they took Resident #1 back to their room and had brought another piece of sausage for them. Certified Nurse Aide #1 stated they had just set down the other piece of sausage and were cutting it when they looked at Resident #1. Resident #1 looked like they were trying to swallow and were making a weird noise. It was just before Resident #1 made that noise that Resident Assistant #1 had come into the room. Certified Nurse Aide #1 stated they told Resident Assistant #1 to go get the nurse. They stated that Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 came into the room. Certified Nurse Aide #1 stated that they left the room to call a code blue (a universal healthcare alert signaling a patient is experiencing a life-threatening medical emergency) and called 911. They stated that they sent Resident Assistant #1 to wait for the ambulance. Certified Nurse Aide #1 stated they were not that familiar with Resident #1, and they did not realize Resident #1 was supposed to have a mechanical soft diet. Certified Nurse Aide #1 stated the casing was still on the sausage that Resident #1 was eating. They should have called dietary for an alternative meal because they were responsible for preparing meal trays.During an interview on 05/19/2026 at 12:25 PM, Speech Language Pathologist #1 stated Resident #1 was admitted to the facility on a mechanical soft diet and that was their baseline prior to admission. They stated the sausage that Resident #1 was given on 03/28/2026 was considered a regular diet texture and not a mechanical soft diet texture. They stated that certified nurse aides were not trained to cut regular foods into a mechanical soft texture; that was something that needed to be processed in the kitchen. They stated Resident #1 should not have been given the regular textured sausage because there was the potential for choking to occur.During an interview on 05/19/2026 at 12:32 PM, Registered Dietitian #1 stated a mechanical soft diet was interchangeable with a ground diet meaning the meats were meant to be ground. They stated that dietary staff in the kitchen were responsible for preparing the different textures of diets because they were the ones who were trained to do that. The certified nurse aides were not trained to cut a regular diet texture into a mechanical soft diet texture. Registered Dietitian #1 stated the sausage that Resident #1 received would have been considered a regular texture diet.During a telephone interview on 05/19/2026 at 1:53 PM, Licensed Practical Nurse #1 stated they remembered standing at the nurses' station with Registered Nurse Supervisor #1 when Resident Assistant #1 was calling for help. They stated Registered Nurse Supervisor #1 was in front of them, so they did not see Resident #1's face when they entered the room, but instead they immediately went behind Resident #1 because Registered Nurse Supervisor #1 told them to start abdominal thrusts. Licensed Practical Nurse #1 stated as they performed abdominal thrusts was when Resident #1 went limp. They stated everything happened so quickly and all they remembered was a sheriff arriving and using a suction thing on Resident #1. They stated that as soon as the ambulance was there, Resident #1 had a pulse. Licensed Practical Nurse #1 stated it was a very hectic day, and they did not recall telling Certified Nurse Aide #1 to give Resident #1 Resident #2's meal tray. They stated Certified Nurse Aide #1 should have called the kitchen for an alternate meal tray.During an interview on 05/19/2026 at 3:06 PM, Resident Assistant #1 stated they remembered walking into Resident #1's room and both Resident #1 and Certified Nurse Aide #1 were in the room. They stated they saw Resident #1 chewing and then it looked like they swallowed. As they swallowed, they had a gasp-like noise. Their breathing completely changed. They stated that they went to go get the nurse immediately.During an interview on 05/20/2026 at 9:49 AM, Registered Nurse Supervisor #1 stated when they entered Resident #1's room, they [Resident #1] had a slight cough and Certified Nurse Aide #1 stated Resident #1 was choking. They stated abdominal thrusts were attempted and during the abdominal thrusts was when Resident #1 became rigid and unresponsive. They stated they attempted to look in Resident #1's mouth and it was a little open at first but then they clenched it shut. Registered Nurse Supervisor #1 stated they were told by Certified Nurse Aide #1 that Resident #1 had just taken a bite of sausage and started choking. Because Resident #1 was having trouble breathing right after taking a bite of food, they stated they thought Resident #1 was choking. They stated a sheriff had entered the room at some point and used a portable suction machine. They stated that they had never seen a machine like that, but it must have worked because after the sheriff used it, Resident #1 started breathing again.During an interview on 05/20/2026 at 10:40 AM, the Director of Nursing stated their expectation was that staff call the kitchen for an alternate meal. They should not use another resident's tray because it could be the wrong diet type. Certified nurse aides should not cut up a regular texture diet into a mechanical soft texture diet because there was a risk of choking. The Director of Nursing stated that a sheriff deputy had arrived at the facility and used a portable suction device and only a one to two centimeter flake of food had come out.During a telephone interview on 05/20/2026 at 11:13 AM, the Administrator stated their expectation when a resident was not eating their meal was that the staff obtain an alternative meal from the kitchen and not use another resident's meal tray. They stated they were conflicted on if a certified nurse aide was trained in cutting up a regular texture meal into a mechanical soft meal because where they came from, certified nurses were trained on consistency. They stated they were not 100% sure about the policies and procedures of the facility.During a telephone interview on 05/20/2026 at 12:05 PM, Nurse Practitioner #1 stated that staff should have given Resident #1 the correct consistency diet because there was potential for a choking episode. Choking could lead to aspiration, aspiration pneumonia and oxygen deprivation. They stated any oxygen deprivation to the brain, heart or lungs could lead to a cardiac arrest.During a telephone interview on 05/20/2026 at 1:26 PM, the Medical Director stated they were informed that Resident #1 was fed a piece of sausage and there was a question of aspiration. They stated that they were told by the facility that a portable suction machine was used and nothing was seen in it. The Medical Director stated that something has to be at least 0.5 centimeters for someone to choke on it. They stated they were unaware of the one to two centimeter flat flake of food that was in the portable suction machine after the sheriff used it on Resident #1. They stated that flake of food was big enough for Resident #1 to choke on. They stated that Resident Assistant #1 and Certified Nurse Aide #1 visually seeing Resident #1 eating, attempting to swallow and then gasp was consistent with a choking event. They stated that choking could lead to respiratory distress and could lead to cardio-pulmonary arrest.During a telephone interview on 05/21/2026 at 9:27 AM, Direct Support Assistant #1 stated Resident #1 was on a minced moist, ground diet. They stated that someone had always sat with Resident #1 because they would shovel food in their mouth sometimes. They stated that Resident #1 had a risk for choking.During an observation and interview on 05/21/2026 at 10:45 AM, the Administrator presented a photograph that was on their cellular phone. They stated the photograph was of the portable suction machine that the sheriff had used on Resident #1. In the picture was a device with a reddish colored object that appeared consistent with the measurements of one to two centimeters. 10 New York Codes, Rules and Regulations 415.12(h)(1)(i)(2) The Survey team determined the immediacy was removed on 05/21/2026 at 8:00 PM based on the following corrective actions taken by the facility:All active staff were immediately in-serviced regarding descriptions of all mechanically altered diets, how to access diet orders and verifying meal tickets prior to offering or assisting residents with food and the importance of receiving the correct diet consistency.A full house clinical chart review to ensure all mechanically altered diet orders match the meal ticket and the care plan to ensure that there were no discrepancies.An audit of post education was completed.The facility policy and procedures for Choking and The Dining Experience were reviewed.

Based on observation, interview, and record review conducted during the Standard survey, completed on 5/16/25, the facility did not ensure that a resident with a Foley catheter (a tube inserted into the bladder to drain urine) received appropriate treatment and services to prevent urinary tract infections for one (Resident #48) of two residents reviewed. Specifically, Resident #48, had a history of urinary tract infections and infection control practices were not maintained. The finding is: The policy and procedure titled Foley Catheter Care, dated 1/2025, documented catheter care will be provided every shift and as needed as soiling occurs. The policy and procedure titled Catheter- Positioning & Emptying of Drainage Bag, dated 2/2025, documented never allow the urinary drainage bag to touch the floor, this causes contamination. Resident #48 had diagnoses including osteomyelitis from a sacral wound (an infection in the bone near the base of the spine), urinary retention, and a history of urinary tract infections. The Minimum Data Set (a resident assessment tool) dated 3/5/25 documented Resident #48 was severely cognitively impaired, was usually understood and understands. They had an indwelling urinary catheter (a tube inserted into the bladder to drain urine), and they were dependent on staff for toileting. The comprehensive care plan documented Resident #48's had a history of urinary tract infections, were incontinent of bowel, and had a Foley catheter for urinary retention. Staff were to keep the tubing and bag below the level of the bladder, monitor for signs of urinary tract infection and provide bowel incontinent care every 2-3 hours. The Certified Nurse Aide care plan (guide used by staff to provide care) dated 5/15/25, documented Resident #48 had a Foley catheter: Position the bag and tubing below the level of the bladder. Provide Foley bag cover for dignity and keep tubing off the floor. The provider note dated 5/2/25, signed by Medical Director #1, documented Resident #48 was evaluated following their hospitalization . The resident had been transferred to the hospital due to a change in their overall mentation, hypotension (low blood pressure) and hypoxemia (low blood oxygen). They were also suspected of a possible Foley acquired urinary tract infection. The wound evaluation and management summary, dated 5/9/25, signed by Medical Doctor #2, documented Resident #48 returned to the hospital on 5/1/25 for a urinary tract infection. During observations on 5/12/25 at 11:24 AM and 5/14/25 at 9:36 AM, Resident #48 was lying in bed. The bed was in the lowest position. The Foley catheter bag was in a blue privacy bag attached to the bed, lying on the floor, with approximately 18 inches of tubing lying directly on the floor. During an interview on 5/14/25 at 12:12 PM, Certified Nurse Aide #4 was seated next to Resident #48's bed, feeding them lunch. They stated they did not notice if the catheter tubing was on the floor when they came in the room, they just started to raise the bed and sat down. Certified Nurse Aide #4 stated the catheter tubing should never be on the floor for infection control purposes. During an interview on 5/15/25 at 10:20 AM, Certified Nurse Aide #5 stated they occasionally noticed Resident #48's catheter tubing on the floor in their room. They stated when they saw it, they placed it in the privacy bag. Certified Nurse Aide #5 stated the tubing should never be on the floor because it could cause a urinary tract infection. During an interview on 5/15/25 at 10:30 AM, Licensed Practical Nurse #3 stated the Certified Nurse Aide's, and the nurses were both responsible for assuring the catheter tubing was placed properly. They stated the tubing should never touch the floor for infection prevention. During an interview on 5/15/25 at 10:44 AM, Licensed Practical Nurse #4, Unit Manager stated all staff were responsible for the proper placement of the Foley bag and tubing. Staff were taught that the tubing should never touch the floor. When the bed was in the lowest position the tubing should be rolled up and placed in the blue privacy bag along with the collection bag. Licensed Practical Nurse #4 stated Resident #48 has had a urinary tract infection since admission. During an interview on 5/15/25 at 11:09 AM, the Director of Nursing stated the Certified Nurse Aides were educated on the proper care and placement of catheter tubing. They expected the staff to ensure the tubing was not on the floor because that was an infection risk. During an interview on 5/16/25 at 9:41 AM, Medical Director #1 stated they expected the staff to keep the Foley catheter maintained with the tubing off the floor because that could lead to a urinary tract infection. They stated Resident #48 had a history of urinary tract infections. 10 NYCRR 415.12 (d)(1)

Based on observation, interview and record review conducted during the Standard survey completed on 5/16/25, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for one (1) (Resident #30) of four (4) residents reviewed. Specifically, Resident #30 was not provided with the removal of unwanted facial hair. The finding is: The policy titled Activities of Daily Living - Bathing/ Grooming, dated 1/2025, documented the facility would bathe/shower/groom residents based upon their comprehensive assessment and consistent with the resident's preferences, needs, and choices. If a resident had no specific shaving preference, the facility would offer assistance with shaving as needed when unwanted facial hair was noted. The facility would take into account residents individualized needs and scheduled when implementing shower schedules for residents who did not have a preference. All bathing and showering activities must be documented in the resident's medical record, including any issues and concerns. The policy titled Maintaining Residents Respect, Preferences, and Dignity, dated 2/2025, documented the mission of the facility was to provide loving care to all residents in a timely manner that bespeaks dignity, respect, compassion, sensitivity and concern. One area of focus included respecting residents care needs which included assuring resident preferences with matters related to personal appearance were consistently honored and grooming resident as they wished to be groomed (facial hair shaved/trimmed). Resident #30 had diagnoses including chronic obstructive pulmonary disorder, chronic pain syndrome, and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 2/8/25 documented Resident #30 had severe cognitive impairment, usually understands, was usually understood. The comprehensive care plan dated 2/12/25 documented Resident #30 required an extensive assist of one (1) staff member for bathing, a limited assist of one (1) staff member for personal hygiene, and to offer the resident facial shaving as needed and per their request. The Kardex (a guide used by staff to provide care) with an as of date of 5/14/25, documented Resident #30 required a mouth inspection daily, to report changes to the nurse. Offer facial shaving as needed and per their request. Review of Resident #30's Progress Notes dated 4/1/25 to 5/14/25 revealed there was no documented evidence the resident refused to be shaved. Review of Follow Up Question Report Bathing Schedule dated 5/1/25 - 5/14/25 documented Resident #30 received a shower on 5/6/25 and a bed bath on 5/13/25. There was no documented evidence the resident refused to be shaved. During intermittent observations and interviews on 5/12/25 at 11:05 AM, 5/13/25 at 8:22 AM, and 5/14/25 at 8:37 AM, Resident #30 had white facial hair present longer than 1/4 inch on their upper lip and chin that curled at the ends. Resident #30 grabbed at their chin and stated they would usually shave their facial hair; did not know they currently had any and would like for someone to shave them. Resident #30 stated they were unable to shave them self. During an interview and observation on 5/14/25 at 12:58 PM, Certified Nurse Aide #1 (also responsible for morning care 5/14) transferred Resident #30 into bed, performed incontinent care on them, and then transferred them back into bed while Licensed Practical Nurse #1 Unit Manager assisted. Prior to, during, and following care, Certified Nurse Aide #1 did not offer or provide facial hair removal to Resident #30. Certified Nurse Aide #1 stated shaving was provided to residents on shower days and as needed, and that they should have offered to remove Resident #30's facial hair during morning care. However, if someone was providing any care to a resident and they had facial hair, they should offer to remove it. Certified Nurse Aide #1 stated it was important to offer and remove unwanted facial hair from residents for dignity reasons, so they can feel good about themselves. During an interview on 5/14/25 at 1:25 PM, Licensed Practical Nurse #1 Unit Manager stated they would have expected staff to have shaved Resident #30 when they provided their shower the night prior, but Certified Nurse Aide #1 should have offered to shave Resident #30 during care that day, especially since it was not offered on their scheduled shower day. They stated all residents were care planned to what their preferences were, and Resident #30's was to be shaved as needed. It was important to offer to shave residents for dignity purposes, the Certified Nurse Aide assigned to the resident was responsible for ensuring facial hair was removed or at least offered to be removed. During an interview on 5/16/25 at 11:00 AM, Assistant Director of Nursing/Educator stated they expected staff to address facial hair with any type of care. They stated staff were trained to review the residents care plan prior to care to see what their preferences were, talk to the resident, and then provide care. They stated all nursing staff caring for the resident were responsible for ensuring facial hair removal was offered and provided, it was important for dignity reasons. Additionally, they stated Resident #30 was very [NAME] and proper, so they were surprised family had not said anything because the resident would never allow something like that in the past. During an interview on 5/16/25 at 12:04 PM, Director of Nursing #1 stated they expected shaving to be offered and provided to all residents as part of their activities of daily living, should be offered during showers and anytime facial hair was visible. They stated the Certified Nurse Aide assigned to the resident was responsible for offering and nursing leadership was responsible for follow through. Director of Nursing #1 stated staff should have offered to shave Resident #30 during care, it was important for dignity reasons. They stated they were not aware of any refusals from Resident #30 regarding hands on care. 10NYCRR 415.12(a)(3)

