Every finding on record at Greene Meadows Nursing and Rehabilitation Center

Based on observation, interview, and record review conducted during survey, the facility failed to ensure each resident received adequate supervision and to prevent accidents for three (Resident #'s 30, 110, and 129) of 103 residents reviewed. Specifically, Resident #30, who required supervision and touch assistance for eating, was observed alone in their room, lying flat on their bed while eating; Resident #110, who required supervision or assistance with eating, was observed in a dining room reclined at a fifteen-degree angle in a lounge chair with a food tray on a table next to them, while staff was noted to hand the resident bowls of food and walk away while resident was making audible gurgling sounds; Resident #129, who required supervision while eating and was on aspiration precautions (care taken to prevent food or liquids from entering the lungs), was left unsupervised while eating. This resulted in Immediate Jeopardy and had the likelihood to place other vulnerable residents at risk for serious harm, serious injury, serious impairment, or death.Findings include:Facility policy titled Activities of Daily Living Dining-Eating Assistance and Restorative Dinning (Eating/Swallowing), dated 03/2025, documented to prepare for mealtime position resident comfortably in bed or chair as close to 90 degrees as possible. Residents requiring supervision with eating should not be left alone in their room.Facility provided line list of all residents in the building dated 08/04/2026, identifying 103 residents required supervision or assistance with eating.Facility provided a line list of all residents in the building as of 08/04/2026, identifying 22 residents with aspiration precautions.Resident#30Resident #30 was admitted to the facility with diagnoses of cognitive communication deficit, need for assistance with personal care, and muscle weakness. The Minimum Data Set (a resident assessment tool), dated 07/15/2026, documented the resident was able to be understood, understood others and was significantly cognitively impaired.Resident #30's Care Plan, Focus on Functional Abilities-Self Care dated 07/10/2026 documented the resident required supervision and touch assistance with eating.During an observation on 8/03/2026 at 1:08 PM, Resident #30 was observed alone lying flat in their bed trying to eat.Resident#110Resident #110 was admitted to the facility with diagnoses of dysphagia (difficulty swallowing food), adult failure to thrive (significant decline in physical and emotional well-being), and unspecified dementia (a group of symptoms affecting memory, thinking and social abilities). The Minimum Data Set, dated [DATE], documented the resident was rarely able to be understood, rarely understood others, and was so significantly cognitively impaired, they were unable to complete the assessment.Medical Director #1's dietary order for Resident #110 dated 07/17/2026 documented crush medications that can be crushed, mix in pudding to facilitate administration due to dysphagia.Medical Director #1's dietary order for Resident #110 dated 07/26/2026 documented a regular diet with consistency of soft, bite size pieces. Sandwiches except peanut butter, crust okay, and food in bowls.During an observation on 07/28/2026 at 12:25 PM, Resident #110 was observed in the second floor south dining room in a lounge chair reclined to a fifteen-degree angle with their food tray next to them on a table. Staff were noted to hand the resident bowls of food with a spoon and walk away. It was noted that Resident #110 was making occasional gurgling sounds while eating pudding but was able to swallow and was not noted to cough or choke while doing so.Resident #129Resident #129 was admitted to the facility with diagnoses of acute respiratory failure with hypoxia (lungs do not get enough oxygen into the blood to keep organs working normally), diabetes mellitus Type 2 (the body cannot use insulin correctly and sugar builds up in the blood), and muscle weakness. The Minimum Data Set, dated [DATE], documented the resident was able to be understood, understood others and was minimally cognitively impaired.Facility policy titled Aspiration Precautions dated 07/23/2023 documented, any resident with a physician order for aspiration precautions would be identified, care planned, and eat meals supervised in accordance with their plan of care.Resident #129's Care Plan, Focus on Functional Abilities-Self Care dated 07/10/2026 documented, the resident required supervision and touch assistance with eating.Physicians' orders by Medical Director #1 for Resident #129 dated 07/22/2026 documented resident was placed on aspiration precautions.Speech Language Pathologist #1 skilled treatment notes for Resident #129 dated 07/31/2026, documented completion of a Fiberoptic Endoscopic Evaluation Swallowing (clinical test used to assess how well a person swallows). It stated there was smaller-than-normal amount of material remaining in the throat after a swallow; compensatory swallowing, established a plan to improve swallowing strength and endurance using effortful swallows during meals, and recommended supervision during meals.Resident #129's Certified Nurse Aide Eating/Toileting Instructions, active 07/22/2026, identified the resident's expected self-performance during meals as supervision. Nursing instructions directed staff to provide supervision, verbal prompts for effortful swallow, alternating solids and liquids, small bites, and aspiration precautions during meals.During an observation on 7/28/2026 at 1:30 PM, Resident #129 was eating alone in their room in a wheelchair with their plate on their lap and was not visible from the doorway. No staff were present in the room.During an observation on 8/03/2026 at 1:09 PM, Resident #129 was eating a pureed diet alone in their room in a wheelchair with their plate on their lap and was not visible from the doorway. No staff were present in the room.During an observation on 8/04/2026 at 9:39 AM, Resident #129 was eating alone in their room in a wheelchair. Resident #129 was behind a curtain that divided the room and was not visible from the doorway, hallway, or nurses station. No staff were present in the room.Interviews:During an interview on 08/03/2026 at 3:30 PM, Certified Nurse Aide #2 stated if residents needed supervision while eating, it would be the nurse's responsibility. If a nurse was unavailable to supervise a resident who required supervision, they would keep an eye on the resident. They were unaware of Resident #129's eating precautions. Resident #129 was on their assignment at the time.During an interview on 08/03/2026 at 3:25 PM Licensed Practical Nurse #4 stated that a resident should be sitting upright when eating. They did not know off the top of their head which residents were on aspiration precautions, but stated it would be in the residents' orders, care plan and on their meal ticket.During an interview on 08/03/2026 at 3:26 PM, Director of Nursing #1 stated the resident's instruction for feeding status was in the electronic medical records on the certified nurse aide care card. When the certified nurse aide logged into the electronic medical record and selected a resident, the care card would automatically pop up. All licensed staff had the same access to the care card and would also be able to see the feeding and supervision level on the residents' care plan. Director of Nursing #1 stated it was their expectation that any resident who had instructions for supervision or above would be in sight of staff at all times while eating. Residents should be sitting up as high as tolerable during meals, never lying flat. A resident with aspiration precautions should be sitting up, with appropriate consistency diet, not left alone, and sitting up for at least 30 minutes post meal. Staff were trained on feeding upon hire and annually. Director of Nursing #1 stated with the first-floor dining room being closed, residents had been eating in their room. They would discuss with staff to assure residents that needed supervision were brought to the hall of common areas during mealtimes. During an interview on 08/04/2026 at 9:42 AM, Licensed Practical Nurse #1 confirmed Resident #129 was eating alone and stated the resident was on aspiration precautions and required supervision during meals. They did not know the details of Resident #129's care needs.During an interview on 08/04/2026 at 10:00 AM Certified Nurse Aide #1 stated they were assigned to Resident #129 but were unable to supervise them because they were supervising another resident, who also required aspiration precautions. Certified Nurse Aide #1 stated that residents who required supervision were sometimes seated near the doorway so staff could observe them.During an interview on 08/04/2026 at 10:55 AM, Certified Nurse Aide #5 stated, when asked if they had received any information or education prior to start of shift today, they responded that they did not know what the surveyor was talking about, could the surveyor provide what information they were talking about.During an interview on 08/04/2026 at 11:06 AM, Certified Nurse Aides #7 stated they had not received any education/information from the day before (08/03/2026).During an interview on 08/04/2026 at 11:25 AM, Resident #133 had an order for aspiration precautions on admission [DATE]. They stated they had been at the facility for one day and staff had not been with them during meals. The resident stated that during the meal that day, a staff member was present in the room but remained on the opposite side of the room and was not with them while they ate.During an interview on 08/04/2026 at 11:30 AM, Resident #15, who was on aspiration precautions, stated they always ate in their room alone unless they went to the dining room. No one was with them while they ate in their room. During an interview on 08/04/2026 at 11:35 AM, Resident #6, who was on aspiration precautions, stated that when they ate in their room it was without supervision. They normally ate in the dining room and were on a pureed diet.During an interview on 08/04/2026 at 10:12 AM, Director of Nursing #1 stated they discussed with unit managers and supervisors, prior to dinner last night (08/03/2026) regarding making sure residents who needed supervision and/or assistance were to be brought to the hall or common area during mealtimes. They stated they also spoke with the 11:00 PM - 7:00 AM supervisor over the phone last night when they came on shift and discussed the mealtime supervision. There was no formal education provided for staff that required signatures. During an interview on 08/04/2026 at 11:40 AM, Administrator #1 stated that there was a team discussion after the survey team left the building on 08/03/2026 to discuss setting up residents to eat. There was some concern raised by the staff at the meeting that residents eating in the hallway would be a dignity issue. Administrator #1 stated that there needed to be a backup plan for resident dining if the dining room was not available. Present at the meeting were unit managers, Director of Nursing #1, department heads, Administrator #1 and Assistant Director of Nursing #1. Administrator #1 stated it was the expectation that morning (08/04/2026) that residents on aspiration precautions would either be in the common area or in their room with a staff member watching them. The level of supervision depended on the residents' needs. Certified Nurse Aide training included how to ensure that residents who needed supervision, feeding or watching were kept safe while dining. The specific resident needs would be on the care plan which would translate over to the certified nurse aide instructions. Certified Nurse Aides were to check their assignments daily to ensure they knew what the residents in their assignments needed. Unit Managers were at the meeting held the previous evening (08/03/2026) and were to instruct the staff on the floor. Director of Nursing #1 called supervisors last evening to tell them what the staff needed to be told for the off shifts. Unit managers were supposed to reinforce teaching with day staff today (08/04/2026). Administrator #1 expected that Unit Managers would know who was on aspiration precautions. Activity aides were trained the same way Certified Nurse Aides were. Administrator #1 stated that they had not considered including Activity aides in the education needed for resident safety while eating. The message that was supposed to be given to all the staff was that residents with aspiration precautions should not eat unsupervised. The plan was for unit staff to leave the residents on aspiration precautions to choose if they wanted to eat in the common area or be in their room with someone while they ate. Administrator #1 stated they would complete immediate re-education.During an interview on 08/04/2026 at 4:00 PM, Medical Director #1 stated aspiration precautions did not automatically require meal supervision. Clinical judgment and the resident's current condition took precedence over standing orders or the electronic health record. Residents maintaining weight, tolerating the prescribed diet, and without recent respiratory events could eat independently regardless of the electronic record. Medical Director #1 stated, I don't care what the electronic health record says. I care about what the clinical situation is, and stated electronic orders often lagged the resident's current condition. Individualized interventions, including one-to-one supervision during meals, verbal cueing, alternating solids and liquids, effortful swallow, and other speech-language pathology recommendations, were determined on a case-by-case basis. They stated disagreement with speech-language pathology recommendations could occur based on clinical assessment. Medical Director #1 stated no residents needed to be watched while eating. Medical Director #1 stated aspiration could not be diagnosed in a nursing home. Medical Director #1 stated the speech-language pathology established whether a resident required a downgraded diet and stated if the resident was doing good and maintaining weight, they're good. They stated, I don't know where you're going with this, but are you telling me if they're on a downgraded diet, they need to be supervised? I can guarantee the hospital staff are not sitting with patients watching them eat. A Certified Nurse Aide is not going to sit and watch them. I do not think every person on a special diet needs to be babysat. Discussion included Resident #129 with a care plan directing one-to-one supervision during meals, alternating liquids and solids, verbal cueing, effortful swallow, and other therapist-directed interventions. Medical Director #1 stated, they did not care what the occupational therapist or the speech-language pathology says. Medical Director #1 stated recommendations remained case-by-case and a resident who did not have any issues in one year did not need to be watched during meals.During an interview on 08/05/2026 at 11:29 AM, Licensed Practical Nurse #1 stated residents requiring aspiration precautions were identified through physician orders, care plans, and meal tickets. Residents admitted to the facility received a speech-language therapy evaluation, and recommendations were forwarded to the physician. Resident-specific interventions and diet consistencies were identified in physician orders and care plans. Aspiration precautions included direct supervision during meals, positioning residents at 90 degrees, and having residents out of bed. Speech-language therapy recommendations signed by the physician were expected to be followed. During an interview on 08/05/2026 at 11:45 AM, Registered Nurse Manager #1 stated aspiration precautions included having residents out of bed, maintaining an upright 90-degree position during meals, and direct observation while eating.During an interview on 08/06/2026 at 10:33 AM, Director of Nursing #1 and Assistant Director of Nursing #1 stated aspiration precautions were expected to be followed as ordered until formally changed. Nursing staff were not authorized to deviate from physician orders based on clinical judgment alone. Aspiration precautions could not be discontinued without a new physician order and corresponding care plan revision. Residents with active orders for meal supervision were expected to be supervised.During an interview on 08/06/2026 at 11:20 AM, Nurse Educator #1 stated staff were instructed to position residents upright during meals and maintain that position for approximately 30 minutes after eating. Out-of-bed dining was preferred; however, residents retained the right to remain in bed if appropriately positioned. If a resident insisted on lying flat while eating, staff were expected to remove the meal tray until the resident was positioned safely, educate the resident regarding aspiration risk, and assist with proper positioning. Residents requiring aspiration precautions and residents with cognitive impairment requiring feeding assistance were expected to receive meal supervision. A meal tray placed on a resident's lap while lying in bed was not considered appropriate positioning. Staff identified resident-specific feeding interventions through shift report and the electronic medical record containing resident care information. Staff education included recognizing signs and symptoms of aspiration and immediately notifying nursing staff when aspiration was suspected.During an interview on 08/06/2026 at 11:40 AM, Nurse Practitioner #1 stated determination of aspiration precautions was based on factors including resident food tolerance, review of hospital discharge documentation, and speech-language therapy evaluations. Speech-language therapy evaluated swallowing function and provided recommendations regarding aspiration precautions and swallowing interventions. Speech-language therapy recommendations, including meal supervision, verbal cueing, alternating solids and liquids, and effortful swallow techniques, were expected to be followed. Residents with physician orders, care plans, and certified nursing assistant instructions requiring meal supervision were expected to receive meal supervision. Staff were not expected to discontinue meal supervision because a resident appeared to be eating well or maintaining weight. Observation of a resident eating alone despite documented meal supervision would not be consistent with expectations.10 New York Codes, Rules, and Regulations 415.12(h)(1)On 08/04/2026, Immediate Jeopardy was identified. Administrator #1 and Director of Nursing #1 were notified. The facility returned the signed IJ Template on 08/04/2026.On 08/04/2026, an approved immediacy removal plan was accepted.Based on observation, interviews, and record review, the facility completed implementation of the removal plan on 08/05/2026.Immediate Jeopardy was lifted based on the following corrective actions taken by the facility: A facility-wide report was generated from physician and/or diet orders to identify all residents with active aspiration precaution orders. 22 residents were identified with aspiration precautions. The 22 residents identified with aspiration precautions were cross-referenced with their current care plans and Certified Nurse Aide accountability information to ensure aspiration precautions were accurately reflected. Residents identified with aspiration precautions were relocated to a common dining/monitored area during meals for direct staff supervision. Residents who could not be relocated to a common area were supervised in their rooms. The facility reviewed and revised the Aspiration Precautions policy on 08/04/2026 to include supervision in the resident's room for residents with aspiration precautions. Facility-wide education titled, Aspiration Precautions and Mealtime Supervision, was initiated for Certified Nursing Aides, Licensed Practical Nurses (LPNs), Registered Nurses, and Activity Aides trained to feed residents. Education records, staff attendance sheets, and employee rosters were received and reviewed. Nursing management was educated regarding the Aspiration Precautions and Mealtime Supervision audit process. Meal observations were conducted on 08/05/2026 during breakfast and lunch on multiple nursing units. Residents identified with aspiration precautions were observed appropriately positioned and supervised during meals. Record review of sampled residents with aspiration precautions identified the aspiration precautions were reflected in the residents' care plans and CNA/Kardex instructions. Staff interviews conducted on 08/05/2026 and 08/13/2026 verified knowledge of aspiration precautions, appropriate positioning, mealtime supervision, and where to locate resident-specific aspiration interventions. Director of Nursing #1 initiated meal audits to ensure residents with active aspiration precaution orders were appropriately positioned and supervised during meals. Meal audits dated 08/05/2026 were received and reviewed.

Based on observation and interviews during the recertification survey, the facility failed to ensure garbage and refuse was disposed properly. Specifically, the garbage dumpster was not closed, clean and in good repair; and garbage littered the dumpster area. The findings include:During observations on 07/28/2026 at 10:30 AM, the dumpster was open and soiled, the plastic lid had a large crack, and the area was littered and had vegetation overgrowth. During an interview on 07/28/2026 at 11:31 AM, Food Service Director #1 stated that they would contact the maintenance department to have the dumpster and area cleaned and have the lid replaced. New York Codes, Rules, and Regulations Title 10 S415.14(h)

Based on observation, manufacturer's directions review, and interview during the survey, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, automatic dishwashing machine was not operating within the manufacturer's specifications, bulk food containers were not properly labeled, and surfaces required cleaning. The findings include:During observations 07/28/2026 10:30 AM:The water pressure during the automatic dishwashing machine final rinse was 12 pounds per square inch. The manufacturer information plate states that the water pressure is not to be less than 20 pounds per square inch.The bulk food containers were not labeled.The slicer, K-rated fire extinguisher, and 2 of 2 kitchenette microwave ovens were soiled with food particles.The second-floor kitchenette shelving trim was missing, exposing raw wood. During an interview on 07/28/2026 at 11:31 AM, Food Service Director #1 stated that they would contact the maintenance department to adjust the dishwashing machine final rinse water pressure, repair the shelving trim in the first-floor kitchenette, label the bulk food containers, and clean the slicer, microwave ovens, and fire extinguisher. New York Codes, Rules, and Regulations Title 10 415.14(h)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure residents were provided with food and drink that was palatable, flavorful, and at a safe and appetizing temperature. Specifically, (a) for Resident #46, food was not served at an appetizing temperature during a lunch meal on 08/03/2026 and stated that the food was unappealing; and (b) for Resident #60 food was not served at an appetizing temperature during a lunch meal on 08/03/2026 and stated the food was not appetizing to them. Findings include: Facility Policy titled, Food and Nutritional Services, date last revised 07/18/2023, documented each resident was provided with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The documented procedure included in pertinent part, trays would be set up in the dietary department in the order of their delivery. A diet card should accompany each tray and contain the following information: Name, room number, diet, food allergies, adaptive equipment, location for meal delivery, dislikes of different foods, and beverage preferences. Meals would be provided in a timely manner so that hot foods were served hot and cold foods were served cold. Menus for regular and therapeutic diets were written at least two weeks in advance. Documented under tray line process, in pertinent part, was that all hot food was maintained at 140 degrees Fahrenheit or higher and cold items were kept under refrigeration until served or placed on ice to maintain temperature at 41 degrees Fahrenheit or below. Resident #46 was admitted to the facility with the diagnoses of major depressive disorder, recurrent, unspecified (two or more episodes of low mood and unending sadness), blindness (inability to see), and need for assistance with personal care (required help to maintain activities of daily living). The Minimum Data Set, dated [DATE], documented the resident was blind, understood others, was able to be understood, and was minimally cognitively impaired. During a test tray observation on 08/03/2026 at 12:34 PM, Resident #46 was served the following items: Breaded Chicken with white gravy which was observed to be palatable and at 147.0 degrees Fahrenheit. Egg noodles without gravy or sauce which was observed to be overcooked, easily macerated and at 132.1 degrees Fahrenheit. Two containers of industrial packaged apple juice. Both tasted and were dated appropriately, but one was 56.7 degrees Fahrenheit and the other was 60.1 degrees Fahrenheit. Canned pears which were observed to be palatable appearing and tasted as expected, however were served at 72.3 degrees Fahrenheit and the meal ticket stated mandarin oranges which were not on the tray presented. Chocolate Milk was served at 44.4 degrees Fahrenheit but tasted as expected. Under special instructions was printed NO KNIFES ON TRAY. A plastic knife was noted to be served on the tray. Resident #60 was admitted to the facility with diagnoses of type 2 diabetes mellitus with foot ulcer (a chronic condition characterized by high blood sugar resulting from insulin resistance and relative insulin deficiency, leading to an open sore or wound caused by nerve damage, poor blood flow, and high blood sugar,) hypertensive heart disease without heart failure (a condition where the heart muscle has thickened or changed structure from long-term high blood pressure, but is not failing to pump blood,) and chronic kidney disease (a long-term condition where the kidneys are damaged and lose their ability to filter blood properly, leading to a gradual loss of function over time.) The Minimum Data Set, dated [DATE], documents the resident could be understood and understood others and was cognitively intact. During a test tray observation on 08/03/2026 at 12:40 PM, Resident #60 was served the following items: Garden salad, which was observed to appear freshly prepared, but was 69.6 degrees Fahrenheit. Fat free milk which was 50.1 degrees Fahrenheit. An item titled Maryland chicken which was observed to lack significant flavor and was served at 137.1 degrees Fahrenheit. Pureed vegetables served at an appropriate temperature. Canned pears which were observed to be overly crispy and not easily macerated and served at 75.6 degrees Fahrenheit. Additionally, mandarin oranges were listed on the meal ticket however were not on the tray. Ranch dressing, salt and pepper were noted to be present on the tray, however there were no utensils on tray, no hot chocolate as listed on ticket, and no water as listed on ticket. During an interview on 07/28/2026 at 7:12 PM, Resident #1 stated that there was no dietitian in the building and that the food they were served was not the food that they were supposed to have. states there is no dietitian. The diet she is served is not the one ordered. During an interview on 07/31/2026 at 11:21 AM, Resident #4 stated that the food could be better and frequently, they did not get food that they expected to receive. During an interview on 07/31/2026 at 10:05 AM, Resident # 54 state that the food was not good, and meals tended to be repetitive. One day may be chicken and then the next the facility would serve the same chicken but add gravy to make it something different. During an interview on 07/31/2026 at 09:54 AM, Resident #71 stated that they had been served expired food in the past. During an interview on 07/28/2026 at 11:42 AM, Resident #14 stated that the food served was not always appetizing. During an interview on 07/28/2026 at 12:50 PM, Resident #88 stated that the lunch they had been served that day did not taste good, and the rice wasn't cooked. Resident #88 stated they did not eat their lunch and staff did not offer them anything else. Resident #88 also stated that they did not ask for anything either. During an interview on 07/28/2026 at 9:50 AM Resident #123 stated the food was bad and they ordered a lot but was recently told they were not allowed to have food in their room anymore. During an interview on 08/03/2026 at 3:36 PM, Certified Nurse Aide #4 state that they put thresident at their assigned seat, gave them a clothing protector, cleaned their hands, and then made sure the tray was correct. Certified Nurse Aide #4 stated they checked the consistency of the food to ensure that it was correct, set the resident up and if they needed to be fed, they would do so. During an interview on 08/03/2026 at 3:43 PM, Licensed Practical Nurse #2 stated that they made sure the tray matched the ticket with consistency or that an aide was sitting with the resident while they ate if it was required. During an interview on 08/10/2026 at 1:33 PM, Administrator #1 stated that there was food committee that met to address resident concerns about the food served at the facility. Administrator #1 stated that the Food Service Director met with the once a month and the Dietician met with the residents individually. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)

Based on interviews, observations, and record review conducted during a survey, facility failed to ensure that respiratory care was provided according to professional standards for one (Resident #3) of one reviewed. Specifically, Resident #3 had in accurate orders for continuous positive airway pressure machine (medical device that provides steady pressure through an air mask worn while sleeping) with no diagnosis of a respiratory condition requiring the use of the continuous positive airway pressure machine and was not care planned for a respiratory diagnosis indicating the use for or of the continuous positive airway pressure machine. Cross Reference Tag F0656 Findings include: Resident #3 Resident #3 was admitted to the facility with diagnoses of heart failure (heart muscle don't pump as well as it should), morbid obesity (severely overweight), and cough. The Minimum Data Set (an assessment tool), dated 07/08/2026, documented the resident was able to be understood, sometimes understood others and was significantly cognitively impaired. Review of comprehensive list of residents' active diagnosis, revealed a diagnosis of cough and no further documented evidence of respiratory diagnoses. Physician's orders dated 07/10/2026 entered by Licensed Practical Nurse #3 and signed by Medical Director #1 documented Continuous Positive Airway Pressure machine at 4.0 pressure via face mask to be placed on at bedtime and removed in the morning every other day. During an observation on 08/07/2026 at 11:10 AM, a continuous positive airway pressure machine was noted on resident's bedside table. During an interview on 08/10/2026 at 09:43 AM, Registered Nurse #2 stated the nurses receive orders from the provider for continuous positive airway pressure machine use and enter the orders into the electronic medical record for the providers to review and sign. They would expect to see a diagnosis of sleep apnea or related for use of a continuous positive airway pressure machine and would expect the order to be for daily application and removal. During an interview on 08/10/2026 at 9:49 AM, Licensed Practical Nurse #3 stated they received orders from the provider and entered them into the resident's electronic health record for review. They reviewed Resident #3's electronic medical record and stated there was no respiratory diagnosis related to use of a continuous positive airway pressure machine. They then reviewed the order in the electronic medical record and stated the proper use for a continuous positive airway pressure machine would be to place every night and remove every morning. They must have entered the order incorrectly on 07/10/2026 for the continuous positive airway pressure machine and were unsure why the provider did not catch it. The resident did use the continuous positive airway pressure machine every night unless they refused. During an interview on 08/10/2026 at 10:00 AM, Nurse Practitioner #1 stated a continuous positive airway pressure machine should be used every night, and the resident should have a sleep apnea diagnosis. The order for use every other day was inappropriate. During an interview on 08/10/2026 at 1:10 PM, Director of Nursing #1stated any resident with a Continuous Positive Airway Pressure machine should have a correlating diagnosis. The orders for continuous positive airway pressure machine should be for use every day not every other day. The process for orders was, a licensed practical nurse may enter an order, the nurse manager would review all new orders within the next business day, and the provider would review the order prior to signing. 10 New York Codes, Rules, and Regulations 415.12(k)(6)