Based on observation, interviews and record review conducted during the Standard survey completed on 5/16/25, the facility did not ensure correct installation, use, and maintenance of bed rails for one (1) (Resident #3) of one (1) resident reviewed. Specifically, the half bedrails were loose, not secure per the manufacturer's recommendations, and documentation of routine inspections was inconsistent. The finding is: The policy and procedure titled General Bed Safety revised 1/2025 documented the facility is committed to promoting resident safety and preventing accidents by ensuring appropriate bed safety practices. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety. When indicated, side rail/enablers shall be installed and used in accordance with manufacturer's instructions and current best practices. Some side rails may have slight give this does not indicate malfunction or disrepair as long as: the hardware is secure, and there is no risk of entrapment or collapse. Routine inspections shall be conducted by the maintenance department to verify that bed and side rails are in good repair, properly installed, and free from hazards. Nursing staff should assess bed position and lock status during routine rounding and before/after providing care. Any deviations from safety inspection must be corrected immediately and reported to the administrator. The policy and procedure titled Bed Rail Safety Inspection revised 1/2025 documented the nursing staff caring for residents will report any concerns to the Maintenance Department/designee for re-assessment. This includes but is not limited to bed rails that are loose and can be pulled away from the side of the bed, rails that are bent and broken, and mattresses that are not flush with the headboard or the foot board. Resident #3 had diagnoses including left hemiplegia (paralysis on one side of the body), bipolar disorder, and morbid obesity. The Minimum Data Set (a resident assessment) dated 2/22/25, documented the resident was cognitively intact, understood and understands; siderails were not used, and the resident was seventy inches tall and weighed 267 pounds. The comprehensive care plan dated 3/12/25 documented Resident #3 had bilateral side rails (bari bed-a heavy-duty bed that is wider than a normal hospital bed) and required assistance from two staff members for bed mobility. The Physical Therapy Side Rail/ Grab Bar Evaluation dated 4/22/25 documented bilateral side rails were recommended and enhanced bed mobility tasks. During observation and interview on 5/13/25 at 9:18AM, Resident #3 was seated in their wheelchair in their room. The bari bed had two half metal side rails in the up position. The side rails were attached to the bed frame with a black bolt knob and the side rails were unable to be lowered. The side rails wobbled away from the bed frame two to three inches laterally on the bottom and approximately six inches laterally toward the top. Resident #3 stated the side rails were for bed mobility and independence. The side rails were so loose the aides fell on their belly sometimes when providing them incontinent care. Resident #3 stated the side rails were tightened by turning the black bolt knob on the bottom of the bed frame and maintenance staff completed visual checks. The Bariatric Bed User Manual and User Instructions for Half-Length, Clamp-on Rails dated 2021, provided by the facility on 5/13/25 at 4:00PM, documented the following warnings: make sure the rails are secured properly before using the bed to avoid possible injury and the side rails do not fall within any weight limitations and may be damaged if excessive pressure is placed on them. There was no routine maintenance recommendations documented in the manual. The Bed-Mobility-Physical Therapy Side Rail/ Grab Bar Evaluation from 12/2024 through 5/2025, identified by the Maintenance Assistant on 5/16/25 at 9:02AM as the Monthly audit tool for inspecting side rails, revealed no documented evidence that Resident #3's side rails were inspected consistently. The audit tool was blank in the months of 12/2024, 2/2025, 3/2025, and 4/2025. During observation of incontinent care on 5/14/25 at 1:43PM, Certified Nurse Aide #2 raised Resident #3's bed at their mid-thigh level. Certified Nurse Aide #3 guided Resident #3's right hand and Resident #3 grabbed the left side rail to pull themselves over to their left side. The left side rail bent inward two to three inches toward Resident #3. Certified Nurse Aide #2 then assisted Resident #3 on their right side toward Certified Nurse Aide #3. Resident #3 was unable to use their left hand to grab the side rail and unable to pull themselves over. While providing incontinent care both, Certified Nurse Aide #2, Certified Nurse Aide #3 leaned on the half side rails which bent inward towards Resident #3. Certified Nurse Aide #2 stated the half side rails could not be lowered and were in the way when performing incontinent care. Certified Nurse Aide #2 tightened the black bolt knob on the left half side rail and stated that it was as tight as it got. No matter how much you tightened the bolt, the side rails were always loose and could snap off during positioning. Certified Nurse Aide #3 stated the loose side rails could cause a fall out of the bed and were not safe. During an interview on 5/16/25 at 9:29AM, Occupational Therapist #1 stated Resident #3 used the half side rails for bed mobility. They checked Resident #3's side rails last on 4/22/25 and ensured Resident #3 was still capable to use them. Maintenance completed monthly inspections of the side rails and ensured they worked properly and were secure. The Occupational Therapist #1 stated that on 5/15/14 at 7:30 AM they tried to tighten them, they were still not one hundred percent secure and were a safety concern. The side rails could loosen again and could come off as Resident #3's grabbing onto them. The bar could come off and hit Resident #3 in the face. A loose positioning bar was counterproductive. A stable, secure structure was the goal which allowed Resident #3 to participate in care safely without injuring themselves. Occupational Therapist #1 recommended changing out the bed. During an interview on 5/16/25 at 11:25AM, the Maintenance Assistant stated they checked for loose bolts and ensured the side rails were secure monthly. They typically documented OK after the side rails were inspected and must have forgot as Resident #3's was blank. Resident #3's entire bed was switched out because the original side rails could no longer be tightened sufficiently. The bolt was stripped, and the side rails were a hazard. During an interview on 5/16/25 at 10:03AM, the Director of Therapy stated they last checked Resident #3's half side rails on 1/22/25. There was some movement but not enough movement to cause concern. During an interview on 5/16/25 at 11:43M, Licensed Practical Nurse #2, Unit Manager stated Resident #3 has had those half side rails for a long time, and tended to wiggle, and tighten them up regularly. Unbalanced side rails impeded positioning and could cause an arm injury. During an interview on 5/16/25 at 12:07PM, the Maintenance Director stated the Bari bed had loose side rails that were not secure. During an interview on 5/16/25 at 12:55PM, the Director of Nursing stated the half side rails were a last resort for bed mobility. Unstable side rails that moved back and forth could cause a fall out of bed and should not have been used. The maintenance assistant should have identified the loose side rails during their monthly inspection and replaced them. During an interview on 5/16/25 at 1:05PM, the Administrator stated Certified Nurse Aide #2 and Certified Nurse Aide #3 should have reported Resident #3's loose rails to maintenance, the unit manager or the Administrator. The rails should have been changed out sooner. 10 NYCRR 415.12(h)(1)

Based on observation, interview, and record review conducted during an Extended Standard survey started on 7/17/23 and completed on 7/25/23, the facility did not ensure that each resident received adequate supervision to prevent accidents for one (Resident #43) of 10 residents reviewed. Specifically, the facility failed to provide adequate supervision to provide a safe environment for Resident #43, who is severely cognitively impaired with a history of resident-to-resident altercations because of unsafe wandering into other residents' rooms. Subsequently, Resident #43 had 8 documented falls from 3/4/23 to 7/21/23 and changes in the plan have been ineffective. This resulted in no actual harm with the likely hood for more than minimal harm that is Immediate Jeopardy and Substandard Quality of Care to Resident #43's health and safety. The policy and procedure (P&P) titled Accident/Incident - Investigation & Reporting documented the purpose was to provide the guidelines for completion, investigation, care plan interventions and regulatory reporting of all Accident & Incidents (A/I); to ensure timeliness of such reporting, and to ensure the appropriate follow-up and monitoring post-incident occurs. Upon the observation or report of an accident and/or incident the staff member must report the occurrence immediately to the charge nurse and the nursing supervisor. This includes a potential for harm that may occur based on an unsafe condition, item, and or situation. Immediate action(s) must be taken at the time of the incident to keep the resident in the safest environment. Action(s) will be noted on the A/I. The immediate action(s) will be reviewed by the Interdisciplinary Team and evaluated and/or altered if indicated. The resident's Care Plan and profile sheet will be updated by the team at this time. 1. Resident #43 was admitted to the facility with diagnoses of dementia with agitation, anxiety disorder and depression. The Minimum Data Set (MDS- a resident assessment tool) dated 6/13/23 documented the resident was severely cognitively impaired, wandered daily and had several falls since prior assessment with and without injuries. The current comprehensive care plan (CCP) initiated on 3/3/23 Resident #43 was at risk for falls related to an unsteady gait, confusion, and behaviors. Documented interventions included to encourage the resident to wear appropriate footwear when walking. A safe environment with even floors free from spills and/or clutter, adequate glare-free light, handrails on walls, and personal items within reach. Additionally, Physical Therapy (PT) was to evaluate and treat as ordered and as needed. Place a workable call light within reach and encourage resident to use it. Initiated 3/6/23 the CCP documented Resident #43 was independent with ambulation requiring occasional checkups/redirection, out of bed (OOB) to standard chair in a supervised area. The CCP documented the PT following evaluations: - 3/4/23 Physical Therapy (PT) consult completed, there were no documented added safety interventions. - 3/14/23 PT consult completed, documented a recommendation to be in supervised offer resident to lay down and to place resident in bed when tired. Resident keeps walking even once tired. - 4/12/23 PT consult completed, provide daily checkups and to monitor resident whereabouts. - 5/7/23 PT and OT (Occupational Therapy) consult completed and therapy program. - 5/12/23 PT consult completed. There were no documented changes in therapy plan. The CCP was revised on 6/14/23 to include Resident #43 removes their helmet frequently and staff was to assist as needed. The helmet was implemented via physician orders on 5/15/23. The CCP documented Resident #43 had dementia with psychosis, anxiety, and depression. The resident was easily distracted with the inability to concentrate, inability to problem solve, lacked acceptance to current condition, was not easily redirected and had behaviors directed at others (swears at staff, swings their cane, and wanders with no destination). Documented interventions dated 3/4/23 included to allow resident time to answer questions, verbalize feelings and fears. Consult with pastoral care, social services, and psychosocial services as needed (PRN), encourage socialization, provide 1:1 support PRN, provide opportunities for resident family to participate in care. When conflict arises, remove resident to a calm safe environment. Additional interventions dated 4/28/23 documented to redirect PRN and 5/8/23 staff will redirect resident away from the short hall, and out of other's rooms when possible. The CCP and Kardex identified as current and dated 7/20/23 did not document person- centered interventions to meet the residents specific needs to prevent the resident from wandering. Changes in the CCP have not been effective to prevent potentially avoidable accidents. The CCP did not document or include social and recreational preferences. The physicians Order Summary Report dated 3/3/23 through 7/31/23 documented an order dated 5/15/23, Must wear helmet for protection at all times as tolerated every shift for frequent falls with head trauma. Review of Resident #43's Accident/ Incident (A/I) Reports dated 3/3/23 through 7/21/23 revealed the following: -3/4/23 at 2:36 PM, the resident had a witnessed fall. The resident sat self on the floor in hallway. The report documented the resident had no injuries. -3/14/23 at 7:30 PM, the resident had a witnessed fall. The resident was noted to be leaning backwards more than normal. The resident was ambulating past the nurse's station holding onto a wheelchair and fell backwards hitting the back of their head on the floor, sustaining a hematoma (collection of blood under the skin). The A/I report documented the resident had very poor safety awareness would not rest when they were tired and continued to walk even when unsafe. The plan was for staff to encourage the resident to rest when tired. - 4/12/23 at 3:50 PM the resident had an unwitnessed fall and was found lying on the floor in another resident's room on their left side. The resident complained of some pain to their neck and had a nickel sized contusion (soft tissue injury) on their left temple and bruising to their face. The report documented for staff to do daily checkups and monitor whereabouts. - 4/27/23 at 11:22 AM documented a physical incident. Resident #43 ambulated into Resident #60's room. Resident #60 was observed dragging Resident #43 on the floor out of their room. Resident #43 was assisted to a recliner in the common area for lunch, and a stop barrier sign placed across Resident #60's door. In addition, Other Information documented, Resident #43 has severe dementia, they ambulate independently and wanders in and out of rooms without purpose, their safety awareness is limited. The report documented resident-to-resident physical abuse. - 4/30/23 at 2:28 PM, the resident had an unwitnessed incident and was found lying in doorway of Resident #60's room. Resident #43's head was toward the hallway and Resident #60 was standing by #43. Resident #60 continuously opens their door and takes down the barrier stop sign, that is to keep others out of their room. Resident #43 continuously wanders in and out of residents' rooms, lying on beds and just wanders in without purpose. The A/I report documented that staff will continue to redirect as able. Resident #43 continues to wander even when tired. (Redirection previously implemented 4/28/23) - 5/7/23 at 5:58 PM, the resident had a witnessed fall. Resident #43 was holding onto Certified Nursing Assistant (CNA) #13 shirt, so they didn't fall. CNA #13 turned around observed the resident fall, hitting their head on the wall, and falling to the floor. Resident #43 had been ambulating throughout the day leaning to the side. The report documented Resident #43 had advanced dementia, resists sleeping and continuously ambulates even when tired. When the resident was put into bed, the resident gets right up. When assisted to a chair, the resident gets right up. -5/8/23 at 5:15 PM documented a physical incident. At 4:15 PM, Resident #43 was witnessed walking out of Resident #60's room while Resident #60 was walking into their room. When they met, Resident #60 reached out and placed both their hands on Resident #43's upper chest, collar bone/shoulder areas and pushed Resident #43. Resident #43 fell backwards onto their buttocks/back and bumped their head on the floor. The incident report documented, the physical contact was inappropriate and had the potential to cause physical harm and was considered resident-to-resident abuse. Will continue to redirect Resident #43 when wandering into other rooms as is possible. -5/9/23 at 9:11 PM documented a physical incident. Resident #43 wandered into Resident #39's room, Resident #39 pulled Resident #43 down causing Resident #43 to lay on their back across Resident #39's abdomen. Resident #39 was witnessed holding Resident #43 in place while hitting Resident #43 in the chest with a closed fist. The report documented the physical contact was inappropriate and was the definition of physical resident-to-resident abuse. Resident #43 was placed on 15 min checks for their safety. Resident #43 continues to wander throughout the unit without purpose or direction. - 5/12/23 at 8:07 PM documented the resident had a witnessed fall. Resident #43 was reaching for something on the floor, lost their balance and fell , hitting their head, sustaining a hematoma on their forehead. Resident #43 was assisted to bed, they got back up and began to again wander the unit. Resident #43 wanders without direction or purpose regardless of how tired they are. - 7/19/23 at 12:50 PM documented the resident had a witness fall. Resident #43 had a fall in dining room in front of another resident's tray table. A visitor reported they witnessed Resident #43 reach for another resident's food which was on a movable tray table, and the other resident pulled the tray table back causing Resident #43 to lose their balance and fall. The incident report documented, CP as followed. There were no additional interventions implemented on the A/I report or documented in the CCP. - 7/21/23 at 2:00 PM the resident had an unwitnessed incident and Resident #43 observed lying on their right side on the floor in front of the nurses' station, their helmet was not on. Neuro checks were initiated. During observations on 7/17/23 at 2:51 PM and 7/18/23 at 8:43 AM Resident #43 was observed to be ambulating aimlessly with a shuffled gait throughout the unit hallways without a soft helmet on their head. There was no staff intervention or redirection. During a continual observation on 7/19/23 at 9:59 AM through 10:18 AM Resident #43 was not wearing a helmet as planned. Observations revealed the following: 9:59 AM- Resident #43 was walking independently throughout the hallway. Staff assisted the resident to the dining room and encouraged Resident #43 to sit in a standard chair. Resident #43 sat down for 60 seconds then stood up and walked from the standard chair to the nearest furniture 5 feet away and was continuously touching furniture (table, chairs) and other residents as they passed by them. Resident #43 used the hallway railing to aimlessly walk on the unit's short hall. 10:02 AM- Resident #43 entered Resident #17's room on the short hall and laid down on the bed near the window. Resident #17 was in the room. At 10:07 AM, staff removed Resident #43 from Resident #17's room and allowed Resident #43 to continue to independently walk hallways of the short hall following and holding onto the handrails, without their helmet in place as planned. 10:18 AM- Resident #43 walked independently into the dining room following the wall of the dining room, sat down on Resident #110's lap for 5 seconds, and then got up and continued to walk aimlessly. There was no staff in the area at this time. During intermittent observations on 7/19/23 revealed the following: 12:40 PM- Resident #43 was walking with a shuffled gait leaning forward with two staff members arm in arm and sat the resident in a stationary chair for lunch. Resident #43 was not wearing a soft helmet. The staff encouraged Resident #43 to sit down and eat their meal. 12:52 PM- Resident #43 (without staff intervention) walked independently out of the dining room through the doorway nearest the long hall. Resident #43 continued to walk and guide themselves by holding onto and touching the nurses' station desktop until they reached the dining room doorway nearest the short hall on the opposite side of the dining room. At 12:53 PM, Resident #43 re-entered the dining room from short hall side, and a noise was heard. Resident #43 was laying on the floor on their left side, and their head was on the floor. Resident #43 was on laying on the floor in front of a resident that was seated eating lunch in a stationary chair with a rolling tray able in front of them. Staff assisted Resident #43 to a standing position and walked the resident to their room at 12:58 PM. 12:59 PM- the Assistant Director of Nursing (ADON) exited Resident #43's room. Resident #43 was observed walking independently in their room towards the roommate's side of the room without a helmet. At 1:15 PM Resident #43 continued to walk independently around their room on the roommate's side of the room without their helmet in place as planned. During an interview on 7/19/23 at 1:00 PM, the ADON stated they were in Resident #43's room to assess the resident after a fall. The ADON stated that Resident #43 was constantly walking independently. When they placed the resident in bed or a chair they would not stay there and would continue to get up and walk. During intermittent observations on 7/20/23 revealed the following: 7:15 AM- Resident #43 was in bed sleeping and there was no helmet located in the resident's room. 8:31 AM- Resident #43 was seated in the dining room without their helmet in place. During an interview on 7/20/23 at 8:32 AM, CNA #7 stated they provided care to Resident #43 that morning and that they did not know if the resident had a history of falls, or if they were to wear a helmet. CNA #7 stated there was not a helmet in the resident's room. During an interview on 7/20/23 at 8:37 AM, CNA #4 stated they were familiar with Resident #43 and provided care to Resident #43 on 7/17/23 and 7/19/23. CNA #4 stated that Resident #43 wandered all the time, and often will lean forward when they were tired but would not stop walking. CNA #4 stated they were not aware of any safety interventions for the resident. They further stated they do not believe the resident had a helmet for their safety and has not seen the resident wear a helmet. During an interview on 7/20/23 at 8:43 AM, CNA #8 stated they were familiar with Resident #43 and stated the resident wandered all the time. The resident was supposed to wear a helmet, but Resident #43 refused to wear it. Therefore, they do the best they could redirecting the resident as needed but the resident doesn't stop wandering. During an interview on 7/20/23 at 9:24 AM, Licensed Practical Nurse (LPN) #14 stated Resident #43 was supposed to wear a helmet for their safety, but the resident refused the helmet. LPN #14 stated they were not aware of any additional interventions. LPN #14 stated they would expect staff to ambulate with Resident #43 if they were tired or wandering unsafely. During an interview on 7/20/23 at 10:32 AM, CNA #9 stated they provided care to Resident #43 on 7/14/23, 7/15/23, 7/16/23 and 7/18/23 and did not offer to put the helmet on because the resident refuses the helmet. CNA #9 stated the helmet was for the resident's safety related to their frequent falls, hitting their head and there were not any additional interventions. CNA #9 stated Resident #43 wandered all the time on the unit and wandered into other resident's rooms. Staff do the best they can to redirect Resident #43. During intermittent observations on 7/21/23 revealed the following: 9:14 AM- Resident #43 was laying on Resident #39's bed (previous resident to resident incident 5/9). Staff redirected Resident #43 out of the room. 1:39 PM- Resident #43 was laying on their left side on the floor in front of the nurses' station. The resident did not have a helmet in place, there was no staff at nurses' station or in the hallways. The LPN #2 Unit Manger (UM), in their office near the nurses' station. The LPN #2 UM was made aware that Resident #43 was on the floor. During an observation and interview on 7/24/23 at 7:42 AM, Resident #43 walked independently in the hallway without their helmet in place. Resident #43 then walked into and laid down on Resident #34's bed with visibly wet pants. At 7:43 AM, LPN #2 UM assisted Resident #43 out of Resident #34's room. At that time LPN #2 stated Resident #43 was incontinent of urine and should not be wandering into other resident's rooms for their safety. LPN #2 UM stated Resident #43 currently doesn't have a helmet in place because it was lost 7/21/23 in the afternoon and they were unable to find it. During an interview on 7/24/23 at 10:57 AM, CNA #12 stated they worked 7/22/23 and 7/23/23 during the evening shifts. CNA #12 stated that staff were unable to find the helmet, and Resident #43 was placed on 1:1 supervision (constant staff member). CNA #12 stated there were no additional interventions put into place after the 1:1 was stopped on 7/22/23. The resident continued to wander on the unit, and in and out of other resident's rooms. CNA #12 stated they continued to redirect the resident when they were able but that did not prevent the resident from wandering into other resident's rooms. During an interview on 7/24/23 at 11:32 AM, LPN #1 stated they were unable to locate Resident #43's helmet since 7/21/23 in the afternoon. LPN #1 stated that 1:1 supervision was put into place for 24 hours but should have been for the entire weekend or until the helmet was found. LPN #1 stated that staff do the best they can by redirecting the resident, but the resident wanders aimlessly on the unit and enters other resident's rooms frequently. LPN #1 stated they were unable to prevent Resident #43 from wandering into other resident's rooms unless they can provide 1:1 supervision and there was not enough staff to accommodate that intervention. LPN #1 stated they believed they were unable to provide a safe environment. During an interview on 7/24/23 at 11:53 AM, LPN #2 UM stated if Resident #43 refused the helmet, they expected the staff to attempt to reapply the helmet a few times. LPN #2 UM stated when the helmet was missing on 7/21/23 in the afternoon they asked the Administrator for 1:1 supervision for the resident's safety. The Administrator approved 1:1 supervisor for 24 hours but could not provide a 1:1 any longer than the 24 hours because there was not enough staff. LPN #2 UM stated Resident #42 continued to independently wander without the helmet on Sunday 7/23/22 and during the morning of 7/24/23 because the helmet was unable to be located. LPN #2 UM stated the staff do the best they can by redirecting Resident #43, but they were unable to prevent the resident from entering other resident's rooms. LPN #2 stated they believed the facility was unable to provide a safe environment for this resident. During an interview on 7/24/23 at 12:47 PM, the Director of Nursing (DON) stated they were unaware Resident #43 refused the helmet and there were no additional interventions for the resident's safety. The DON stated, staff do the best they could by redirecting the resident. The DON stated they reviewed of the A/I reports and had not asked the Administrator for additional staff to provide oversight for Resident #43. The DON stated they had been made aware the Administrator provided a 1:1 staff member for Resident's #43 on Friday (7/21) for 24 hours but had not inquired why. The DON stated the only intervention that would provide a safe environment for Resident #43 was a 1:1 supervision, 24 hours 7 days a week, and the facility was unable to meet the resident's needs. The DON stated they were not able to keep Resident #43 in a safe environment. During an interview on 7/24/23 at 1:49 PM, the Administrator stated there were many wandering residents on this unit, that's what they do, it's a dementia unit. I can't stop them from falling, wandering and going into other resident's rooms. There were stop signs and special door handles but Resident #43 continued to wander. Staff continued to try their best to keep the resident safe, but they were unable to prevent them from wandering. The Administrator stated they did not have any additional interventions at this time for Resident #43 and a 1:1 was provided to the unit on Friday for only 24 hours, as !:1 was not a long-term intervention. Based on the survey team's observations, staff interviews and record review the survey team declared the facility removed the immediacy as of 7/25/2023 at 3:00 PM prior to exit. Corrective actions the facility took to remove the immediacy included: 1. A 1:1 Staff member was assigned to Resident #43. 2. Care plan interventions were updated to include 1:1 supervision at all times, and an interdisciplinary team meeting was held on 7/24/24 to discuss Resident #43 specific interventions. 3. Facility provided immediate staff education to all nursing staff regarding 1:1 supervision and Resident #43 specific activities interventions. Ongoing education occurred shift to shift forward to ensure all nursing staff were educated. Facility anticipated 90 % (percent) of all education would be completed 7/25/23 by 3:00 PM. Continuous education would continue until 100 % of all scheduled nursing staff were educated including agency staff. Any staff scheduled off would be educated prior to the start of their shift. 10 NYCRR 415.12(l)(2)(ii)

Based on observation, interview, and record review conducted during a Complaint Investigation (#NY00311987 & #NY00310989) during the Extended survey completed on 7/25/23, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, are reported immediately and no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for four (Residents #4, #17, #76, #234) of nine residents reviewed for reporting of alleged violations. Specifically, the facility did not report to the New_York State Department of Health (NYSDOH) agency within the required time frames. The issues involved residents who had an injury of unknown origin and the injury (Residents #4, #17, #76), and a resident who was found outside of the facility, sleeping on the grass unsupervised without staff knowledge at 2:00 AM (Resident #234). The findings are, but not limited to, the following: The policy and procedure (P&P) titled Accident/Incident - Investigation & Reporting dated 6/2022 documented if the incident was an elopement, an alleged physical abuse or any other incident that meets the criteria of a reportable incident per the DOH regulations, the Nursing Supervisor/Nurse Manager will immediately notify the Administrator and Director of Nursing (DON) regardless of the time in which the incident was discovered.If there is 'reasonable cause' to believe that abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of residents property has occurred and or there is obvious serious bodily injury the DOH was to be notified immediately (but not later than 2 hours) after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. In addition, the policy documented an elopement occurs when a resident leaves the building undetected, and injury of unknown origin was reportable to the NYS DOH if injury without known incident and facility is unable to rule out abuse or a care plan violation. 1. Resident #4 was admitted with diagnoses of dementia and schizophrenia. Review of the Minimum Data Set (MDS - resident assessment tool) dated 5/5/23 documented that the resident was severely cognitively impaired, understands others, and is understood by others. Review of the nursing progress notes dated 2/27/23 at 2:57 PM documented that the Nurse Practitioner (NP) examined the resident after the resident fell on [DATE] and there were no bruised areas on Resident #4. Review of the nursing progress notes dated 3/3/23 at 2:43 PM documented that the NP examined the resident after nursing reported a bruised area on Resident #4 right elbow. Further review of that progress note documented that the NP ordered an x-ray for the elbow, use pain medication for any discomfort, and elevate the elbow with a pillow for comfort. Review of a Radiology Results Report dated 3/3/23 at 11:58 PM documented that Resident #4 had an acute nondisplaced olecranon process fracture (a broken elbow). Further review of the Radiology Results Report documented that the NP reviewed the x-ray on 3/6/23 at 12:56PM. Review of the nursing progress notes dated 3/5/23 at 2:18 PM documented a follow up to the x-ray that Resident #4 had a broken elbow, the supervisor was notified, the DON was notified, the physician assistant (PA) was notified, and the physician was notified. Review of the nursing progress notes dated 3/5/23 at 2:50 PM documented that per a telephone conversation, the PA, and Registered Nurse (RN) #2 wanted Resident #4 to be sent to the hospital due to a possible fracture. During an interview on 7/24/23 at 7:59 AM, Licensed Practical Nurse (LPN) #1 stated that Resident #4 had a purple-colored bruise from their elbow down their forearm. They stated they thought the bruise was from a previous fall Resident #4 had on 2/25/23. They stated that it looked like a fresh bruise. They stated they did not report the bruise to the DON because they thought the bruise was from the previous fall. During an interview on 7/24/23 at 8:01 AM, LPN #2 Unit Manager (UM) stated that a bruise that was purple was a fresh bruise. They stated it should have been reported to the supervisor and reported to the DON as soon as the bruise was found. During an interview on 7/24/23 at 8:13 AM LPN Supervisor #3 stated that a fresh bruise from an unknown origin should be reported immediately to the DON and an investigation started. During an interview on 7/24/23 at 4:23 PM, the DON stated that an injury of unknown origin was reportable to the State agency and needed to be reported immediately. They stated they expected their staff to report any injury of unknown origin to them as they have two hours to report that injury to the State. During an interview on 7/25/23 at 9:42 AM, the Administrator stated that they expected the staff to report any injury of unknown origin to them or the DON so it can be reported to the State in a timely manner. 2. Resident #17 was admitted with diagnoses of dementia with behavioral disturbance, atherosclerotic heart disease (ASHD), and diabetes mellitus. Review of the MDS dated [DATE] documented that the resident was severely cognitively impaired, usually understands others, and is usually understood by others and does not exhibit behaviors. Additionally, the MDS documented the resident required extensive assistance of one staff member for transfers, and extensive assistance of two staff members for bed mobility, dressing, toilet use and personal hygiene. Review of the comprehensive care plan (CCP) dated 12/7/22 documented resident was at risk for falls related to weakness and dementia with history of falls with injury, interventions included resident needed a safe environment with even floors free from spills and or clutter, adequate glare free light, a working and reachable call light, handrails on walls and personal items within reach. An intervention dated 1/19/23 documented to keep the resident in a supervised area when not in bed. Review of Progress Notes dated 6/17/23 through 7/14/23 revealed the following: -On 6/17/23 at 12:09 AM, LPN #16 documented during resident care that shift, there was purple / blue bruising to their left hip measuring 7.4 centimeter (cm) x (by) 7 cm and 2 bruises to the left outer thigh measuring 6 cm x 4.2 cm and 5.3 cm x 2 cm. The resident was unable to give description of what happened. -On 6/17/23 at 3:20 AM, LPN #16 documented a bruise to left cheek bone 2 cm round and left rib cage 3 cm round. - On 6/17/23 at 5:35 AM, LPN #6 documented it was reported to them that the resident had bruising to their left thigh, hip and rib cage area left cheek unknown origin areas, light purple in color. -On 6/17/23 at 11:20 AM, LPN #2 UM documented Follow up bruising - bruising continued on left side, no noted recent fall, no c/o of discomfort, resident is on Plavix (prevents platelets in the blood from making clots) and baby aspirin (ASA). -On 6/19/23 at 1:00 PM, the NP documented nursing reported unusual bruising evident at the left cheek and left lateral hip, nursing denied any falls occurring recently. The left flank (side of the body) region had ecchymosis (bruising) noted. The resident was taking both ASA and Plavix long-term anticoagulation and would discontinue ASA due to recent bruising. Review of Resident #17 Accident / Incident Report dated 6/16/23 at 10:49 PM documented, during patient care, the resident was noted with purple and blue bruising to their left hip, left thigh, left rib cage, and left cheek bone. The resident was unable to give a description. Immediate Action include the supervisor was made aware, the physician made aware, discontinue ASA, and labs pending. There were four staff statements attached, and documented they were not aware of the bruising. During an interview on 7/21/23 at 9:21 AM LPN #2 UM stated the resident sustained bruising on the left side of their body, of unknown origin and believed it may have been related to the ASA, although upon further discussion LPN #2 UM stated the bruising was unlikely related to ASA because the bruising was only on the left side of the body. UM LPN #2 stated they had not ruled out abuse related to the injuries of unknown origin and should have been reported to the NYSDOH within 2 hours of finding the bruising. During an interview on 7/21/23 at 11:33 AM, the NP stated they were familiar with the resident and the facility should have ruled out abuse through an investigation and should have reported the bruising of unknown origin to the NYSDOH as required because aspirin would not have just affected the left side of the body. During an interview on 7/21/23 at 3:01 PM, LPN #16 stated they were familiar with the resident and recall putting the resident into bed and noted the bruising on 6/16/23. LPN #16 stated they notified the nursing supervisor, completed the A/I and had initiated collecting statements from staff. LPN #16 stated the UM should have continued collecting statements from staff who provided care to the resident for at least the past 24 hours to determine the reasons for the bruising and rule out abuse. LPN #16 stated they do not know how the resident sustained the bruising and the facility should have reported the injuries of unknown origin to the NYSDOH within 2 hours. During an interview on 7/21/23 at 3:55 PM, the DON stated injuries of unknown origin were to be investigated to rule out abuse. The DON stated they had not ruled out abuse and should have reported the injuries of unknown origin to the NYSDOH within 2 hours as required. During an interview on 7/24/23 at 5:32 PM, the Medical Director stated any injury of unknown origin should be investigated to rule out abuse and reported to the NYSDOH as required. 3. Resident #234 was readmitted with diagnoses of dementia with behavioral disturbances, anxiety disorder, and epilepsy. Review of the MDS dated [DATE] documented the resident was moderately cognitively impaired, sometimes understands and sometimes is understood by others. The CCP initiated on 12/2/21, documented Resident #234 was at risk for safety issues, was cognitively impaired related to mental diagnosis and dementia, interventions included the resident would be supervised around all environments, staff needed to remove resident from any area that was unsafe. On 3/9/22, the resident was identified at risk for elopement related to cognitive impairment, delirium / recent change in mental status, dementia, and mental illness. Interventions included to avoid leaving unattended or unobserved for long periods of time, calmly redirect to an appropriate area and engage in activities or tasks to keep the resident occupied. Review of Progress Notes dated 7/27/22 through 8/15/22 revealed the following: -On 8/6/22 at 5:26 PM, resident was alert with confusion, frequently yelling out and wandering out of their room with staff redirecting. -On 8/7/22 at 5:33 AM, the resident wandered into hallway calling out for water, resident redirected back to their room. -On 8/10/22 at 12:46 AM, the resident was not found in their room, upon looking for resident, it was noted that the courtyard door was open and it hadn't been before. The resident was noted laying on the grass outside and had a skin tear to their left arm. Review of Resident #234's Accident / Incident Report dated 8/10/22 at 12:19 AM documented the resident was found out in the courtyard, laying in the grass in a gown and non -skid socks. A skin tear was noted to their left forearm 2 cm by 1.5 cm. The resident was noted in their bed by CNAs 20 minutes prior. Other information included Resident #234's safety awareness was altered due to their mental health/illness and they were redirected. The supervisor was to ensure that all courtyard doors were closed and locked before dark. In addition, the DON documented the resident was asleep in their bed 20 minutes before observed lying in the grass in the courtyard. Resident had an abrasion (not a skin tear as first reported) to their forearm. Resident was dressed in a gown, non -skid socks, brief was off and on the floor in their room. Care to continue as planned. During an interview on 7/21/23 at 4:21 PM, LPN #3 stated they were familiar with Resident #234 and recalled the incident when the resident was found in the courtyard in the middle of the night, and they should not have been able to get out of the building in this courtyard because it was not supervised, and this was considered an elopement. LPN #3 stated the courtyard doors were to be locked by 8 PM to ensure the courtyard was not accessible. During an interview on 7/24/23 at 12:37 PM, the DON stated Resident #234 was not alert and oriented and should not have wandered out of the building into the enclosed courtyard at 2:00 AM because it was not supervised at night and would not be considered a resident area. The DON stated the courtyard doors should have been locked by 8:00 PM to prevent residents access and it wasn't. The DON stated, I don't know if this incident needed to be reported. During an interview on 7/24/23 at 1:34 PM, the Administrator stated the courtyard doors were to be locked by 8 PM to prevent residents from going outside unattended in the middle of the night, therefore is a non-residential area at 2 AM and the incident should have been reported to the NYSDOH as required. 10 NYCRR 415.4(b)(4)