Based on interview and record review conducted during a survey, the facility failed to ensure that comprehensive care plans were developed and implemented according to professional standards for three (Resident #s 3, 62, 126) of 34 residents. Specifically, Resident #3 had orders for continuous positive airway pressure machine (medical device that provides steady pressure through an air mask worn while sleeping), and a care plan was not developed for indications or use, Resident #62 had orders for aspiration precautions (precautions taken to prevent food or liquids from entering the lungs) and a care plan was not developed, and Resident #126 had orders for continuous positive airway pressure machine and a care plan was not developed for indications or use. Findings include: The policy and procedure titled Care Planning Process and Care Conference reviewed 05/2025 documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident based off the resident assessment. Facility policy titled Activities of Daily Living Dining-Eating Assistance and Restorative Dinning (Eating/Swallowing) dated 03/2025 documented, care plans would be initiated and revised as necessary to reflect current level of resident function and include supportive treatments for eating/swallowing problems. Resident #3 Resident #3 was admitted to the facility with diagnoses of heart failure (heart muscle does not pump as well as it should), morbid obesity (severely overweight), and cough. The Minimum Data Set, dated [DATE], documented the resident was able to be understood, sometimes understood others and was significantly cognitively impaired. Physician's orders for Resident #3 dated 07/10/2026 documented Continuous Positive Airway Pressure machine at 4.0 pressure via face mask to be placed on at bedtime and removed in the morning every other day. Review of Resident #3's comprehensive care plan effective 07/01/2026, focus Ineffective Airway/Oxygen revealed no documented evidence of continuous positive airway pressure machine use. Review of Resident #3's nursing note dated 07/06/2026 by Registered Nurse #1 documented the resident's spouse would bring the continuous positive airway pressure machine to the facility the next day. Resident #62 Resident #62 was admitted to the facility with diagnoses of unspecified dementia (a decline in mental ability severe enough to interfere with daily life), type 2 diabetes mellitus with unspecified complications (the body cannot use insulin correctly and sugar builds up in the blood) and hypertensive heart disease without heart failure (chronic high blood pressure.) The Minimum Data Set, dated [DATE], documented the resident could be understood, understood others, and was moderately cognitively impaired. Physician's orders for Resident #62 dated 07/16/2026 documented resident was ordered aspiration precautions. Review of Resident #3's comprehensive care plan effective 07/01/2026, revealed no documented evidence of ineffective airway or aspiration precautions. Resident #126 Resident #126 was admitted to the facility with diagnoses obstructive sleep apnea (when breathing stops while you sleep), morbid obesity (severely overweight), and shortness of breath. The Minimum Data Set, dated [DATE], documented the resident was able to be understood, understood others, and was cognitively intact. Physician's orders for Resident #126 dated 07/21/2026 documented Continuous Positive Airway Pressure machine at 4.0 pressure via face mask to be placed on at bedtime and removed in the morning every day. Review of Resident #126's comprehensive care plan effective 07/21/2026, focus Ineffective Airway/Oxygen revealed no documented evidence of continuous positive airway pressure machine use. During an interview on 08/04/2026 at 11:40 AM, Administrator #1 stated the specific resident needs would be on the care plan. During an interview on 08/10/2026 at 09:43 AM, Registered Nurse #2 stated that any resident who had an order for a continuous positive airway pressure machine or oxygen should have a care plan reflecting the use. They would expect to see an ineffective airway focus with interventions to include the use of oxygen, continuous positive airway pressure machine, or any precautions. During an interview on 08/10/2026 at 09:49 AM, Licensed Practical Nurse #3 stated there should be a care plan in place for any resident that had a continuous positive airway pressure machine or oxygen use. During an interview on 08/10/2026 at 1:10 PM, Director of Nursing #1 stated any resident with a continuous positive airway pressure machine should have a correlating diagnosis and a care plan in place. If a resident constantly refused treatment a care plan for refusal of care should be in place as well. 10 New York Codes, Rules, and Regulations 415.11(c)(1)

Based on record review and interviews during a survey, the facility failed to ensure alleged violations involving abuse, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to officials (including to the State Agency) for two (Residents #54 and 71) of 5 residents reviewed for abuse and accidents. Specifically, for Resident #54 staff witnessed suspected abuse that was reported to the State Survey Agency more than 24 hours after the incident occurred. For Resident #71 staff witnessed suspected abuse that was reported to the State Survey Agency 9.5 hours after the incident occurred. Findings include: The facility policy titled Incident Reporting and Investigation last reviewed 10/2025 documented, all incidents where there is abuse will be reported to the Director of Nursing and Administrator immediately for further review and reporting based on State and Federal regulations. Resident #54 Resident #54 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, morbid obesity, and major depressive disorder. The Minimum Data Set (an assessment tool) dated 06/16/2026, documented the resident could be understood, could understand others and had intact cognition for decisions of daily living. A facility document titled Accident/Incident Investigation documented that on 07/06/2026 at 9:00 AM certified Nurse Aide #11 was heard swearing at Resident #54. A Nursing Home Incident Submission Report documented the incident was reported to the Department of Health on 07/07/2026 at 18:30. Resident #71 Resident #71 was admitted to the facility with diagnoses of spastic hemiplegia (left side), morbid obesity, and peripheral vascular disease. The Minimum Data Set (an assessment tool) dated 05/17/2026, documented the resident could be understood, could understand others and had intact cognition for decisions of daily living. A facility document titled Accident/Incident Investigation documented that on 07/07/2026 at 9:00 AM certified Nurse Aide #11 was witnessed striking Resident #71 on their head. A Nursing Home Incident Submission Report documented the incident was reported to the Department of Health on 07/07/2026 at 18:30. During an interview on 08/10/2026 at 12:10 PM Administrator #1 stated the incidents involved abuse allegations and should have been reported within two hours, but they weren't reported to administration until early in the evening when we reported it to the Department of Health. Education was provided to the staff that should have reported the abuse allegations to administration immediately. 10 New York Codes, Rules, and Regulations 483.12(c)(1)(4)

Based on record review and interviews conducted during the recertification survey, the facility failed to ensure that residents were informed of the need to alter treatment according to professional standards for 1 of 4 residents reviewed. Specifically, for Resident #60, the facility failed to inform the resident of a change in the dosing of ordered insulin.The findings include: Review of the facility policy titled Change in Condition, dated 06/28/2023, documents the resident, attending physician, and resident representative, if applicable, will be notified promptly of a significant change in condition, accident/incident, change in treatment, and/or transfer/discharge. Resident #60 was admitted to the facility with diagnoses of type 2 diabetes mellitus with foot ulcer (a chronic condition characterized by high blood sugar resulting from insulin resistance and relative insulin deficiency, leading to an open sore or wound caused by nerve damage, poor blood flow, and high blood sugar,) hypertensive heart disease without heart failure (a condition where the heart muscle has thickened or changed structure from long-term high blood pressure, but is not failing to pump blood,) and chronic kidney disease (a long-term condition where the kidneys are damaged and lose their ability to filter blood properly, leading to a gradual loss of function over time.) The Minimum Data Set (MDS, an assessment tool) dated 05/24/2026, documents the resident could be understood and understood others and was cognitively intact. Record review of nursing note dated 08/06/2026 written by Licensed Practical Nurse #5 documented Resident #60 was seen by Nurse Practitioner #2 this shift for period review, new order to change sliding scale to start at two units and start eight units Fiasp Flex Touch Insulin (a rapid-acting prescription medication used to control high blood sugar in adults and children with diabetes) before meals in addition to sliding scale. During an interview on 08/07/2026 at 09:54 AM, Resident #60 stated that no one told them there was a change in their medication. Stated they saw the nurse practitioner yesterday, but no one told them that the insulin dose had changed. During an interview on 08/07/2026 at 09:58 AM, Registered Nurse #3 stated that Resident #60 is alert and oriented and makes their own decisions. Stated that changes in medication would be reported to the resident. Stated that if there was a significant change in condition or the resident was being sent to the hospital, the resident's representative, health care proxy/power of attorney, would be updated. Stated that they could find no documentation in the electronic health record that Resident #60 was notified of the change in medication that was made the previous day by the nurse practitioner. During an interview on 08/07/2026 at 09:58 AM, Licensed Practical Nurse #5 stated they did not notify Resident #60 that they had a change in insulin dosing. Stated they would notify Resident #60 today of the change. During an interview on 08/07/2026 at 10:28 AM, Assistant Director of Nursing #1 stated that residents that are alert and oriented that make their own decisions should be notified if there is a change in their medications. Stated that this should be done by whoever put the order in. If the nurse practitioner puts in the order, the nurses should be updated if the resident was informed of the change so that the staff can notify the resident if this was not done. 10 New York Codes, Rules, and Regulations 415.3 (f)(1)(iv)

Based on record review and interviews during a survey, the facility failed to ensure a resident's designated representative had the right to be informed in advance, by the physician or other practitioner or professional, of treatment options and to choose the alternative or option they preferred for two (2) (Resident #s 3 and 21) of five (5) residents reviewed for resident rights. Specifically, there was no documented evidence that treatment options and informed, documented consent was obtained for the use of psychotropic medications for Resident #3 and Resident #21.Findings include: The facility's policy and procedure titled Psychotropic Medication Use, Including Use in Dementia Residents last revised 3/19/2025, documented the attending physician and other staff would gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. An informed consent/risks and benefits would be reviewed with the resident representative and resident (if appropriate) prior to initiating or increasing dosage of a psychotropic medication. The resident and/or resident representative had the right to accept or decline the initiation or increase of a psychotropic medication; documentation by informed consent or present in the progress notes should be in the medical record. Resident #3 was admitted to the facility with the diagnoses of vascular dementia, severe, with psychotic disturbance (an advanced major neurocognitive disorder caused by reduced or blocked blood flow to the brain that featured profound cognitive and physical decline), major depressive disorder, recurrent, severe with psychological symptoms (repeated episodes of severe clinical depression accompanied by a loss of touch with reality, such as hallucinations or delusions), and morbid obesity (excessive body fat). The Minimum Data Set (an assessment tool), dated 7/08/2026, documented the resident was sometimes understood, sometimes understood others, and severely cognitively impaired. A physician's order, dated 7/07/2026, documented that Resident #3 was ordered to receive Venlafaxine extended release 150 milligram capsule, give two (2) capsules (300 milligrams) by oral route once daily, every day at 8:00 AM for major depressive disorder, recurrent, severe with psychological symptoms. A review of facility provided forms, titled Informed Consent for Psychotropic Medications, revealed that no signed consent was received for the use of Venlafaxine at any dose or for any duration for Resident #3. Resident # 21 was admitted to the facility with the diagnoses of vascular dementia, unspecified severity, with agitation (an advanced major neurocognitive disorder caused by reduced or blocked blood flow to the brain that featured profound cognitive and physical decline), anxiety disorder, unspecified (a mental health condition involving excessive, ongoing fear, dread, and nervousness that were out of proportion to actual situations), and major depressive disorder, recurrent, unspecified (two or more depressive episodes but the medical record did not specify the severity or specific clinical features). The Minimum Data Set, dated [DATE], documented the resident was able to be understood, usually understood others, and mostly cognitively intact. A physician's order, dated 7/30/2026 documented that Resident #21 was ordered to receive Lorazepam 0.5 milligram tablet, give one (1) tablet (0.5 milligrams) by oral route two (2) times per day, maximum daily dose: two (2) tablets, every day at 8:00 AM and 5:00 PM for anxiety disorder. A review of facility provided forms, titled Informed Consent for Psychotropic Medications, revealed that no signed consent was received for the use of Lorazepam at any dose or for any duration for Resident # During an interview on 8/10/2026 at 9:56 AM, Nurse Practitioner #1 stated that when residents come to the facility from the hospital, sometimes their medication regimen needed to be altered. Residents on psychotropic medications were put on a list to see the psych providers. The primary team or psych team would obtain permission to use the medications from the family before altering the course of treatment. The providers worked together to manage the residents During an interview on 8/10/2026 at 1:09 PM, Director of Nursing #1 stated that when residents were ordered to receive any medications that were considered psychotropics, or that altered the mood or emotional state of the resident, typically, the medication would be recommended by a medical provider. Psychiatry would be consulted and either they or the medical provider would reach out to the resident's family to obtain consent to use the medication. Director of Nursing #1 was not aware that Resident #3 and Resident #21 were missing consents for their respective medications. 42 New York Code of Rules and Regulations 483.10 (c)(1)(4)(5)

Based on interviews, observations, and record review conducted during a survey, the facility failed to ensure residents were treated with dignity and respect according to professional standards for two (Resident #56 and #71) out of 34. Specifically, Resident #56 had incontinence care provided while the curtains in their room at the end of their bed allowing them to be seen by others in the room and Resident #71, while interviewing the resident, a staff member entered the room without knocking or identify themselves. Findings include: Facility policy titled Residents Rights reviewed 05/2025, documented employees were to treat residents with kindness, respect, and dignity. Facility policy titled Dignity and Respect reviewed 04/2025, documented were to promote, maintain, and protect residents' privacy, including bodily privacy during assistance with personal care. Privacy curtains were to be used while the resident was being dressed, undressed, toileted, and bathed. Staff were to knock and to await response from the resident prior to entering the resident's room. Resident #56 Resident #56 was admitted to the facility with diagnoses of bipolar disorder (mental health condition with episodes of high energy and low mood), need for assistance with personal care, and extrapyramidal and movement disorder (muscle stiffness, tremors, slowed movements or excessive, unwanted movements). The Minimum Data Set, dated [DATE], documented the resident was able to be understood, understood others and was cognitively intact. During an observation on 08/03/2026 at 10:55 AM, Resident #56 was in their bed, incontinence care performed by Certified Nurse Aid #6. Residents room was a four-person room. Resident #56 was in bed two, residents in bed one and bed four were present in the room. The privacy curtain at the end of the bed was left open, Resident #56 could be seen by the resident in bed's three and four. Resident #71 Resident #71 was admitted to the facility with diagnoses of spastic hemiplegia left side (one side of the body has stiff, tight muscles and weakness due to damage in the brain's motor pathways), morbid obesity (severely overweight), and peripheral vascular disease (reduce blood flow to the arms or legs). The Minimum Data Set (an assessment tool) dated 05/17/2026, documented the resident could be understood, could understand others and was cognitively intact. During an observation on 07/31/2026 at 09:56 AM, Resident #71 was in their bed completing an interview with surveyor, the door to the resident's room was closed. Licensed Practical Nurse #4 entered the room without knocking and waiting for a response to enter. Licensed Practical Nurse #4 when entered the room and saw surveyor stated sorry, I'll come back later. They then exited the room. During an interview on 07/31/2026 at 09:56 AM, Resident #71 stated the staff enter the room without knocking or announcing themselves all the time. There is no such thing as privacy here. During an interview on 08/03/2026 at 10:58 AM, Certified Nurse Aid #6 stated the privacy curtains should be completely closed while providing care for a resident. The privacy curtains in Resident #56's room were not working well, and they did not want them to break when they pulled them closed at the bottom of the bed. During an interview on 08/03/2026 at 11:00 AM, Licensed Practical Nurse #4 stated privacy curtains should be closed at all times while a resident is having care provided. During an interview on 08/10/2026 at 1:30 PM, Administrator #1 stated all staff should knock prior to entering resident's rooms. While staff are assisting a resident with any personal care including incontinence care the privacy curtains in the room should be closed, the residents should not be able to be seen by anyone in the room. 10 New York Codes, Rules, and Regulations 415.3(c)(1)(i)

Based on observation, record review and interviews during a survey, the facility failed to ensure licensed nurses and certified nurse aides had the specific competencies and skills necessary to care for resident needs. Specifically, the nursing staff did not possess the knowledge needed to complete the tasks assigned to their position regarding the resident population with mental health disorders.Findings include: The Facility Assessment, last reviewed 5/26/2026, documented that psychiatric/mood disorders such as psychosis, impaired cognition, mental disorders, depression, bipolar disorder, schizophrenia, post-traumatic stress disorder, and anxiety disorder were treated at the facility. Further documented was that the facility and it's staff would be able to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. Documented under staff training/education and competencies were the following topics:Annual Training Topics Communication - effective communications for direct care staff Resident's rights and facility responsibilities - ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents Abuse, neglect, and exploitation - training that at a minimum educates staff on- (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or the misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention. (4) Social media, photograph restrictions Infection control - infection prevention and control program including mandatory training that includes the written standards, policies, and procedures for the program, PPE use, disinfecting/cleaning, handwashing, transmission-based precautions, Enhanced barrier precautions. Culture change (that is, person-centered and person-directed care) Required in-service training for nurse aides. In-service training includes:- Is sufficient to ensure the continuing competence of nurse aides and is less than 12 hours per year.- Include dementia management training and resident abuse prevention training.- Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff.- For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life Cultural competency and sensitivity (ability of organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of residents). Sensitivity to gender identification, sexual preference, preferred pronoun and HIV status. Trauma Informed Care delivery Hazardous Medication handling Dementia Care and Management Safe Resident Handling Emergency Preparedness: Emergency Plan and Disaster Training Documented under staff competencies were the following topics: Person-centered care - This included but was not limited to person-centered care planning, education of resident and family /resident representative about treatments and medications, documentation of resident treatment preferences, end-of-life care, and advance care planning Activities of daily living - bathing (e.g., tub, shower, sitz, bed), bed-making (occupied and unoccupied), bedpan, dressing, feeding, nail and hair care, perineal care (female and male), mouth care (brushing teeth or dentures), providing resident privacy, range of motion (upper or lower extremity), transfers, using gait belt, using mechanic lifts Disaster planning and procedures - active shooter, elopement, fire, flood, power outage, tornado Infection control- hand hygiene, isolation, standard universal precautions including use of personal protective equipment, MRSA/VRE/CDI precautions, environmental cleaning Medication administration - injectable, oral, subcutaneous, topical Measurements: blood pressure, orthostatic blood pressure, body temperature, urinary output including urinary drainage bags, height and weight, radial and apical pulse, respirations, recording intake and output, urine test for glucose/acetone Resident assessment and examinations - admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessment Caring for persons with Alzheimer's or unspecified dementia Specialized care - catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post-op care, trach care/suctioning, tube feedings, wound care/dressings, dialysis care Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder and implementing nonpharmacological interventions. Understanding triggers for trauma and ways to identify and prevent them during care delivery. A review of employee files for Certified Nurse Aide #s 6, 12, 13, and 14 revealed that no specific training related to caring for residents with mental and psychosocial disorders was provided. A review of employee files for Licensed Practical Nurse #7 revealed that no specific training related to caring for residents with mental and psychosocial disorders was provided. During an interview on 8/10/2026 at 10:34 AM, Nurse Educator #1 stated that there weremandatory educations like Alzheimer's and Dementia training and Trauma/LGBTQIA+ training. There was no specific psychiatric disorder management training. Nurse Educator #1 stated that they recently did an in-house education on depression in February 2026. Nurse Educator #1 stated that Unit Managers, Social Workers, and Nurses to pass education to Certified Nurse Aides that they receive related to resident care. There was a difference in education requirements for nurses versus certified nurse aides and some training and education might have been meant for higher level staff. Nurse Educator #1 stated that they trusted the Certified Nurse Aides to be able to know how to handle residents with behaviors and if they did not know, they would ask the staff that knew the residents and check the care plan and notes. Nurse Educator #1 stated that there was also no education that covers psychotropic medications and what to side effects or issues that would be caused by them. During an interview on 8/10/2026 at 10:50 AM, Assistant Director of Nursing #1 stated there was no specific psychiatric disorder education for certified nurse aides. Nurses and Nurse Managers were taught about psychotropic medications and antipsychotics and how to share the information with their staff. Assistant Director of Nursing #1 stated that nurses, especially nurse managers, were taught to look at the paperwork, ensure consent was obtained, and were responsible for sharing knowledge about behaviors, and how to manage them. Managers would get taught and then they would do little huddle lessons on the units with lower staff. Staff were supposed to call Director of Nursing #1 or Assistant Director of Nursing #1 before calling a provider to discuss behaviors and resident management. It was preferred that people who knew the residents to comment on what was happening before reaching for more medications or new orders. During an interview on 8/10/2026 at 11:33 AM, Licensed Practical Nurse #5 stated that they believed they had received education about depression and other psych disorders but couldn't speak to when it was and it was possible that it was a long time ago. Communication regarding resident behavior and emotional needs was mainly done verbally. During an interview on 8/10/2026 at 11:38 AM, Registered Nurse #3 stated that they were educated about psych disorders that included refusals, reapproach and getting assistance. It was education that was provided to nurses, and they were expected to tell certified nurse aides. During an interview on 8/10/2026 at 1:09 PM, Director of Nursing #1 stated that there was education regarding psychiatric disorders, and it was tied into dementia training. Nonpharmacological methods of deescalation were taught, and staff were encouraged to call upper-level staff for help since there was a good chance they would know what worked for certain residents. It was ultimately up to the provider to decide the course of action and that was also covered in the education. 42 New York Code of Rules and Regulations 483.35 (a)(3)(4)(c)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure a report of the results of all investigations to the administrator or their designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for one (Resident #1) of three residents reviewed. Specifically, the facility reported to The Department of Health a suspected misappropriation of Resident #1's personal property by facility staff on 9/26/2023. The results of the investigation and corrective actions were not submitted.Findings include:An undated facility document titled Facility Reported Incidents Follow-up Investigation Instructions documented, within 5 business days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified.Resident #1Resident #1 was admitted to the facility with diagnoses of cellulitis (a common, potentially serious bacterial infection of the skin and the deep underlying tissue) of right lower limb, osteoarthritis, and atrial fibrillation (an irregular heart rhythm). The Minimum Data Set (an assessment tool) dated 9/26/2023, documented the resident could be understood, could understand others and had intact cognition for decisions of daily living. A Nursing Home Facility Incident Report documented submission on 9/26/2023 at 11:02 AM. The allegation type was misappropriation of resident property. Specifically, an agency contracted staff person allegedly took Resident #1's driver's license, social security card, and bank debit card from their phone case and used the debit card to make purchases from the facility vending machine and a local store. There was no documented evidence that the facility reported the results of the investigations to the State Survey Agency, and if the alleged violation was verified appropriate corrective action was taken. During an interview on 6/04/2026 at 1:00 PM, Director of Nursing #1 stated they were out sick when this incident took place and, in their absence, the Assistant Director of Nursing oversaw the investigation and submissions to the Department of Health. The investigation should have been submitted within 5 working days.During an interview on 6/05/2026 at 12:15 PM, Administrator #1 stated they did not have any documentation of the investigation being submitted to the Department of Health. The previous Administrator completed the investigation and should have submitted it within five days of the incident. 10 New York Codes, Rules, and Regulations 415.4(b)(2)

Based on record review and interviews during a survey, the facility failed to ensure each resident was free from misappropriation of resident property and exploitation for one (Resident #1) of three residents reviewed. Specifically, an agency contracted staff person took Resident #1's driver's license, social security card, and bank debit card from their phone case and used the debit card to make purchases from the facility vending machine and a local store. Findings include: Resident #1 was admitted to the facility with diagnoses of cellulitis (a common, potentially serious bacterial infection of the skin and the deep underlying of right lower limb, osteoarthritis, and atrial fibrillation. The Minimum Data Set (an assessment tool) dated 9/26/2023, documented the resident could be understood, could understand others and had intact cognition for decisions of daily living. The facility's Abuse Prevention and Investigation Policy last reviewed 8/2025 documented the facility prohibits the mistreatment, neglect, and abuse of residents and misappropriation/exploitation of resident property by anyone including staff, family, and visitors. The facility's Incident Statement Form dated 9/26/2023 documented Resident #1 reported to staff that their spouse called to tell them the bank reported fraudulent charges to the bank debit card were made. The Resident reported their bank debit card, social security card, and driver's license were missing from their phone case. In a signed statement from Administrator #2 dated 9/26/2023 documented that Resident #1's spouse called to report they had been alerted to purchases made with the Resident's credit card from a vending machine located in the facility. There was video footage to support the purchases at the transaction times reported. The undated facility document titled Quality Assurance Investigational Summary documented the resident reported missing items from their phone case and fraudulent charges being made to the missing bank card. [NAME] County State Troopers responded and viewed the video footage showing the accused accessing the vending machine in the facility at the time of the reported fraudulent charges being made to the resident's card. The conclusion of the investigation was the resident had been subjected to mistreatment. The resident's social security card, driver's license, and debit card were taken from their phone case during the night. As a result, this has caused the resident psychological distress. During an interview on 6/04/2026 at 11:30 AM, facility Administrator #1 stated the accused staff was only employed for 1 day through an agency. The incident was reported to the agency and local police department. During an interview on 6/04/2026 at 1:00 PM, Director of Nursing #1 stated they were out sick when this incident took place and, in their absence, the Assistant Director of Nursing oversaw the investigation and submissions to the Department of Health. Past Non-compliance -F602 Based on the following corrective action taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement at the time of this survey: The incident was reported appropriately to the State Survey Agency, accused staff's employment agency, and local law enforcement. A thorough investigation was completed, which resulted in the suspect being identified and terminated. It was determined there were no other victims of misappropriation by staff. Education was provided on 10/28/2023 to all facility staff on abuse, abuse reporting, misappropriation of property, and exploitation. At the time of survey, there were no additional incidents of misappropriated personal property identified since this incident. 10 New York Codes, Rules, and Regulations: 415.4(b)

Based on observation and interviews during the recertification survey dated 09/07/2023 through 09/14/2023, the facility did not provide effective housekeeping services on three (3) of 3 resident units and the resident common areas. Specifically, the following ceiling tiles had water stains: 11 ceiling tiles had water stains in room [ROOM NUMBER], 5 ceiling tiles were stained in room [ROOM NUMBER], 2 tiles were stained in #140, 2 ceiling tiles were stained in the corridor outside of room [ROOM NUMBER], 6 were stained in the corridor outside of room [ROOM NUMBER], 5 ceiling tiles were stained by the first floor nurse station, 6 were stained in the Activities Room, 8 were stained in the corridor outside the Activities Room, 1 ceiling tile was stained in room [ROOM NUMBER], 2 in #215, 2 in #220, 3 in #242, 5 ceiling tiles were stained in the corridor outside of room [ROOM NUMBER], 9 in the corridor between room #s 207 and 220, 16 in the corridor between room #s 231 and 243, 25 ceiling tiles were stained by the second floor nurse station, 8 were stained in the second floor high-side dining room, and 2 in the second floor low-side dining room; and the windows in room #s 114, 118, 125, 126, 129, 131, 132, 140, 201, 204, 211, 215, 224, 225, 226, 233, 242, and 249 and in the Lobby were soiled with water stains and air-borne debris. This is evidenced as follows: Stained Ceiling Tiles During observations on 09/12/2023 at 1:54 PM, the following ceiling tiles had water stains: 11 ceiling tiles had water stains in room [ROOM NUMBER], 5 ceiling tiles were stained in room [ROOM NUMBER], 2 tiles were stained in #140, 2 ceiling tiles were stained in the corridor outside of room [ROOM NUMBER], 6 were stained in the corridor outside of room [ROOM NUMBER], 5 ceiling tiles were stained by the first floor nurse station, 6 were stained in the Activities Room, 8 were stained in the corridor outside the Activities Room, 1 ceiling tile was stained in room [ROOM NUMBER], 2 in #215, 2 in #220, 3 in #242, 5 ceiling tiles were stained in the corridor outside of room [ROOM NUMBER], 9 in the corridor between room #s 207 and 220, 16 in the corridor between room #s 231 and 243, 25 ceiling tiles were stained by the second floor nurse station, 8 were stained in the second floor high-side dining room, and 2 in the second floor low-side dining room. Soiled Windows During observations on 09/12/2023 at 1:54 PM, the windows in room #s 114, 118, 125, 126, 129, 131, 132, 140, 201, 204, 211, 215, 224, 225, 226, 233, 242, and 249 and in the Lobby were soiled with water stains and air-borne debris. The document titled Housekeeping Operations Manual and dated 03/2020, (the manual housekeepers are to follow for cleaning the facility) documents that windows are to be cleaned monthly. The document titled SC & BP Services Inc. dated (document not dated), is the facility policy on cleaning windows, and documents that housekeepers will notify the Maintenance Director to remove windows if they need cleaning on the outside. Interviews During interviews with the Administrator and the Director of Building and Grounds on 09/13/2023 at 12:01 PM, the Director of Building and Grounds stated that stained ceiling tiles on the first floor are due to condensation from the chilled water lines servicing the air conditioning (AC) system, and to solve the problem, the original insulation-wrap on the AC water lines need to be professionally replaced when the AC system is not running. The Director of Building and Grounds stated that on the second floor, the stained are due to roof leaks that have been repaired, but the facility ran out of new tiles; new ceiling tiles are scheduled to arrive onsite on 09/20/23. The Director of Building and Grounds stated that windows can be removed for cleaning, and upon request, the maintenance department will assist housekeepers with removing then reinstalling windows. The Administrator stated that the facility is aware of the issue with stained ceiling tiles, the stains are caused by condensation from the AC water lines dripping onto the tiles, and ownership will be contacted about having the AC water lines properly insulated; the Administrator emphasized that stained tiles are replaced as they become available from the supplier. The Administrator stated that facility knows the windows need cleaning, and the onsite cleaning company director, when contacted in May 2023, stated that their service did not include cleaning windows (either inside or outside). Further, the Administrator accepted responsibility during this interview, for not having contacted but will now contact both the facility ownership and the cleaning company ownership for clarification and a resolution regarding cleaning the facility windows; and housekeeping staff will be re-educated on the window cleaning policy and procedures. 483.10(i)(3); 10 NYCRR 415.5(h)(4)