Based on observation, interview, and record review conducted during a Complaint Investigation (#NY00311987 & #NY00300989) conducted during the Extended survey completed on 7/25/23, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment have evidence that alleged violations are thoroughly investigated for four of nine residents (Residents #4, #17, 76 and #234) reviewed for abuse. Specifically, a resident had a purple bruise on their elbow and forearm and did not have an investigation initiated for an injury of unknown origin (Resident #4); and the facility did not have thorough investigations that included staff statements for a resident with bruising on their left side including their cheek, rib cage, hip, and thigh (Resident #17); a resident with a bruise on their right forearm (Resident #76) and a resident found lying on the ground outside the facility at 2:00 AM (Resident #234). The findings are, but not limited to: The policy and procedure (P&P) titled Accident/Incident - Investigation & Reporting dated 6/2022 documented upon notification of an accident/ incident the Nursing Supervisor is required to initiate an investigation, regardless of where the accident/incident occurred at the facility. The investigation should rule out or confirm abuse, exploitation, or neglect through a review of supporting evidence, including interviews and statements that offer valid information, observations, and record review. 1. Resident #4 was admitted with diagnoses of dementia and schizophrenia. Review of the Minimum Data Set (MDS - resident assessment tool) dated 5/5/23 documented that the resident was severely cognitively impaired, understands others, and is understood by others. Review of the nursing progress notes dated 2/27/23 at 2:57 PM, documented that the Nurse Practitioner (NP) examined the resident after the resident fell on [DATE] and there were no bruised areas on Resident #4. Review of the nursing progress notes dated 3/3/23 at 2:43 PM documented that the NP examined the resident after nursing reported a bruised area on Resident #4 right elbow. Further review of that progress note documented that the NP ordered an x-ray for the elbow, use pain medication for any discomfort, and elevate the elbow with a pillow for comfort. Review of a Radiology Results Report dated 3/3/23 at 11:58 PM documented that the resident had an acute nondisplaced olecranon process fracture (a broken elbow). Further review of the Radiology Results Report documented that the NP reviewed the x-ray on 3/6/23 at 12:56 PM. Review of the nursing progress notes dated 3/5/23 at 2:18 PM documented a follow up to the x-ray that Resident #4 had a broken elbow, the supervisor was notified, the Director of Nursing (DON) was notified, the physician assistant (PA) was notified, and the physician was notified. Review of the nursing progress notes dated 3/5/23 at 2:50 PM documented that per a telephone conversation, the PA, and Registered Nurse (RN) #2 wanted Resident #4 to be sent to the hospital due to a possible fracture. During an interview on 7/24/23 at 7:59 AM, Licensed Practical Nurse (LPN) #1 stated that Resident #4 had a purple-colored bruise from their elbow down their forearm. They stated that they thought the bruise was from a previous fall Resident #4 had on 2/25/23 so an investigation was not initiated. They stated that it looked like a fresh bruise. They stated they did not report the bruise to the DON because they thought the bruise was from the previous fall. During an interview on 7/24/23 at 8:01 AM LPN #2 Unit Manager (UM) stated that a bruise that is purple is a fresh bruise. They stated it should have been reported to the supervisor and reported to the Director of Nursing (DON) as soon as the bruise was found. They stated an investigation should have been initiated immediately. During an interview on 7/24/23 at 8:13 AM, LPN Supervisor #3 stated that a fresh bruise from an unknown origin should be reported immediately to the DON and an investigation started. They stated that witness interviews should have been initiated for staff for the last 24 hours. They stated an accident and incident report should be initiated and the DON or the Administrator should be contacted. During an interview on 7/24/23 at 4:23 PM, the DON stated that an injury of unknown origin should have an investigation initiated immediately. The DON stated that witness statements from staff who worked the previous 72 hours. They stated a Registered Nurse (RN) assessment should be done and the assessment should be in the accident and incident report. The DON stated that they expect their staff to initiate an accident and incident report for any injury of unknown origin. During an interview on 7/25/23 at 9:42 AM, the Administrator stated that they expect the staff to report any injury of unknown origin to them or the DON. They stated that staff should initiate an investigation, initiate witness statements, and initiate an accident and incident report. 2. Resident #17 was admitted with diagnoses of dementia with behavioral disturbance, atherosclerotic heart disease (ASHD), and diabetes mellitus. Review of the MDS dated [DATE] documented that the resident was severely cognitively impaired, usually understands others, and is usually understood by others and does not exhibit behaviors. Review of the comprehensive care plan (CCP) dated 12/7/22 documented resident is at risk for falls related to weakness and dementia with history of falls with injury, interventions included resident needs a safe environment with even floors free from spills and or clutter, adequate glare free light, a working and reachable call light, handrails on walls and personal items within reach and an intervention dated 1/19/23 documented resident in supervised area when not in bed. Review of Progress Notes dated 6/17/23 through 6/19/23 revealed the following: -On 6/17/23 at 12:09 AM, LPN #16 documented during resident care that shift, there was purple / blue bruising to their left hip measuring 7.4 centimeters (cm) x (by) 7 cm and 2 bruises to the left outer thigh measuring 6 cm x 4.2 cm and 5.3 cm x 2 cm. The resident was unable to give description of what happened. -On 6/17/23 at 3:20 AM, LPN #16 documented a bruise to left cheek bone 2 cm round and left rib cage 3 cm round. - On 6/17/23 at 5:35 AM, LPN #6 documented it was reported to them that the resident had bruising to their left thigh, hip and rib cage area left cheek unknown origin areas, light purple in color. -On 6/17/23 at 11:20 AM, LPN #2 UM documented Follow up bruising - bruising continued on left side, no noted recent fall, no c/o of discomfort, resident is on Plavix (prevents platelets in the blood from making clots) and baby aspirin (ASA). -On 6/19/23 at 1:00 PM, the NP documented nursing reported unusual bruising evident at the left cheek and left lateral hip, nursing denied any falls occurring recently. The left flank (side of the body) region had ecchymosis (bruising) noted. The resident was taking both ASA and Plavix long-term anticoagulation and would discontinue ASA due to recent bruising. Review of the Progress Notes dated 6/17/23 to 6/22/23 revealed there was no documentation a thorough investigation was completed. Review of Resident #17 Accident / Incident Report dated 6/16/23 at 10:49 PM documented, during patient care, the resident was noted with purple and blue bruising to their left hip, left thigh, left rib cage, and left cheek bone. The resident was unable to give a description. Immediate Action include the supervisor was made aware, the physician made aware, discontinue ASA, and labs pending. There were four staff statements attached, and documented they were not aware of the bruising. There was no documented evidence all the staff members who were assigned to the resident the previous 24 hours were interviewed. During an interview on 7/21/23 at 9:21 AM, LPN #2 UM stated to complete a thorough investigation to rule out abuse, all staff involved with the resident's care for the past 24 hours prior to the noted injury, are interviewed and / or statements written to determine the cause and / or to rule out abuse. LPN #2 UM stated collecting statements from staff for an investigation is a group effort between them, the Nursing Supervisor and DON, and ultimately it is the DON's responsibility to ensure a thorough investigation is completed to rule out abuse. LPN #2 UM stated they have no evidence all the staff members who were assigned to the resident the previous 24 hours were interviewed which included LPN #1, LPN #9, CNA #14 and CNA #15, therefore a thorough investigation was not completed. In addition, LPN #2 UM stated ASA would not have caused bruising to just the left side of the resident's body, therefore there is no evidence to rule out abuse. During an interview on 7/21/23 at 11:33 AM, the NP stated they were familiar with the resident and contributed the bruising to the ASA but believed the resident may have bumped into something, but abuse should have been ruled out. The NP stated the facility should have completed a thorough investigation to rule out abuse and should have reported the bruising of unknown origin to the NYSDOH as required because aspirin would not have just affected the left side of the body. During an interview on 7/21/23 at 3:01 PM, LPN #16 stated they notified the Nursing Supervisor, completed the A/I and had initiated collecting statements from staff. LPN #16 stated the UM should have continued collecting statements from staff who provided care to the resident for at least the past 24 hours to determine the reasons for the bruising and rule out abuse. LPN #16 stated the facility should have completed a thorough investigation to rule out abuse. During an interview on 7/21/23 at 3:55 PM, the DON stated to complete a thorough investigation to rule out abuse, all staff involved with the resident's care for the past 72 hours prior to the noted injury, were supposed to be interviewed and/or statements written to determine the cause and/or to rule out abuse. The DON stated the nursing supervisor was supposed to initiate the investigation and the LPN #2 UM was responsible to complete a thorough investigation. The DON stated they do not have any evidence all the staff members were interviewed to ensure a thorough investigation was completed to rule out abuse. During an interview on 7/24/23 at 5:32 PM, the Medical Director stated they expect any injury of unknown origin to be thoroughly investigated to rule out abuse. During an interview on 7/24/23 at 1:41 PM, the Administrator stated they would expect a thorough investigation to be completed to rule out abuse. 3. Resident #234 was readmitted with diagnoses of dementia with behavioral disturbances, anxiety disorder, and epilepsy. Review of the MDS dated [DATE] documented the resident was moderately cognitively impaired, sometimes understands and sometimes is understood by others. The CCP initiated on 12/2/21, documented Resident #234 was at risk for safety issues, was cognitively impaired related to mental diagnosis and dementia, interventions included the resident would be supervised around all environments, staff needed to remove resident from any area that was unsafe. On 3/9/22, the resident was identified at risk for elopement related to cognitive impairment, delirium / recent change in mental status, dementia, and mental illness. Interventions included to avoid leaving unattended or unobserved for long periods of time, calmly redirect to an appropriate area and engage in activities or tasks to keep the resident occupied. Review of Progress Notes dated 8/10/22 at 12:46 AM, the resident was not found in their room, upon looking for resident, it was noted that the courtyard door was open, and it hadn't been before. The resident was noted laying on the grass outside and had a skin tear to their left arm. Review of Progress Notes dated from 8/10/22-8/15/22 revealed no documented evidence a thorough investigation was completed. Review of Resident #234's Accident / Incident Report dated 8/10/22 at 12:19 AM documented the resident was found out in the courtyard, laying in the grass in a gown and non -skid socks. A skin tear was noted to their left forearm 2 cm by 1.5 cm. The resident was noted in their bed by CNAs 20 minutes prior. Other information included Resident #234's safety awareness was altered due to their mental health/illness and they were redirected. The supervisor was to ensure that all courtyard doors were closed and locked before dark. In addition, the DON documented the resident was asleep in their bed 20 minutes before observed lying in the grass in the courtyard. Resident had an abrasion (not a skin tear as first reported) to their forearm. Resident was dressed in a gown, non -skid socks, brief was off and on the floor in their room. Care to continue as planned. There was no documented evidence an investigation was completed including staff statements to determine why the door was not locked. During an interview on 7/21/23 at 4:21 PM, LPN #3 stated they recall Resident #234 was found in the courtyard in the middle of the night. LPN #3 stated they believe the courtyard doors were to be locked by 8 PM by the nursing supervisor but believes the courtyard doors were not locked. LPN #3 stated the resident was in an unsupervised area late at night and a thorough investigation should have been done because it is considered an elopement. During an interview on 7/24/23 at 12:37 PM, the DON stated Resident #234 was not alert and oriented and got out to the enclosed courtyard off Unit 1 at 2:00 AM unsupervised on 8/10/22 because the courtyard door was not locked. The DON state they did not believe this to be an elopement because the resident was seen 20 min prior in their room, therefore an investigation was not completed. During an interview on 7/24/23 at 1:34 PM, the Administrator stated they would have expected a thorough investigation to have been completed because the resident got out into the courtyard a 2:00 AM unsupervised. 10 NYCRR 415.4(b)(3)

Based on observation, interview and record review conducted during the Extended survey completed on 7/25/23, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of one facility. Specifically, the facility did not have adequate nursing staff based on the facility's established minimum number of staff for each unit and each shift. The findings are: 1. The Facility assessment dated [DATE] documented staffing levels were adjusted based on patient acuity and census. The total residents at the time of the facility assessment were 128 and a total capacity of 160. The Facility Assessment documented the staffing levels including: Day shift: 1 Licensed Practical Nurse (LPN) on each unit (4 total), 2 Certified Nurse Aides (CNA) on each unit (8 total) Evening shift: 1 LPN on each unit (4 total), 2 CNAs on each unit (8 total) Night shift: 1 LPN on each unit (4 total), 2 CNAs on each unit (8 total). Review of the Daily Schedule from 7/8/23-7/25/23 documented the facility did not meet their minimum number of CNAs on: 7/8/23 night shift - 5 (down 3) 7/9/23 evening shift - 7 (down 1) 7/9/23 night shift - 5 (down 3) 7/10/23 night shift - 6 (down 2) 7/13/23 night shift - 7 (down 1) 7/14/23 night shift - 5 (down 3) 7/15/23 evening shift - 7.5 (down 0.5) 7/15/23 night shift - 7 (down 1) 7/16/23 night shift - 6.5 (down 1.5) 7/22/23 night shift - 7.5 (down 0.5) 1a. Interviews with Residents and Family Members: During a Resident Council meeting held on 7/18/23 at 10:06 AM with 11 residents participating, they stated they needed to wait a long time for the call light to be answered. They would wait between 20-45 minutes for bathroom care. They stated the evening shift was the worst for call light times. During an interview on 7/17/23 at 3:10 PM, Resident #108 stated there was not enough staff. Resident #108 stated in the afternoon the wait time was 15-20 minutes but in the evening time the wait time was one hour. During an interview on 7/18/23 at 10:10 AM, an anonymous family member on the [NAME] Oak unit stated there was not enough staff to supervise the residents. The family member stated, when they recently came in to visit their family member, there was not enough staff. The family member stated they could not find their resident. They asked the staff for help locating the resident and the staff did not know where the resident was. It took staff 45 minutes to find the resident, who was in another resident's room on [NAME] Oak. 1b. Observations: During an observation on 7/19/23 at 9:59 AM, Resident #43 was observed ambulating into another resident's room and laying on the bed closest to the door. Resident #43 then got up and moved to the window bed. Resident #43 was in another resident's room for 8 minutes prior to staff removing Resident #43 from the room. During an observation on 7/19/23 from 12:22 PM to 1:06 PM, Resident #101 was ambulating up and down the hallway entering and exiting multiple residents' rooms. Resident #101 stayed in each room for approximately 15 seconds before ambulating into the next one. During an observation on 7/21/23 at 9:14 AM, Resident #43 was observed sleeping in another resident's bed for an unknown length of time. During an observation on 7/24/23 at 7:42 AM, Resident #43 was observed wearing pants that were wet from the left side of the buttocks down to the thigh. Resident #43 ambulated into another resident's room and laid in the bed on top of the bed covers. Staff was notified and Resident #43 was removed from the room. 1c. Staff Interviews: During an interview on 7/20/23 at 8:43 AM, CNA #8 stated all staff would do was keep an eye on the residents and do the best they could. During an interview on 7/20/23 at 10:32 AM, CNA #9 stated sometimes they would find Resident #43 in other residents' beds and staff would just watch the residents the best they could. During an interview on 7/20/23 at 3:00 PM, CNA #10 stated they were asked at least 3 times a week to work into the evening shift after working day shift because there was not enough staff for evening shift. During an interview on 7/20/23 at 4:29 PM, CNA #11 stated they were asked frequently to work into evening shift from day shift because there was not enough staff. CNA #11 stated it was difficult to work with 2 CNAs on the evening shift. During an interview on 7/21/23 at 3:10 PM, the Staffing Coordinator stated, for day and evening shifts they assigned 3 CNAs for each unit and for night shift 2 CNAs for each unit. They based the staffing needs using the census and acuity for each unit. The [NAME] Oak unit was staffed higher because there were more behaviors. The Director of Nursing (DON) determined if other units had a higher acuity. Either the Staffing Coordinator or Nurse Supervisor were responsible to call staff and replace whoever called off. During an interview on 7/24/23 at 11:32 AM, LPN #1 stated, there were six residents that would wander in and out of other residents' rooms. The staff were unable to prevent residents from wandering in and out of rooms. Residents would remove stop signs if they were on the door. Three of the residents who were wandering in and out of rooms had a history of resident-to-resident altercations. There was a potential for resident-to-resident altercations when residents wandered into other residents' room. LPN #1 stated they did not think there was enough staff to supervise all the residents. It was the responsibility of the facility to ensure the residents safety. During an interview on 7/25/23 at 11:55 AM, the Director of Nursing (DON) stated, the critical staffing for the facility was two CNAs for each unit and every shift. The minimum staffing number depended on the acuity of the unit. The DON stated two CNAs on the [NAME] Oak unit was not enough staff to care for the residents. There were times that three CNAs would be enough and there were times that three CNAs would not be enough depending on the acuity and behaviors at that time. There were times a CNA was sent from another unit to [NAME] Oak because there was a need for more staff on that unit. However, it was difficult to tell another unit they needed to work with less staff because another unit needed more staff. During an interview on 7/25/23 at 12:02 PM, the Administrator stated it was challenging to meet the state minimal requirement for staffing. The minimal requirement for staffing was 3.5 hours per resident per day. The Administrator stated they could not say that the minimal requirement was met, and the facility would fall below the minimum. The Administrator requested to review the facility assessment that was given upon entrance to the facility. During an interview on 7/25/23 at 1:35 PM, the Administrator had returned the facility assessment and stated, they changed the facility assessment because there were nights that the facility had fallen below their minimum staffing and only had one CNA on units. The Administrator stated they would prefer more CNAs in the facility due to the increased acuity. The Administrator stated if there were more than one CNA on either North Shore, Euclid, or Maple Units, they would send the CNA to [NAME] Oak because it needed more staff. The Administrator stated they would use an all hands-on deck approach when staffing was below minimal by calling agency and any staff from other departments to help. The only departments that were not called in were maintenance, dietary and housekeeping. 10NYCRR 415.13 (a)(1)(i-iii)