Based on observation, record review, and interviews during the recertification survey dated 09/07/2023 through 09/14/2023, the facility did not ensure food brought for residents by family or visitors (food) was stored in a way that is either separate or easily distinguishable from facility food and was labeled according to the facility policy in two (2) of 2 kitchenettes. Specifically, in the One South Nourishment Station (kitchenette) refrigerator, an insulated bag containing cut watermelon, and cottage cheese did not have an identifying label with a name, date, or room number. In the Second Floor Kitchenette refrigerator, a restaurant entre labeled with a resident name and room number was not dated. This is evidenced is as follows: During observations on 09/07/2023 at 10:03 AM, in the One South Nourishment Station (kitchenette) refrigerator, an insulated bag containing cut watermelon and cottage cheese did not have an identifying label with a name, date, or room number. In the Second Floor Kitchenette refrigerator, a restaurant entre labeled with a resident name and room number was not dated. A document titled Outside Food Policy undated dated documented that food brought by family/visitors is to be labeled and dated by staff. During an interview on 09/07/2023 at 2:14 PM, the Regional Manager/(named) company stated that when the facility receives food [NAME] to residents from visitors, the food should be labeled with the resident name, room number and date. During an interview on 09/07/2023 at 2:17 PM, the Administrator stated that nursing or dietary are responsible to label food brought in for residents with the resident name, date, and room number; and the food found during survey has since been discarded. The Administrator stated that to prevent reoccurrence, the nursing and dietary departments will be in-serviced not to store their personal food (if that is the issue) in the kitchenette refrigerators and will be in-serviced to properly label food that is brought in for residents. 10 NYCRR (no state equivalent tag)

Based on observation, record review, and interviews during the recertification survey dated 09/07/2023 through 09/14/2023, the facility did not ensure food was stored, prepared, distributed, or served food in accordance with professional standards for food service safety in the main kitchen and two (2) of 2 kitchenettes. Specifically, in the main kitchen, the facility did not have test papers to check the concentration of the chemical sanitizer in the low-temperature dishwashing machine, and the facility did not have test papers to check the concentration of quaternary ammonium compound (QAC) used to manually sanitize food contact equipment in the 3-compartment sink. In the main kitchen, the slicer was soiled with food particles; the kitchen floor, floor behind cooking equipment, and walk-in freezer floor were soiled with food particles and/or a black build-up; and the ceiling was soiled with black dust. In the One South kitchenette, the microwave oven, freezer door gasket, floor, waste receptacle, and countertop were soiled with food particles or dirt. In the Second Floor kitchenette, the microwave oven, refrigerator, walls, and floor were soiled with food particles and/or dirt. This is evidenced as follows: During observations of the on 09/07/2023 at 10:03 AM, in the main kitchen, the facility did not have test papers to check the concentration of the chemical sanitizer in the low-temperature dishwashing machine, and the facility did not have test papers to check the concentration of QAC used to manually sanitize food contact equipment in the 3-compartment sink. In the main kitchen, the slicer was soiled with food particles; the kitchen floor, floor behind cooking equipment, and walk-in freezer floor were soiled with food particles and/or a black build-up; and the ceiling was soiled with black dust. In the One South kitchenette, the microwave oven, freezer door gasket, floor, waste receptacle, and countertop were soiled with food particles or dirt. In the Second Floor Kitchenette, the microwave oven, refrigerator, walls, and floor were soiled with food particles and/or dirt. During an interview with the Regional Manager/(named) company and the Director of Dietary Department on 09/07/2023 at 10:53 AM, the Regional Manager/(named) company stated that it is an oversight as to why the slicer, kitchen floor, floor behind cooking equipment, ceiling, and walk-in freezer floor are not clean, but housekeepers are responsible for keeping the kitchenettes clean including the floors and counter tops. The Regional Manager/(named)company stated that test papers were on the premises last month, and that though it cannot be accounted for as to why there are not any, more test strips will be brought to the facility today. The Director of Dietary Department stated that the floor was cleaned last night and soiled only from this morning. The Director of Dietary Department stated that the concentration of sanitizer should be checked 3 times per day, and staff are instructed to notify the supervisor when out of test papers, but no one did. During an interview on 09/07/2023 at 2:04 PM, the Administrator stated that the Regional Manager/(named) company has since brought in the test papers for the dishwashing machine and QAC, the Director of Dietary Department will be consulted regarding properly cleaning the kitchen, ensuring test papers are on the premises for use, and auditing for compliance. The Administrator stated that all kitchen staff will be in-serviced on communication with their supervisors regarding not having test papers. 10 NYCRR 415.14(h)

Based on record review and interview conducted during the recertification survey dated 9/7/2023 through 9/14/2022, the facility did not ensure the development of comprehensive person-centered care plans, that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 2 (Resident #s 19 and #80) of 30 residents reviewed for comprehensive care plans (CCP). Specifically, for Residents #19 and #80, the facility did not ensure a CCP was developed to address the use of psychotropic medications and for Resident #80, did not ensure a CCP was person-centered. This was evidenced by The Policy and Procedure (P&P) titled Care Planning Process and Care Conference dated 6/2023 documented the facility will develop a comprehensive, resident centered care plan for each resident based on the individual needs/problems of each resident. Resident #19 Resident #19 was admitted to the facility with the diagnoses of major depressive disorder, hypothyroidism, and generalized anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated 7/21/2023, documented that the resident was understood, could understand others and was cognitively intact. The Physician's Order documented alprazolam (a psychotropic medication used to treat anxiety and panic disorders) 0.5 mg give 1 tablet by oral route two times per day for anxiety disorder due to known physiological condition. The Physician's Order documented trazodone (a psychotropic medication used to treat depression) 50 mg give 1.5 tablets (75 mg) by oral route once daily at bedtime for insomnia. The Physician's Order documented fluoxetine (a psychotropic medication used to treat depression) 20 mg give 1 capsule by oral route daily in the morning for major depressive disorder. The Physician's Order documented duloxetine (a psychotropic medication used to treat depression) 60 mg extended release give 1 capsule by oral route one daily for major depressive disorder. The Physician's Order documented levothyroxine (a medication used to treat hypothyroidism) 100 mcg give 1 tablet by oral route once daily for hypothyroidism. The Comprehensive Care Plans (CCP) did not include a care plan that addressed the use of psychotropic medication. The CCP titled Hypo/Hyperthyroidism did not clearly indicate which diagnosis the resident was receiving medication for, hypothryoidism or hyperthryoidism. The interventions also were not resident specific with the only intervention being administer medication as ordered. During an interview on 9/14/2023 at 10:25 AM, the Director of Nursing (DON) stated that if a resident is prescribed a psychotropic medication there should be a corresponding care plan. The DON stated that a care plan should be individualized and resident centered to include specific diagnoses, interventions and goals. Resident #80 Resident #80 was admitted to the facility with the diagnoses of generalized anxiety disorder, vascular dementia, and psychotic disorder with delusions due to known physiological condition. The Minimum Data Set (MDS - an assessment tool) dated 8/13/23, documented that resident was sometimes understood, could sometimes understand others and was severely cognitively impaired. The Physician's Order documented quetiapine (a psychotropic medication used to treat psychotic disorders) 25 mg give 1 tablet by oral route 3 times a day for psychotic disorder with delusions due to known physiological condition. The Physician's Order documented alprazolam (a psychotropic medication used to treat anxiety and panic disorders) 0.5 mg give 1 tablet by oral route 2 times per day for 7 days as needed for anxiety disorder. The Medication Administration Record documented this as needed medication as administered 9/6/2023, 9/7/2023, and 9/9/2023. The Comprehensive Care Plan (CCP) did not include a care plan that addressed the use of psychotropic medications. During an interview on 9/14/2023 at 10:25 AM, the Director of Nursing (DON) stated that if a resident is prescribed a psychotropic medication there should be a corresponding care plan. 10 NYCRR 415.11(c)(1)

Based on interviews and record reviews conducted during the recertification and abbreviated survey (Case #NY00298115) the facility did not ensure prompt efforts were made to file and resolve a grievance concerning missing items and did not take appropriate timely corrective action in accordance with State Law for 1 (Resident #116) of 1 resident reviewed for grievances. Specifically, for Resident #116, the facility did not ensure they promptly acknowledged the resident's complaint regarding missing hearing aids and did not promptly make attempts to resolve the complaint. This was evidenced by: A document titled Grievance/Concern Form dated 10/2016 and revised 5/2018, 9/2017, 1/2020, 3/19/2021, and 10/28/2021 documented the following; Policy: Our facility will assist residents, their representatives, family members or resident advocates in filing a grievance/concern form or completing a review on the customer service kiosk when concerns are expressed, which may not be able to be handled immediately by the facility staff, requires further investigation, or requires consultation with other facility staff, the attending physicians or outside service providers. Purpose; To assist residents, their representatives, family members or resident advocates to file a Grievance/Concern Form or complete a review on the Customer service kiosk to resolve concerns in a timely, professional manner to bring resolution to the concern. Procedure: 1. Any resident, his/her representative, family member or advocate may file a Grievance/Concern Form or complete a review on the Customer service kiosk regarding treatment, facility services, Medical care, behavior of other residents or staff members, theft of property, missing items, Discrimination, etc. without fear of threat or reprisal in any form. 2. All new residents will be informed of the information on how to file a grievance/concern and who the grievance officer is at the facility. 3. The facility will post information on how to file a grievance and information on the name, phone number and contact information (including mail and email) for the facility grievance officer. Grievances may be received in writing, orally or anonymously. 4. As necessary, the facility will take immediate action to prevent further potential violations of any resident rights while the alleged violation is being investigated. 5. The facility will practice immediate reporting standards as required by state law of all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator or the provider. 6. The grievance official at the facility will ensure that all written grievance decisions include the date the grievance/concern was received, a summary statement of the resident's grievance/concern, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance/concern was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance/concern, and the date the written decision was issued. 7. The facility will maintain evidence demonstrating the results of the grievances for a period of no less than 3 years from the issuance of the grievance decision. 8. Grievance/concern forms may be submitted orally or in writing to any facility staff member or anonymously. Staff receiving the concern will immediately report the issue to the Unit Manager on duty. The Unit Manager or RN Supervisor will resolve the issue or assist the resident, resident representative or concerned person to complete a Grievance/Concern Form or complete the form, If accepting an oral compliant which cannot be immediately resolved. 9. The resident or concerned person filing a Grievance/Concern Form will be offered the opportunity to sign the written form. 10. The Grievance Form will be submitted to the Grievance Official if the concern was not adequately resolved by the Unit Manager or RN Supervisor. The Grievance Official or designee will bring the concern to the Administrator's or Director of Nursing's attention as soon as possible, if unresolved. 11. Upon receipt of a written Grievance/Concern Form, the Grievance Official or designee will forward the Concern Form to the appropriate department for investigation. The investigating department will submit a written report of findings and resolutions to Grievance Official. 12. If the concern has not been resolved to the satisfaction of the resident / resident representative, within 5 days the Administrator will review the findings with the person who completed the investigation to determine what corrective action, if any, needs to be taken. 13. The original written Grievance/Concern Form, investigation report with resolution, and written summary will be filed in the facility Concern Log in the Social Service Office. The Grievance Official will complete the Resident Concern Log. 14. The grievance official at the facility will be notified at the next business day. A summary of the investigation and findings will be provided to the resident/resident representative in accordance with the facility's grievance process. A document titled Inventory/Personal Belongings dated 03/2019 and revised 1/2020, 3/2020, and 8/11/2023 documented the following; Policy: Residents are permitted to retain and use personal possessions and appropriate clothing as space permit. Procedure: A documented inventory of all residents' personal belongings will be completed upon admission by the nursing department, or another department identified by the facility. The inventory sheet will be updated when new items are acquired if the facility has been notified by the responsible party. 1. Each resident will be offered/provided a locked drawer or equivalent with key for small valuables. 2. Missing items should be reported immediately to a staff member on the unit and placed on a concern/grievance form with follow through based on the concern grievance policy. 3. Missing items will be thoroughly investigated and replaced if listed on the inventory form as approved by the Administrator. The outcome of the investigation will be discussed with the resident and/or resident representative. (Hearing aids and dentures will be replaced at the facility discretion based on the investigation and facility responsibility). 4. The facility will ensure protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death or per State specific guidelines. 5. Facility representative and resident/resident representative will sign, date and time the inventory sheet when items are picked up. If another party is picking up the belongings other than the resident/resident representative, written permission from the resident or representative must be documented. 6. The facility representative releasing the belongings will document in the medical record the disposition of the belongings. Resident #116 Resident #116 was admitted to the facility with diagnoses of metabolic encephalopathy, diabetes mellitus, malnutrition, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS, an assessment tool) dated 8/02/2021, documented the resident was understood and could understand others with intact cognition for daily decision making. The resident was discharged from the facility prior to this survey. A review of the resident's medical records did not include documentation of the following: 1. Written summary of the grievance. 2. Documentation regarding that the resident's hearing aids were missing. 3. Inventory of items the resident brought to the nursing facility. 4. Summary of the resolution of findings and outcome. 5. Grievance officers follow up with HCP in writing. A Physician phone order dated 7/19/2023 at 11:36 AM, documented the following: Treatment, Bilateral hearing aids to be kept in case bedside when not in use. Every day 7:00 AM to 3:00 PM: 3:00 PM -11:00 PM. The electronic Treatment Administration Record (eTAR) for 7/2021 documented the following: Bilateral hearing aids to be kept in case at bedside when not in use. Start Date: 07/19/2021 11:36 AM. Nursing initials for Signatures were recorded on both shifts beginning on 7/19/2021 to 7/30/2021. One shift on 7/28/2021, 7:00 AM to 3:00 PM was missing a signature. A Nursing Progress Note dated 7/30/2021 at 7:13 PM, documented the following; called to resident's room to assess lethargy and weakness. Physician notified; resident ordered to ER for evaluation. 911 called. Daughter notified. During an interview on 9/13/2023 at 8:30 AM with Residents #116 HCP stated the resident was discharged from the facility in the evening and sent out to the hospital for complications. The HCP was not going to allow the resident to return and went to the facility to pick up the resident's belongings. The Social Worker (SW) brought the residents items to them and on inspection of the residents belongings while the SW was present it was discovered the hearing aids were missing. A grievance was completed, and a missing items report was done. The SW reported they were going to look for them and call when they were located. That never happened. Multiple forms of contact with the facility to resolve this and replace the lost HA was continued until July of 2022 when a complaint was filed with New York State Department of Health. (NYSDOH). During an interview on 9/13/2023 at 9:35 AM, Licensed Practical Nurse Unit Manager (LPNUM) #1 stated they were at the facility during Resident #116's admission. The eTAR was initialed when a check was done during the day and evening shift that the residents hearing aids were observed bedside. LPNUM #1 stated You would have to open the case in the residents bedside stand, observe the hearing aids were there or in the residents ears and then verify by signing the eTAR. If the hearing aids were missing, you would notify the supervisor and search for the item or items missing. If not found the grievance officer was notified and a missing items/grievance form was completed. LPNUM #1 further stated an investigation should be started if an item is lost or missing and the family should be notified. During an interview on 9/13/2023 at 10:45 AM, SW #1 stated they were the Grievance Officer for the facility. Grievances are reviewed with the residents in Resident Council and at admission. A form listing items that the resident brought with them was completed when admitted . The SW stated they were not at the facility during the residents admission but had worked with Resident #116 Health Care Proxy (HCP) to try to resolve the complaint and replacement of the hearing aids. The concerns of the missing hearing aids were escalated to the corporate level but never resolved. Documentation of the grievance and a resident personal items list was not included in the residents records. The SW stated they were aware of the missing items because the HCP had continually called about replacing the items. A grievance should have been done and placed in the residents record and an investigation into what was done to find the HA should have been done as well. It was the responsibility of the facility to replace the HA once they were lost. The grievance process was not followed. During an interview on 9/13/2023 at 11:15 AM, the Director of Nursing (DON) stated the matter of the missing hearing aids had not been resolved. The SW had been working on the matter. The DON did not provide documention of an investigation or a grievance regarding Resident #116's missing hearing aids. The SW who was at the facility at the time of the residents admission no longer works at the facility. Facility records from Resident #116 stay were not onsite. An inventory of Resident #116's personal property was not available. During an interview on 9/14/2023 at 1:36 PM, the Administrator stated they had not been the ADMIN at the time of Resident #116's admission. The facility had finally reimbursed the residents HCP for the missing HA yesterday. This should not have gone unaddressed for 2 years. The grievance process that was in place to protect the residents was not followed. An investigation was not completed and that made it difficult to trace the actual events that occurred. The SW who was no longer at the facility and the previous Administrator had not followed through with Corporate to address the situation. 10NYCRR 415.3(c)(1)(ii)

Based on observation and interview during a recertification and abbreviated survey conducted on 9/7/2023 to 9/14/2023, the facility did not ensure that the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility was posted in a place readily accessible to residents, and family members and legal representatives of residents, and did not ensure to post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Specifically, the facility did not ensure that the residents and staff knew where the survey report was located. This was evidenced by: During a meeting with a group of 6 residents on 9/7/2023 at 3:01 PM, the residents stated they did not know where the survey report was located. During an observation on 9/7/2023 at 4:15 PM, surveyors were not able to locate the survey results on the units and at the front desk. During an interview on 9/7/2023 at 4:35 PM, the receptionist at the front desk was unable to find the survey results and requested assistance from the Director of Nursing (DON). During an observation on 9/7/2023 at 4:48 PM, the DON found the Survey Results Binder behind the reception desk. The Survey Results Binder was facing backwards and not readily available to residents and staff without their asking and without going behind the desk. During an interview on 9/7/2023 at 5:01 PM, the DON stated the binder had been tethered to the wall and must have pulled away. They were not sure how long it had been like that but that would need to be addressed to be in compliance with the regulation. 10NYCRR415.3(c)(1)(v)

Based on record review, observation, and interview during the recertification survey on 9/7/2023 through 9/14/2022, the facility did not ensure each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, in 2 (2 North and 2 South), of 2 dining rooms and 1 (Resident #3) observed. Specifically, residents in the 2 North and 2 South dining rooms waited for up to 31 minutes after their dining mates were served, for their meals to be served and for Resident #3, personal care was provided with an opened door, exposing the resident to anyone in the hallway. The findings are: Finding 1: The policy and procedure titled Food and Nutritional Services dated 7/18/2023 documented, meals will be provided in a timely manner so that hot foods are served hot and cold foods are served cold. A schedule of mealtimes was provided that documented the lunch meals were served to the units at the following times: 1 South at 12:05 PM 1 South at 12:30 PM 2 North at 12:15 PM 2 North at 12:40 PM 2 South at 12:25 PM 2 South at 12:30 PM During a meal observation on 9/7/2023 on Unit 2 North the first food service cart arrived on the unit at 1:20 PM and residents were served meals in their rooms and in the dining room. At 1:29 PM a second cart arrived on the unit, with staff bringing meals to residents in their rooms and in the dining room. At 1:37 PM a third cart arrived on the unit and was served to the remaining 3 residents in the dining room. Most residents in the dining room had already completed their meals before the last three (3) were served. During a meal observation on 9/7/2023 in the 2 South dining room at 1:29 PM, five (5) residents had finished their meals while others had not yet been served. At 1:43 PM the remaining residents were served. During a meal observation on 9/11/2023 on Unit 2 North the first food service cart arrived on the unit at 12:22 PM and residents were served meals in their rooms and in the dining room. At 12:51 pm there were 5 residents in the 2 North dining room, 3 had already finished their meals while the other 2 had not yet been served. At 12:53 PM, a second cart arrived on the unit, with staff bringing meals to residents in their rooms and serving the remaining residents in the dining room. During a meal observation on 9/11/2023 in the 2 South dining room at 12:46 PM, the first food service cart arrived and 4four (4) of fourteen (14) residents seated in the dining room were served. At 1:08 PM, the second cart arrived and the remining residents were served. During meal observation on 9/12/2023 at 12:50 PM, nine (9) residents were in the 2 North dining room. One (1) resident had not been served and Certified Nurse Aid (CNA) #1 stated they were going to find the tray. At 12:54 PM ,CNA #1 returned with the resident's tray stating it was on a cart on 2 South Unit. CNA #1 stated this is a common problem, they typically try to re-organize the trays as the carts come up because there is no organization. During an interview on 9/07/23 at 1:20 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) #2 stated most lunches have not arrived yet, we got one (1) cart on each unit and many residents are upset because they didn't get theirs yet. During an interview on 09/11/2023 at 12:12 PM, the Regional Manager notified the survey team that two (3) carts are served onto each unit, one (1) cart is delivered to each unit; then after each unit has received one (1) cart delivered, the 2nd cart is delivered to each unit. During an interview on 09/12/2023 at 12:35 PM, Resident #2 stated if their tray is not on the first cart, they know they will wait for at least 20 minutes to get any food, it's frustrating. During an interview on 09/14/2023 at 11:15 AM, the facility Administrator stated we've identified issues with food service, we're using a dietary management company and have notified their higher leadership. They have been sending people onsite periodically for audits and reviewing policy and process, also our dietician is involved. During an interview on 09/14/2023 at 11:15 AM, the Director of Nursing stated they have identified the issues with late and cold meals and are working to solve it. Finding 2: Resident #3 was admitted with diagnosis of multiple sclerosis, seizure disorder, and anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated 8/19/2023, documented that the resident was understood, could understand others and had moderately impaired cognition. During an observation on 9/12/2023 at 1:54 PM, a staff member was observed from the hallway assisting Resident #3 with personal hygiene. The resident's door was open, the privacy curtain was not pulled, and the resident was observed to be exposed from the waist up using their arms to cover private areas. During an interview on 9/12/2023 2:30 PM, CNA #2 stated they had provided care to the resident and was not aware the resident was exposed while they were providing care. CNA #2 stated they might have pulled the curtain back to go get something and not closed it completely when they came back. CNA #2 stated they would never intentionally leave a resident exposed. During an interview on 9/12/2023 2:40 PM, LPN/UM #2 stated the curtain or the door should be closed any time care is provided. 10NYCRR 483.10)a)(1)

Based on record review and staff interviews during an abbreviated survey (Case #NY 591), the facility did not ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one resident (Resident #1) of four residents reviewed. Specifically, for Resident #1, the facility did not ensure that upon acute changes in the resident's condition on 4/5/16, 4/7/16 and 4/12/16, that a qualified (authorized) person performed a thorough assessment, that the physician was immediately consulted and that the resident's family member was notified. On 4/13/16, the physician was contacted and the resident was sent to the hospital. This delay in treatment resulted in harm to the resident as evidenced by: The clarification of section 6209 of article 139 of the Education Law states: Licensed Practical Nurses in New York State do not have assessment privileges; they may not interpret patient clinical data or act independently on such data; they may not triage; they may not create, initiate, or alter nursing care goals or establish nursing care plans. Resident #1: The resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 7/15; severe cognitive impairment. Additionally, the MDS documented that the resident was able to make self understood and was able to understand others. A facility Policy and Procedure (P&P) entitled Notification of Changes revised on 2/2013, documented, Nurse immediately notifies physician, resident and designated representative of a significant improvement or decline in the resident's physical, mental or psychosocial status. It documented Immediately shall mean as soon as possible. Additionally, the Policy and Procedure documented Notification is documented in nurses notes and reflects name of person notified and the change in condition and/or treatment. A Nursing Progress Note written by LPN (Licensed Practical Nurse) #1 on 4/5/16 at 4:35 am, documented that the resident complained of not feeling well and having the chills. The resident's temperature was documented as 97.6 and the resident's blood sugar was documented as 135. Additionally, the note documented that the findings would be passed onto the dayshift. There is no documented evidence that the resident was thoroughly assessed by a qualified (authorized) person, no documented evidence that the physician was consulted, and no documented evidence that the family member was notified. A Nursing Progress Note written by LPN #2 on 4/5/16 at 12:03 pm, documented that the resident States she feels a little under the weather. The note documented that the findings were put on the physician's board for review and nursing will continue to monitor. There is no documented evidence of a thorough assessment by a qualified person. Review of the Doctor's Rounds log dated 4/5/16, revealed that the resident had c/o (complaint of) not feeling well - chills, the resident's blood sugar was 135 and her temperature was 97.5. Additionally, arm swelling was documented. Review of the 24 Hour Report (nursing communication report) dated 4/5/16, revealed no documented evidence of the change in the resident's condition. There is no documented evidence in the medical record of the resident's condition on 4/6/16. An MDS note written by the Registered Nurse (RN) on 4/7/16 at 2:18 pm, documented She complains of a 10 out of 10 pain in her stomach and chest. There is no documented evidence that the resident was thoroughly assessed by a qualified person, no documented evidence that the physician was consulted, and no documented evidence that the family member was notified. Review of the Comprehensive Care Plan (CCP) entitled Pain Management - CAA (Care Area Assessment) #19 modified on 1/12/16, documented the resident was assessed for pain today denies pain at this time. There were no further updates to the resident's CCP. Review of the Medication Administration Record [REDACTED]. There is no documented evidence that the resident was given any additional pain medication on 4/7/16. There is no documented evidence on the 24 Hour Report dated 4/7/16, regarding the resident's report of 10 out of 10 pain in her stomach and chest. A Nursing Progress Note written by the Registered Nurse (RN) Supervisor #1 on 4/12/16 at 10:44 pm, documented that the resident was diaphoretic (sweating) and the resident states that she has not been feeling well. There is no documented evidence of a thorough assessment by a qualified person and no documented evidence that the physician was consulted. A Nursing Progress Note written by LPN #3 on 4/12/16 at 11:20 pm, documented that the resident's son asked what was going on with his mother stating that she is not the same. The note documented that he will be calling the Director of Nursing (DON) in the morning and he was requesting that laboratory tests be done. Additionally, the note documented written in doctor's book. Review of the Doctor's Rounds log for 4/12/16, revealed no documented evidence of the resident's condition and no documentation regarding the resident's son's request for laboratory tests. There is no documented evidence of the resident's condition on the 24 Hour Report dated 4/12/16. A Nursing Progress Note written by the LPN #1 on 4/13/16 at 12:49 am, documented the resident was very weak, needed 2 assist for transfer, diaphoretic, winded and pale. The note documented that the supervisor was aware. There is no documented evidence that the resident was thoroughly assessed by a qualified person, no documented evidence that the physician was consulted and no documented evidence that the family member was notified. Review of the Resident Nursing Instructions report dated 4/7/15, documented that the resident was a one person assist with a walker for transfers. A Nursing Progress Note written by the LPN #1 on 4/13/16 at 7:07 am, documented the resident stayed in her wheelchair for the rest of the night, refused to go back to bed, refused to let the CNAs provide care lethargic and will update day shift. A Nursing Progress Note written by the LPN Nurse Manager (2-South) on 4/13/16 at 8:24 am, documented that she received report from the outgoing nurse that the resident is not her usual self. It was documented that she assessed resident and she is noted to be very lethargic, speaking and dozing off during speech, mild diaphoresis, [MEDICAL CONDITION] (accumulation of excess fluid in the tissues in which external pressure leaves a persistant depression in the tissues) (to right arm especially hand), she has difficulty moving her right hand, skin cool to touch, slight inspiratory heaving. The note documented that the resident stated that she did not want to go to the hospital, but after explaining to the resident that it would be best for her safety, the resident agreed to go. It was documented that the physician was called and ordered the resident to be sent to the hospital. There is no documented evidence of a thorough assessment of the resident by a qualified person. The Hospital History and Physical report dated 4/13/16, documented that the resident was transferred to the emergency roiagnom on [DATE], due to shortness of breath and weakness. Additionally, it was documented that the patient was given intravenous antibiotics for a urinary tract infection in the emergency roiagnom on [DATE]. The Hospital Discharge/Death Summary dated 4/17/16, documented a date of admission as 4/13/16, the admitting [DIAGNOSES REDACTED]. During an interview on 5/4/16 at 1:37 pm, with the LPN Nurse Manager (2-South), she stated that the 24 Hour Report is used to let everyone know what is happening on the unit. She stated that if something happens, the nurse writes a note and queues it to be on the 24 Hour Report. Regarding the Nursing Progress Note on 4/5/16 (the resident had complaint of chills), she stated The note in the doctor's book should have been called to the doctor and stated The nurse should have called the Nursing Supervisor. She stated that the resident had a tumor in her chest and did not want further testing. She stated that when she came into work on 4/13/16, the LPN mentioned something about the resident. She stated I looked back 3 shifts (at the nursing notes) and made the determination that she had to go to the hospital. She said she talked to the RN Nurse Manager from 2-North about the resident. She stated that she attends morning meetings every morning, and when asked if she ever discussed the resident in the meetings, she stated that the resident's delusions and psych issues were discussed. She stated We generally talk about things that are on the 24 Hour Report. She stated The nurses know they need to flag the notes for the 24 Hour Report. She stated that the computer system for the electronic medical record has been operational since March or April of 2015. During an interview on 5/5/16 at 8:40 am, with the Director of Nursing (DON), she stated that a couple of weeks before the resident went to the hospital, a chest CT (computed tomography) revealed a mass on her lung. She stated that the physician spoke with the resident and her son in depth, but the resident did not want any further testing. Regarding the resident 's change of condition on 4/5/16, she stated that the nurse should have called the Nursing Supervisor and the note should have been flagged for the 24 Hour Report. She stated that the physician should have been called; not written in the doctor's log. She stated that they discuss the residents in morning meeting. Regarding the residents report of 10/10 pain during the MDS interview on 4/7/16, she stated that she should have flagged the note to be on the 24 Hour Report, and stated that the nurse is a Nursing Supervisor. Regarding the resident's change of condition during the evening on 4/12/16, she stated that the RN should have taken a complete set of vitals and should have called the physician. She stated It's not appropriate to obtain just a temperature and a blood sugar. Regarding the resident's change of condition on 4/12/16, during the night shift, she stated that the nurse should have called the Nursing Supervisor and he should have seen her and documented his assessment. She stated that she was with the LPN Nurse Manager the morning that the resident went to the hospital. She, stated I should have written an RN note. During an interview on 5/5/16 at 11:00 am, with the Physician/Medical Director, he stated that for any changes in the resident's condition, he would expect the nurse to contact the Nursing Supervisor and contact the doctor. He stated that he would expect the nurse to call him when the resident reported 10 out of 10 pain in her stomach and chest. He stated Although the nurses were aware that this resident had something serious going on in her lungs, does not negate nursing's responsibility to contact him or the NP (nurse practitioner) to do what is best for the resident. He stated that even if the nurses were confused about what they should do for this resident, they should still contact him to find out the best course of action. He also stated that a discussion with Nursing on 4/5/16 might have made a difference on what may have happened to her on 4/12/16. He stated that there were plenty of options for the resident; whether it be acute care or palliative care. He stated The point is, I should have been called. He stated I have a concern. If Nursing is treating this patient like this, what are they doing with the others? He stated There's a problem here and something needs to be done about it. During a phone interview on 5/24/16 at 9:20 am, with the MDS RN, regarding the MDS note written on 4/7/16, she stated It wasn't a very good note. She stated that the resident always complained of pain 10 out of 10, no matter what she was doing, even if she was sitting there watching television. She stated If you look at the Medex, you will see that she was medicated for pain. When asked if she thought the resident's pain score was a 10, she stated Pain is what the resident says it is. When asked if she notified the Nurse Manager or the MD, she stated No. During a phone interview on 5/25/16 at 9:58 am, with the night shift RN Supervisor #2, he stated that during the shift on 4/4/16 and 4/12/16, he was not notified about the resident. He stated They didn't tell me she was diaphoretic. Nobody told me anything. He stated Who was the nurse? He stated that if he was called, he would have checked the resident's vital signs, and called the physician. He stated I think she was a diabetic. We should have checked her blood sugar if she was diaphoretic. During a phone interview on 5/25/16 at 12:57 pm, with LPN #1, she stated that she called the RN Supervisor #2 during the night shift on 4/4/16, after the resident reported that she wasn't feeling well and had chills. She stated The Supervisor told me to get the blood sugar. When asked if the RN Supervisor assessed the resident, she stated It was almost medication pass time. I am not sure if he saw the resident. She stated that she marked the nurse's note she wrote to be included on the 24 Hour Report. She stated that during the night shift on 4/12/16, she called RN Supervisor (#2) about the resident. She stated that she told him that the resident didn't want to go to the hospital. When asked if the RN Supervisor (#2) assessed the resident she stated He was on the unit. I'm not sure if he followed through with the resident. She stated that she marked the nurse's note she wrote to be included on the 24 Hour Report. She also stated that she reported off to the LPN Charge Nurse in the morning. 10 NYCRR 415.12