Based on observation, interview, and record review conducted during the Extended survey completed on 7/25/23, the facility did not ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming, personal and oral hygiene for two of five residents (Resident #13 & #116) reviewed. Specifically, there was lack of oral and perineal (the groin area) care during morning care and staff did not wash their hands or change gloves after providing bowel incontinence care (Resident #13); and a resident who was dependent on staff for hygiene with facial hair was not shaved or offered to be shaved after their shower (Resident #116). The findings are: The policy and procedure (P&P) titled Morning Care dated 10/2021 documented morning care will be offered and provided to all residents daily including oral hygiene, washing perineal and rectal areas, and provide shaving as needed. 1.Resident #13 diagnosis that included neuromuscular dysfunction of bladder (bladder with diminished sensation) urinary tract infection, Parkinson disease (tremors and rigidity of movement). Review of the minimum data sets (MDS - a resident assessment tool) dated 6/29/23 documented that the resident was cognitively intact, was understood by others, understands others, and was totally dependent on staff for hygiene. Review of the kardex report (a guide for staff to provide care) dated 7/20/23 documented Resident #13 was dependent on staff for bathing/showering and oral hygiene. Oral care routine, brush teeth, clean gums with toothette (disposable oral care swab), rinse mouth with wash. Review of Resident #13's Occupational Therapy Discharge Summary dated 6/21/23 documented that the resident was totally dependent on staff for personal hygiene. Review of the comprehensive care plan (CCP) initiated on 6/26/23 documented that Resident #13 had an ADL self-care performance deficit related to chronic sacral ulcer and bowel incontinence. Interventions included to provide peri (perineal) care after each incontinent episode. Oral care routine, brush teeth, clean gums with toothette, rinse mouth with wash. Monitor/document/report PRN (as needed) any s/s (signs or symptoms) of oral/dental problems needing attention. During an interview on 7/18/23 at 9:45 AM, Resident #13's family member stated that staff were not brushing the resident's teeth and they brought mouth wash so Resident #13 had oral care. The family member also noted that Resident #13 lost half a tooth on 7/16/23. During an observation of morning (AM) care on 7/20/23 at 7:14 AM, Certified Nursing Aide (CNA) #7 donned gloves, placed several damp washcloths on the resident's bed side table, and provided Resident #13 bowel incontinent care. CNA #7 removed a medium amount of soft feces from the residents' buttocks and placed the soiled washcloths directly on the floor without a barrier. CNA #7 did not perform perineal care and placed a new brief on Resident #13 while using the same gloves utilized for bowel incontinent care. CNA #7 then washed the residents face and underarms. CNA #2 handed Resident #13's clothing to CNA #7, who then dressed the resident wearing the same gloves used while providing bowel incontinent care. Once AM care was completed, CNA #7 proceeded to the restroom removed and disposed of their contaminated gloves and washed their hands. CNA #7 did not perform or offer oral care to Resident #13. During an interview on 7/20/23 at 8:17 AM, CNA #7 stated morning care included waking up the patient, cleaning the patient and getting their clothes ready. CNA #7 stated that they knew they should have performed peri care but today they forgot. CNA #7 stated that Resident #13 had feces in their brief, and they should have changed their gloves and washed their hands after incontinent care before touching clean items such as clean brief, clean pad, resident's catheter, and residents clothing to prevent cross contamination. CNA #7 stated peri care should be done to prevent urinary tract infections. CNA #7 stated oral care and brushing teeth should have been performed and they should have asked if Resident #13 would've liked their teeth brushed. CNA #7 stated they should have performed oral care because this would help to reduce tooth decay. During an interview on 7/20/23 at 8:34 AM, Unit Manager (UM) Licensed Practical Nurse (LPN) #2 stated the CNA should wash their hands before applying gloves, after removing gloves and as needed when gloves become soiled or contaminated while performing morning care. LPN #2 stated they would expect the CNA to use a basin filled with clean warm water, wash the resident with a clean cloth, rinse resident with a clean cloth, and dry the resident's hands, face, arm pits, and hair with a dry clean towel. LPN #2 stated the CNA should perform oral care, incontinent care, foley care and peri care during morning care. LPN #2 stated the CNA should provide oral care in the morning, and at bedtime to reduce the risk of tooth decay and infection. LPN #2 stated CNA #7 should have cleaned perineal area to reduce the risk of urinary tract infections as this resident currently had a UTI. During an interview on 7/24/23 at 1:24 PM, the Director of Nursing (DON) stated that morning care included the body being cleansed and asking the resident if they wanted to be shaved. The DON stated that supplies should include a basin, wash cloths, towels, soap, shaving supplies. The DON stated the CNA should use clean cloths and they should have a plastic bag to place soiled items in. The DON stated that peri care should be done because resident could have had feces in the perineal area, and this would cause infection if not cleaned. The DON stated that oral care should have been done first, according to the care plan and oral care was important for the resident's overall health, especially in the elderly, it keeps their mouth clean. 2. Resident #116 had diagnoses which included cerebral infarction (stroke), hemiplegia (paralysis on one side of the body), and anemia. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 6/10/23 documented the resident had moderate cognitive impairment and required total assistance for personal hygiene. Review of Resident #116's CCP initiated on 3/3/23 documented the resident had an ADL self-care performance deficit related to muscle weakness, interventions included extensive assistance for personal hygiene. Review of Resident #116's kardex dated 7/19/23 documented the resident required extensive assistance for personal hygiene. Review of Resident #116's Nursing Progress Notes dated 7/7/23- 7/18/23 had no documented evidence that the resident refused to have hairs shaved from their chin. During intermittent observations on 7/17/23 at 10:53 AM, 7/18/23 at 8:25 AM, and 7/19/23 at 8:21 AM, Resident #116 had multiple 1/4-1/2 long hairs on their chin. During an observation of morning care on 7/19/23 at 8:21 AM, Certified Nurse Aide (CNA) #5 and CNA #6 completed Resident #116's morning care. CNA #5 wheeled Resident #116 out of their room and to the lounge. CNA #5 did not attempt to shave the resident's chin hair, nor did they offer the resident to be shaved prior to leaving their room. During an interview on 7/19/23 at 9:16 AM, CNA #5 stated they saw the hair on Resident #116's chin, and it should have been shaved during morning care. CNA #5 stated Resident #116 would be more presentable and would feel better about themselves without chin hair. During an interview on 7/19/23 at 9:17 AM, CNA #6 stated Resident #116 was dependent on the staff for ADL care and for all their basic needs. CNA #6 stated they should have attempted to shave Resident #116 because it was a dignity issue. During an interview on 7/19/23 at 9:19 AM, Registered Nurse (RN) #1 stated residents should have been checked for facial hair and shaved routinely, if there was facial hair of any kind. RN #1 stated staff should have attempted to shave Resident #116 during the morning care observation. During an interview on 7/21/23 at 11:47 AM, the DON stated they would expect the CNAs to complete morning care head to toe, including attempting to shave residents with facial hair. They stated residents with facial hair should have at the very least, been offered to be shaved. The DON stated this was considered a dignity and quality of care problem. 10NYCRR 415.12(a)(3)

Based on interview and record review conducted during the Extended survey completed on 7/25/23, the facility did not ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician's orders and the comprehensive person-centered care plan for one (Resident #131) of one resident reviewed for peripherally inserted central catheter (PICC - a long, thin tube that is inserted through a vein in an arm and passed through to the larger veins near the heart) use. Specifically, there was no documented physician order to remove the PICC line and the PICC line was removed by a Registered Nurse (RN) who did not have any documented evidence of special training or certification. The finding is: The policy and procedure titled, PICC Line Removal dated 9/2017 documented that the PICC line shall be removed by an RN with an order from the physician or an authorized prescriber when a resident signs out against medical advice (AMA). 1. Resident #131 was admitted to the facility with diagnoses of infection and inflammation reaction due to internal left hip prothesis (an infected artificial left hip joint). Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/14/23 documented that the resident had an unplanned discharge into the community. Review of Resident #131 physician Order Summary Report dated 6/12/23 documented that the resident had a PICC line dressing change once a week on Wednesdays. Further review of the order summary report did not document a written order for PICC line removal. Review of Resident #131 comprehensive care plan (CCP) initiated on 6/13/23 documented that the resident had a PICC line in their right upper extremity (arm). Review of nursing Progress Note dated 6/14/23 at 1:19 PM documented that Resident #131 wanted to leave the facility AMA, signed AMA paperwork, and received education concerning not having home services set up by the facility. A nursing Progress Note dated 6/14/23 at 1:23 PM, written by RN #3, documented that they pulled out the PICC line due to Resident #131 leaving AMA, a dressing was intact, and the line was removed easily. Review of an email dated 7/21/23 from the Nursing Board of the New_York State Education Department documented that a PICC line may be removed by an RN under certain conditions such as completed relevant training and successfully demonstrated the insertion or removal of a PICC line. Further review of the email documented that there had to be a valid order for a PICC line to be removed. Review of RN #3's personnel file revealed that there was no documented evidence of special training or certification for PICC line removal. During an interview on 7/20/23 at 2:06 PM, RN #3 stated that they removed the PICC at the request of the Director of Nursing (DON). They stated that they were not aware that they needed an order to remove a PICC line and were not aware that they should have measured the PICC line prior to its removal. They stated that they did not wear personal protection equipment (PPE) of a gown, a mask, or a face shield but only wore a pair of clean gloves when they removed the PICC line. RN #3 stated that they were not aware that removing a PICC line without special training or certification was not in a RN's scope of practice and that they did not have certification or special training for PICC line removal. During an interview on 7/20/23 at 2:51 PM, the Nurse Practitioner (NP) stated that they gave a verbal order for the removal of the PICC line. They stated they believed removal of a PICC line was in the scope of practice for a nursing home RN. They stated that the RN should have worn a gown, goggles, mask, and gloves in case there is contaminated blood that could get on the nurse or resident. They stated that the removed PICC line should be thrown away in a red hazardous bag or a sharps container. During an interview on 7/20/23 at 4:04 PM, the DON stated that they were not aware that RNs needed special training or certification for PICC lines to be removed. The DON stated that they were not aware of any policy for the removal of PICC lines. The DON stated that they expect the nurses to wear a gown, mask, and sterile gloves when a PICC line was removed. They stated that they received the verbal order from the NP, but they did not add the order to the resident's medical record. During an interview on 7/24/23 at 3:44 PM, the Medical Director stated that they expected the nurses to have special training before a PICC line was removed. They stated that they expected the nurse to wear PPE including a gown, a mask, goggles or face shield, and sterile gloves when a PICC line was removed. They stated that the PICC line should be measured before it is removed so the nurse knows if the entire PICC line is removed. They stated that they expect the end of PICC line to be examined and if there were any issues, the Medical Director or the NP should be notified. They stated they expected the nurse to clean the area where the PICC line was inserted with antiseptic product prior to it being removed. They stated that there should be an in-service taught to nurses about PICC line removals. During an interview on 7/25/23 at 9:42 AM, the Administrator stated that a nurse should have special training for a PICC line to be removed. 10 NYCRR 415.12 (k)(2)

Based on observation, interview, and record review conducted during the Extended survey completed 7/25/23, the facility did not ensure that a resident, with an indwelling catheter (Foley - tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTIs) to the extent possible for two (Resident #s12 and 13) of two residents with a history of UTIs, reviewed for urinary catheters. Specifically, staff did not provide catheter care for Resident #13 and staff improperly emptied the urine drainage bags for Residents #12 and #13. The findings are: Review of policy and procedure (P&P) titled Catheter-Positioning & Emptying of Drainage Bag revised 5/2022 documented to change the drainage bag and tubing whenever it becomes soiled, whenever the catheter is changed or at least monthly. Before emptying the drainage bag, wash your hands. Don (put on) gloves, wipe the spigot with an alcohol sponge. Empty the bag without letting the spigot touch the receptacle. When the bag is empty, wipe the spigot with another alcohol sponge. Close spigot and replace it into the holder. Review of P&P titled Hand Hygiene effective 4/2020, documented all employees will wash hands before starting work, after handling soiled materials, and at any other time hands have been soiled during the course of the workday. Gloves should be changed in between residents when direct care is provided. Review of undated facility document titled Lesson: Urinary Catheter Care, documented hand washing has been recognized by the Centers for Disease Control and Prevention as the most important way to prevent the spread of infection. Hand washing should be done: (1) before you start patient care; (2) when your hands are visible soiled; (3) after contact with a patient; (4) after contact with anybody secretions; (5) before and after putting on gloves, and (6) before and after using the bathroom. Wear gloves when providing urinary catheter care. 1.Resident #13 diagnoses included neurogenic bladder (a bladder malfunction due to nerve or spinal cord damage), hemiparesis (paralysis on one side of the body) and UTI. Review of the minimum data set (MDS - a resident assessment tool) dated 6/9/23 documented that the resident was cognitively intact, was totally dependent on staff for personal hygiene and toileting and had an indwelling urinary catheter. Review of the comprehensive care plan (CCP) revised on 1/20/23 documented the resident had a catheter (a tube that is inserted into the urinary tract) for a neurogenic bladder. Review of Resident #13 Kardex report (a guide used by staff to provide care) dated 7/20/23 documented Resident #13 was dependent on staff for bathing/showering. During an observation of morning (AM) care on 7/20/23 at 7:14 AM, Certified Nursing Aide (CNA) #7 donned gloves, placed several damp washcloths on the resident's bed side table, and provided Resident #13 bowel incontinent care. CNA #7 placed a new brief on Resident #13, then washed the residents face and underarms. Once AM care was completed, CNA #7 removed and disposed of their contaminated gloves and washed their hands. CNA #7 did not provide perineal or catheter care for Resident #13. During an observation on 7/24/23 at 7:57 AM, CNA #7 washed their hands, put on clean gloves, placed a barrier on floor, and emptied Resident #13's urine collection bag without wiping the spigot with an alcohol wipe before draining. CNA #7 drained the urine into a clean clear cylinder, closed the spigot without utilizing an alcohol wipe prior to closing the spigot and returning spigot to the holder. During an interview on 7/20/23 at 8:17 AM, CNA #7 stated they did not do perineal care or wash Resident #13's catheter tubing. CNA #7 stated they normally clean the peri-area and catheter with morning care, it should have been done to help reduce infections and the resident was at high risk for urinary tract infections. During an interview on 7/20/23 at 9:45 AM Licensed Practical Nurse/Unit Manager (LPN/UM) #2 stated CNA #7 should have cleaned Resident #13 perineal area and should have washed the catheter tubing at the peri area site.(insertion site?) During an interview on 7/21/23 at 1:50 PM, the Director of Nursing (DON) stated they would expect CNA #7 to have cleaned Resident #13's peri area and catheter tubing during morning care to help prevent urinary tract infections. During an interview on 7/24/23 at 8:13 AM, CNA #7 stated that they forgot to use an alcohol wipe before and after emptying the catheter bag. CNA #7 stated that the reason to use an alcohol wipe is to ensure that the resident does not get a urinary tract infection. During an interview on 7/24/23 at 1:24 PM, the DON stated that the CNAs were trained to use alcohol wipes to disinfect the spigot before and after draining the catheter. The DON stated that the CNAs should use alcohol wipes when performing catheter care to prevent urinary tract infections. 2. Resident #12 diagnoses included chronic kidney disease, neuromuscular dysfunction of bladder (nerves and muscles of bladder don't work well together) and UTI. The Minimum Data Set (MDS-a resident assessment tool) dated 6/16/23 documented Resident #12 had moderate cognitive impairment and had an indwelling catheter. The CCP revised 12/6/21, documented Resident #12 had an indwelling catheter due to skin breakdown and urine retention. Interventions included: Monitor and document intake and output as per facility policy, provide foley and peri-care every shift, monitor and report to MD (medical doctor) as needed for signs/symptoms of a UTI. On 4/10/23, the CCP documented Resident #12 had a UTI and antibiotics were ordered. A physician Progress Note dated 5/9/23 at 9:40 AM, documented Resident #12 had a continuous indwelling foley catheter due to bladder outlet obstruction and had a significant history of ureterolithiasis (kidney stone) with infection and subsequent sepsis (a severe blood infection). During an observation on 7/20/23 at 9:28 AM, CNA #3 placed a barrier on floor under Resident #12's catheter drainage bag hanging from bed frame, placed a clear measuring container on the barrier, the spigot was removed from the drainage bag, urine was drained from drainage bag and spigot was replaced in the holder on drainage bag. CNA #3 did not disinfect the spigot with alcohol. During an interview on 7/20/23 at 10:06 AM, CNA #3 stated a lot of times staff used alcohol wipes to disinfect the spigot. CNA #3 stated they had access to alcohol wipes and just forgot to clean the spigot. CNA #3 stated they would want to use alcohol wipes to keep the spigot clean and reduce introducing any infections. During an interview on 7/25/23 at 10:01 AM, Licensed Practical Nurse (LPN)/Unit Manager (UM) #13 stated they expected the nursing staff to use alcohol to wipe the spigot on the urinary drainage bag after draining urine to prevent infection. LPN #13 stated bacteria can be introduced into drainage bag and cause infection if the spigot wasn't disinfected. During an interview on 7/25/23 at 9:21 AM, Registered Nurse Adult Educator (RN) #4 stated nursing staff should be wiping the spigot with alcohol prior to emptying contents of the catheter drainage bag and again after removal of contents. RN #4 stated it was a closed system and they would not want any bacteria to be introduced that could cause an infection or UTI. During an interview on 7/25/23 at 11:21 AM, the DON stated they expected nursing staff to maintain infection control while providing catheter care. The DON stated the spigot should be cleansed with alcohol so residents don't get UTI's. 10 NYCRR 415. 12 (d)(1)

Based on interviews and record reviews conducted during an Extended Survey completed on 7/25/23, the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for one (Resident #8) of one resident reviewed. Specifically, a Telemedicine (tele med) Psych Consult was not completed for Resident #8 as ordered by the physician for their explosive behaviors with care. The policy and procedure (P&P) titled Telehealth Services dated 4/2022 documented all residents will have access to telehealth medical, and psychiatric/psychological services. The use of electronic communication and information technologies to provide or support clinical psychiatric care at a distance. An order for a telemedicine/telehealth services consult will be obtained along with any other requirement as per the telemedicine services provider agreement. Scheduling of appointments for general telemedicine services will be handled by Nursing in conjunction with the nursing department scheduler; Social Services will set up any psychiatric/psychological telehealth services with assistance from Nursing. The finding is: 1. Resident #8 had diagnoses that included traumatic brain injury (TBI) with mental and behavioral disorders, cerebral vascular accident (CVA- a stroke), and right leg above knee amputation. The Minimum Data Set, dated dated dated [DATE] documented the resident was severely cognitively impaired, had long-term and short-term memory loss and occasionally rejected care. Additionally, the Patient Health Questionnaire-9 (PHQ-9, standardized interview that screens for symptoms of depression) documented resident being short tempered, easily annoyed. Physician orders dated 7/20/23, documented tele psyche evaluation related to (r/t) explosive behavior with care dated 4/7/23 and documented Order Status - Active. In addition, Lorazepam (Ativan) 0.5 mg two times a day for anxious behaviors, initiated 4/7/23. Review of Progress Notes dated 4/7/23 through 7/25/23 documented the following: - 4/7/23 at 10:58 AM Licensed Practical Nurse (LPN) #1 documented, Medical Director (MD) in to see resident for admission History and Physical (H&P), made aware Resident was very verbally abusive, kicks and tries to punch staff with care. Ordered tele med psyche eval for explosive behavior, Keppra level and Ativan 0.5 mg by mouth twice a day. - 4/7/23 at 7:47 PM LPN #4 documented, Resident became visibly agitated, arms tensed, yelling, and cursing. - 4/14/23 at 12:38 AM LPN #18 documented, Resident continues to yell out and swear at staff during hands on care (HOC). - 5/31/23 at 12:48 PM Social Worker (SW) documented, resident at times will yell, swear and attempts to kick staff during care but behaviors have decreased since admission. - 6/30/23 at 3:48 PM SW documented, resident at times will yell, swear and resistive to care. -7/7/23 at 3:46 PM LPN #5 documented, resident is reported to be screaming and thrashing when Certified Nursing Assistant (CNA) attempted to get out of bed. Review of Physician's Progress Noted dated 4/7/23 at 12:37 PM MD documented, Nursing stated that resident was extremely anxious, and they are having difficulty with daily care. Psych - displays uncooperativeness and anxiety. Ativan added due to resident's marked anxieties and will continue to monitor them. Review of the undated comprehensive care plan identified as current by the Director of Nursing (DON), revealed there was no documented evidence Resident was evaluated by tele psyche as ordered. Review of the Resident's electronic medical record from 4/7/23 through 7/20/23 revealed there was no psychiatric/psychotherapy evaluations, and the facility was unable to provide any. During an interview on 7/21/23 at 3:18 PM, LPN #2 Unit Manager (UM) stated they were not aware Resident #8 had an order for tele psyche. The nurse who took the order should have sent a consult referral form to LPN #17 to set up the appointment. LPN #2 stated Resident #8 was not seen by tele psych as ordered. During an interview on 7/21/23 at 3:26 PM, LPN #17 stated they had not received a referral form for the tele psych physician appoint for Resident #8. LPN #17 reviewed Resident #8's medical record and stated, there was an active order since 4/7/23 for a tele psych evaluation and Resident #8 had not been seen. During an interview on 7/21/23 at 4:10 PM, the DON stated Resident #8 should have been seen by tele psych as order for their behaviors and to ensure appropriateness of the new antipsychotic medication. During an interview on 7/24/23 at 5:33 PM, the MD stated they ordered a tele psych evaluation for Resident #8 because of their behaviors and to ensure the appropriateness of the antipsychotic medication that was initiated. The MD stated they would have expected their order to have been followed. 10 NYCRR 415.12(f)(1)

Based on interview and record review conducted during the Extended survey completed on 7/25/23, the facility did not implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for one (Resident #12) of one resident reviewed. Specifically, Resident #12 was receiving Cipro (an antibiotic) since 4/21/23 as a urinary tract infection (UTI) prophylaxis (prevention) without documented evidence to support its continued use, appropriate indications for its continued use, and a lack of monitoring and tracking its use by the infection preventionist (IP). The finding is: Review of the policy and procedure (P&P) titled Antibiotic Stewardship Program dated 1/2023, documented that it is the facility's policy to ensure that the use of antibiotics within the facility is done so in a way that optimizes the treatment of infections while striving to reduce adverse events. As the nursing home resident is especially suspectable to adverse events brought about by the overuse of antibiotics. Infection Preventionist (IP) will utilize several strategies such as tracking antibiotic use, monitoring adherence to established prescribing standards, and reviewing antibiotic resistance patterns within the facility. Providing regular feedback on antibiotic use and resistance to prescribing clinicians and nursing staff will help to keep antibiotic stewardship in the forefront. The IP will be responsible for the regular reporting of information on antibiotic use and resistance to doctors, nurses, and relevant staff to assist in keeping track and assuring appropriate antibiotic therapy is being utilized, and unnecessary antibiotic use can be decreased. 1. Resident #12 diagnoses included chronic kidney disease (CKD), neuromuscular dysfunction of bladder (nerves and muscles of bladder don't work well together) and osteomyelitis (infection of bone). The Minimum Data Set (MDS-a resident assessment tool) dated 6/16/23 documented Resident #12 had moderate cognitive impairment, usually understood, and usually understands. The MDS documented the resident did not have a urinary tract infection in the last thirty days and had an indwelling catheter (tube inserted into the bladder to drain urine). The Comprehensive Care Plan (CCP) revised 4/10/23, documented Resident #12 had a UTI. Interventions included to give antibiotic therapy (ABT) as ordered. Monitor/document for side effects and effectiveness. (Initiated: 2/3/23); Monitor/document/report to MD (Medical Doctor) as needed for signs/symptoms of UTI. Monitoring for long-term antibiotic use was not reflected in the plan. The Order Listing Report, date range:1/1/23-7/31/23, documented an active order to give Cipro 125 mg (milligrams) by mouth (po) at bedtime (HS) for prophylaxis revised on 7/17/23; UA (urinalysis-test to examine urine) C&S (Culture and Sensitivity) one time only for testing completed 2/1/23; Repeat U/A, C&S 2/16/23 one time only; and an active order dated 3/29/23 to see the urologist via TeleMed (Telemedicine-virtual appointment using technology) as needed. The Medication Administration Record (MAR) dated April 2023 through July 2023 documented Resident #12 received Cipro 125 mg po every day at HS for prophylaxis starting on 4/21/23, and there was no stop date. Additionally, Resident #12 received Clindamycin (antibiotic) 300 mg four times a day for an infection to left lower extremity from 7/19/23-7/23/23, and Bactrim DS (double strength) (antibiotic) 800-160 MG po twice a day was ordered 7/23/23 for a MRSA (Methicillin resistant staphylococcus aureus: an antibiotic resistant bacteria) infection to left leg wound. Review of the most current TeleMed Consult with Urologist dated 3/30/23, revealed the assessment/plan did not make a recommendation for prophylactic antibiotic use. The handwritten facility Antibiotic Tracking Form from 4/1/2023 through 7/18/2023 revealed Resident #12 was included on the tracking tool for Cipro 125 mg po q HS indefinite prophylaxis in April 2023. Cipro was not listed or monitored and tracked monthly thereafter. Physician/Provider Progress Notes dated 1/28/23, 5/9/23, 7/10/23, and 7/21/23 documented diagnoses of neurogenic bladder and/or neuromuscular dysfunction of bladder and use of an indwelling catheter with no evidence of signs and symptoms of a UTI. Additionally, the medication list did not reflect the use of Cipro. The Provider note dated, 4/21/23 documented foley catheter change due to occlusion in tube. Chronic indwelling catheter in place, draining clear, yellow urine with evidence of some mucous and no evidence of infection noted. Noted that Resident #12 complained of burning at site. Plan: Cipro 125 mg q HS for UTI prophylaxis due to history of recurrent catheter associated UTI's and frequent reports of dysuria. Continue to monitor. Review of laboratory diagnostics/results dated 4/21/23 to 7/21/23 revealed there was no evidence confirming Resident #12 had a urinary tract infection. Interdisciplinary Team (IDT) progress notes dated 4/10/23 through 7/25/23 documented Resident #12 was followed by the high-risk team due to chronic foley due to urinary retention. Foley was patent draining clear yellow urine and no urinary complaints offered. Additionally, the use of Cipro prophylactically was not mentioned. During intermittent observations 7/18/23 to 7/21/23 between 8:29 AM and 4:23 PM, foley catheter was draining clear yellow urine. During an interview on 7/19/23 at 8:37 AM, Resident #12 denied any urinary complaints and stated they did not know why they were still taking an antibiotic for a UTI. During an interview on 7/20/23 at 10:15 AM, IP/Registered Nurse (RN) #2 stated they were responsible for tracking ABT use in the facility. RN #2 stated they were not aware of any ABT reports provided by the pharmacy. RN #2 stated there were no residents currently receiving prophylaxis ABT in the facility. Additionally, RN #2 stated if ABT's were used unnecessarily residents could develop C-Diff and/or build immunity/resistance to ABT's. During a telephone interview on 7/20/23 at 2:10 PM, Pharmacy Consultant stated they complete Monthly Medication Review (MMR) and monitor ABT usage during that time. Pharmacy consultant stated they can track ABT use for facility and offer a report of ABT use if requested. Pharmacy consult stated they had no record of facility requesting and had not recently provided facility with an ABT report. Pharmacy Consultant stated it would be important to track use of ABT's for excessive or unnecessary use that can cause ABT resistance. During a telephone interview on 7/24/23 at 11:45 AM, the Pharmacy Consultant stated prophylactic antibiotic use should be reviewed, checked for appropriate dosing, effectiveness and if number of UTI's have been reduced. The Pharmacy Consultant stated the IP should be tracking and monitoring the of ABT use and UTI's. Additionally, Pharmacy Consultant stated they would expect the facility to be tracking there ABT use monthly. During a telephone interview on 7/24/23 at 12:58 PM, the Urologist stated they did not prescribe Cipro to Resident #12. The Urologist stated if they were to place someone on a prophylactic ABT, the use for it would be well documented. Additionally, the Urologist stated they would expect the facility to contact them if they had difficulty managing urinary concerns. During an interview on 7/24/23 at 7:10 PM, IP/Registered Nurse (RN) #2, stated they weren't aware they needed to track the Cipro monthly. Additionally, RN #2 stated if it's not carried over on the tracking form, the MD wouldn't be aware that Resident #12 was still taking Cipro upon their review of the tracking form. During an interview on 7/25/23 at 11:04 AM, Medical Director (MD) stated they would expect the IP to track ABT use. The Medical Director stated they review the facility tracking form for ABT use monthly at QAPI (Quality Assurance and Performance Improvement) meeting for appropriateness of care. MD stated they try to limit use of ABT's to prevent ABT resistance. Additionally, MD stated they would expect nursing to document on ABT use and for s/s of infection. Just because they are on an ABT doesn't mean they can't develop an infection. During an interview on 7/25/23 at 11:21 AM, Director of Nursing (DON) stated they really didn't have a lot to do with ABT stewardship, the IP handles that. Antibiotics were to be reviewed monthly by the provider and the IP. 10 NYCRR 415.12(l)(1)