Based on observation, record review and interview, the facility did not ensure that residents who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable; and residents having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for one (1) (Resident #6) of six (6) residents reviewed for pressure sores during a standard recertification survey. Specifically, Resident #6, who was assessed as at risk for development of pressure sores, developed a right ankle pressure sore and additional pressure sores to the right and left lateral heels. The facility did not provide regular monitoring of the resident's pressure sores, did not implement pressure relieving devices timely, did not update the resident's care plan timely in regards to the pressure sores, did not provide a timely dietary assessment after pressure sores developed, and did not track and measure the resident's pressure sores. Subsequently, the resident developed unstageable pressure sores to the right ankle, right and left heels. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident #6: The resident was admitted to the nursing home on 2/21/11 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented that the resident scored a 10/15 on the brief interview for mental status indicating that the resident is understood and understands with moderate cognitive impairment for daily decision making. A Braden scale assessment dated [DATE] documented a score of 17 indicating at risk for pressure sores. A facility policy for pressure sore assessment for susceptibility dated 12/2010 documented that residents would be assessed for predisposition to pressure sores on a regular basis and that residents identified as being susceptible to the development of pressure sores would receive appropriate preventative intervention. The Comprehensive care plan (CCP) for potential skin integrity impairment dated 3/4/11 documented no open areas on the ten evaluations that were completed from 5/23/11 - 10/25/13. Under the evaluation dated 4/29/14, eleven days after the right ankle pressure sore was discovered, it documented; see actual skin integrity impairment plan of care. The progress note written by a Registered Nurse (RN) dated 2/18/14 documented a 0.7 centimeter (cm) x 0.5 cm area of eschar to the right ankle with a 2.0 cm area of redness surrounding eschar area. A nutritional care progress note written by the Dietary Technician dated 2/19/14 documented that an area was noted to the right ankle on 2/18/14. There was no documented evidence of a nutritional assessment and evaluation for the nutritional needs. Two months after the pressure sore was identified, on 4/17/14, the Registered Dietician documented a nutritional assessment that noted under skin condition, "right ankle". There was no documented evidence of a description of this area and did not document the area was a pressure sore. A physician order [REDACTED]. A physician order [REDACTED]. A progress note written by the Registered Nurse (RN) dated 4/14/14 at 1:45 pm documented three (3) areas to the three (3) middle toes of the right foot. This note documented all areas measured 0.3 cm x 0.3 cm. A physician order [REDACTED]. The CCP for actual pressure sores was implemented on 4/29/14, over 2 months after the right ankle pressure sore was identified, documented under action/approach to use a Lynard splint (off-loading boot) when in bed and Ankle Foot Orthosis (AFO) brace to RLE when out of bed. There was no documented evidence that the care plan reviewed and updated after the eschar areas were noted to the right three middle toe on 4/14/14. A Certified Nursing Assistant (CNA) care guide located in the resident's closet documented to discontinue AFO until Orthotist checks. This CNA care guide had interventions dated 4/18/14 to use AFO to RLE while ambulating but it was yellowed out with no discontinue date. It further noted to use Lynard splint to RLE when in bed at all times but was also yellowed out with a discontinue date of 5/13/14. There were no other care plan interventions on the CNA care card for off-loading the lower extremities. A physician renewal order dated 5/23/14 documented a line through Lynard splint to RLE when "out of bed ". This order noted to apply safe gel and dressing to right toes every shift and to cleanse right lateral ankle with normal saline, followed by Santyl and moist gauze with kling daily. A weekly skin integrity flow sheet dated 5/30/14 documented a stage 3 to the right ankle measurement measuring 1.8 cm x 1.1 cm x 0.5 cm and eschar to right toe #2 measuring 0.3 cm x 0.2 cm and right toe #3 measuring 0.2 cm x 0.2 cm. During an observation on 6/3/14 at 2:30 pm, the resident was in bed lying on his back. The resident was observed with a dressing to the right ankle and both heels. There was no off-loading devices noted to the lower extremities. During an observation on 6/4/14 at 3:15 pm and 3:30 pm, the resident was in bed lying on his back. The resident was observed with a dressing to the right ankle and both heels. The resident lifted his leg for the surveyor and a large reddened area was noted to the right lateral heel with an approximately 1.5 cm dark linear area going through it. The right ankle pressure sore was covered with a clear occlusive dressing and entire wound base had yellow color. There was no off-loading devices noted to the lower extremities During observations on 6/5/14 at 8:00 am, 8:20 am, and 8:50 am, the resident was in bed lying on his back. The resident's comforter was bunched up at the bottom of his bed and his heal was in contact with the comforter. The resident's right ankle dressing was hanging off and his pressure ulcer was exposed. During an observation of the pressure sore dressing change on 6/5/14 at 9:25 am, the Registered Nurse Manager (RNM) measured the right ankle pressure sore at 1.8 cm x 1.4 cm x <0.5 cm. The RNM measured the left lateral heel pressure sore at 6.0 cm x 2.6 cm with linear black line in the center. The RNM did not measure the area on the right lateral heel until it was brought to her attention by the surveyor. There was no documented evidence of assessment, tracking or monitoring the resident's pressure sores. A Memorandum dated 6/5/14 for Decubitus/wounds documented that the resident's right outer ankle pressure sore measured 1.8 cm x 1.4cm x <0.5cm, the right 2nd toe pressure sore measured 0.2cm x 0.2cm and the right 3rd toe pressure sore measured 0.2cm x 0.2cm, and the right heel pressure sore measured; 6.0 cm x 3.0 cm with a 1.2 cm black linear line. The box for stage of the wound for the right heel was blank. During an interview on 6/5/14 at 3:30 pm the Dietary Technician stated that she did a quarterly nutritional assessment and did not do an assessment of the resident's dietary needs at the time that the pressure sore was identified, but that she should have. The Dietary Technician further stated that the resident's unit did not take part in the weekly wound rounds and that the former nurse manager measured the wounds for each resident on this unit, put them on a "cheat sheet" and then gave her a copy of the cheat sheet that she used to do her weekly documentation of the wound. During an interview on 6/6/14 at 8:40 am, the Registered Nurse, who changed the resident's dressing on the evening shift after the heel area was noted by the surveyor stated, he did the dressing change but did not notice the reddened area with linear dark line on the resident's heel. During an interview on 6/6/14 at 8:45 am the Registered Nurse Manager (RNM) stated that she had only been there a short time and the care planning was the responsibility of the previous RNM. She stated that the care plan should have been implemented for an actual skin integrity at the time that it was identified in 2/2014 and that it should have been updated to reflect the areas on the resident's toes when they were identified in 4/2014. She further stated that interventions should have been in place to prevent the resident from developing the new "deep tissue injury" to his heel. The RNM stated that the physician was made aware and that they are going to get the resident a pressure reducing mattress as well as off-loading his heels on pillows, and checking skin integrity daily. During an interview on 6/6/14 at 9:30 am the Director of Nursing (DON) stated that her expectation was that the resident's pressure sore would have immediately been care planned, off-loading would be implemented and that dietary would assess the resident's nutritional status. She further stated that she would expect that the nurse measuring the wound would document the measurements and assessment of the wound. During an interview on 6/6/14 at approximately 1:00 pm the resident's physician stated that he would have expected that some kind of interventions were in place to prevent the resident from getting the pressure sores. 10NYCRR 415.12(c)(1)

Based on medical record review and staff interview during an abbreviated survey (Case # NY 731) the facility did not ensure the resident environment remains as free from accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents for one (Resident #1) of three resident ' s reviewed. Specifically, Resident #1 had a history of [REDACTED]. She was placed on one on one (1:1) supervision. While the resident was on 1:1 supervision the resident broke a CD (compact disc) in half and cut her wrist. She was transferred to the emergency room (ER) and according to the ER report sustained injuries to her left hand as follows: superficial laceration to the dorsal aspect of the first web space, superficial laceration over her left wrist, superficial scratch of the radial aspect of the wrist, and superficial laceration to the dorsal between the 3 and 4 web carpal. This was isolated and resulted in actual harm. This was evidenced by: Resident #1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS), date illegible, assessed the resident as having severely impaired cognition. The Comprehensive Care Plan (CCP) entitled Unsafe Wandering/Elopement initiated 7/6/13 documented the resident was at risk for unsafe wandering/elopement as evidenced by the following: history of attempts to leave facility unattended, resident wanders aimlessly, impaired safety awareness, disoriented to place. Places resident at significant risk of getting to a potentially dangerous place/stairs/outside of facility. Significantly intrudes on the privacy or activity of others. Approaches included Wanderguard (a device that alerts staff a resident is wandering) and a motion detector to the resident ' s door. The CCP entitled Mood State Psychosocial Well Being initiated 7/16/13 documented the resident displays possible indications of depression, anxiety or sad mood. Indications present were listed as: sad mood, agitation, anxiety, combative at times. Goals included the resident will not harm self or others. Approaches included: Monitor episodes and attempt to determine underlying cause, acknowledge residents thought process during 1:1 interaction, and facilitate referral to psych as ordered. The CCP entitled Ineffective Coping; initiated 7/30/13 documented the following approaches: 8/1/13 1:1, keep MD and family updated, medicate if other intervention doesn ' t ' t work, 11/8/13 Private room, 11/11/13 1:1, 11/14/13 Redirect to private room to vent . The facility did not have a policy or procedure providing direction for staff on 1:1 supervision. The Nurse Practitioner ' s Progress Record dated 8/5/13 documented resident seen regarding recent behaviors and falls. Multiple falls but fortunately no injuries. Resident has been agitated, throwing things, broke some windows. Resident wants to leave, seems to be fearful and delusional at times. Continue with Klonopin (a medication used to treat anxiety) as ordered, monitor behaviors, calm approach and frequent observations. The Nurse Practitioner ' s Progress Record dated 8/12/13 documented resident was seen again in ER for behavioral issues, aggressive and agitated toward staff. She has had multiple falls. Difficult situation trying to manage aggressive agitated behaviors and safety issues. The Nurses Notes dated 8/19/13 at 9:00 pm documented resident noted with increased agitation, angry after dinner. Yelling "a name" persistently. Resident anxious, angry, attempted to stand and ambulate unassisted. 1:1, books, puzzles, toileting. Propelled by staff, continued to yell, grabbing at doors. Grabbing, hitting, kicking at staff, removing lap buddy. Resident ambulated, with increased anxiety, crying. Given massage, calmer. Began to look at books, talk with other residents and staff. The Nurses Notes dated 8/21/13 at 4:00 pm documented resident ate dinner, ambulated with staff, 1:1 provided. At 7:45 pm resident began to get angry attempting to stand unassisted, smacking at staff. Staff unable to control with one assist-attempt to massage resident grabbing at staff, digging nails into (illegible) attempt to bite. Offered food, fluids-threw at staff. Attempting to grab other resident ' s clothes, yelling loudly " a name " and cursing. Resident will stop behavior for 1-5 minutes then restart. Nurse Practitioner made aware of increased anger, combative behaviors, requiring two assist to prevent injury to resident/staff/other residents. Attempted to put resident to bed, kicking, attempts to bite, pushing weight backwards. Attempt to allow resident to propel unit in wheelchair, enters other resident ' s rooms screaming " a name. " Resident brought near nurse ' s station 9:45 pm. Continues to frequently require 2 assist-disrobing. Resident currently at nurse ' s station with 1:1. The Nurse ' s Note dated 9/6/13 at 12:00 pm documented resident anxious, annoyed. " I want to get the hell out of here. " Resident propels self to all windows. Attempt to offer resident to call family, food, fluids, ambulate, toilet, unsuccessful. Resident pushes wheelchair backwards yelling out " a name " repeatedly. Resident enters other rooms yelling. Staff 1:1 to provide safety to resident and others, swats at staff, curses at other residents and propels self around unit. Rests then becomes angry again -paranoia/anger lasted 2 hours then became very calm. The Nurse ' s Note dated 9/10/13 at 11:20 am documented a new order for psych services as needed. The Psychological Services: Diagnostic Evaluation dated 9/12/13 documented the resident was seen for angry outbursts. Resident understands more than it seems. Has angry outbursts, attention seeking which warrant a trial of psychotherapy. The Psychological Services Progress Note dated 9/19/13 documented the resident had symptoms of depression and mood swings. Functional/Behavioral challenges were identified as adjustment difficulty and attention seeking. Resident wants to go home, agitated, upset about loss of independence, guarded. Reinforced realistic expectations and helped to calm resident. The Nurse ' s Note dated 9/23/13 at 6:15 pm documented resident difficult to deal with -agitated, wants to " get out of here and go home. " Attempts to redirect her, resident kept stating " If you don ' t let me out of here I ' m going to break a window, there are lots of windows here. " Call placed to resident ' s son, she was still irate with him, kept stating she was going to go home and she would break windows if she couldn ' t go home. Taken to dining room, cool, quiet room and resident calmed down with Licensed Practical Nurse (LPN). The Psychological Services Progress Note dated 9/26/13 documented the resident had symptoms of anxiety, anger, and mood swings. Functional/Behavioral challenges were identified as adjustment difficulty and inappropriate behaviors and interactive skills. Resident with volatile moods and behavior, easily upset. Calmed and smiled as we met, discussed interests. The Psychological Services Progress Note dated 10/3/13 documented the resident had symptoms of anxiety and depression. Functional/Behavioral challenges were identified as inappropriate behaviors and interactive skills. Resident restless, irritable, anxious, worries needlessly. Reinforced positive events/thoughts, encouraged a sense of security. The Psychological Services Progress Note dated 10/11/13 documented the resident had symptoms of anxiety, depression, and mood swings. Functional/Behavioral challenges were identified as adjustment difficulty. Resident wants to leave, minimizes the need for care, impatient. Talked about her " clearing " up her thoughts and understanding that she ' s here because she ' s not able to live alone. The Psychological Services Progress Note dated 10/15/13 documented the resident had symptoms of anxiety, depression, anger, and mood swings. Functional/Behavioral challenges were identified as adjustment difficulty and inappropriate behaviors and interactive skills. Resident irritable, restless and agitated, wants to go " home. " Resident coming to terms with long-term care needs, beginning to explore interests and hobbies. The Psychological Services Progress Note dated 10/24/13 documented the resident had symptoms of anxiety and depression. Functional/Behavioral challenges were identified as adjustment difficulty, attention seeking and inappropriate behaviors and interactive skills. Resident unsettled, worries about what is expected of her. Reviewed expectations and consequences, reassured and helped to calm, establish a sense of predictability. The Nurse ' s Note dated 10/25/13 at 9:10 pm documented altercation ensued between resident #1 and resident #2. Resident #2 banged into resident #1's wheelchair several times and resident pushed the wheelchair away. Resident #1. slapped Resident #4, and resident #1 hit her back. Both residents were separated and neither sustained injury. The Nurse ' s Note dated 10/26/13 at 2:15 pm documented resident started with increased agitation in dining room, yelling wants to get out. Resident taken outside with no success, swinging and hitting staff. Taken back inside. Call to Nurse Practitioner, resident hitting at windows in secretary office. The CCP for Potential Risk for Suicidal Behavior initiated 10/26/13 documented the resident stated she wants to take pills so she can overdose, feels like she ' s in a jail. A review of the Nurse ' s Notes did not contain any documentation regarding the resident ' s statement that she wanted to kill herself. The Nurse Practitioner ' s Progress Record dated 10/28/13 documented resident seen regarding statement she made to nursing about harming self by overdosing on pills because she is in jail. Period of increased agitation and altercation with another resident. Observe behaviors, follow up with psychologist, same medications for now. Behavioral management of agitation, change environment, separate from other residents. The Nurse ' s Notes dated 10/30/13 at 9:15 pm documented resident agitated, tried walking with resident, tried laying resident down, Certified Nurse Aide (CNA) stayed with her in room due to agitation. Resident got out of bed CNA assisted resident in wheelchair. Moved to table by nurse ' s station, another male resident already sitting at table. Resident yelling she wanted out of here, wanted to kill someone. While I started to call MD resident threw cup of water on other resident. He stood up and she hit male resident in face, able to get to both residents and separated them. Telephone call to MD, he ordered Risperdal (an antipsychotic) 0.5 mg. Resident refused to take, wanted cops to take her out of here before she killed someone. Telephone call to MD and new order received to send resident to ER. Resident less agitated knowing State Troopers are coming. The resident went to the ER at 9:35 pm. The Psychological Services Progress Note dated 10/31/13 documented the resident had symptoms of depression. Functional/Behavioral challenges were identified as adjustment difficulty. Resident stated she wanted to overdose on pills and feels she was " in jail. " Resident denied intention to self-harm, agreed to let staff know if self-harm thoughts return, resident stated " I don ' t feel that way now " (suicidal). The Nurse ' s Note dated 11/1/13 at 6:30 pm documented resident weeping, overwhelmed, states she ' s been held here against her will stating no crime was committed and no charges were issued. She wants to see a lawyer. Attempted to console her with massage and food-refused both. Weeping, increased agitation. The Nurse ' s note dated 11/1/13 at 7:00 pm documented physician (MD) notified resident uncontrollable, throwing picture frames, pumpkins, and soda bottles at staff. New order to send to ER for evaluation. The Nurse ' s Note dated 11/1/13 at 7:10 pm documented 911 notified, family, and hospital notified of need for ER visit. The Nurse ' s Note dated 11/1/13 at 7:25 pm documented County Sheriff here speaking with resident and EMTs notified. The Nurse ' s Note dated 11/1/13 at 9:50 pm documented resident #1 was verbally abusive to Resident #4, calling her a " dumb [***] " and threatening to " kill herself. " The CCP entitled Potential Risk for Suicidal Behavior, revised 11/3/13, documented resident with violent behavior and threats of killing herself, altercation with male resident. The Nurse Practitioner ' s Progress record dated 11/4/13 documented resident calm now, but multiple recent aggressive outbursts, threatening to harm self and others. Verbally and physically aggressive toward staff and other residents requiring 911 call to police. Resident seen in emergency room twice for evaluation of above behaviors. Resident with dementia with psychotic features and unpredictable aggressiveness toward staff and other residents. Behavioral management of mood as much as possible-will ask psychologist for recommendations to decrease agitation before behavior escalates. A facility used Screen dated 11/6/13 documented depression is a focus of weekly psychotherapy. Resident denies suicidal thoughts at this time stating that she ' s " very bored " most of the time. The CCP entitled Potential Risk for Suicidal Behavior, revised 11/5/13, documented altercation with another female resident. The Psychological Services Progress Note dated 11/6/13 documented the resident had symptoms of depression and mood swings. Functional/Behavioral challenges were identified as adjustment difficulty and inappropriate behaviors and interactive skills. Resident with mood swings, angry outbursts, suicidal comments. Resident denies suicidal thoughts/intent. Met with team to discuss treatment plan. The Nurse ' s Noted dated 11/9/13 at 2:40 pm documented at 12:15 pm resident was trying to elope off the unit via fire exit by dining room. Stated she needs the keys to get out of here so she can go home to eat with her family. Resident trying to turn knob, pulling on it and kicking door. Resident then headed down hallway in wheelchair. Stopped at medication cart in front of room 240. Grabbed book off cart and started hitting this writer with it. When asked to stop and return book resident then threw book on ground, broke open with pages scattered. While this writer picking up pages resident grabbed two leg rests out of wheelchair in hallway and started swinging them toward this writer. Then resident headed into room 240 swinging leg rests. This writer was behind resident and slowly backed out of room with resident, who became more agitated. CNA came into hall and was watching resident while MD paged. Resident went into room 234 swinging leg rests at staff and TV, hitting TV multiple times. Resident backed out of room and continued swinging leg rests headed toward nurse ' s station. Entire time resident yelling she needs to get out to eat with her family. Multiple residents in hallway moved to safety. This writer was safely able to retrieve leg rests from resident. Several other staff and supervisor on unit. Resident still trying to leave unit headed toward elevator. Supervisor 1:1 with resident. Call placed to resident ' s son. Son and daughter in to visit. The Nurse ' s Note dated 11/11/13 at 2:30 pm documented resident has increased agitation. This morning resident was in dining room and stated she was going to break out the windows to get out of here. Resident brought to other dining room and stated look at all this glass I ' ll have to break to get out. Resident removed from dining room and placed on 1:1. Resident also tried to leave unit via elevator. Removed from elevator without incident. The Psychological Services Progress Note dated 11/14/13 documented the resident had symptoms of anxiety, depression and anger. Functional/Behavioral challenges were identified as adjustment difficulty and inappropriate behaviors and interactive skills. Resident threatening with wheelchair leg rests, increasing behavioral outbursts, denies she ' s having problems. Reinforced positive behavior and encouraged attendance at programs, gently confronted with inappropriate aggressive acts. The Psychiatric Diagnostic Evaluation dated 11/14/13 documented the resident was seen by an MD regarding her agitation and violent behaviors. Resident stated I am very short ...no patience, I don ' t know why-I feel lonesome. Assessment of the resident revealed impulsivity, short temper, feelings of loneliness and boredom-resulting in temper outbursts or aggressive behaviors. This is most likely secondary to vascular disease of the brain. The Nurse ' s Note dated 11/16/13 at 10:15 pm documented 1:1 continues. Resident became increasingly agitated in dining room while waiting for dinner, yelling at other residents and tried to hit a resident while they wheeled passed. The Psychological Services Progress Note dated 11/21/13 documented the resident had symptoms of depression. Functional/Behavioral challenges were identified as aggression, memory/cognition/decision making difficulty, and short tempered/easily annoyed. Resident aggressive, verbal threats. One to one aide to prevent harm to others/self, resident admits she is short tempered. Aggression has decreased, moods have improved. Reinforce need to be patient, tolerant, and attempts to join activities. The Psychological Services Note dated 11/25/13 documented the resident had symptoms of depression and anger. Functional/Behavioral challenges were identified as inappropriate behaviors and interactive skills and noncompliance with treatment. Resident combative, noncompliant (requires 1 to 1 now), despondent over loss of independence and control. Improved compliance and moods, sessions help to reinforce consequences and positive behavior. The Nurse ' s Note dated 11/29/13 at 1:30 pm documented 1:1 continues, no behaviors. The Psychological Services Progress Note dated 12/4/13 documented the resident had symptoms of depression, anger, and mood swings. Functional/Behavioral challenges were identified as adjustment difficulty and inappropriate behaviors and interactive skills. Resident with occasional violent outbursts requiring one on one aide, irritable. Reinforced positive thoughts, consequences, acknowledged having had a good Thanksgiving. The Nurse ' s Note dated 12/7/13 at 8:05 pm documented resident was agitated. Resident re-directed several times with no change in behavior. Stated she wanted out of the facility but didn ' t want to kill herself as a means of leaving. Made a couple attempts to exit by the elevator with the 1:1 behind. She became agitated in the dining room so was moved to the nurse ' s station for dining. She attempted to remove the tray table from Resident #5. He held it with his hand so she hit him on the top of his right hand. No injuries noted. Residents were separated. The Nurse ' s Note dated 12/8/13 at 11:30 am documented resident is calm and pleasant continues with 1:1. Alert-(illegible)-reading magazines, paper-puzzles-no signs or symptoms of agitation. Staff continue to monitor with direct 1:1 supervision entire shift. The Nurse ' s Note dated 12/9/13 at 6:30 pm documented no behaviors at this time. Resident remains 1:1. Will continue to monitor. The Nurse ' s Note dated 12/10/13 at 8:00 pm documented this nurse was called to room by CNA. CNA stated that resident was bleeding somewhere from her hands. Resident ' s left hand was wrapped with a blanket, when I unwrapped it, resident ' s both hands were covered with dry blood, cleansed both hands, right hand no open areas, on resident ' s left hand wrist area abrasions noted, on back of resident ' s hand 2 areas, left side deep cut and right side deep cut, steri strip applied to left side. Right side dry sterile dressing applied and area wrapped with Kling by supervisor. MD called. New order send to ER for treatment and evaluation. Son called, updated. Supervisor aware and present. Call placed to 911. The Incident Report dated 12/10/13 at 8:00 pm documented the resident had open cuts to hand and left wrist. Resident cut her own left wrist and hand posterior with broken CD. Resident found sitting on bed, staff had already removed bloody CD from patient area. Staff cleaning resident ' s wrist/hand of blood. Resident crying at times and stated " I didn ' t think it was so hard to get an artery so that the blood would just spurt out. " The Resident Version of Incident/Accident form documented the resident stated " I thought that I could cut my artery. " In the Incident Statement Form dated 12/10/13 LPN #1 documented CNA brought me half of a CD approximately 20 minutes before incident. Asked where it came from. CNA stated I found it on resident ' s floor, but I didn ' t see any other pieces. I took CD, put on my desk. CNA returned to room and I went on break. In the Incident Statement Form dated 12/10/13 CNA #1 documented I heard the doorway alarm going off. I went to go check on it when I got there LPN #2 was already there holding resident ' s hand talking as she was trying to look and clean up her hand. Registered Nurse Supervisor (RNS) also there. I then went to get wash cloths and wet them for the resident. Resident was saying that she tried to cut an artery more than once. In the Incident Statement Form dated 12/10/13 CNA #2 documented I was doing a 1:1 with another resident. I was sitting in lobby with resident, CNA #4 was sitting in lobby area for 5-10 minutes when alarm sounded, at that time CNA #4 went to investigate. In the Incident Statement Form dated 12/10/13 CNA #3 documented LPN #2 and I were outside utility room and resident ' s alarm went off. CNA #4 asked me to answer the alarm, CNA #4 was sitting at the table. I looked and told CNA #4 that resident was walking around her room in the dark. CNA #4 walked in the room, resident was crying and she had her hand in a bath blanket. I asked resident what happened, she started to cry. LPN #2 said she had something in her right hand. I found a sharp object covered with dry blood. I asked her again what happened and resident stated she wanted to see if she cut her arteries will they bleed. In the Incident Statement Form dated 12/10/13 CNA #4 documented I came back from my dinner break, resident was in the dining room, trying to get out of there. I brought her back to her room, took her to the bathroom, she was telling me she was upset because the food did not come on time and she did not like to wait. As she laid down in bed I clipped the alarm on her and sat down in a chair beside her bed. She was ok for a few minutes but kept asking why I was in there, and said she couldn ' t sleep while being watched and asked me to leave. I then grabbed a chair and sat right outside her door. Not even five minutes later she sits up, alarm goes off, I come in she says she thought that we were friends, I asked her why she says this, she was agitated because she was clipped to an alarm. I explained to her that it was for her safety and why it had to be there, she argued that she felt like an animal. I clipped her again and tried to calm her down, still agitated I left the room, other CNA says she doesn ' t need alarm while in bed, grabs the care plan to make sure so we go into remove it. Resident was upset that we went into her closet, we explained it was to look at the care plan to see if we could remove the alarm, resident was extremely agitated so out of fear I left the room, asked other CNA to make sure motion sensor was on, I went and sat at table to talk about this with another CNA and less than five minutes the bathroom alarm is going off. I go in to help her to use it and she says she doesn ' t have to go and sits on her bed. Then I find pieces of a CD on the floor, pick them up and bring them to the nurse and sit back down. Ten minutes later the alarm goes off, nurse was right outside the door with other CNA, I asked was that her alarm, they said yes, so I go into the room, she is sitting up in bed, looking upset, I ask her what ' s wrong, she replies nothing and asks me to leave. I then sat on the bed next to her and asked her to talk to me, tell me what ' s bothering her, she wouldn ' t talk. I noticed she ' s holding a bath blanket, lifted it and saw blood, went and got the nurse and supervisor. When I went back into the room she had made several comments about wanting to commit suicide, that she was so sorry and ashamed, that she felt like she had no family and no home, and that she did not want to be here anymore, as she hugged me and wept. In the Incident Statement Form dated 12/10/13 LPN #2 documented I was standing in the hallway by the clean utility room and heard resident ' s motion detector ringing. I was talking to CNA # 3, CNA #4 was sitting at the table near the alcove conversing with CNA #2. CNA #4 asked us if we could check on resident because her alarm was sounding, CNA #3 peeked in the room and told CNA #4 that resident was walking around. CNA #4 proceeded to room and moments later CNA #4 came running to me saying that the resident was bleeding from her hands. When I approached resident, she was crying and wouldn ' t talk. I reassured her that everything was okay and she ' s not in trouble. She allowed me to unwrap her left wrist because she had it wrapped with a bath blanket. I found dried blood on both hands, I cleansed her left hand and wrist with normal saline when I noticed that she was holding a broken CD in her hand tightly. I asked her for the CD and she willingly gave it to me, then I noticed another broken piece in her right hand, I again asked her if I could have it and she gave it to me. Both pieces of the CD were covered with dry blood. Resident has a superficial abrasion left wrist area, on the top of her hand she has 2 deep cuts. I was able to apply steri strips to the one on the left side and a dry sterile dressing to the right side. RNS wrapped area with Kling. 1:1 in room with resident for safety. I asked resident what happened, resident stated " I tried to cut my artery. " Resident also stated " I didn ' t think it was so hard to get an artery. " In the Incident Statement Form dated 12/10/13 the RNS documented I was supervisor on 3-11 at time of occurrence. I was down on another unit assisting staff with admissions when CNA #4 came down and informed me of being needed immediately on other unit. I went up immediately, while in the elevator CNA #4 stated resident tried to " commit suicide, " that she cut herself with a broken CD and there was blood all over. I found resident sitting on bed, LPN #2 with resident, cleaning up blood from her hand and wrist. I asked CNA #4 where she was during this occurrence and she stated she was out in the hallway because resident couldn ' t sleep with her in the room. I educated CNA #4 of 1:1 should be constant visual supervision. While standing at resident ' s bedside, resident stated " I didn ' t think it was so hard to get an artery so that the blood would just spurt out. If I got an artery it would be over quicker. " The Psychological Services Progress Note dated 12/12/13 documented the resident had symptoms of depression and anger. Functional/Behavioral challenges were identified as aggression and inappropriate behaviors and interactive skills. Resident broke a CD, cut her wrist in attempt to kill herself despite constant supervision. ER last night, angry, irritable. Resident denies wishes/intent to self-harm. Will continue to support staff and resident in attempts to minimize anger and aggressive behavior, continue follow up with psychiatry. During an interview on 1/30/14 at 12:15 pm the Director of Nursing (DON) stated that the resident had periods of confusion and would get very frustrated. She stated at the time of the incident the resident was on a 1:1, however it was not a " visual " 1:1 at the time. During an observation on 1/31/14 at 10:35 am it was noted that inside the resident ' s room could not be seen from the nurse ' s station. An alcove to the left of the resident ' s room and around the corner was also noted with a table and chairs. The resident ' s room was not visible from this area. During an interview on 1/31/14 at 10:50 am LPN #3 stated that the resident ' s behavior has been unpredictable since she was admitted . She stated the resident had been on 1:1 for a long time prior to the incident of trying to cut her wrist. She further stated the resident has always needed to be closely watched. During an interview on 2/27/14 at 10:40 am LPN #1 stated that she was working on the unit the evening the resident attempted to cut her wrist with a CD. She stated she was on break at the time the incident occurred. She stated the resident was on a 1:1 which meant the staff member assigned to the resident had to keep their eyes on her, stay close, stay in room with her, engage her in activities, etc. She stated the resident was originally put on a 1:1 as she had broken some windows, had multiple resident to resident altercations, and was physically abusive to staff. She stated prior to the incident CNA #4 had given her half of a broken CD found in the resident ' s room. She stated at the time she thought it was weird and she went into the resident ' s room to look for the other half. She stated the resident had a CD player, but the top was closed. She stated she looked around, even went through the resident ' s sheets, but could not find any other pieces of the CD. She stated the resident must have had the other half in her clothes or under her buttocks. She stated she kept the other half of the CD and then went out for break. She stated prior to leaving for break she noticed CNA #4 was at the table. She stated she asked the CNA if everything was okay, and the CNA stated she was fine and was going to go back into the resident ' s room. She stated when she returned from break, the incident had already occurred. She further stated she questioned CNA #4, who was the resident ' s 1:1 why she wasn ' t with the resident. During an interview on 2/25/14 at 2:05 pm LPN #2 stated she was working on the unit as the treatment nurse the evening of the incident. She stated the resident was a 1:1 which meant staff had to keep an eye on the resident at all times. She stated the resident was placed on 1:1 initially because she had made a lot of threats of suicide in the past. She stated she was in the hallway and the resident ' s sensor alarm was going off. She stated the resident ' s 1:1, CNA #4, was sitting down by the nurse ' s station talking to another CNA. CNA #4 looked around the corner, and asked for me and another CNA to check on the resident. The resident was walking around her room so CNA #4 got up and went into resident ' s room. She stated CNA #4 came to her and told her the resident was bleeding and holding her wrist. During an interview on 2/25/14 at 2:30 pm CNA #2 stated she was working between two units the evening of the incident, doing a 1:1 with another resident. She stated Resident #1 was also on a 1:1 which meant you needed to be with her at all times, watching them and preventing them from harm. She stated she was unsure why Resident #1 was originally put on 1:1 but she thought it was because she had dementia, was unstable, and had multiple falls. She further stated she heard what was going on as she was sitting by the nurse ' s station with the resident she was assigned to do 1:1 with. During an interview on 2/25/14 at 1:40 pm CNA #3 stated she was working on the unit the evening of the incident. She stated the resident was on a 1:1 when the incident happened, which meant the resident should be totally supervised at all times and that you needed to have your eyes on the resident at all times. She stated the resident had always been on 1:1, at least the last 3-4 months, as the resident was combative. She stated CNA #4 should have been in the room with the resident but she was sitting at the table. She stated the resident was walking around in her room, she had blood on her hand and a broken CD. She stated the resident stated " I took it and wanted to see if it bled. " She stated she asked why CNA #4 was not with the resident, that she was there for the resident ' s safety, and CNA #4 started to cry. During an

Based on medical record review and staff interviews during an abbreviated survey (Case # 849) it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the facility failed failed to have an effective system in place to adequately manage the quality of care delivered to an insulin dependant diabetic, including transcription of insulin orders, management of hypoglycemic episodes, notification of the physician of significant blood sugar results, and the subsequent necessary follow up of the resident. Specifically, on 12/31/13 an order was received to increase the residents morning [MEDICATION NAME] insulin from 5 to 6 units and to call the physician if blood sugar is below 90. The order was neither transcribed according to the facility policy or checked to ensure it was accurately recorded. On 1/27/14 the resident's blood sugar was 88. The physician was not notified, and the resident received 56 units of insulin in error rather than 6 as ordered. The resident's 4:00 pm blood sugar was 41. The Licensed Practical Nurse (LPN) did not notify the supervisor or physician. A repeat blood sugar of 66 was identified and 3 units of insulin were administered by the LPN according to the physician's standing order. Again the physician was not notified. At approximately 11:00 pm the resident was found unresponsive with a blood sugar of 17. [MEDICATION NAME] was administered according to the standing physician order [REDACTED]. The resident was pronounced dead at 11:45 pm. This resulted in actual harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. The facility was able to remove the immediacy prior to exit. This is evidenced by the following : Refer to F 157 - Resident Rights- Scope/Severity J Refer to F 309 - Quality of Care - Scope/Severity J Refer to F 333 - Quality of Care - Scope/Severity J During an interview on 1/31/14 at 2:45 pm, the Administrator stated that it is his expectation that nursing staff follow the facility policies and procedures related to appropriate care to resident's. The Administrator further stated that on 1/28/14, his performance improvement committee had met and identified an increase in medication errors and had put a plan in place to determine the root cause of the increase. The Administrator stated that he was unaware of Resident #1's death until the late afternoon of 1/28/14 at which time a full investigation into the events was initiated. 10 NYCRR 415.26

Based on medical record review and staff interviews during an abbreviated survey (Case #NY 849), the facility failed to ensure that residents were free of significant medication errors for 1 (#1) of 16 residents reviewed. The facility failed to ensure that effective systems were in place to ensure physician orders [REDACTED]. Additionally, the facility failed to ensure that finger stick blood sugar (FSBS) results were assessed, managed, monitored, and reported to the physician as indicated. Specifically, on [DATE] an order was received to increase the residents morning [MEDICATION NAME]from 5 units to 6 units and to call the physician if blood sugar is below 90. The order was not transcribed clearly or correctly, resulting in resident #1, receiving an incorrect dose of 56 units of [MEDICATION NAME]on the morning of [DATE], when her morning FSBS result was 88. The physician was not notified of this FSBS result that was below 90. Later the same day, at 4 PM, the FSBS result was 41. The Licensed Practical Nurse (LPN), did not notify the nursing supervisor or physician of this very low blood sugar. She gave the resident milk and juice to drink, and repeated the FSBS testing. The repeat FSBS result was 66, again the physician was not notified of the residents low blood sugar result and the LPN administered insulin 3 units according to the physician's standing order. No additional FSBS were monitored until approximately 11:00 pm when the resident was found unresponsive. A FSBS test, at that time, revealed a blood sugar of 17, (critically low). [MEDICATION NAME] (a medication that increases blood sugar levels) was administered once according to the physician standing orders, a second dose of [MEDICATION NAME] was administered without physician notification. The resident was pronounced dead at 11:45 pm. This had the potential to affect all diabetics in the facility. This resulted in actual harm that is Substandard Quality of Care and Immediate Jeopardy to the health and safety of the resident. The facility was able to remove the immediacy prior to exit. This is evidenced by: Facility Policy and Procedure titled "Medication Orders, Transcription." last revised ,[DATE] documented the policy ensures that medication orders are reviewed for accuracy, completeness and safety with consideration of medical diagnosis. The policy documented that the MAR (Medication Administration Record) is a 30 day record that contains administration times, day of the week, date, the start/stop date of the medication and any label or dose instructions. The policy documented that a nurse will check the printed medication sheet against the physician orders [REDACTED]. Facility Policy and Procedure titled "Medication Administration" last reviewed ,[DATE] documented utilization of the 6 Rights of Medication Administration which includes, right dose and when preparing medications for administration, read the label three (3) times. The policy further documented that newly printed medication sheets will be checked by the 11:00 pm - 7:00 am nurse. Two licensed nurses will check medication sheets with the most recent physician medication orders and will be initialed and dated by the nurses. Facility Policy and Procedure titled "[DIAGNOSES REDACTED]: Management of" (undated) documented that the physician's orders [REDACTED]. Resident #1: Resident #1 was readmitted to the facility on [DATE] diagnosed with [REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident with moderate cognitive impairment. Physician order [REDACTED]. [MEDICATION NAME] 5 units every morning and Regular insulin 3 units subcutaneously (S.Q.) at dinner time. Comprehensive Care Plan for a [DIAGNOSES REDACTED].#1 is an insulin dependant diabetic with the documented goal of maintaining normal blood glucose levels through approaches that included: monitor fingerstick blood sugars per physician orders, monitor for signs and symptoms of hypo/[MEDICAL CONDITION] and follow policy, and to administer insulin as ordered. Physician order [REDACTED]. The order is marked with "noted, LPN #1's name, and [DATE]." There are no other nurse's initials on the order. The medication storage box for the [MEDICATION NAME] documented "inject 6 units (S.Q.) every morning." Medication Administration Record (MAR) for [DATE] documented a handwritten order for [MEDICATION NAME] 56 or 66 (there are two numbers together, the first number is unclear and appears as though a 6 is written directly over a 5) units in the morning dated [DATE]. Handwritten in the same slot was documented "(Six units [DATE])." MAR for [DATE] documented finger stick blood sugars two times per day at 6:00 am and at 4:00 pm and call the physician for blood sugar under 90 and over 300. Entry on [DATE] at 6:00 am signed by Registered Nurse Supervisor (RNS) #1 documented a blood sugar of 88. Entry on [DATE] at 4:00 pm signed by Licensed Practical Nurse (LPN) #2 documented a blood sugar of 66. MAR for [DATE] documented Regular insulin 3 Units S.Q. at dinnertime and call the physician for blood sugar under 90 or above 300. Entry for [DATE] documented LPN #2 administered the medication. During an interview on [DATE] at 12:15 pm, the Director of Nursing (DON) stated that Resident #1 was found on [DATE] at 11:00 pm with a low blood sugar of 17 and subsequently expired. The DON stated during the facility investigation, it was determined that RNS #1 administered 56 unit of [MEDICATION NAME] on the morning of [DATE] instead of the physician ordered 6 units. The DON stated "11 to 13 (nursing) staff saw this and no one corrected it. This is confusing." pointing to the MAR entry "[MEDICATION NAME] (an unclear number) 6 units." The DON stated that the investigation revealed that LPN #1 received a physician's orders [REDACTED]. The DON stated that rather than discontinuing the MAR entry, LPN #1 attempted to write over the 5 to make it a 6. The DON stated LPN #1 should have yellowed out the MAR entry, discontinuing it, and should have made a new entry for 6 units of [MEDICATION NAME]. The DON stated that at some point during the month, another LPN placed the "(Six units [DATE])" in an effort to clarify the entry. The DON stated that she remains unsure of who may have written the "6" next to the 6 written over the 5 that LPN #1 wrote. During an interview on [DATE] at 2:00 pm, LPN #2 stated that on [DATE] at approximately 5:00 pm, she checked Resident #1's blood sugar which was 41. LPN #2 stated that she gave Resident #1 cranberry juice and thickened milk, waited 10 minutes and retested the residents blood sugar, which at that time was 66 and she administered 3 units of regular insulin. LPN #2 stated that she gave the resident her dinner tray and encouraged her to eat. LPN #2 stated that she informed RNS #2 that the resident's blood sugar was 66 and RNS #2 asked if the resident had her dinner tray and what else had she been given, to which LPN #2 responded, cranberry juice and thickened milk. LPN #2 stated that she removed the resident's meal tray at 6:30 pm noting that she consumed approximately 360 milliliters of fluids and very little, if any food. LPN #2 stated she did not recheck the resident's blood sugar. LPN #2 stated that at approximately 11:00 pm, she was alerted by a Certified Nurses Assistant (CNA) that the resident was not responding to her as usual. LPN #2 stated that she responded to Resident #1's room and found the resident with her head down, unresponsive and twitching. LPN #2 stated she tested her blood sugar, which was 17. LPN #2 stated immediate efforts were made to raise Resident #1's blood sugar and 911 was called. During an interview on [DATE] at 9:00 am, RNS #2 stated that on [DATE] at approximately 5:20 pm, she passed Resident #1's room and was informed by LPN #2 that the resident's blood sugar was 66. RNS #2 stated that she told LPN #2 to give Resident #1 milk and try to get her to eat. RNS #2 stated that she was informed by LPN #2 that the resident drank two glasses of thickened milk and one glass of thickened cranberry juice and RNS #2 noted that Resident #1's dinner tray was in front of her. RNS #2 stated that she did not contact the resident's physician nor did she direct or ensure that LPN #2 had. RNS #2 stated she had not heard anything further about the resident until 11:00 pm when a CNA reported that the resident was not responding to her as usual. RNS #2 stated when she responded to the resident's room, she was advised that the resident's current blood sugar was 17. During an interview on [DATE] at 1:30 pm, Resident #1's physician stated on [DATE] he was informed that Resident #1 was administered 56 units of [MEDICATION NAME] instead of 6, in error, on the morning of [DATE]. The physician stated that the medication error was a major cause in the resident's death. During an interview on [DATE] at 2:00 pm, RNS #1 stated that she was the RNS and was assigned to a medication cart on the 11:00 pm ([DATE]) to 7:00 am shift on [DATE]. RNS #1 stated that at approximately 6:30 am, a half hour later than usual, she took Resident #1's fingerstick blood sugar which was 88. RNS #1 stated that she figured that because she was a little later than usual, a blood sugar of 88, only two points below the parameter of 90, was not cause for concern. and gave the resident her other medications in applesauce to make sure she had enough nourishment before breakfast. RNS #1 stated that she did not contact the resident's physician and proceeded to administer the resident's [MEDICATION NAME]. RNS #1 stated that she administered 56 units of [MEDICATION NAME] to the resident after reading what she thought was a 5 and a 6. RNS #1 stated that she checked the MAR against the box containing the [MEDICATION NAME], noting the resident's name and the name of the medication. RNS #1 stated that she did not read the order on the box which stated "inject 6 units (S.Q.) every morning." RNS #1 stated that she returned to work between 10:50 pm and 11:00 pm on [DATE] and was soon alerted that the resident was unresponsive and when her blood sugar was taken it was 15. RNS #1 stated that after the resident had expired, she told the hospice representative and maybe some of the other nurses that she had given 56 units earlier that morning. RNS #1 stated that it wasn't until she received a call from the DON on [DATE] at around 5:00 pm who asked how many units she had administered, and when she said 56, the DON stated that the resident was only ordered 6 units. During an interview on [DATE] at 3:30 pm, LPN #1 stated that she was the nurse who took the physician order [REDACTED]. LPN #1 stated that normally she would yellow out the old order on the MAR and start a new entry, however, it was a busy day that day and so she just wrote a 6 over the 5 on the MAR. LPN #1 stated that the order should have been verified by the night nurse, which did not occur. The facility was able to remove the Immediate Jeopardy prior to exit by: convening the Quality Assurane team to determine the root cause of the medication error, re-educating 100 percent of licensed staff in transcription of orders, physician notification, and medication administration; insulin competencies were performed on all nurses that administer medication, a glycemia competency has been performed on all licensed staff; all medexs were audited to ensure accuracy with all physicians orders, all diabetic orders are reviewed daily to ensure accuracy; all residents receiving a fingerstick blood sugar will be audited each shift to ensure physician parameters were followed. Additionally, a reference guide for all types of insulin has been added to each medication cart. The Administrator/Director of Nurses reviews each incident report daily to ensure completeness and appropriatenessof actions taken, including physician notification. 10 NYCRR 415.12(m)(2)