Based on interview and record review conducted during a Complaint Investigation (#NY00311987) during an Extended survey completed on 7/25/23, the facility did not ensure that the physician was immediately informed when there was significant change in the resident's physical, mental, psychological status for one (Resident #4) of two residents reviewed for notification of change. Specifically, the physician was not immediately notified that Resident #4 had a fractured elbow. The finding is: The policy and procedure titled, Change in Status Notification dated 6/15/21 documented that the resident's attending physician or designee will be notified when there is a significant change in the resident's condition. 1. Resident #4 was admitted with diagnoses of dementia and schizophrenia. The Minimum Data Set (MDS - resident assessment tool) dated 5/5/23 documented the resident was severely cognitively impaired, understands and was understood by others. The nursing progress notes dated 2/27/23 at 2:57 PM documented the Nurse Practitioner (NP) examined Resident #4 after the resident fell on [DATE] and there were no bruised areas. The nursing progress notes dated 3/3/23 at 2:43 PM documented the NP examined Resident #4 after nursing reported a bruised area on the resident's right elbow. The note documented the NP ordered an x-ray for the elbow, use pain medication for any discomfort, and elevate the elbow with a pillow for comfort. A Radiology Results Report dated 3/3/23 at 11:58 PM documented Resident #4 had an acute nondisplaced olecranon process fracture (a broken elbow). The Radiology Results Report documented the NP reviewed the x-ray on 3/6/23 at 12:56 PM. Review of the nursing progress notes on 3/4/23 from 7:46 AM to 10:41 PM, revealed there no documented evidence that a physician was notified on 3/4/23. Review of the nursing progress notes dated 3/5/23 at 2:18 PM documented a follow up to the x-ray that Resident #4 had a broken elbow, the Supervisor was notified, the Director of Nursing (DON) was notified, the physician assistant (PA) was notified, and the physician was notified. A nursing progress notes dated 3/5/23 at 2:50 PM documented that per a telephone conversation, the PA, and Registered Nurse (RN) #2 wanted Resident #4 to be sent to the hospital due to a possible fracture. Review of the [NAME] Oak unit 24-hour reports dated 3/3/23 documented that Resident #4 had an x-ray of their right elbow and forearm due to a bruise. The 24-hour report dated 3/4/23 - 3/5/23 documented that an x-ray was done on 3/3/23 at 7:00 PM. The reports dated 3/4/23 - 3/5/23 24-hour report documented that the resident was sent to the hospital due to an elbow fracture. During an interview on 7/21/23 at 9:56 AM, the Medical Director stated they should be notified right away for an x-ray that shows a fracture. The Medical Director stated they were available anytime for a nurse to contact them. During an interview on 7/21/23 at 10:24 AM, Licensed Practical Nurse (LPN) #7 stated that if a resident had a fracture anywhere, the physician should be notified immediately. LPN #7 stated that the supervisor can review x-rays on their dashboard in the electronic dashboard as it will say that the x-ray was not reviewed by the physician or nurse practitioner (NP). During an interview on 7/21/23 at 11:23 AM, LPN Nurse Supervisor #8, they stated that LPN #9 brought the x-ray to their attention. LPN #8 stated they took a picture of the x-ray report and sent it to the overnight on-call provider via a text from the Supervisor mobile phone between 3:00 AM and 5:00 AM on 3/4/23. They stated that if they did not hear back from the on-call provider within a certain amount of time, they should have notified the Director of Nursing (DON). LPN #8 stated that if they didn't hear from the DON, they should have notified the physician. LPN #8 stated they would have documented that information in the nursing progress notes. During an interview on 7/21/23 at 11:49 AM, the PA stated that they do not recall being notified about Resident #4's x-ray. They do not recall any incident with Resident #4's elbow being fractured. They stated that they expect to be notified and would have deferred to the physician in the morning. The PA stated they would expect staff to notify the physician by 7:00 AM. During an interview on 7/21/23 at 12:02 PM, the Staffing Coordinator stated they have the nursing supervisor's phone until the nurse supervisor starts their shift. They stated that the nursing supervisor's take a picture of any reports and send it to the PA via the supervisor mobile phone if it is after hours. An observation during this interview of the supervisor phone revealed there were no texts to the PA on 3/4/23 concerning Resident #4's x-ray results. An additional observation of the supervisor mobile phone revealed there were no pictures taken of x-rays or other reports from 3/1/23 to 3/10/23. During an interview on 7/21/23 at 12:19 PM, Registered Nurse (RN) #1 Unit Manager stated that they worked on 3/4/23 as the supervisor. They stated that they did not receive any information concerning Resident #4's x-ray result. They stated that they would have notified the physician right way if they did. RN #8 also stated that if they were aware of the resident's elbow, they would have done an RN assessment. RN #8 stated that they were to take a picture of the results and text them to the on-call provider. During an interview on 7/21/23 at 12:38 PM, LPN #9 stated that they do not recall reporting Resident #4's x-ray results to LPN #8 Nursing Supervisor. They stated that x-ray or laboratory results were sent to the main fax machine and the Supervisor checks that machine on their rounds. They also stated they would have notified the physician and the DON of any x-ray results. During an interview on 7/21/23 at 12:47 PM, RN #2 Unit Manager stated they did not recall the incident with Resident #4's elbow. They stated the physician should be notified about x-ray results right away. They also stated that the DON should be notified and would follow the direction of the DON. During an interview on 7/21/23 at 3:01 PM, the DON, they stated the physician or the on-call provider should be notified immediately for any result especially a fracture. The DON stated that if the nurse could not get a hold of the provider, the nurse should contact the DON who then will contact the provider. They stated that faxes were sent to the main fax machine and the nursing supervisor can review any reports sent to the facility on their rounds. During an interview on 7/25/23 at 9:42 AM with the Administrator, they stated they expected the nursing staff to notify the physician immediately of any x-ray that showed a fracture. 10 NYCRR 415.3(e)(2)(ii)(a)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY00304366) completed on 4/24/23, the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner or clinical specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies, and procedures for notification of a practitioner for one (Resident #1) of three residents reviewed. Specifically, there was no evidence the facility promptly notified the medical provider with a positive urine culture and sensitivity (C&S-laboratory test to determine the presence of bacteria and the appropriate antibiotic for treatment of an infection if identified) report, received on 10/21/22. The finding is: The policy and procedure (P&P) titled Change in status notification and dated 11/8/22 documented the resident's attending physician or designee and responsible party will be notified by the nursing manager/nursing supervisor/designee when any situation which requires a change in the resident's plan of care, medication or treatment regimen including abnormal lab values. 1. Resident #1 was admitted to the facility with diagnoses which included anoxic brain damage (death of brain cells due to a complete lack of oxygen to the brain) quadriplegia (paralysis of all four limbs), and urinary tract infection (UTI). The Minimum Data Set (MDS - a resident assessment tool) dated 10/16/22 documented Resident #1 was cognitively intact, understands, and was understood. The Comprehensive Care Plan (CCP) initiated on 8/24/20, documented Resident #1 had a history of UTI. Interventions included contact precautions, encourage adequate fluid intake, give antibiotic medications (ABT) as ordered, obtain lab work as ordered, report lab results to the medical doctor and follow up as indicated. Review of the Order Summary Report revealed an order was received on 10/17/22 for Resident #1 to have a urine analysis (UA) and C&S obtained for a possible UTI. An order was also received for ciprofloxacin (Cipro-an ABT medication) 500 milligrams (mg) at bedtime for 5 days for a UTI on 10/24/22. Review of the Lab Results Report documented: -A urine culture was collected on 10/17/22 at 9:00 PM and the results were reported on 10/21/22 at 7:31 AM. The results documented a positive growth of Escherichia coli (a gram-negative bacteria). The report documented the Physician's Assistant (PA) reviewed the lab on 10/24/22 at 8:27 AM. -A urine culture was collected on 10/20/22 at 6:57 AM and the results were reported on 10/23/22 at 8:06 AM. The results documented a positive growth of Escherichia coli. The report documented that the PA reviewed the lab on 10/24/22 at 8:26 AM. Resident #1's progress notes documented: -10/16/22 at 10:19 PM, the resident stated they were coming down with a UTI. -10/20/22 at 5:11 AM, a repeat UA and C&S was collected via clean catch. Resident complained of burning upon voiding (urinating) and urine was dark, cloudy and had a very foul smell. -10/21/22 at 4:39 AM, monitored for pending UA and C&S. Urine appeared dark in color, had foul odor and resident complained of urinary discomfort when voiding -10/22/22 at 4:28 AM, monitored for pending UA and C&S. Urine appeared dark in color, had foul odor and resident complained of urinary discomfort when voiding. -10/24/22 at 10:51 AM, the PA saw the resident and a new order was received to start Cipro 500 mg daily for 5 days for a UTI. During a telephone interview on 4/24/23 at 12:59 PM, the Assistant Director of Nursing (ADON) stated that they were the facility's Infection Preventionist (IP) and the former unit manager in October of 2022. The ADON stated most of the time the floor nurse would see an abnormal lab result and call the medical provider or place the lab into the IPC book for the provider to review. The ADON stated the unit manager was to check for returned lab results in the morning, but they did not have a specific staff member assigned on the off shifts or weekends to monitor if/or when a lab result was completed. The ADON stated that Resident #1 often had urinary complaints, frequent UTI's and would see a urologist. After review of Resident #1's EMR, the ADON stated that Resident #1 had urine C&S completed on 10/17/22, 10/20/22 and 10/31/22. The ADON stated the urine C&S results collected on 10/17/22 were received on 10/21/22. They stated they could not locate documentation that the medical provider was notified when the results were received, and the medical provider should have been notified. The ADON stated that the PA started an ABT on 10/24/22 after review of the labs. The ADON stated that after reviewing what was documented in the EMR, a delay in treatment for Resident #1 occurred. The ADON stated the importance of reporting a positive urine culture result to the medical provider was so that Resident #1's symptoms of burning upon urination could be treated. During a telephone interview on 4/24/23 at 1:33 PM, the PA stated they did not recall why a second urine C&S was ordered for Resident #1 on 10/20/22 when a there was a urine C&S pending from 10/17/22. They stated the urine results were reviewed on 10/24/22 when they arrived at the facility on that Monday. The PA stated their expectation was that the facility staff would notify a provider that same day when a positive urine result was received. The PA stated they would consider it a delay in treatment that the positive urine C&S lab result report on 10/21/22 was not addressed until 10/24/22. During a telephone interview on 4/24/23 at 1:46 PM, the Director of Nursing (DON) stated the unit managers, and the night shift supervisors were responsible for looking at lab results and the lab results that were not critical were to be reported to the medical provider the next the morning. The DON stated the unit managers, and the weekend supervisors were responsible for monitoring if pending urine C&S results were returned from the lab. They stated that they did not know why the medical provider was not notified until 10/24/22 about Resident #1's urine C&S that was collected on 10/17/22 and reported positive on 10/21/22. They stated that the provider should have been notified on 10/21/22 when the result was received and that there was a delay in care. The DON stated the importance of timely notification of a positive urine C&S to the medical provider was so the resident gets treated appropriately and does not get septic (a life-threatening complication of an infection). 10 NYCRR 415.20

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY 554) completed during the Standard survey on 6/17/21, the facility did not provide an environment as free from accident hazards as possible and devices to prevent accidents for one (Resident #73) of three residents reviewed. Specifically, the facility did not ensure scheduled routine maintenance of positioning bars was conducted. On 3/25/20 an equipment failure of the positioning bar occurred resulting in a fall with injury. The finding is: Review of the facility policy and procedure (P&P) entitled Side Rail & Grab bar Use dated 10/17 revealed side rails will be assessed by Maintenance during the room of the day audit with all negative findings being immediately corrected. Side rails found to be loose or un-safe by staff should be immediately addressed with Maintenance. If noted on off-shifts or weekends, resident must be transferred to another bed until side rails can be assessed and addressed. A facility (P&P) titled Preventative Maintenance dated 12/19 revealed the maintenance department shall conduct routine safety inspections of various areas of the building to ensure the physical plant, devices, and equipment are free from hazards to promote resident safety. Bed function per room a day schedule conducted daily. 1. Resident #73 had diagnoses including Alzheimer's disease, dementia, and anxiety. The Minimum Data Set (MDS - a resident assessment tool) dated 2/27/20 documented the resident was severely cognitively impaired. The MDS further documented the resident was independent with bed mobility (how a resident moves to and from lying position, turn side to side, and positions body while in bed) and transfers (how a resident moves between surfaces including to and from bed, chair, wheelchair, standing position). Review of the Physical Therapy Quarterly Side rail/Grab bar Evaluation dated 2/25/20 revealed Resident #73 used bilateral positioning bars (grab bars) to enhance bed mobility. Review of the Comprehensive Care Plan (CCP) dated 3/25/20 documented Falls as a focused area of concern related to history of falls. The planned interventions included: provide safe environment: maintenance to fix/repair positioning bar; therapy consult for falls. Review of the Visual/Bedside Kardex Report (guide used by staff to provide care) As of 3/1/2020 documented Resident #73 was independent with bed mobility with BPB (bilateral positioning bars). Review of facility documents Deep Clean Checkoff List from 12/1/19-3/31/20 revealed there was no documentation Resident #73's room was deep cleaned, including inspection of positioning bars. Review of the Nursing Progress Note dated 3/25/20 at 8:04 AM Licensed Practical Nurse (LPN) #1 documented she heard yelling and when she entered the room, Resident #73 was lying on the window side of the bed with a positioning bar under them. Resident #73 stated, I don't know what happened. The positioning bar broke off bed. The resident had a small pool of blood under their head with a laceration on the left side of head, nose, and a skin tear to left bicep. Review of the Nursing Progress Note dated 3/25/20 at 8:07 AM the Assistant Director of Nursing (ADON) documented Resident #73 had a 4 cm (centimeter) laceration on left side of forehead, 0.5 cm laceration to left side of nose and left arm skin abrasion that measured 6 cm by 3 cm. In addition, the ADON documented a 1 cm abrasion to the left eyebrow. A Provider Note dated 3/25/20 at 11:14 AM the Physician's Assistant documented Resident #73 had fallen when the side bar broke off the bed. Resident # 73 was noted with a laceration to the left side of their forehead, the bridge of the nose, and a skin tear to the left upper arm. X-rays to bilateral hips obtained with low suspicion for fracture. Review of the unsigned facility investigation form dated 3/25/20 at 7:45 AM documented resident #73 was observed lying on the floor next to the bed with the positioning bar lying under them. Predisposing environmental factors included an equipment failure. The positioning bar on the right side of the bed broke and the resident lost balance and fell . Review of a signed statement written by the Director of Maintenance on 3/25/20 documented he entered Resident #73's room and observed a broken positioning bar base. The broken part of the bar was immediately removed and replaced. The bed was inspected, and no other problems were apparent. Review of a facility document labeled Incident Investigation dated 3/25/20 signed by the facility's previous Administrator, documented maintenance department replaced the positioning bar and a full house positioning bar audit was completed. No house audit tool of the positioning bars was provided. Review of the Occupational Therapy Consultation Form dated 3/25/20 documented Resident #73 fell in room while attempting to stand and the positioning bar broke causing the resident to fall. The resident was evaluated for bed mobility and transfer safety. Occupational Therapy documented services were not recommended however the positioning bar malfunctioned causing it to break. On 6/14/21 at 3:21 PM Resident #73 was observed in bed. No positioning bars were attached to the bed. During an interview on 6/15/21 at 9:55 AM the Director of Maintenance stated he was not aware of the broken positioning bar until the previous Administrator notified him after Resident #73 fell . The Director of Maintenance stated he looked at the bar and saw that the positioning bar had broken particle board that snapped in half at the base and it slid out from under the mattress which caused the resident to fall when bearing weight on the bar. The Director of Maintenance stated Occupational Therapists (OTs) were responsible for inspecting the positioning bars quarterly and the positioning bars were inspected when the room of the day was assigned to housekeeping. Maintenance would only make repairs when needed, and no scheduled routine maintenance was planned for the positioning bars. The Director of Maintenance stated the facility used a web-based maintenance management system for reporting equipment that needed to be fixed and they had no record of the positioning bar being reported. The Director of Maintenance stated the staff also verbally communicated when there was an issue with equipment. During an interview on 6/15/21 at 10:03 AM, the Director of Rehab Services stated OTs conducted quarterly assessments to ensure residents required the continued use of the positioning bars. The quarterly assessments included visual inspection of the equipment but did not include checking the positioning bar to ensure it was securely attached to the bed. During a telephone interview on 6/15/21 at 12:57 PM, LPN #1 stated they were unaware how or why the positioning bar broke. LPN # 1 stated they did not recall if the positioning bars were secured to the bed and that Resident #73 was able to transfer themselves. LPN #1 stated the base of the bar broke causing Resident #73 to fall and sustain a laceration to the left forehead, across the nose and a skin tear to the left arm. During an interview on 6/15/21 at 2:46 PM, Certified Nurse Aide (CNA) #1 stated she knew the facility had a system for communicating with maintenance to report needed repairs but could not recall the protocol to do so. CNA #1 stated Resident #73's positioning bars were wiggly and that she verbally communicated this to the Director of Maintenance, but was unaware when she reported the needed repair. On 6/16/21 at 8:07 AM during visual inspection of the positioning bars of an unoccupied bed, the Director of Maintenance stated he had never done a visual inspection of the particle board once attached to the box spring. The Director of Maintenance stated the particle board was not viable and had the tendency to split. During an interview on 6/17/21 at 11:40AM the Director of Nurses (DON) couldn't remember how or why the positioning bar broke and expected Maintenance kept a log of regular scheduled maintenance to ensure the positioning bars are adequately functioning for resident safety. Housekeeping was responsible to clean the assigned Room of the day monthly which included a thorough cleaning and inspection of the room, but not necessarily visual or hands on inspection of the positioning bars. During an interview on 6/17/21 at 1:13 PM the Administrator stated she expected regular scheduled inspections of the positioning bars at least monthly for safety and preventative maintenance. 415.12 (h)(2)