Based on interview and record review during an abbreviated survey (case #NY 849), the facility failed to ensure that necessary care and services were provided to maintain the highest practicable physical, mental and psychosocial well-being for one resident (#1) of three reviewed. Specifically, the facility failed to ensure that necessary care and treatment were provided to resident #1, an insulin dependant diabetic. The facility failed to ensure that; insulin orders were transcribed correctly, finger stick blood sugar (FSBS) results were assessed, managed, monitored, and reported to the physician as indicated. Specifically, on [DATE] an order was received to increase the residents morning [MEDICATION NAME]from 5 units to 6 units and to call the physician if blood sugar is below 90. The order was not transcribed clearly or correctly, resulting in resident #1, receiving an incorrect dose of 56 units of [MEDICATION NAME]on the morning of [DATE], when her morning FSBS result was 88. The physician was not notified of this FSBS result that was below 90. Later the same day, at 4 PM, the FSBS result was 41. The Licensed Practical Nurse (LPN), did not notify the nursing supervisor or physician of this very low blood sugar. She gave the resident milk and juice to drink, and repeated the FSBS testing. The repeat FSBS result was 66, again the physician was not notified of the residents low blood sugar result and the LPN administered insulin 3 units according to the physician's standing order. No additional FSBS were monitored until approximately 11:00 pm when the resident was found unresponsive. A FSBS test, at that time, revealed a blood sugar of 17, (critically low). The unresponsive resident was given sugar and thickened liquids by mouth. [MEDICATION NAME] (a medication that increases blood sugar levels) was administered once according to the physician standing orders, a second dose of [MEDICATION NAME] was administered without physician notification. The resident was pronounced dead at 11:45 pm. This resulted in actual harm to resident #1 that is Immediate Jeopardy and Substandard Quality of Care to the health and safety of residents. The facility was able to remove the immediacy prior to exit. This is evidenced by the following: Facility Policy and Procedure titled "Medication Orders, Transcription." last revised ,[DATE] documented the policy ensures that medication orders are reviewed for accuracy, completeness and safety with consideration of medical diagnosis. The policy documented that the MAR (Medication Administration Record) is a 30 day record that contains administration times, day of the week, date, the start/stop date of the medication and any label or dose instructions. The policy documented that a nurse will check the printed medication sheet against the physician orders [REDACTED]. Facility Policy and Procedure titled "Medication Administration" last reviewed ,[DATE] documented utilization of the 6 Rights of Medication Administration which includes, right dose and when preparing medications for administration, read the label three (3) times. The policy further documented that newly printed medication sheets will be checked by the 11 pm - 7 am nurse. Two licensed nurses will check medication sheets with the most recent physician medication orders and will be initialed and dated by the nurses. Facility Policy and Procedure titled "[DIAGNOSES REDACTED]: Management of" (undated) documented that the physician's orders [REDACTED]. Facility Policy and Procedure titled "Notification of Changes" last revised ,[DATE] documented that the resident's physician must be notified immediately when there is a decline in the resident's health condition or a need to alter treatment significantly. Resident #1: Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set, (MDS, a standardized assessment tool), dated [DATE] assessed the resident with moderate cognitive impairment. Physician order [REDACTED]. Give [MEDICATION NAME]5 units every morning and Regular insulin 3 units subcutaneously (S.Q.) at dinner time. Physician order [REDACTED]. The order is marked with "noted, LPN #1's name, and [DATE]." There are no other nurse's initials on the order. Comprehensive Care Plan, titled [DIAGNOSES REDACTED].#1 was an insulin dependant diabetic. The documented goal was to maintain normal blood glucose levels through approaches that included: monitor accu-checks (FSBS testing device) per physician orders, monitor for signs and symptoms of hypo/[MEDICAL CONDITION] and follow policy, and to administer insulin as ordered. The medication storage box for the [MEDICATION NAME] insulin, included documentation to "inject 6 units (S.Q.) every morning." The MAR dated [DATE], included an entry for [MEDICATION NAME] insulin, the dose to be given is unclear as it is written, written over, crossed out, and added to. The first number of the dose is unclear and appears as though a 6 is written directly over a 5, a second number 6 has been added next to it, dated [DATE]. Handwritten test in the same administration box are the words "(Six units [DATE])." The MAR dated [DATE] included (FSBS), finger stick blood sugars two times per day at 6:00 am and at 4:00 pm, call the physician for blood sugar under 90 and over 300. An entry on [DATE] at 6:00 am signed by RNS #1 documented a blood sugar of 88. An entry on [DATE] at 4:00 pm signed by LPN #2 documented a blood sugar of 66. The MAR dated [DATE] documented Regular insulin 3 Units S.Q. at dinnertime and call the physician for blood sugar under 90 or above 300. The Regular insulin 3 units was signed as being given by LPN #2 on [DATE]. During an interview on [DATE] at 12:15 pm, the Director of Nursing (DON) stated that Resident #1 was found on [DATE] at 11:00 pm with a low blood sugar of 17 and subsequently expired. The DON stated that the facility determined the following sequence of events: - [DATE], 6 am , Registered Nurse Supervisor (RNS) #1 obtained a FSBS result of 88 The DON stated that the physician's orders [REDACTED]. - The DON stated that RNS #1 did not contact the physician and administered the morning [MEDICATION NAME] insulin. - [DATE] at dinnertime, LPN #2 noted Resident #1's blood sugar to be 41. LPN #2 gave the juice and milk, rechecked her blood sugar which had reached 66 and administered the resident her scheduled 3 units of Regular insulin. LPN #2 never contacted the physician. The DON stated during the facility investigation, it was also determined that there had been an error in the administration of the morning insulin dose on [DATE]. RNS #1 had administered 56 unit of [MEDICATION NAME]instead of the physician ordered 6 units. The DON stated the MAR had been seen by approximately "11 to 13 (nursing) staff, and no one had corrected it. This is confusing." pointing to the MAR entry "[MEDICATION NAME] (an unclear number) 6 units." The DON stated that further investigation revealed that on [DATE], LPN #1 received a physician's orders [REDACTED]. The DON stated that rather than discontinuing the MAR entry for the 5 units and writing a new entry, LPN #1 attempted to write over the 5 to make it a 6. The DON stated LPN #1 should have yellowed out the MAR entry, discontinuing it, and made a new entry for 6 units of [MEDICATION NAME]. The DON stated that the MAR entry had not been checked by additional staff for accuracy, which is contrary to facility policy. The DON went on to say, that at some point during the month, another LPN added the "(Six units [DATE])" in an effort to clarify the entry. The DON stated that she remains unsure of who may have written the "6" next to the 6 written over the 5 that LPN #1 wrote. During an interview on [DATE] at 2:00 pm, LPN #2 stated that on [DATE] at approximately 5:00 pm, she checked Resident #1's blood sugar which was 41. LPN #2 stated that she gave Resident #1 cranberry juice and thickened milk, waited 10 minutes and retested the residents blood sugar, which at that time was 66, so she administered 3 units of regular insulin. LPN #2 stated that she gave the resident her dinner tray and encouraged her to eat. LPN #2 stated that she informed Registered Nurse Supervisor (RNS) #2 that the resident's blood sugar was 66 and RNS #2 asked if the resident had her dinner tray and what else had she been given, to which LPN #2 responded, cranberry juice and thickened milk. LPN #2 stated that she removed the resident's meal tray at 6:30 pm noting that the resident had consumed approximately 360 milliliters of fluids and very little, if any food. LPN #2 stated she did not recheck the resident's blood sugar. During the same interview, LPN #2 stated that at approximately 11:00 pm, she was alerted by a Certified Nurses Assistant (CNA) that the resident was not responding to her as usual. LPN #2 stated that she arrived at Resident #1's room and found the resident with her head down, unresponsive and twitching. LPN #2 stated that she tested the FSBS and found that it was 17. LPN #2 stated that she placed a packet of sugar in the resident's mouth with a small amount of liquid in an effort to raise the resident's blood sugar. LPN #2 stated she then administered [MEDICATION NAME], which brought the resident's blood sugar to 25. At that time, RNS #2 called 911, and obtained a physician order [REDACTED]. LPN #2 stated that that she stayed with Resident #1, LPN #3 administered the second dose of [MEDICATION NAME] in the resident's abdomen and when the paramedics arrived, [MEDICATION NAME] 50% was administered by intravenous. A short time later, the paramedic indicated that the resident had expired. LPN #2 went on to say that that while they were in the resident's room with the paramedic, RNS #1, RNS #2, and LPN #3 had a discussion in which she reported the resident's blood sugar of 66 and her administration of 3 units of Regular insulin, RNS #2 stated that she had given the resident 56 units of [MEDICATION NAME] in the morning with a blood sugar of 88. During an interview on [DATE] at 9:00 am, RNS #2 stated that on [DATE] at approximately 5:20 pm, she passed Resident #1's room and was informed by LPN #2 that the resident's blood sugar was 66. RNS #2 stated that she told LPN #2 to give Resident #1 milk and try to get her to eat. RNS #2 stated that she was informed by LPN #2 that the resident drank two glasses of thickened milk and one glass of thickened cranberry juice and her dinner tray was in front of her. RNS #2 stated that she did not contact the resident's physician nor did she direct or ensure that LPN #2 had. RNS #2 stated she did not hear anything further until about 11:00 pm, when a CNA reported that the resident was not responding. RNS #2 stated when she arrived at the resident's room, she was advised that the resident's current blood sugar was 17. RNS#2 stated that she recalls a conversation in the resident's room when RNS #1 stated that she had given the resident 56 units of [MEDICATION NAME]at 6:30 am. RNS #2 stated that she was not aware that the resident was administered 3 units of regular insulin by LPN #2 until at dinnertime, until she was told by the Assistant Director of Nursing (ADON) on [DATE] at approximately 2:30 pm. During an interview on [DATE] at 11:50 am, the Nurse Practitioner (NP) stated that she was in to see Resident #1 during the day on [DATE] and had no major issues. The NP stated she received a call in the early morning hours ([DATE]) from one of the nurses stating that Resident #1 was found with a blood sugar of 17, [MEDICATION NAME] was administered, they wanted permission to give another dose, the paramedics were there and the resident had expired. The NP stated that she awoke from a sound sleep, she thinks all of the information was given at the same time, she was trying to put it all together. The NP stated that she called back to the facility and asked what had happened. The NP stated she was told that the resident had received 3 units of regular insulin in the afternoon and had not eaten any supper. The NP stated she was also informed that the resident received 56 units in the morning, and didn't think anything of it because she was focused on the short acting (regular) insulin at that point. The NP stated that she was not feeling comfortable with the situation but at that time didn't put it all together. The NP stated that she had a knot in her stomach and at approximately 1:00 am, she called the resident's physician to discuss the situation because "something just wasn't right." The NP reviewed her cellular phone call history and stated she got the call from the facility at 12:27 am on [DATE]. During an interview on [DATE] at 1:30 pm, Resident #1's physician stated that he received a call from the NP at approximately 1:00 am on [DATE] advising him that Resident #1 was found with a blood sugar of 17 and that she had expired. The physician stated that the following morning, he was informed that Resident #1 was administered 3 units of regular insulin with a blood sugar of 66 around suppertime. The physician stated that it wasn't until LPN #2 approached him on the nursing floor to discuss Resident #1 in the late afternoon that he was informed that 56 units of [MEDICATION NAME] instead of 6 was administered by RNS #1, in error, on the morning of [DATE]. The physician stated that, that medication error, the 56 Units of [MEDICATION NAME], instead of the ordered 6 Units, was a major cause in the resident's death. During an interview on [DATE] at 2:00 pm, RNS #1 stated that she was the RNS and was assigned to a medication cart on the 11:00 pm ([DATE]) to 7:00 am shift on [DATE]. RNS #1 stated that at approximately 6:30 am, a half hour later than usual, she tested Resident #1's FSBS, which was 88. RNS #1 stated that she figured that because she was a little later than usual, a blood sugar of 88, only two points below the parameter of 90, was not cause for concern. and gave the resident her other medications in applesauce to make sure she had enough nourishment before breakfast. RNS #1 stated that she did not contact the resident's physician and proceeded to administer the resident's [MEDICATION NAME]. RNS #1 stated that she administered 56 units of [MEDICATION NAME] to the resident after reading what she thought was a 5 and a 6. RNS #1 stated that she checked the MAR against the box containing the [MEDICATION NAME], noting the resident's name and the name of the medication. RNS #1 stated that she did not read the order on the box which stated "inject 6 units (S.Q.) every morning". RNS #1 stated that when she returned to work between 10:50 pm and 11:00 pm on [DATE], she was alerted that the resident was unresponsive, and her blood sugar was "15". RNS #1 stated that after the resident had expired, she discussed with nursing staff that she had given 56 units (of [MEDICATION NAME] insulin) earlier that morning. RNS #1 stated that she did not know of the [MEDICATION NAME] error until she was contacted by the DON on [DATE] at around 5:00 pm. The DON asked her how many units she had administered, and when she said 56, the DON stated that the physician order [REDACTED]. During an interview on [DATE] at 3:30 pm, LPN #1 stated that she was the nurse who took the physician order [REDACTED]. LPN #1 stated that normally she would yellow out the old order on the MAR and start a new entry, however, it was a busy day, so she just wrote a 6 over the 5 on the MAR. LPN #1 stated that the order should have been verified by the night nurse, which did not occur. The facility was able to remove the Immediate Jeopardy prior to exit by: convening the Quality Assurane team to determine the root cause of the medication error, re-educating 100 percent of licensed staff in transcription of orders, physician notification, and medication administration; insulin competencies were performed on all nurses that administer medication, a glycemia competency has been performed on all licensed staff; all medexs were audited to ensure accuracy with all physicians orders, all diabetic orders are reviewed daily to ensure accuracy; all residents receiving a fingerstick blood sugar will be audited each shift to ensure physician parameters were followed. Additionally, a reference guide for all types of insulin has been added to each medication cart. The Administrator/Director of Nurses reviews each incident report daily to ensure completeness and appropriatenessof actions taken, including physician notification. 10 NYCRR 415.12

Based on record review and staff interviews during an abbreviated survey (Case # NY 49), the facility failed to ensure that the physician was immediately informed when there was a significant change in the resident's physical status for 2 (#s- 1 and 2) of 3 residents reviewed. Specifically, the facility failed to notify the physician when Resident #1 and Resident # 2 experienced low blood sugars. This resulted in actual harm for Resident #1 and no actual harm for Resident #2 that was Immediate Jeopardy to the Health and Safety of the residents. The facility was able to remove the immediacy prior to exit. This is a repeat deficiency from the recertification survey of ,[DATE]. This is evidenced by: Facility Policy and Procedure titled "Notification of Changes" last revised ,[DATE] documented that the resident's physician must be notified immediately when there is a decline in the resident's health condition or a need to alter treatment significantly. Facility Policy and Procedure titled "[DIAGNOSES REDACTED]: Management of" (undated) documented that the physician's orders [REDACTED]. Resident #1: Resident #1 was readmitted to the facility on [DATE] diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident with moderate cognitive impairment. Physician order [REDACTED]. [MEDICATION NAME] 5 units every morning and Regular insulin 3 units subcutaneously (S.Q.) at dinner time. Comprehensive Care Plan for a [DIAGNOSES REDACTED].#1 is an insulin dependant diabetic with the documented goal of maintaining normal blood glucose levels through approaches that included: monitor fingerstick blood sugars per physician orders, monitor for signs and symptoms of hypo/[MEDICAL CONDITION] and follow policy, and to administer insulin as ordered. During an interview on [DATE] at 2:00 pm, Licensed practical nurse (LPN) #2 stated that on [DATE] at approximately 5:00 pm, she checked Resident #1's blood sugar which was 41. LPN #2 stated that because she has a diabetic family member, she did not contact the resident's physician, instead she attempted to raise the resident's blood sugar, LPN #2 stated that she gave Resident #1 cranberry juice and thickened milk, waited 10 minutes and retested the resident's blood sugar, which at that time was 66 and she administered 3 units of regular insulin. LPN #2 stated that she gave the resident her dinner tray and encouraged her to eat. LPN #2 stated that she informed Registered Nurses Supervisor (RNS) #2 that the resident's blood sugar was 66 however did not report the previous blood sugar of 41. She stated that RNS #2 asked if the resident had her dinner tray and what else had she been given, to which LPN #2 responded, cranberry juice and thickened milk. LPN #2 stated that she removed the resident's meal tray at 6:30 pm noting that she consumed approximately 360 milliliters of fluids and very little, if any food. LPN #2 stated she did not recheck the resident's blood sugar. LPN #2 stated that at approximately 11:00 pm, she was alerted by a Certified Nurses Assistant (CNA) that the resident was not responding to her as usual. LPN #2 stated that she responded to Resident #1's room and found the resident with her head down, unresponsive and twitching. LPN #2 stated she tested her blood sugar, which was 17. LPN #2 stated immediate efforts were made to raise Resident #1's blood sugar and 911 was called. During an interview on [DATE] at 9:00 am, RNS #2 stated that on [DATE] at approximately 5:20 pm, she passed Resident #1's room and was informed by LPN #2 that the resident's blood sugar was 66. RNS #2 stated that she told LPN #2 to give Resident #1 milk and try to get her to eat. RNS #2 stated that she was informed by LPN #2 that the resident drank two glasses of thickened milk and one glass of thickened cranberry juice and RNS #2 noted that Resident #1's dinner tray was in front of her. RNS #2 stated that she was not advised that the resident's blood sugar was 41. RNS #2 stated she did not contact the resident's physician nor did she direct or ensure that LPN #2 had. RNS #2 stated she had not heard anything further about the resident until 11:00 pm when a CNA reported that the resident was not responding to her as usual. RNS #2 stated when she responded to the resident's room, she was advised that the resident's current blood sugar was 17. During an interview on [DATE] at 1:30 pm, Resident #1's physician stated that he was not notified of Resident #1's blood sugar of 88 at 6:00 am on [DATE], nor was he notified of the resident's blood sugar of 41 or subsequent 66 at 5:00 pm, and was contacted at approximately 1:00 am on [DATE] from the Nurse Practitioner (NP) that the resident had expired after experiencing a blood sugar of 17. The resident's physician stated that the NP was on-call so the NP should have been contacted. During an interview on [DATE] at 2:00 pm, RNS #1 stated that she was the RNS and was assigned to a medication cart on the 11:00 pm ([DATE]) to 7:00 am shift on [DATE]. RNS #1 stated that at approximately 6:30 am, a half hour later than usual, she took Resident #1's fingerstick blood sugar which was 88. RNS #1 stated that she figured that because she was a little later than usual, a blood sugar of 88, only two points below the parameter of 90, was not cause for concern. and gave the resident her other medications in applesauce to make sure she had enough nourishment before breakfast. RNS #1 stated that she did not contact the resident's physician and proceeded to administer the resident's [MEDICATION NAME]. During an interview on [DATE] at approximately 3:00 pm, the NP stated that she was on-call on [DATE], however, did not receive a call in the morning regarding Resident #1's blood sugar of 88. The NP stated that she examined the resident during the day, noted the blood sugar of 88 and didn't think much of it. The NP stated that she was in the facility until early evening but was not notified that the Resident #1 was noted with a blood sugar of 41 or subsequent 66. The NP stated she received a call from the nursing staff in the late evening on [DATE] that the resident had been found with a blood sugar of 17, had received one dose of [MEDICATION NAME] and were requesting an order for [REDACTED]. The NP stated that Resident #1 had parameters of blood sugars lower than 90 and greater than 300 contact the physician. The NP stated that we do that so we are notified in time to treat the change in condition "before a resident is in real trouble". The NP stated "I am almost sure I was still here in the facility at 5:00 pm, I could have examined the resident, I definitely would not have given the regular insulin." Resident #2 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as cognitively intact. The physician's order [REDACTED]. Sliding scale coverage with Humalog 3 milliliters (ml) vial. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' s blood sugar at 12:00 pm was 52 with " juice " written underneath it. There was no documented evidence the physician was made aware of Resident #2 ' s blood sugar. During an interview on [DATE] at 3:00 pm LPN #4 stated that she gave the resident juice and his blood sugar came up. She further stated she did not notify the physician of the resident ' s low blood sugar reading. During an interview on [DATE] at 3:15 pm the Registered Nurse Manager #3 stated they did notify the physician of the low blood sugar, however it just must not be in the notes. She could not provide any documented evidence the physician was made aware. The facility was able to remove the Immediate Jeopardy prior to exit by: convening the Quality Assurane team to determine the root cause of the medication error, re-educating 100 percent of licensed staff in transcription of orders, physician notification, and medication administration; insulin competencies were performed on all nurses that administer medication, a glycemia competency has been performed on all licensed staff; all medexs were audited to ensure accuracy with all physicians orders, all diabetic orders are reviewed daily to ensure accuracy; all residents receiving a fingerstick blood sugar will be audited each shift to ensure physician parameters were followed. Additionally, a reference guide for all types of insulin has been added to each medication cart. The Administrator/Director of Nurses reviews each incident report daily to ensure completeness and appropriatenessof actions taken, including physician notification. 10 NYCRR 415.3(e)(2)(ii)(b)

Based on medical record review and staff interviews the Quality Assurance (QA) program did not have a program that readily identified issues that had the potential to cause serious harm to residents during an abbreviated survey (NY 830). Specifically, for four (# 1, #2, #3, # 4) of four residents reviewed the QA program did not ensure staff recognized and reported potential abuse of residents resulting in the nursing home not investigating and protect residents from potential recurrence. In addition, the facility does not complete thorough investigations of witnessed accidents and incidents to identify trends and prevent repeat occurrences. This resulted in no actual harm, with the potential for widespread harm that is Immediate Jeopardy for the residents health and safety. This has the potential to effect all of the residents in the facility. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Contracted with experienced consultants to assist in addressing the issues identified by the NYSDOH. The consultant was on site 11/1/13 and will continue to provide frequent services until the facility is deemed back in compliance with State and Federal conditions of participation. 2. Completed the investigation of the incident(s) identified by NYSDOH. As part of the investigation performed a root cause analysis to identify causation factors related to the event. 3. Immediate staff education was provided to assist staff in identifying what constitutes abuse and what actions are required if abuse is suspected. As of Sunday 11/3/13, 93% of the staff have been inserviced. All staff not scheduled to be inserviced prior to beginning their assignment. 4. The incident and accident policy has been reviewed and updated as appropriate. Nursing staff has been inserviced on the facility policy on initiating an incident/accident report. All accidents and incident, witnessed or not witnessed will have an accident/incident report completed. 5. The care plan of the resident involved in the NYSDOH investigation has been reviewed. 6. The Psychologist who regularly follows the resident will review the current behavior plan of the resident noted int he NYSDOH investigation and familiarize the staff as to what appropriate interventions are to be used in response to behavioral episodes. 7. An evaluation of accidents/incidents on 2-South for the last two weeks, will be conducted to determine if behavioral interventions were appropriate and in place at the time of the incident. 8. The Administrator/Director of Nursing services, or designee, will review all accident/incident reports to determine completeness of the report and appropriateness of actions taken. 9 The 24-hour report log will be reviewed by Administrator/Supervisory staff daily to ensure an accident/incident report has been initiated, as appropriate. This was evidenced by: Refer to F 223 scope and severity-L Refer to F 225 scope and severity - L During an interview on 10/30/13 at 1:40 pm, the Assistant Director of Nursing (ADON) stated, if events are witnessed an incident report does not need to be completed. The event should be documented in the nurse notes, a care plan change if necessary should be done. In order to determine if an incident report should be completed she would talk to the staff member to see if it could have been prevented and if it could not have been prevented there would be no incident report. Stated she would not know an incident occurred without the an incident report, there was no other tracking system of incidents/injuries. During an interview on 10/30/13 at 4:00 pm, the Director of Nursing (DON) stated that an incident report did not need to be completed if a staff sees an incident happen and it was not preventable, and a nurse note should be written. DON did say that she would expect an incident report if there was an injury such as a bruise or skin tear or if it was of unknown origin. She did not know where the staff were coming from with not doing incident reports on injuries. During an interview on 10/31/13 at 2:00 pm the Administrator stated the QA Committee meets on a quarterly basis and the attendees include, Administrator, DON, Board Members, Medical Director, Nurse Manager, Infection Control Nurse and line staff are invited. On a monthly basis there is a meeting with the Pharmacy representative and Physicians. I&As are reviewed by the Director of Nursing (DON) for types of events and investigations. A monthly report of the I&A's are printed quarterly and reviewed by the DON, and reviewed again in the QA meetings. The facility is presently working on a new program entitled Safety Matters Program that is taking a new look at the reports of I&As. The facility is also making an Administrative presence (Administrator, DON, or ADON) during the 3:00 pm to 11:00 pm shift and the weekends. Allegations of abuse should be reported to administration immediately and appropriate steps would be taken. He was not aware of incident reports not being done for witnessed incidents. Any incident should trigger an incident report and investigation. 10 NYCRR 415.27(a-c)

Based on medical record review and interviews during an partial extended abbreviated survey (Complaint # NY 830), the facility failed to ensure it was administrated in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administration failed to ensure staff recognize and report potential abuse of residents resulting in the failure by the nursing home to investigate and protect resident from potential recurrence for 4 (# 1, # 2, # 3, #4) of four residents reviewed. In addition, the administration failed to ensure that thorough investigations of witnessed accidents and incidents were completed to identify trends and prevent repeat occurrences for residents. This resulted in actual harm, with the potential for widespread serious harm that is Immediate Jeopardy for the residents health and safety. This has the potential to effect all of the residents in the facility. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Contracted with experienced consultants to assist in addressing the issues identified by the NYSDOH. The consultant was on site 11/1/13 and will continue to provide frequent services until the facility is deemed back in compliance with State and Federal conditions of participation. 2. Completed the investigation of the incident(s) identified by NYSDOH. As part of the investigation performed a root cause analysis to identify causation factors related to the event. 3. Immediate staff education was provided to assist staff in identifying what constitutes abuse and what actions are required if abuse is suspected. As of Sunday 11/3/13, 93% of the staff have been inserviced. All staff not scheduled to be inserviced prior to beginning their assignment. 4. The incident and accident policy has been reviewed and updated as appropriate. Nursing staff has been inserviced on the facility policy on initiating an incident/accident report. All accidents and incident, witnessed or not witnessed will have an accident/incident report completed. 5. The care plan of the resident involved in the NYSDOH investigation has been reviewed. 6. The Psychologist who regularly follows the resident will review the current behavior plan of the resident noted int he NYSDOH investigation and familiarize the staff as to what appropriate interventions are to be used in response to behavioral episodes. 7. An evaluation of accidents/incidents on 2-South for the last two weeks, will be conducted to determine if behavioral interventions were appropriate and in place at the time of the incident. 8. The Administrator/Director of Nursing services, or designee, will review all accident/incident reports to determine completeness of the report and appropriateness of actions taken. 9 The 24-hour report log will be reviewed by Administrator/Supervisory staff daily to ensure an accident/incident report has been initiated, as appropriate. Interviews revealed the facility staff do not complete incident reports/investigations for incidents/events that are witnessed by a staff member. These incidents result in no tracking system for resident incidents, types of incidents, staff involved in incidents and no opportunity to attempt to prevent recurrence. Additionally, staff do not recognize possible incidents of abuse, neglect or mistreatment. This is evidence by five staff members forcibly getting a developmentally disabled Resident into a shower room and completing a shower against the wishes of the resident, and another Resident who reported rough treatment by a Certified Nurse Aide (CNA) that was not investigated. This was evidenced by: Refer to F 223 scope and severity-K Refer to F 225 scope and severity - L During an interview on 10/30/13 at 1:40 pm, the Assistant Director of Nursing (ADON) stated, if events are witnessed an incident report does not need to be completed. The event should be documented in the nurse notes, a care plan change if necessary should be done. In order to determine if an incident report should be completed she would talk to the staff member to see if it could have been prevented and if it could not have been prevented there would be no incident report. Stated she would not know an incident occurred without the an incident report, there was no other tracking system of incidents/injuries. During an interview on 10/30/13 at 4:00 pm, the Director of Nursing (DON) stated that an incident report did not need to be completed if a staff sees an incident happen and it was not preventable, and a nurse note should be written. DON did say that she would expect an incident report if there was an injury such as a bruise or skin tear or if it was of unknown origin. She did not know where the staff were coming from with not doing incident reports on injuries. During an interview on 10/31/13 at 2:00 pm the Administrator stated he was not aware of incident reports not being done for witnessed incidents. Any incident should trigger an incident report and investigation. I&As are reviewed by the Director of Nursing (DON) for types of events and investigations. Allegations of abuse should be reported to administration immediately and appropriate steps would be taken. Administrator was not aware of Resident # 1's shower of 10/10/13 and stated it was inappropriate for five staff members to have given that shower. Resident # 2's allegation should have been reported to the Registered Nurse Supervisor (RNS) and Administration, and an investigation should have taken place. 10NYCRR 415.26

Based on record review, observation and staff interview during a partial extended abbreviated survey (Complaint # NY 830), the facility failed to thoroughly investigate and report to the DOH all alleged violations involving abuse, neglect, and mistreatment, including injuries of unknown origin for 4 (Resident #s 1, 2, 3, 4) of 4 residents reviewed. Specifically, the facility does not complete thorough investigations of witnessed accidents and incidents to identify trends and prevent repeat occurrences. This resulted in no actual harm, with the potential for widespread serious harm that is Immediate Jeopardy and Substandard Quality of Care for the residents health and safety. This has the potential to effect all of the residents in the facility. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Contracted with experienced consultants to assist in addressing the issues identified by the NYSDOH. The consultant was on site 11/1/13 and will continue to provide frequent services until the facility is deemed back in compliance with State and Federal conditions of participation. 2. Completed the investigation of the incidents identified by NYSDOH. As part of the investigation performed a root cause analysis to identify causation factors related to the event. 3. Immediate staff education was provided to assist staff in identifying what constitutes abuse and what actions are required if abuse is suspected. As of Sunday 11/3/13, 93% of the staff have been inserviced. All staff not inserviced are scheduled to be inserviced prior to beginning their next assignment. 4. The incident and accident policy has been reviewed and updated as appropriate. Nursing staff has been inserviced on the facility policy on initiating an incident/accident report. All accidents and incident, witnessed or not witnessed will have an accident/incident report completed. 5. The care plan of the resident involved in the NYSDOH investigation has been reviewed for appropriateness. 6. The Psychologist who regularly follows Resident #1 will review the current behavior plan of the resident noted in the NYSDOH investigation and familiarize the staff as to what appropriate interventions are to be used in response to behavioral episodes. 7. An evaluation of accidents/incidents on 2-South for the last two weeks, will be conducted to determine if behavioral interventions were appropriate and in place at the time of the incident. 8. The Administrator/Director of Nursing services, or designee, will review all accident/incident reports to determine completeness of the report and appropriateness of actions taken. 9 The 24-hour report log will be reviewed by Administrator/Supervisory staff daily to ensure an accident/incident report has been initiated, as appropriate. P&P entitled Abuse, Mistreatment, Neglect, Misappropriation of Resident Property, Injuries of Unknown Origin dated as revised 02/2008 documented It is the policy of the facility to inform staff that it is their legal obligation to report actual or suspected instances of resident abuse, mistreatment, neglect, misappropriation or resident property, and injuries of unknown origin. Any person who knows or has reasonable cause to believe that a resident has been abused, mistreated or neglected has a duty to report it immediately to the NYSDOH, the person must also report the incident to the Supervisor and to the Administrator. The heading entitled Procedure documented an investigation will be conducted by the facility once there is reasonable cause to believe that abuse, neglect or mistreatment has occurred. The heading entitled Investigation of Actual or Suspected Resident Abuse, Mistreatment, Neglect or Injuries of Unknown Origin documented upon receipt of a report of suspected abuse, mistreatment or neglect, including injuries of unknown source, the Supervisor shall gather the information immediately available to assess the situation. A Registered Nurse (RN) assessment will be conducted immediately and preventative measures will be instituted. The Supervisor should notify the DON and the Administrator of the suspected resident abuse, mistreatment or neglect. P&P entitled Incidents and Accidents and dated as revised 10/8/2008 documented an I&A report is initiated when there is an unexpected, unintended event that can cause a resident bodily injury, when an actual injury has occurred and any incidence involving the behavior of a resident or staff member that poses a threat to a resident or staff member. The heading entitled Purpose documented to ensure adequate and appropriate evaluation and management of all accidents and incidents that occur within the facility. The heading entitled Procedure documented RN to assess and evaluate all residents following an I&A; RN or Licensed Practical Nurse (LPNS) to initiate incident report; RN Manager (RNM) or Nursing Supervisor is to complete investigation; documentation in the nurse notes must include a detailed description of the incident or accident with follow-up assessment and evaluation documented every shift for 72 hours. P&P entitled Skin Tear, Treatment and dated as revised 7/2001 documented its purpose to outline a specific treatment modality for skin tears in order to promote healing and prevent infection and formulate an individualized prevention plan to prevent recurrence. Procedure included use of transparent dressing or steri strips. Documentation included; note treatment and area of skin tear on treatment sheet; document size, location, and reason for occurrence and actions taken in nurse notes; note occurrence on twenty four hour report; and complete incident report with skin tear investigation protocol. Resident # 1: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had severe cognitive impairment with a BIMS score of 1 according to the Minimum Data Set ((MDS) dated [DATE]. Anonymous telephone complaint to the NYSDOH Hotline documented on 10/10/2013 the resident was forced to shower despite his refusal. A nurse and a CAN showered him with his clothes on. This resulted in multiple bruises to his body. Investigation revealed that two LPNs and three CNAs forced a Resident with the [DIAGNOSES REDACTED]. During this incident Resident #1 sustained a significant bruise to his right hand. There was no incident report, monitoring of the right hand, or notification of the shower and/or bruise to the physician, nurse manager or administration. Observation of the Resident on 10/30/13 at 10:25 am and accompanied by the RNM # 1, found the Resident in his room lying in bed with the lights off. Resident did hold his hand out to be visually observed, but did not allow touch. There was evidence of a fading bruise to his right hand that appeared to encompass the posterior hand to the mid portion between the top and middle knuckles. Resident denied pain at that time and stated he sustained the bruise in a fall. There was no documented fall for this Resident. Care plan dated 3/24/11 entitled Behaviors related to (r/t) Mental [MEDICAL CONDITION] as evidenced by (aeb) verbally and physically abusive and yelling out, compulsive behaviors, occasionally refuses care and meals. Interventions included allow resident to go in own room to vent, if refusing care reapproach at a later time. Care plan dated 9/27/11 and entitled Self Care deficits documented needs assist with Activities of Daily Living (DAL) due to mental status and refusal to do own ALS. Approaches included, use staff member who is familiar with resident, offer shower weekly if refuses, give bed bath, provide assistance as needed to complete ALS. Certified Nurse Aide (CAN) Care plan dated 9/24/13 documented Independent for Transfer/Ambulation. Resident alert forgetful; easily agitated, very repetitive and routine oriented, if resident has behaviors be firm in approach. Resident may be hard to understand, get staff who is familiar; use extensive assist with ALS like to get up early. physician progress notes [REDACTED]. Stays in room part of day, not aggressive toward staff or other residents but has history of in past. [DIAGNOSES REDACTED]. Psychologist progress note dated 10/15/13 documented noncompliant with hygiene, self-isolative, sleeps a lot, wants to go home. Plan documented reinforced positive ties with brother, encouraged activities for enjoyment. Psychologist progress note dated 10/24/13 documented self isolative, deteriorating ALS, fears showers because "they took my head off", broke his head. Plan documented reinforced hygiene gains (recent haircut) and encouraged him to be more active and not sleep all day. Nursing progress note dated 10/10/13 at 10:40 PM and signed by LPNS # 1 documented, Resident was incontinent of stool after Milk of Magnesia. Stool on clothes, resident agitated, yelling and hitting the wall, resistive to care. Bruise noted to right hand knuckle. Resident assisted to shower, was able to shower resident, shave and clip fingernails. Resident pleasant at this time, states he feels much better. Also states he would like a shower once a month. There was no further nursing notes until 10/28/13 which documented, seen by Podiatry. There was no incident report completed following the shower and the bruised hand. Twenty Four Hour Report dated 10/10/13 documented on the 3:00 PM to 11:00 PM (evening) shift for Resident # 1, bruise to right hand knuckle. There was no further documentation on twenty four hour report of Resident # 1's shower or bruised hand. Incident Report dated 10/30/13 documented Healing bruise to top of right hand. Description of incident documented bruise found during care on top of right hand. Assessed for pain, measured, put on geri, physician notified, new order for x-ray, care plan updated. Documented under Investigative Protocol included Resident is on aspirin therapy, and Resident has a history of being combative and aggressive. Statement dated 10/10/13 and signed by CAN # 1 documented while showering the patient we noticed a bruise on his hand. The nurse said the bruise was there from blood work or something. (review of Resident laboratory results (labs) revealed no blood draws for labs had been done since 8/2013. During an interview on 10/30/13 at 10:05 am Registered Nurse Manager (RNM) # 1 stated that Resident # 1 did have a past history of violent behaviors and family has been called in to assist when needed. Recently Resident's behavior had become less aggressive but remains a problem with maintaining his hygiene. Resident does come to the nurse station for help when his clothes are dirty. Resident has not been seen by a Psychiatrist, but was seen by a Psychiatry Nurse Practitioner in the past. The facility does have a Psychologist that sees Resident # 1, but the facility does not have a Psychiatrist and the attending physician monitors his Psychiatric medications. RNM stated that the LPNS involved in the shower on 10/10/13 did report to her the following week that Resident # 1 had been very soiled in feces and he was strongly encouraged to shower. RNM did not ask for the LPNS to explain what strongly encouraged meant and was not aware that five people were involved in getting the Resident into the shower. RNM stated she was not aware of the bruise on the right hand. RNM stated that incidents witnessed by staff members are to be documented in the nurse notes and do not require an incident report. Given the size of the bruise it should have been assessed by an RN supervisor (RNS) and an incident report should have been done; the physician should have been notified and the area should have been monitored. During an interview on 10/30/13 at 1:05 PM, RNM # 2 stated that witnessed events did not require incident reports. RNM stated there would sometimes be incident reports completed if there was a skin tear that required physician to be called. During an interview on 10/30/13 at 1:15 PM, CAN # 5 stated it takes four people to shower Resident # 1, one to hold the shower chair, one to hold the shower nozzle, one to wash the body and one to wash the hair. CAN did not assist with the shower on 10/10/13 but saw that the four people had cornered the Resident when he refused the shower and he tried to run away. Resident # 1 refuses care all of the time and always bangs his hands on the walls, but CAN was not aware of a bruise. During an interview on 10/30/13 at 2:10 PM, CAN # 1 stated that Resident #1 was not on their assignment. On the night of 10/10/13 CAN #1 heard Resident #1 screaming and went to help because he is known to get out of control. LPNS # 1 was pleading with him to go to his room to be changed. CAN #1 went into the Resident's room and proceeded to strip and remake the bed while the Resident was walking in and out of the room cursing. There was five people (CAN # 1, CAN # 2 CAN # 3, LPNS # 1, and LPNS # 2) involved in getting the Resident to the shower and no one really touched the Resident but guided him in the shower. Once they stripped his clothes he calmed down and he willingly took the shower. CAN #1 stated he gets out of control frequently and they would usually ignore him until he settles down. CAN #1 did see the bruise during the shower and stated that LPNS # 1 said the bruise was already there. During an interview on 10/30/13 at 2:30 PM LPNS # 2 stated that the Resident #1 was not usually a behavior problem, and she was not aware of any special monitoring for this Resident's behavior. On 10/10/13 the Resident #1 had taken his soiled underwear off, put his pants back on and brought his soiled underwear to the nurse station. LPNS # 1 told him you have to take a shower and Resident #1 said no. While LPNS # 1 was in the room with the Resident, LPNS # 2 and CAN # 1 made the bed. The staff (CAN # 1, CAN # 2 CAN # 3, LPNS # 1, and LPNS # 2) then were standing around the Resident blocking him from moving and guided him in the shower. LPNS # 1 then asked Resident to take his clothes off and he did then sat in the chair. Residents right hand began to bruise right away, LPNS #1 did not remember if RNS assessed the hand. LPNS # 1 asked the RNS if an I&A needed to be done and she was told no, LPNS #1 not aware if the physician was called. Resident # 1 receives a bath or shower once every two months. LPNS # 2 did not feel the shower event was abuse. During an interview on 10/30/13 at 3:00 PM, CAN # 2 stated he was typically assigned to Resident # 1, and that he had calmed down with his behaviors lately. CAN #2 had returned from break after dinner and the Resident was sitting in a chair at the nurse station. The LPNS # 1 told him the Resident needed a shower and Resident #1 was being blocked from moving by LPNS # 1, at which time the Resident ran away. CAN #2 stated that the Resident got scared with the five staff surrounding him. CAN # 2 and another CAN was standing behind the Resident holding his pants and LPNS # 1 had her hands on his left arm and was pulling him towards the shower. While he was being pulled into the shower a third CAN was adjusting the water, the Resident started freaking out while LPNS # 1 was dragging him to the shower. At that point buzzers were ringing and CAN # 2 and LPNS # 2 left. During an interview on 10/30/13 at 3:30 PM, CAN # 8 stated that the 11:00 PM to 7:00 am (night shift) shift would occasionally provide care to Resident #1. To CAN's knowledge, the Resident had not been bathed in approximately three months. CAN had seen on 10/10/13 that five people had circled around the Resident and told him he was taking a shower because he smelled. After the shower there was a big bruise on his hand from above his wrist to his knuckles. During an interview on 10/30/13 at 3:45 PM, CAN # 3 stated on the evening of 10/10/13 Resident # 1 brought his soiled underwear to the nurse station. LPNS # 1 and LPNS # 2 tried to get him into his room by calling for him. Resident #1 kept walking from his room to the chair at the nurse station, and she blocked the female residents sitting in the hall so he could not go near them. At one point he went into his room and hit something, not sure if he had a bruise or not. It was a tough situation trying to get him into the shower. CAN #3 stated he was not pulled into the shower, the staff (CAN # 1, CAN # 2 CAN # 3, LPNS # 1, and LPNS # 2) were walking with him to the shower. During an interview on 10/30/13 at 4:00 PM, the Director of Nursing (DON) stated that an incident report did not need to be completed if a staff sees an incident happen and it was not preventable, and a nurse note should be written. DON did say that she would expect an incident report if there was an injury such as a bruise or skin tear or if it was of unknown origin. She did not know where the staff were coming from with not doing incident reports on injuries. During an interview on 10/31/13 at 8:20 am the ADON stated that she was not aware of the shower on 10/10/13 that took place. This past Friday (10/25/13) she heard the Psychologist talking to the Social Worker about Resident # 1 and that he complained that someone took his head off with the shower. ADON then summoned LPNS # 1 to speak with the Psychologist. The LPNS stated she had recently given the Resident a shower and when the Psychologist asked the LPNS if she put her hands on him she stated no, there were no issues with the shower. ADON stated the Resident had not had another shower since that one and she did have a concern that his skin was not being monitored regularly. She stated the RNM involves the family when needed to deal with the Resident. During an interview on 10/31/13 at 10:15 am, LPNS # 1 stated that four to six months ago Resident # 1 did allow care, but then he changed in recent months for the worse and started not letting CNAs clean him. On 10/10/13 in the early part of the shift she had given the Resident Milk of Magnesia (laxative) because he complained of a stomach ache and this was a physician order. He came out of the room later and had feces all over him, the LPNS went into his room and put a chair in front of the sink. The Resident became upset and was hitting his arms against the wall in his room and went out to the nursing station. While he was in the hall hitting the wall the other nurse and the three CNAs heard the commotion and came to help. Stated the five people bordered him while he was screaming, and told him we were going to take a shower. Stated two CNAs had him by his pants in the back guiding him into the shower and she was in the front of him with supplies in her hands and not touching the Resident. Once the Resident was in the shower he calmed down almost immediately and allowed the shower and shave. Upon review of the events LPNS # 1 stated that at one point she did have her hands on his arms. LPNS #1 stated the Resident's hand started to swell within minutes of hitting the wall and then he continued to hit the wall. After the shower the LPNS offered to place ice on the Resident's hand but he refused. The RNS came onto the floor after the shower and the LPNS told her about his right hand at which time the RNS looked at his hand and asked him how it felt. Resident showed her his hand but then took it back. An incident report was not done, stated the RNS said it was not needed because it was witnessed. LPNS told RNM # 1 the next day that she had gotten the Resident to take a shower. LPNS was "almost positive" she told the RNM about banging his hand. LPNS stated that it had been over a month prior to 10/10/13 that the Resident had a bath, and that he had not been bathed since the 10/10/13 shower. The LPNS stated that she did not feel that the shower could be considered abusive. During an interview on 10/31/13 at 10:50 am, RNM # 1 stated she was not sure what day she was told about the shower but she was not told about the bruise to his hand. LPNS # 1 told the RNM that Resident # 1 was full of stool and had to strongly encourage Resident # 1 to take a shower. It did not occur to the RNM to look into the shower further, or to question about what strongly encouraged meant. Resident usually gave up after being asked to do something over and over. Resident was given MOM because he complained of a stomach ache, this order was written because they did not know how much he goes every day and if he complained the MOM and subsequent bowel movement would relieve his discomfort. If the RNM had known about the bruise to his right hand she would have assessed it, notified the physician and updated the care plan. The Resident used to bathe once per day at 4:00 am, she had no recollection in changes of him. RNM would keep encouraging him to wash when needed and would get family, psychology and physician involved. RNM not aware of any other resources that could be used to help in dealing with the Resident's behavior. During an interview on 10/31/13 at 12:25 PM the Psychologist stated that the Resident did mention a shower to her during a session after 10/10/13 but she did not know when he was referring to. She would talk to him about showers and the Resident said he took a shower and they chopped my head off. Psychologist felt this was possibly a long time ago and maybe the reason for him not wanting to bathe. Psychologist spoke with the RNM # 1 and the ADON to ask them if they were aware of any problem with a shower and also talked to LPNS # 1 who told her the Resident was fine with her (LPNS # 1) and had no problems with him. The facility will utilize the brother as needed to assist with the Resident's behaviors and they try to have staff members care for him, that are closer to him. The Resident does not like to have anyone in his space. Psychologist is comfortable with his plan of care, that he seems to be comfortable although seems depressed and hopeless. The facility has no Psychiatrist and he should probably have a Psychiatrist to review him, as a Psychologist is not qualified to advise on medications. During an interview on 10/31/13 at 12:50 PM the DON stated Resident # 1 should not have had a shower using five people, he should have been encouraged to go to his room until he calmed down. Staff should have approached him and left him alone to reapproached later. DON would have expected an incident report to have been done for the shower event and injury to his hand, and for the physician to have been notified. A large bruise with swelling should have been assessed and monitored. During an interview on 10/31/13 at 1:00 PM, RNS stated that an injury to a Resident should be reported to the RNS. She stated if an incident is witnessed an I&A is not required to be done. RNS stated she was not aware of the shower that took place on 10/10/13, but she remembers the bruise to his hand, and was told he hit his hand on the wall. RNS stated she looked at the hand and the Resident was able to move his hand, he told her he hit his hand on the wall. RNS stated if she had seen the five people scenario of the shower she would have stopped it, Resident is difficult but they cannot do that. They should have called the RNS. During an interview on 10/31/13 at 1:25 PM the Director of Social Work stated that the problem with Resident # 1 refusing care and showers was a long standing problem. Social Worker stated that she will try to deal with him when he gets agitated and that he does not like someone to come close to him. In response to the question how should the staff have dealt with the Resident she stated he is tough, and he was looking really rough and he needed a shower. Social Worker stated Resident had been seen by a Psych Nurse Practitioner in the past but the facility only had a Psychologist that comes in at this time. The facility has not had a Psychiatrist in years, and that the attending physicians monitor all the medications themselves. Resident # 2: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had moderate cognitive impairment with a BIMS score of 7 according to the Minimum Data Set ((MDS) dated [DATE]. During the abbreviated survey it was revealed that Resident # 2 had reported to CAN # 2 that CAN # 6 was rough with him, and hit him on the back of the head, the Resident stated that he did not want CAN # 6 to take care of him. CAN # 2 did report this to the LPNS on duty who stated she went and spoke to the Resident, did not feel there was anything to the complaint and did not report the complaint to the RNS. Subsequently, no investigation took place into the complaint. During an interview with the Resident by the DOH investigator the Resident stated that CAN # 6 was rough with him during care, that she had taken him to the shower and afterwards placed him in the hall with no clothing or other covering, and that she refused to push his wheelchair to other areas and that he was unable to do so himself. There was no exact timeline as to when this occurred, other than within the last month. Observation of the Resident on 10/31/13 at 9:20 am found him sitting in his room in a wheelchair; he appeared clean and well groomed with appropriate clothing on. He was a pleasant gentleman and was willing to speak with me in the privacy of his room with the door shut. When asked if he had complained to anyone about a staff member in the recent past he stated that he had talked to CAN # 2 about it. He said the girl was on the heavy side, white with brown hair and that she was rough with him. She did not hurt him because he can take a lot. Resident complained that she would take him somewhere with his wheelchair, leave him and not come back to help him. He stated that she pushed him out of the shower naked and he just sat there naked. Resident was asked if there was a towel or sheet around him and he responded she left me in the hallway with no clothes on. Care plan dated 6/1/12 entitled Self Care Deficits documented Resident is alert and oriented X 3, short term memory intact, adequate vision, and needs assist with Activity of Daily Living (DAL), due to weakness, non ambulatory, [MEDICAL CONDITION] joint disease and [MEDICAL CONDITION]. Interventions included, encourage resident to participate in self care, allow time for resident to complete tasks, and provide range of motion (ROM) as per therapy recommendations. Care plan dated 5/31/12 entitled Resident PT/OT Care Plan documented Self care with assist, transfers with assist of one person with rolling walker as tolerated, wheelchair mobility with staff assist. Interventions included, encourage resident to participate in self care and provide assistance when needed, encourage resident to self propel wheelchair to/from activities/dining room, ambulate resident as tolerated two to three times per day with assistance and rolling walker. Review of Social Work progress notes from 5/31/12 through 8/31/13 did not contain any notes in reference to the Resident complaining of a staff member. Review of nursing progress notes from 7/16/13 through 10/15/13 revealed there was no documentation in regards to Resident # 2's complaint. Nursing Summary/Care Plan review dated 9/13/13 documented; alert, occasionally confused; able to make needs known; one assist with ALS and transfers with rolling walker. Physician 60 Day Renewal dated 9/11/13 documented, doing well, no new problems or concerns, mood seems okay, enjoys company and being outside. During an interview on 10/31/13 at 9:15 am CAN # 7 stated she heard Resident # 2 state he had a problem with a CAN, and he said I told them a long time ago that she was not good. It was about a month ago and that she did tell the charge nurse what she had heard. During an interview on 10/31/13 at 10:45 am LPNS # 1 stated that a CAN told her that the Resident said another CAN was being rough with him. LPNS #1 went and spoke to the Resident and asked him what was going on and he denied the report and said everything was fine. LPNS stated she did not report what the CAN told her to anyone else because she did not think anything about it. She stated that she told the CAN to report it to the RNS. LPNS denied receiving a written statement from the CAN. During an interview on 10/31/13 at 12:50 PM the DON stated that she had no recollection of Resident # 2 making a complaint to a staff member. If she would have known the Resident would have been interviewed as well as staff members and the accused would have been removed from working until the investigation was complete. DON should have been told about this complaint. During an interview on 10/31/13 at 1:00 PM RNS stated she had never heard anything about Resident # 2 complaining about a CAN. RNS would have called the DON at home for a complaint like that, and would have sent the accused CAN home. During an interview on 10/31/13 at 3:00 PM, CAN # 2 stated while the Resident was telling him about another CAN being mean to him that LPNS # 1 was standing outside the doorway and heard the conversation. The Resident stated that CAN # 6 was really mean to him, kicked the bed, and yanked him around while yelling and cursing at him. He also complained that she "knucked" (a short push with one hand) him on the back of his head. CAN # 2 stated that he found a butter knife under the Resident's pillow that night and the CAN reported this to the LPNS # 1. CAN stated he was told to write a statement which he did that night and told LPNS # 1 that he left it on the desk. Resident # 3: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had severe cognitive impairment with a BIMS score of 0 according to the MDS dated [DATE]. During the abbreviated survey, a review of the twenty four hour report sheets dated 9/17/13 revealed that Resident # 3 sustained a skin tear to his left hand and steri strips were applied. There was a nurse note that the incident which resulted with the skin tear was witnessed. There was no incident report, no treatment/monitoring added to the treatment kardex, and no subsequent nurse notes or twenty four hour report notations. There was no evidence that the skin tear was ever monitored. Care plan dated 10/4/13 and entitled Dementia impaired cognition with impaired short term memory, impaired long term memory and impaired decision making. Interventions included, offer simple choices, provide a homelike environment. Care plan dated 10/4/11 and entitled Self Care Deficits, documented needs assist with ALS. Interventions included, encourage resident to participate in self care, allow time for resident to complete tasks, and give assistance as needed. Nursing progress note dated 9/18/13 at 5:45 am documented resident was observed by CAN and nurse when he hit his left hand on his bed, small skin tear on left hand, steri strip applied. There was no subsequent progress notes in regards to the skin tear. Twenty four hour report sheet dated 9/18/13 documented, left hand small skin tear, steri strip applied. There were no subsequent notations on twenty four hour report sheets. Treatment kardex dated September 2013 did not have a documented treatment for [REDACTED]. There was no incident report completed for the skin tear. There was no evidence of physician notification of the skin tear or physician order [REDACTED]. During an interview on 10/30/13 at 1:05 PM, RNM # 1 stated if the nurse and CAN saw the incident that caused the skin tear that it only had to be charted in the nurse notes and an incident report did not need to be done. RNM was not aware that the skin tear was not placed on the treatment kardex. During an interview on 10/31/13 at 12:50 PM the DON stated she would have expected an incident report to have been completed for the skin tear. DON was not aware that an incident report and a treatment transcribed onto the kardex was not done for Resident # 3's skin tear. During an interview on 10/31