Based on observation, interview, and record review during the COVID-19 Infection Control Focused Survey completed on 12/4/20, the facility did not ensure that facility staff were tested for COVID-19 in a manner that is consistent with current standards of practice, and for each instance of testing documented that testing was completed, with the results of each staff tested . Specifically, three employees -- Certified Nurse Assistant (CNA) CNA #1, CNA #2, and Licensed Practical Nurse (LPN) #1) -- of four employees reviewed for timely COVID-19 results had a delay of results. The finding is: The Centers for Medicare & Medicaid Services (CMS) guidance QSO-20-38-NH dated 8/26/20, titled Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID19 Focused Survey Tool, documented with respect to federal regulation 42 CFR 483.80(h): the facility is required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility's testing frequency. Additionally, facilities should have arrangements with a laboratory that can quickly process large numbers of tests with rapid reporting of results (e.g., within 48 hours) to rapidly inform infection prevention initiatives to prevent and limit transmission. If the 48-hour turn-around time cannot be met due to community testing supply shortages, limited access or inability of laboratories to process tests within 48 hours, the facility should have documentation of its efforts to obtain quick turnaround test results with the identified laboratory or laboratories and contact with the local and state health departments. Review of the facility policy and procedure (P&P) titled COVID-19 Testing Requirements: F886 dated 8/26/20 documented in response to QSO Memo 20-38-NH Complying with 483.80(h), facility has established this Policy to test and / or make arrangements for the testing of all facility staff and residents for COVID-19. For staff routine testing, document the date(s) that testing was performed for all staff and the results of each test. Document any issues accessing test supplies: If the facility cannot meet the 48-hour turnaround time on tests, the facility MUST document attempts to gain access, including with laboratory, distributers of [MEDICATION NAME] POC tests and both local AND state health departments. Review of facility employee testing records from 9/28/20 through 12/4/20 revealed the following: -CNA #1 had COVID-19 test results documented on the following weeks: 9/28/20, 10/8/20, 10/19/20, 10/24/20, 10/31/20, 11/11/20, 11/12/20, 11/24/20 and 12/3/20. The facility did not have documented evidence that a COVID-19 test had returned with results for the week of 11/24/20 when CNA #1 was reported working in the facility. Review of an untitled facility log, identified by the Assistant Director of Nursing (ADON) Infection Preventionist (IP), as a log of employee's COVID-19 swab collection dates, revealed CNA #1 was tested on [DATE]. Review of the facility's Final Reports for employee COVID-19 testing records from 9/28/20 through 12/4/20 for 48-hour turnaround time on COVID-19 tests revealed the following: -For CNA #1: · Facility specimen collection date was 11/11/20, date laboratory received specimen was 11/13/20 and date facility received report was 11/16/20 - For CNA #2: · Facility specimen collection date was 11/11/20, date laboratory received specimen was 11/12/20 and date facility received report was 11/16/20 - For LPN #1: · Facility specimen collection date was 10/22/20, date laboratory received specimen was 10/24/20 and date facility received report was 10/27/20 During interviews on 12/4/20 between 3:20 PM and 4:01 PM the Assistant Director of Nursing (ADON) Infection Preventionist (IP) stated she maintains a logging system when the employee COVID-19 swabs were obtained. ADON IP stated there was an issue last week and the employee specimens were sent to laboratory #1, which was the incorrect laboratory, instead of the correct scheduled laboratory #2. ADON IP stated she identified the error the following morning and immediately called laboratory #1 and was informed by a laboratory technician the specimens would be sent to laboratory #2. She stated she now realized some of the employee swab specimens were run by laboratory #1 (incorrect laboratory), and some were forwarded to laboratory #2 and is not sure if all the specimen results have returned. The ADON IP provided a laboratory report form dated 11/24/20 and identified it to be the report for CNA #1 but has CNA #1's first name in both sections for first and last name. She stated due to the incorrect last name on the form the specimen was not tested and there are no results for CNA #1. She additionally stated, there was a delay of COVID-19 specimen test results and the facility believes the received dates on the laboratory forms were incorrectly documented by laboratory #2, indicating the delay of specimens received. The ADON IP stated she does not track if the employee COVID-19 swab results return because she does not have access to employee laboratory results. The ADON IP stated, she does not know how many specimens went to laboratory #1, because she has not reconciled the swabs results obtained on her log with the number of swabs results sent. She stated, she does not know if all the employees that have worked have results returned from last week. During interviews on 12/4/20 between 3:50 PM and 4:52 PM the Director of Nursing (DON) stated, she knew last week that the specimens were sent to the laboratory #1. Laboratory #1 was called immediately, and a laboratory technician informed her the specimens would be sent to laboratory #2. The DON stated, I do not know how many specimens went to laboratory #1 and I do not know if all the test results have returned. The DON further stated, I do not have a tracking system and it is my responsibility, I should have tracked them. The DON stated she had called laboratory #2 to discuss the laboratory reports' received dates because they were different from the dates the facility believed the specimens were sent and believed laboratory #2 will be correcting the received dates. The DON stated she is unable to change to another laboratory because it is the facility's corporation that makes decisions which laboratory to use. The DON stated she had discussed the laboratory delay with the management representative from laboratory #2 and during the weekly corporate calls the corporate leaders were notified of the laboratory results are delayed. The DON stated the facility had not received the COVID-19 testing results for CNA #1 due to the swab testing specimen being labeled with CNA's first name as both, first and last name. The DON stated she called laboratory #1 that had analyzed the specimen and requested the specimen be renamed with the CNA's first name and last name and the results of the analysis be sent to the facility. The facility had not received a response from laboratory #1 as of 4:52 PM on 12/4/20. When asked, the DON was unable to provide any documentation she made to laboratories #1 or #2. During an interview on 12/4/20 at 4:02 PM the Acting Administrator stated she was aware last week that employee specimens went to the incorrect laboratory and some of the employee specimens were tested by two different laboratories. The Acting Administrator stated, it is the DON's responsibility to track the COVID-19 laboratory specimens sent and the number of results returned. The Acting Administrator additionally stated, sometimes the laboratory results come back in 2 days and sometimes a week. She said, the facility believes the received dates on the laboratory #2 forms was incorrectly documented by the laboratory, and this issue had been discussed with laboratory #2. The Acting Administrator stated she did not notify the Department of Health of the delay. At 4:35 PM in an additional interview the Acting Administrator stated I am aware of the 48-hour requirement for laboratory results to return but believes everyone is getting results late because of the spike in the area and (I) have not called other laboratories because corporate makes decisions which laboratory to use. During a telephone interview on 12/4/20 at 5:05 PM Corporate Regional Clinical Nurse stated she is aware the COVID-19 specimen results from laboratory #2 have been delayed. 415.19(a)(1) 400.2

Based on interview and record review during the Standard survey completed on 10/4/19, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified three (Employee #1, Employee #2, Employee #3) of seven employees who were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their employment. The findings are: 1. Record review of the personnel file for Employee #1 (Dietary Aide) revealed Employee #1 was hired on 7/18/19 and the Nurse Aide Registry verification sheet was dated 8/21/19. Record review of the automated time and attendance record revealed Employee #1 first worked in the facility on 7/22/19 and worked nine shifts between 7/22/19 and 8/21/19, when the Nurse Aide Registry was checked for Employee # 1. 2. Record review of the personnel file for Employee #2 (Dietary Aide) revealed Employee #2 was hired on 7/18/19 and the Nurse Aide Registry verification sheet was dated 7/30/19. Record review of the automated time and attendance record revealed Employee #2 first worked in the facility on 7/25/19 and worked three shifts between 7/25/19 and 7/30/19, when the Nurse Aide Registry was checked for Employee # 2. During an interview on 10/3/19 at 4:55 PM, the Food Service Director stated Employee #1 and Employee #2 have the same job duties, which include setting up the White Oak Dining Room before resident meals and serving resident food trays in the Main Dining Room. 3. Record review of the personnel file for Employee #3 (Certified Nurse Aide) revealed Employee #3 was hired on 8/1/19 and the Nurse Aide Registry verification sheet was dated 8/8/19. Record review of the automated time and attendance record revealed Employee #3 first worked in the facility on 8/5/19 and worked two shifts between 8/5/19 and 8/8/19, when the Nurse Aide Registry was checked for Employee # 3. During an interview on 10/2/19 at 1:15 PM, the Human Resources Coordinator stated the Human Resources Coordinator position at this facility was vacant for a few months before she started working here in early (MONTH) 2019. During an interview on 10/2/19 at 2:30 PM, the Administrator stated she was the Acting Human Resources Coordinator while the position was vacant, and she normally checks the Nurse Aide Registry for all new hires prior to their start date, but these were missed. 415.4(b)(1)(ii)(a)(b)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/4/19, the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. One (Resident #85) of one resident reviewed for [MEDICAL TREATMENT] had issues. Specifically, there were no physician orders to address the arteriovenous fistula access site (AVF-a tube or device surgically implanted to create an artificial connection between an artery and a vein) pressure dressing, the lack of a valid physician's order for the resident's fluid restriction and the [MEDICAL TREATMENT] dressing was not removed after [MEDICAL TREATMENT]. The findings is: The policy and procedure (P&P) titled [MEDICAL TREATMENT] with a revision dated of 8/2018 documented the purpose of this policy was to monitor symptoms pre and post-[MEDICAL TREATMENT] treatment to avoid complication during and after [MEDICAL TREATMENT] and ensure lines of communication between the [MEDICAL TREATMENT] center and the facility. The licensed nurse will complete the pre and post [MEDICAL TREATMENT] progress notes on [MEDICAL TREATMENT] days including: monitoring vital signs; description/ location of shunt/ fistula/ [MEDICAL TREATMENT] catheter; presence of AV thrill/ bruit if applicable; presence of excessive bleeding/ hemorrhage; change in condition. Additionally, the P&P documented pressure dressing to be removed per medical doctor (MD) order. 1. Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 8/29/19 revealed the resident was moderately cognitively impaired, was understood and understands. The MDS revealed under section O the resident was receiving [MEDICAL TREATMENT]. Review of a Comprehensive Care Plan (CCP) with a revision date of 4/2/19 revealed the resident had (chronic) [MEDICAL CONDITION] related to (r/t) kidney disease, was on [MEDICAL TREATMENT] every Monday, Wednesday, Friday (M, W, F) with interventions to include fluids per order, restrict or give per order, no blood pressure (B/P) in left arm and medications per order. Review of the Medication Administration Record [REDACTED]. During intermittent observations on 10/1/19 at 7:51 AM and 1:35 PM the resident's left arm AV fistula site had a bandage intact covering the AVF site from [MEDICAL TREATMENT] on 9/30/19. During an observation and interview on 10/3/19 at 8:44 AM the resident's left arm AV fistula site had a bandage intact covering the AVF site from [MEDICAL TREATMENT] on from [MEDICAL TREATMENT] on 10/2/19. When the resident was asked if the nurses removed her [MEDICAL TREATMENT] dressing, she stated, No take it off. During an interview on 10/3/19 at 9:02 AM, Licensed Practical Nurse (LPN #1) stated the rule of thumb was the dressing should be taken off four hours after treatment, unless its bleeding and then it would be put back on and documented in the progress notes. The stated, Is hers still on? During interview on 10/3/19 at 9:05 AM, LPN #1 stated the dressing should have been taken off and it wasn't. LPN #1 reviewed the TAR and stated, It was documented the dressing was taken off last night and it is still on this morning. During an interview on 10/3/19 at 10:04 AM, LPN #1 stated the resident was on a 1500 cc (cubic centimeters) fluid restriction and that someone just forgot to put in the order when she started going to [MEDICAL TREATMENT] again. During an interview on 10/3/19 at 12:40 PM, the Clinical Supervisor from the [MEDICAL TREATMENT] center stated the pressure dressing should be removed after 4 hours, it should not still be on in the morning. During an interview on 10/3/19 at 1:06 PM, the Director of Nursing (DON) stated the [MEDICAL TREATMENT] dressing should be removed 4 to 6 hours post [MEDICAL TREATMENT] and there should be an MD order if a resident is on a fluid restriction. 415.12

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY 405) during the Standard survey completed on 10/4/19, the facility did not ensure the resident environment remains as free from accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents for two (Resident's #27 and #33) of seven residents reviewed for accidents. Specifically, Resident #33 was observed smoking and not utilizing a smoking apron per their plan of care (P[NAME]) and the facility did not ensure Resident #27 had a Dycem (non-slip device) in place as planned after a fall. Additionally, the care plan was not revised after fall. The findings are: 1. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 7/16/19 documented the resident was cognitively intact, was understood and understands. The resident was independent with ambulation and transfers and used a roller walker (walker with wheels). The policy and procedure (P&P) titled Resident Smoking Policy documented the facility does not permit smoking inside the facility. Smoking will be permitted in an outside designated area. The facility will be responsible for supervision for all smokers and placing smoking aprons on residents. All residents that desire to exercise the privilege to smoke will be assessed to determine their smoking safety awareness, assist in supervision needed and/or the need for protective equipment. Review of a Smoking Evaluation dated 4/19/19 at 3:31 PM revealed the resident understands and agreed to use the identified protective equipment while smoking to include a smoking apron. The resident was safe to smoke with supervision and the protective smoking equipment. Review of a Comprehensive Care Plan (CCP) with a revision date of 8/5/19 revealed the resident was able to smoke with supervision in designated area with interventions that included the resident will remain safe while smoking and a smoking apron utilized. During observations on 9/30/19 at 1:13 PM and 10/2/19 at 1:23 PM the resident was in the designated smoking shelter, supervised by staff. However, the resident was not wearing a smoking apron as per his P[NAME]. During an interview on 10/01/19 at 1:49 PM, Resident #33 stated he can go out to smoke at 9:00 AM, 1:00 PM and 7:00 PM and has to be with staff. During an interview on 10/3/19 at 9:40 AM, Maintenance Assistant #2 stated maintenance usually supervises the residents smoking. He was unsure what protective equipment individual residents should use but stated, Everyone is supposed to use an apron. During the same interview Maintenance Assistant #1 stated residents who smoke get assessed by therapy and the information is then communicated to staff. He also stated, Everyone is supposed to us an apron. while smoking. During an interview on 10/3/19 at 10:43 AM, Licensed Practical Nurse (LPN#1) stated residents are assessed by therapy for smoking, they make recommendations on protective equipment and it's put on the residents CCP. During an interview on 10/3/19 at 10:47 AM, the resident stated he is supposed to wear an apron when he smokes but forgets sometimes. When asked if the staff remind him to wear the smoking apron he stated, sometimes. During an interview on 10/3/19 at 10:55 AM, the Director of Rehabilitation stated each resident that smokes gets assessed for safety. The facility policy is the resident has to be able to get outside on their own and everyone has to wear a smoking apron. The evaluation gets communicated to the Interdisciplinary Team (IDT) after it's done. 2. Resident #27 was admitted to the facility 12/7/18 with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was severely cognitively impaired, was understood and understands. The facility P&P titled Accident/ Incident - Investigation & Reporting revised 7/2019 documented, Immediate action(s) must be taken at the time of the incident to keep the resident in the safest environment. The immediate action(s) will be reviewed by the Interdisciplinary Team and evaluated and/or altered if indicated. The resident's Care Plan and profile sheet will be updated by the team at this time. Review of a facility Incident/ Accident Form dated 9/24/19 revealed the resident was observed on the floor. The facility ruled out abuse, neglect, and mistreatment; Resident attempting to ambulate. Has no safety awareness. Slid out of w/chair (wheelchair) to floor. PT (Physical Therapy) referral for Dycem in chair. Review of a facility Fall Consult dated 9/26/19 included the following: - Issued Dycem on w/c (wheelchair) seat to prevent cushion from sliding. - No change to Care Plan/ care guide - Continue current recommendations. Review of the Fall care plan included a revision dated 9/26/19, Therapy referral for Dycem in w/chair. There were no further revisions regarding Dycem on the care plan. The resident was observed in the TV (television) lounge on 10/1/19 at 8:36 AM sitting in her wheelchair, on top of a folded blanket. There was no Dycem observed underneath the blanket. The resident was observed in the TV lounge on 10/2/19 at 10:54 AM sitting in a stationary chair on a fabric cushion, there was no Dycem between the cushion and the chair. The resident was observed in the TV lounge on 10/3/19 at 11:55 AM sitting in a stationary chair on a fabric cushion, there was no Dycem between the cushion and the chair. In addition, the resident's wheelchair did not have Dycem on the seat of the chair. During an interview on 10/4/19 at 8:42 AM, the Director of Rehabilitation stated, The Dycem should be care planned for while she is in her chair, wheelchair or stationary chair. She likes to self-transfer and has had a couple falls. She is not safe in the lounge stationary chair without Dycem. It (Dycem) helps prevent her from falling when she's sliding out. It (Dycem) provides a little friction for safety purposes to keep her more upright and prevent her sliding out or falling. 415.12(h)(1,2)