Based on record review and staff interview during a partial extended abbreviated survey (Complaint # NY 830), the facility failed to ensure a Resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion for 2 (# 1, # 2) of 4 Residents reviewed. Specifically, five staff forcefully showered a developmentally disable resident (Resident #1) against his will. Additionally, Resident #2 reported being treated roughly and being left naked in the hallway, by a Certified Nurse's Assistant (CAN). A second CAN reported the incident to the charge nurse, who dismissed the report after interviewing the resident. This resulted in actual harm, with the potential for widespread serious harm that is Immediate Jeopardy and Substandard Quality of Care for the residents health and safety. This has the potential to effect all of the residents in the facility. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Contracted with experienced consultants to assist in addressing the issues identified by the NYSDOH. The consultant was on site 11/1/13 and will continue to provide frequent services until the facility is deemed back in compliance with State and Federal conditions of participation. 2. Completed the investigation of the incident(s) identified by NYSDOH. As part of the investigation performed a root cause analysis to identify causation factors related to the event. 3. Immediate staff education was provided to assist staff in identifying what constitutes abuse and what actions are required if abuse is suspected. As of Sunday 11/3/13, 93% of the staff have been inserviced. All staff not inserviced are scheduled to be inserviced prior to beginning their next assignment. 4. The incident and accident policy has been reviewed and updated as appropriate. Nursing staff has been inserviced on the facility policy on initiating an incident/accident report. All accidents and incident, witnessed or not witnessed will have an accident/incident report completed. 5. The care plan of the resident involved in the NYSDOH investigation has been reviewed for appropriateness. 6. The Psychologist who regularly follows the resident will review the current behavior plan of the resident noted in the NYSDOH investigation and familiarize the staff as to what appropriate interventions are to be used in response to behavioral episodes. 7. An evaluation of accidents/incidents on 2-South for the last two weeks, will be conducted to determine if behavioral interventions were appropriate and in place at the time of the incident. 8. The Administrator/Director of Nursing services, or designee, will review all accident/incident reports to determine completeness of the report and appropriateness of actions taken. 9. The 24-hour report log will be reviewed by Administrator/Supervisory staff daily to ensure an accident/incident report has been initiated, as appropriate. Policy & Procedure (P&P) entitled Abuse Prohibition Program, dated as revised 10/2008 documented Kaaterskill Care Skilled Nursing and Rehab has a program in place to prohibit abuse, neglect, or mistreatment, for all residents. The heading Identification of Possible Incidents, Allegations, or Residents at Risk documented the following: The Nursing Manager, in conjunction with the Manager of Activities, will identify those residents at risk for abuse. Indicators as follows, no family members, no visitors, not participating in activities, inability to verbalize, residents that wander; An abuse, neglect, mistreatment assessment form will be done quarterly on all residents to identify residents at risk, those residents identified as at risk will be care planned for; a list will be kept by the Director of Nursing (DON) to cross reference with incident reports and to assess residents on a routine basis; for residents with incidents resulting in injuries (i.e. bruise) of an unknown source, Nursing Supervisor completes an incident report and an investigation form; a staff member or anyone else who alleges that another person is guilty of abuse, mistreatment, neglect or misappropriation of resident property, reports same to his/her Supervisor or DON/Administrator and may report directly to the NYSDOH, Hotline numbers are posted on each unit, at the elevators and reception desk. The heading entitled Prevention documented incident reports will be reviewed to indicate trends (same resident, same staff member, same type incident); Residents identified as at risk for potential abuse, neglect or mistreatment will be monitored on an ongoing basis; ongoing inservice education for all staff members on resident abuse, neglect or mistreatment and related topics. The heading entitled Investigation of Incidents or Allegations documented incident reports are accompanied by an investigation form, which contains a synopsis of the facts. It must be accompanied by written statements from witnesses, the nature and results of the investigation will form the basis for decision to report to other authorities; allegations of abuse, neglect, mistreatment or neglect are investigated by the DON or Administrator promptly upon notification in accordance with applicable requirements. The heading entitled Protection of Residents documented when there is credible evidence that an incident or an allegation of abuse has occurred, resident's psychosocial and physical well-being and response will be monitored. Individual supportive therapy may be provided by Social Worker and a medical exam will be preformed by a physician; in the case where a staff member is named in a potential abuse situation, the staff member will be suspended from duty until investigation completion. P&P entitled Abuse, Mistreatment, Neglect, Misappropriation of Resident Property, Injuries of Unknown Origin dated as revised 02/2008 documented It is the policy of the facility to inform staff that it is their legal obligation to report actual or suspected instances of resident abuse, mistreatment, neglect, misappropriation or resident property, and injuries of unknown origin. Any person who knows or has reasonable cause to believe that a resident has been abused, mistreated or neglected has a duty to report it immediately to the NYSDOH, the person must also report the incident to the Supervisor and to the Administrator. The heading entitled "Procedure" documented an investigation will be conducted by the facility once there is reasonable cause to believe that abuse, neglect or mistreatment has occurred. The heading entitled Investigation of Actual or Suspected Resident Abuse, Mistreatment, Neglect or Injuries of Unknown Origin documented upon receipt of a report of suspected abuse, mistreatment or neglect, including injuries of unknown source, the Supervisor shall gather the information immediately available to assess the situation. A Registered Nurse (RN) assessment will be conducted immediately and preventative measures will be instituted. The Supervisor should notify the DON and the Administrator of the suspected resident abuse, mistreatment or neglect. Resident # 1: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had severe cognitive impairment with a BIMS score of 1 according to the Minimum Data Set ((MDS) dated [DATE]. Anonymous telephone complaint to the NYSDOH Hotline documented on 10/10/2013 that the resident was forced to shower despite his refusal. A nurse and a CAN showered him with his clothes on. This resulted in multiple bruises to his body. Investigation revealed that on 10/10/13 during the evening shift, two LPNs and three CNAs forced a Resident with the [DIAGNOSES REDACTED]. During this incident the resident sustained [REDACTED]. There was no incident report, monitoring of the right hand, or notification of the shower and/or bruise to the physician, nurse manager or administration. Observation of the Resident on 10/30/13 at 10:25 am and accompanied by the RNM # 1, found the Resident in his room lying in bed with the lights off. Resident did hold his hand out to be visually observed, but did not allow touch. There was evidence of a fading bruise to his right hand that appeared to encompass the posterior hand to the mid portion between the top and middle knuckles. Resident denied pain at that time and stated he sustained the bruise in a fall. There was no documented fall for this Resident. Care plan dated 3/24/11 entitled Behaviors related to (r/t) Mental [MEDICAL CONDITION] as evidenced by (aeb) verbally and physically abusive and yelling out, compulsive behaviors, occasionally refuses care and meals. Interventions included allow resident to go in own room to vent, if refusing care re-approach at a later time. Care plan dated 9/27/11 and entitled Self Care deficits documented needs assist with Activities of Daily Living (DAL) due to mental status and refusal to do own ALS. Approaches included, use staff member who is familiar with resident, offer shower weekly if refuses, give bed bath, provide assistance as needed to complete ALS. Certified Nurse Aide (CAN) Care plan dated 9/24/13 documented Independent for Transfer/Ambulation. Resident alert forgetful; easily agitated, very repetitive and routine oriented, if resident has behaviors be firm in approach. Resident may be hard to understand, get staff who is familiar; use extensive assist with ALS likes to get up early. physician progress notes [REDACTED]. Stays in room part of day, not aggressive toward staff or other residents but has history of in past. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Psychologist progress note dated 10/15/13 documented noncompliant with hygiene, self-isolative, sleeps a lot, wants to go home. Plan documented reinforced positive ties with brother, encouraged activities for enjoyment. Psychologist progress note dated 10/24/13 documented self isolative, deteriorating ALS, fears showers because "they took my head off", broke his head. Plan documented reinforced hygiene gains (recent haircut) and encouraged him to be more active and not sleep all day. Nursing progress note dated 10/10/13 at 10:40 PM and signed by LPNS # 1 documented, Resident was incontinent of stool after Milk of Magnesia. Stool on clothes, resident agitated, yelling and hitting the wall, resistive to care. Bruise noted to right hand knuckle. Resident assisted to shower, was able to shower resident, shave and clip fingernails. Resident pleasant at this time, states he feels much better. Also states he would like a shower once a month. There was no further nursing notes until 10/28/13 which documented, seen by Podiatry. There was no incident report completed following the shower and the bruised hand. Twenty Four Hour Report dated 10/10/13 documented on the 3:00 PM to 11:00 PM (evening) shift for Resident # 1, "bruise to right hand knuckle". There was no further documentation on twenty four hour report of Resident # 1's shower or bruised hand. Incident Report dated 10/30/13 documented Healing bruise to top of right hand. Description of incident documented bruise found during care on top of right hand measurement 9 centimeters (cm) X 4 cm. Assessed for pain, measured, put on geri, physician notified, new order for x-ray, care plan updated. Documented under Investigative Protocol included Resident is on aspirin therapy, and Resident has a history of being combative and aggressive. Statement dated 10/10/13 and signed by CAN # 1 documented while showering the patient we noticed a bruise on his hand. The nurse said the bruise was there from blood work or something. (review of Resident laboratory results (labs) revealed no blood draws for labs had been done since 8/2013. During an interview on 10/30/13 at 10:05 am Registered Nurse Manager (RNM) # 1 stated that Resident # 1 did have a past history of violent behaviors and family has been called in to assist when needed. Recently Resident's behavior had become less aggressive but remains a problem with maintaining his hygiene. Resident does come to the nurse station for help when his clothes are dirty. Resident has not been seen by a Psychiatrist, but was seen by a Psychiatry Nurse Practitioner in the past. The facility does have a Psychologist that sees Resident # 1, but the facility does not have a Psychiatrist and the attending physician monitors his Psychiatric medications. RNM stated that the LPNS involved in the shower on 10/10/13 did report to her the following week that Resident # 1 had been very soiled in feces and he was strongly encouraged to shower. RNM did not ask for the LPNS to explain what strongly encouraged meant and was not aware that five people were involved in getting the Resident into the shower. RNM stated she was not aware of the bruise on the right hand. RNM stated that incidents witnessed by staff members are to be documented in the nurse notes and do not require an incident report. Given the size of the bruise it should have been assessed by an RN supervisor (RNS) and an incident report should have been done; the physician should have been notified and the area should have been monitored. During an interview on 10/30/13 at 1:15 PM, CAN # 5 stated it takes four people to shower Resident # 1, one to hold the shower chair, one to hold the shower nozzle, one to wash the body and one to wash the hair. CAN #5 did not assist with the shower on 10/10/13 but saw that the four people had cornered the Resident when he refused the shower and he tried to run away. Resident # 1 refuses care all of the time and always bangs his hands on the walls, but CAN #5 was not aware of a bruise. During an interview on 10/30/13 at 2:10 PM, CAN # 1 stated that Resident was not on their assignment. On the night of 10/10/13 CAN #1 heard the Resident screaming and went to help because he is known to get out of control. LPNS # 1 was pleading with him to go to his room to be changed. CAN #1 went into the Resident's room and proceeded to strip and remake the bed while the Resident was walking in and out of the room cursing. There were five people (CAN # 1, CAN # 2 CAN # 3, LPNS # 1, and LPNS # 2) involved in getting the Resident to the shower and no one really touched the Resident but guided him in the shower. Once they stripped his clothes he calmed down and he willingly took the shower. CAN #1 stated he gets out of control frequently and they would usually ignore him until he settles down. CAN did see the bruise during the shower. During an interview on 10/30/13 at 2:30 PM LPNS # 2 stated that the Resident was not usually a behavior problem, and she was not aware of any special monitoring for this Resident's behavior. On 10/10/13 the Resident had taken his soiled underwear off, put his pants back on and brought his soiled underwear to the nurse station. LPNS # 1 told him you have to take a shower and the Resident said no. While LPNS # 1 was in the room with the Resident, LPNS # 2 and CAN # 1 changed the bed. The staff (CAN # 1, CAN # 2 CAN # 3, LPNS # 1, and LPNS # 2) then were standing around the Resident blocking him from moving and guided him in the shower. LPNS # 1 then asked Resident to take his clothes off and he did, then sat in the chair. Residents right hand began to bruise right away, LPNS #2 did not remember if RNS assessed the hand. LPNS # 2 asked the RNS if an I&A needed to be done and she was told no, LPNS #1 was not aware if the physician was called. Resident # 1 receives a bath or shower once every two months. LPNS # 2 did not feel the shower event was abuse. During an interview on 10/30/13 at 3:00 PM, CAN # 2 stated he was typically assigned to Resident # 1, and that he had calmed down with his behaviors lately. CAN #2 had returned from break after dinner and the Resident was sitting in a chair at the nurse station. The LPNS # 1 told him the Resident needed a shower and the Resident was being blocked from moving by LPNS # 1, at which time the Resident ran away. CAN #2 stated that the Resident got scared with the five staff surrounding him. CAN # 2 and another CAN were standing behind the Resident holding his pants and LPNS # 1 had her hands on his left arm and was pulling him towards the shower. While he was being pulled into the shower a third CAN was adjusting the water, the Resident started freaking out while LPNS # 1 was dragging him to the shower. At that point buzzers were ringing and CAN # 2 and LPNS # 2 left. During an interview on 10/30/13 at 3:30 PM, CAN # 8 stated that the 11:00 PM to 7:00 am (night shift) shift would occasionally provide care to Resident #1. To CAN's knowledge, the Resident had not been bathed in approximately three months. CAN had seen on 10/10/13 that five people had circled around the Resident and told him he was taking a shower because he smelled. After the shower there was a big bruise on his hand from above his wrist to his knuckles. During an interview on 10/30/13 at 3:45 PM, CAN # 3 stated on the evening of 10/10/13 Resident # 1 brought his soiled underwear to the nurse station. LPNS # 1 and LPNS # 2 tried to get him into his room by calling for him. Resident kept walking from his room to the chair at the nurse station, and she blocked the female residents sitting in the hall so he could not go near them. At one point he went into his room and hit something, not sure if he had a bruise or not. It was a tough situation trying to get him into the shower. CAN #3 stated he was not pulled into the shower, the staff (CAN # 1, CAN # 2 CAN # 3, LPNS # 1, and LPNS # 2) were walking with him to the shower. During an interview on 10/30/13 at 4:00 PM, the Director of Nursing (DON) stated that an incident report did not need to be completed if a staff sees an incident happen and it was not preventable, and a nurse note should be written. DON did say that she would expect an incident report if there was an injury such as a bruise or skin tear or if it was of unknown origin. She did not know where the staff were coming from with not doing incident reports on injuries. During an interview on 10/31/13 at 8:20 am the ADON stated that she was not aware of the shower on 10/10/13 that took place. This past Friday (10/25/13) she heard the Psychologist talking to the Social Worker about Resident # 1 and that he complained that someone took his head off with the shower. ADON then summoned LPNS # 1 to speak with the Psychologist. The LPNS stated she had recently given the Resident a shower and when the Psychologist asked the LPNS if she put her hands on him she stated no, there were no issues with the shower. ADON stated the Resident had not had another shower since that one and she did have a concern that his skin was not being monitored regularly. She stated the RNM involves the family when needed to deal with the Resident. During an interview on 10/31/13 at 10:15 am, LPNS # 1 stated that four to six months ago Resident # 1 did allow care, but then he changed in recent months for the worse and started not letting CNAs clean him. On 10/10/13 in the early part of the shift she had given the Resident Milk of Magnesia (laxative) because he complained of a stomach ache and this was a physician order. He came out of the room later and had feces all over him, the LPNS went into his room and put a chair in front of the sink. The Resident became upset and was hitting his arms against the wall in his room and went out to the nursing station. While he was in the hall hitting the wall the other nurse and the three CNAs heard the commotion and came to help. Stated the five people bordered him while he was screaming, and told him we were going to take a shower. Stated two CNAs had him by his pants in the back guiding him into the shower and she was in the front of him with supplies in her hands and not touching the Resident. Once the Resident was in the shower he calmed down almost immediately and allowed the shower and shave. Upon review of the events LPNS # 1 stated that at one point she did have her hands on his arms. LPNS stated the Resident's hand started to swell within minutes of hitting the wall and then he continued to hit the wall. After the shower the LPNS offered to place ice on the Resident's hand but he refused. The RNS came onto the floor after the shower and the LPNS told her about his right hand at which time the RNS looked at his hand and asked him how it felt. Resident showed her his hand but then took it back. An incident report was not done, stated the RNS said it was not needed because it was witnessed. LPNS told RNM # 1 the next day that she had gotten the Resident to take a shower. LPNS was "almost positive" she told the RNM about banging his hand. LPNS stated that it had been over a month prior to 10/10/13 that the Resident had a bath, and that he had not been bathed since the 10/10/13 shower. The LPNS stated that she did not feel that the shower could be considered abusive. During an interview on 10/31/13 at 10:50 am, RNM # 1 stated she was not sure what day she was told about the shower but she was not told about the bruise to his hand. LPNS # 1 told the RNM that Resident # 1 was full of stool and had to strongly encourage Resident # 1 to take a shower. It did not occur to the RNM to look into the shower further, or to question about what strongly encouraged meant. Resident usually gave up after being asked to do something over and over. Resident was given MOM because he complained of a stomach ache, this order was written because they did not know how much he goes every day and if he complained the MOM and subsequent bowel movement would relieve his discomfort. If the RNM had known about the bruise to his right hand she would have assessed it, notified the physician and updated the care plan. The Resident used to bathe once per day at 4:00 am, she had no recollection in changes of him. RNM would keep encouraging him to wash when needed and would get family, psychology and physician involved. RNM not aware of any other resources that could be used to help in dealing with the Resident's behavior. During an interview on 10/31/13 at 12:25 PM the Psychologist stated that the Resident did mention a shower to her during a session after 10/10/13 but she did not know when he was referring to. She would talk to him about showers and the Resident said he took a shower and they chopped my head off. Psychologist felt this was possibly a long time ago and maybe the reason for him not wanting to bathe. Psychologist spoke with the RNM # 1 and the ADON to ask them if they were aware of any problem with a shower and also talked to LPNS # 1 who told her the Resident was fine with her (LPNS # 1) and had no problems with him. The facility will utilize the brother as needed to assist with the Resident's behaviors and they try to have staff members care for him, that are closer to him. The Resident does not like to have anyone in his space. The Psychologist is comfortable with his plan of care, that he seems to be comfortable although seems depressed and hopeless. The facility has no Psychiatrist and he should probably have a Psychiatrist to review him, as a Psychologist is not qualified to advise on medications. During an interview on 10/31/13 at 12:50 PM the DON stated Resident # 1 should not have had a shower using five people, he should have been encouraged to go to his room until he calmed down. Staff should have approached him and left him alone to reapproached later. DON would have expected an incident report to have been done for the shower event and injury to his hand, and for the physician to have been notified. A large bruise with swelling should have been assessed and monitored. During an interview on 10/31/13 at 1:00 PM, RNS stated that an injury to a Resident should be reported to the RNS. She stated if an incident is witnessed an I&A is not required to be done. RNS stated she was not aware of the shower that took place on 10/10/13, but she remembers the bruise to his hand, and was told he hit his hand on the wall. RNS stated she looked at the hand and the Resident was able to move his hand, he told her he hit his hand on the wall. RNS stated if she had seen the five people scenario of the shower she would have stopped it, Resident is difficult but they cannot do that. They should have called the RNS. During an interview on 10/31/13 at 1:25 PM the Director of Social Work stated that the problem with Resident # 1 refusing care and showers was a long standing problem. Social Worker stated that she will try to deal with him when he gets agitated and that he does not like someone to come close to him. In response to the question how should the staff have dealt with the Resident she stated he is tough, and he was looking really rough and he needed a shower. Social Worker stated Resident had been seen by a Psych Nurse Practitioner in the past but the facility only had a Psychologist that comes in at this time. The facility has not had a Psychiatrist in years, and that the attending physicians monitor all the medications themselves. Resident # 2: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had moderate cognitive impairment with a BIMS score of 7 according to the Minimum Data Set ((MDS) dated [DATE]. During the abbreviated survey it was revealed that Resident # 2 had reported to CAN # 2 that CAN # 6 was rough with him, and hit him on the back of the head, the Resident stated that he did not want CAN # 6 to take care of him. CAN # 2 did report this to the LPNS on duty who stated she went and spoke to the Resident, did not feel there was anything to the complaint and did not report the complaint to the RNS. Subsequently, no investigation took place into the complaint. During an interview with the Resident by the DOH investigator the Resident stated that CAN # 6 was rough with him during care, that she had taken him to the shower and afterwards placed him in the hall with no clothing or other covering, and that she refused to push his wheelchair to other areas and that he was unable to do so himself. There was no exact timeline as to when this occurred, other than within the last month. Observation of the Resident on 10/31/13 at 9:20 am found him sitting in his room in a wheelchair; he appeared clean and well groomed with appropriate clothing on. He was a pleasant gentleman and was willing to speak with me in the privacy of his room with the door shut. When asked if he had complained to anyone about a staff member in the recent past he stated that he had talked to CAN # 2 about it. He said the girl was on the heavy side, white with brown hair and that she was rough with him. She did not hurt him because he can take a lot. Resident complained that she would take him somewhere with his wheelchair, leave him and not come back to help him. He stated that she pushed him out of the shower naked and he just sat there naked. Resident was asked if there was a towel or sheet around him and he responded she left me in the hallway with no clothes on. Care plan dated 6/1/12 entitled Self Care Deficits documented Resident is alert and oriented X 3, short term memory intact, adequate vision, and needs assist with Activity of Daily Living (DAL), due to weakness, non ambulatory, [MEDICAL CONDITION] joint disease and [MEDICAL CONDITION]. Interventions included, encourage resident to participate in self care, allow time for resident to complete tasks, and provide range of motion (ROM) as per therapy recommendations. Care plan dated 5/31/12 entitled Resident PT/OT Care Plan documented Self care with assist, transfers with assist of one person with rolling walker as tolerated, wheelchair mobility with staff assist. Interventions included, encourage resident to participate in self care and provide assistance when needed, encourage resident to self propel wheelchair to/from activities/dining room, ambulate resident as tolerated two to three times per day with assistance and rolling walker. Review of Social Work progress notes from 5/31/12 through 8/31/13 did not contain any notes in reference to the Resident complaining of a staff member. Review of nursing progress notes from 7/16/13 through 10/15/13 revealed there was no documentation in regards to Resident # 2's complaint. Nursing Summary/Care Plan review dated 9/13/13 documented; alert, occasionally confused; able to make needs known; one assist with ALS and transfers with rolling walker. Physician 60 Day Renewal dated 9/11/13 documented, doing well, no new problems or concerns, mood seems okay, enjoys company and being outside. During an interview on 10/31/13 at 9:15 am CAN # 7 stated she heard Resident # 2 state he had a problem with a CAN, and he said I told them a long time ago that she was not good. It was about a month ago and that she did tell the charge nurse what she had heard. During an interview on 10/31/13 at 10:45 am LPNS # 1 stated that a CAN told her that the Resident said another CAN was being rough with him. The LPNS went and spoke to the Resident and asked him what was going on and he denied the report and said everything was fine. LPNS #1 stated she did not report what the CAN told her to anyone else because she did not think anything about it. LPNS #1 denied receiving a written statement from the CAN. During an interview on 10/31/13 at 12:50 PM the DON stated that she had no recollection of Resident # 2 making a complaint to a staff member. If she would have known the Resident would have been interviewed as well as staff members and the accused would have been removed from working until the investigation was complete. DON should have been told about this complaint. During an interview on 10/31/13 at 1:00 PM RNS stated she had never heard anything about Resident # 2 complaining about a CAN. RNS would have called the DON at home for a complaint like that, and would have sent the accused CAN home. During an interview on 10/31/13 at 3:00 PM, CAN # 2 stated while the Resident was telling him about another CAN being mean to him that LPNS # 1 was standing outside the doorway and heard the conversation. The Resident stated that CAN # 6 was really mean to him, kicked the bed, and yanked him around while yelling and cursing at him. He also complained that she "knucked" (a short push with one hand) him on the back of his head. CNA # 2 stated that he found a butter knife under the Resident's pillow that night and the CNA reported this to the LPN # 1. CNA #2 stated he was told to write a statement which he did that night and told LPN # 1 that he left it on the desk. 10 NYCRR 415.4(b)(1)(i)

Based on interview and record review it was determined during the recertification survey the facility did not provide each resident with sufficient fluid to maintain proper hydration for 1 ( #109) of 7 residents reviewed. Specifically the facility did not maintain a system to monitor and record the fluid and dietary intake of residents. Subsequently, Resident #109 was hospitalized for [REDACTED]. This resulted in actual harm for Resident # 109 that is not immediate jeopardy. This is evidenced by the following example: Resident # 109 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) information dated 9/14/12 assessed the resident with severe cognitive impairment and no impairment of ability to understand or to be understood. The MDS also assessed the resident weighed 146 pounds and was 64 inches tall, required limited assistance of one for eating, and required a therapeutic and mechanically altered diet. The Policy and Procedure for Dehydration, Risk/Fluid Restriction, and 24 hour Intake and Output (I/O) dated 06/2001 documented the Dehydration Risk 24 hour Intake and Output Sheet was initiated when the Registered Dietician/Registered Diet Technician documented the resident was at high risk for dehydration. The Dehydration Risk/Fluid Restriction 24 hour I/O is jointly completed by Certified Nursing Assistants (CNA's) and licensed nurses. For residents with dehydration risk fluids are encouraged and nourishments monitored until resident has taken the entire amount. The Annual Nutrition assessment dated [DATE] documented the residents meal intake was poor, the resident received supplements of 8 ounces of Ensure plus with breakfast, lunch, and dinner, supercereal at breakfast, and 2 Cal HN 60 cubic centimeters (cc) at medication pass. The Annual Nutrition Assessment also documented under estimated nutrition needs that Resident # 109 required 1800 calories per day, 51-64 Grams protein per day and greater than 1920 cc/day of fluids. The Comprehensive Care Plan (CCP) for alteration of nutrition dated 12/20/12 documented that Resident # 109 had an alteration in nutrition, with a goal of consuming greater than 75% of all foods and fluids and will experience no signs or symptoms dehydration. The intervention section of the CCP documented to monitor daily intake, encourage to drink fluids, and monitor for signs and symptoms dehydration. Laboratory data dated 12/18/11 documented that Resident # 109 BUN was 14 (normal levels 7-18 milligrams/deciliter-mg/dL and creatinine 1.1 (normal level 0.6- 1.3 mg/dL). A nurses note dated 12/17/12 documented by mouth (po) fluids were encouraged and will continue to monitor. Nurses notes dated 1/1/13 documented that Resident # 109 refused breakfast and drank only 1/4 of the Ensure. Nurse's note dated 1/2/13 documented 50% of dinner was eaten with much encouragement. The next note available was on 1/11/13 at which time it was documented that Resident # 109 had very poor fluid intake, poor hydration, and that a call was placed to the resident's daughter to see if she (resident's daughter) wanted intravenous hydration. Nurses' note dated 1/11/13 documented a call was made to the physician with a new order received to discontinue [MEDICATION NAME] and obtain an urinalysis, urine for culture and sensitivity, basic metabolic panel, Serum [MEDICATION NAME]-Pyruvic Transaminase(SGPT), and Serum [MEDICATION NAME]-Oxalocetic Transaminase (SGOT). Resident #109 was taking fluids with encouragement, and Resident # 109 was started on intake and output. Nurses' notes further documented at 2:30pm that Resident # 109 was incontinent of moderate amount of stool. Resident # 109 then had a straight catheter placed in the urinary bladder for drainage of urine with returns of approximately 50 milliliters (mL) of creamy, foul smelling urine, a urinalysis and urine for culture and sensitivity was obtained and awaiting transport to laboratory for analysis. The nurses' note dated 1/11/13 further documented the physician called regarding laboratory results, at which time the physician stated Resident #109 had a high BUN level (over 100), the physician was concerned with the resident being in [MEDICAL CONDITION] or having a bleed. The resident' was transferred to the hospital. A physician's note dated 12/27/12 documented that the nurses reported the resident was slightly better functionally and more comfortable in relation to anxiety. The physician note documented he (the physician) will continue medications and that the [MEDICAL CONDITION] stimulating hormone (TSH) slightly better. The physician' s note further documented the nurses report more consistency with medications; under the plan section of the note the physician documented 1. continue same dose [MEDICATION NAME], request TSH level in 6 months and 2. continue [MEDICATION NAME] and [MEDICATION NAME]. A physician's note dated 1/3/13 documented that a discussion was held with Resident's daughter and the physician documented [MEDICATION NAME] not adding anything, (and) behavior is better and she (daughter) agrees, will discontinue [MEDICATION NAME]. A physician's note dated 1/15/13 documented the resident was readmitted from the hospital after a 3 day admission for an increased blood urea nitrogen (BUN) and creatinine. The physician's note documented repeat BUN and creatinine was 87/2.7 prior to return to facility. Resident # 109 had been doing better on [MEDICATION NAME] before this admission, less depressed and that the [MEDICATION NAME] was stopped, however, due to lethargy, [MEDICATION NAME] was stopped in hospital. The physician's note further documented under objective findings Resident # 109 alert, sitting, no enlarged nodes, chest clean, abdomen soft without distention, and no [MEDICAL CONDITION]. The assessment section of the physician's note documented [MEDICAL CONDITION], questionably, resolving. A side comment on the physician's note documented looking up [MEDICATION NAME], no side effects of [MEDICAL CONDITION], however, does cause [MEDICAL CONDITION] which might cause [MEDICAL CONDITION] not clear. There was no evidence of documentation of the amount of fluids the resident consumed, percentages of food intake consumed, or the amount of intake from nutritional supplements for the period 12/2012 and 01/2013. Laboratory data dated 01/11/13 collected at 1:40pm completed while in facility documented the resident's BUN at 131 mg/dL and creatinine level at 4.1 mg/dL . Laboratory data dated 1/11/13 at 10:24pm while in hospital emergency room documented BUN 120 mg/dL and creatinine of 3.8 mg/dL. Laboratory data dated 1/12/13 documented BUN at 87 mg/dL and creatinine 2.7 mg/dL. Hospital records dated 1/11/13 documented the resident was admitted to the hospital with [REDACTED]. Hospital records dated 1/12/13 documented the resident received 3 liters of fluids intravenously during her evaluation in the emergency room . During an interview on 2/5/13 at 9:30am CNA # 1 stated the resident was a poor eater from the time of admission, needing much encouragement for intake, and had good days and bad days for intake of food and fluids. CNA#1 stated the resident received Ensure plus three times daily and would only drink a small amount of the Ensure plus. CNA # 1 stated around the first part of 01/2013 the resident was having more bad days than good days and had a reduced intake of fluids and foods. During an interview on 02/06/13 at 10:00 am CNA # 2 stated she worked with this resident on a daily basis, so she was very familiar with the resident. CNA #2 stated I/O would be recorded on the daily assignment sheet. CNA # 2 stated Resident #109 was not on I/O during the time period of late 12/2012 and early 01/2013. CNA # 2 stated the resident needed increased cuing for fluid intake and during the first part of 01/2013 the CNA noted resident's fluid intake was reduced. The CNA stated she could not recall if nursing supervision was aware of the reduced fluid intake. During an interview on 2/5/13 at 1:30 pm the Registered Nurse Unit Manager (RNUM) stated that Resident # 109 would be started on I/O if her intake was noted to be poor consistently. The RNUM stated I/O was not recorded for this resident during 12/2012 and 01/2013. The RNUM stated that I/O and percentage of dietary intake was not started because CNA's and nurses are trained to report when a resident's intake is reduced. The RNUM stated that I/O was started 2 days before the resident was admitted to the hospital. The RNUM stated she was aware the resident had reduced intake during the early part of 01/2013 and the physician was notified of the reduced intake on 1/11/13. The RNUM stated she agreed no documentation was present in the nurses notes from 1/4/13 to 1/11/13. The RNUM stated that the reduced intake was not discussed with the Dietary Technician (DT). During an interview on 2/5/13 at 1:30pm the DT stated there was no recorded tracking of the I/O or percentage of dietary intake for this resident. The DT stated she completed the Annual Nutrition Assessment on 12/14/12 , the resident's appetite and intake was poor and the resident should have been started on I/O at that time. The DT stated that the resident's estimated intake documented on the Annual Nutrition assessment dated [DATE] was greater than 1920 cc' per day. The DT stated that there was no way to determine the percentage of intake, as noted on the CCP for alteration in nutrition or monitor if that amount was actually being consumed. The DT stated that monitoring of intake was noted based on observations of the CNA's, nurses, and twice a week when the DT would observe meal intake. The DT stated the resident's intake should have been accurately recorded. The DT stated the most accurate way to determine food intake was completion of a 3 day intake study, but information recorded by nursing was often inaccurate and not fully completed. The DT stated she was not aware that the facility policy for initiation of I/O was when the Registered Dietician/Registered Dietetic Technician documented the resident is at high risk for dehydration. During an interview on 2/7/13 at 12:10pm the Registered Dietician (RD) stated that I/O and documentation of percentage of meal intake needed to be recorded. The RD stated there needed to be a visual record implemented for any resident who is at risk for dehydration to properly monitor intake. The RD stated under the current system there was no way to determine if the resident was meeting their goal of 75%. During an interview on 2/7/13 at 12:50pm the Registered Nurse Instructor (RNI) stated staff are trained to observe residents for a reduction in fluid intake and report same to the nurse in charge or the RNUM. The RNI stated that CNA's are trained on orientation to monitor intake and don't receive any more formal training on I/O. During an interview on 2/6/13 at 12:30 pm the Director of Nursing (DON) stated the facility stopped recording dietary intake about 2 years ago. The DON stated there were specific instances when a resident would be placed on I/O, such as when the resident was noted to be at risk for dehydration or when intake was noted to be poor. The DON stated Resident # 109 should have been on I/O to accurately track her intake and obtain a better picture of her hydration status. During an interview on 2/6/13 at 2:00 pm the physician stated he was aware of the resident's reduced intake during 12/2012 and 2013. The physician stated he could not be sure for certain of the reason for the resident's dehydration and acute [MEDICAL CONDITION] on 01/11/13. 10 NYCRR 415.12(j)