Every finding on record at Huntington Hills Center for Health and Rehabilitat

Based on record review and staff interviews, the facility failed to ensure the Minimum Data Set Assessment was completed to accurately reflect each resident's status. This was identified for one (Resident #12) of six residents reviewed for accident and for one (Resident #168) of two residents reviewed for respiratory care. Specifically, 1) Resident #12 had a physician's order for Seroquel (an antipsychotic medication) that was initiated on 02/16/2026; however, the quarterly Minimum Data Set assessment dated [DATE] did not accurately reflect use of an antipsychotic medication by Resident #12. 2) Resident #168 had a physician's order for the use of Bilevel Positive Airway Pressure (a non-invasive ventilator that helps breathing) machine. The admission Minimum Data Set assessment dated [DATE] did not accurately reflect the use of a noninvasive mechanical ventilator by Resident #168. The findings include: The facility lacked documented evidence of policies and procedures related to the Minimum Data Set Assessment including timeliness, completion, accuracy, and submission. A facility letter, written by the facility Administrator, dated 07/17/2026 documented that the facility does not maintain a separate, internal facility policy for the completion of the Minimum Data Set. Instead, the facility officially adopts and strictly adheres to the current centers for Medicare and Medicaid Services Resident Assessment Instrument Version 3.0 Manual as it's governing policy and operational standard. 1 Resident #12 was admitted with diagnoses including non-Alzheimer's dementia (cognitive disorders severe enough to interfere with daily life), anxiety disorder (is a mental health condition characterized by excessive, uncontrollable worry), and bipolar disorder (a mental health condition characterized by significant mood swings). A quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, indicating the resident had severely impaired cognition. The resident did not exhibit any behaviors and did not receive antipsychotic medications since admission/entry or reentry or the prior Omnibus Budget Reconciliation Act Assessment, which ever was more recent. A physician order dated 02/16/2026 documented Seroquel 200 milligrams, 1 tablet by mouth at bedtime for bipolar disorder. During an interview on 07/16/2026 at 2:12 PM, the Minimum Data Set Director stated there are Minimum Data Set Coordinators who complete the assessment. The information for medications is obtained through a review of the medical record, including the Physician orders and the medication administration record. They further stated that either they or the Minimum Data Set Coordinator who completed the document will review the Minimum Data Set for completion and accuracy prior to submission. The Minimum Data Set Director confirmed that the quarterly Minimum Data Set assessment dated [DATE] was inaccurate and did not indicate that psychotropic medications were administered for Resident #12. 2) Resident #168 was admitted with diagnoses including obstructive sleep apnea (a chronic disorder where throat muscles intermittently relax and block the airway during sleep), hypertension (high blood pressure) and chronic kidney disease. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated that Resident #168 had intact cognition. The admission Minimum Data Set assessment documented that Resident #168 had an active diagnosis of obstructive sleep apnea. The admission Minimum Data Set assessment, Section O (Special Treatments, Procedures and Programs) did not document that Resident #168 utilized a non-invasive mechanical ventilator. A Physician's Order dated 06/03/2026 documented Bilevel Positive Airway Pressure machine to be utilized while the resident is sleeping. Apply Bilevel Positive Airway Pressure mask at bedtime and remove the Bilevel Positive Airway Pressure mask in the morning. A review of the Treatment Administration Record revealed that Resident #168 utilized the Bilevel Positive Airway Pressure machine as per the physician's order since 06/04/2026. During an interview on 07/16/2026 at 11:00AM, the Minimum Data Set Director stated that they should have included the noninvasive ventilator in Section O of the admission Minimum Data Set assessment. The Minimum Data Set Director stated that the missing information was an omission on their part. The Minimum Data Set Director stated they should have checked the Minimum Data Set for accuracy. During an interview on 07/16/2026 at 1:39 PM, the Director of Nursing Services stated that all Minimum Data Set assessment should be accurate and reflect the resident's needs and changes in condition. The Director of Nursing Services stated they are not involved with the Minimum Data Set assessments department. During an interview on 07/16/2026 at 2:20 PM, the Administrator stated that they expect the Minimum Data Set assessments are accurate to reflect the resident's needs. The Administrator stated that the facility does not have specific policies related to the Minimum Data Set assessments, they just follow the Resident Assessment Instrument manual. 10 New York Code Rules and Regulations 415.11(b)

Based on observations, record review and interviews, the facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for each resident to meet their medical and nursing needs. This was identified for one (Resident #168) of two resident reviewed for Respiratory Care. Specifically, Resident #168 had a physician's order for a Bilevel Positive Airway Pressure (a non-invasive ventilator that helps breathing) machine. There was no care plan developed to address Resident #168's use of the Bilevel Positive Airway Pressure machine. The findings include:The facility's policy titled. Baseline/Comprehensive Person-Centered Care Plan last revised on 03/2023 documented that a person-centered care plan is developed to include information necessary to properly care for the resident and will address the resident's preferences, goals, desired outcomes, and plan for discharge. Upon admission, respective assessments are completed by identifying functional disabilities and high-risk factors requiring interventions for potential improvement or prevention. Resident #168 was admitted with diagnoses including obstructive sleep apnea (a chronic disorder where throat muscles intermittently relax and block the airway during sleep), hypertension (high blood pressure) and chronic kidney disease. The admission Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score of 15, which indicated that Resident #168 had intact cognition. The admission Minimum Data Set assessment documented that Resident #168 had an active diagnosis of obstructive sleep apnea. The admission Minimum Data Set assessment did not document that Resident #168 needed a non-invasive mechanical ventilator. A Physician's Order dated 06/03/2026 documented Bilevel Positive Airway Pressure machine to be worn while the resident is sleeping. Apply Bilevel Positive Airway Pressure mask at bedtime and remove the mask in the morning. A review of Resident #168's comprehensive care plan did not indicate that Resident #168 required a Bilevel Positive Airway Pressure machine. A review of the Treatment Administration Record revealed that Resident #168 had been using the Bilevel Positive Airway Pressure machine at bedtime since 06/04/2026. During an observation on 07/13/2026 at 10:03 AM, Resident #168 was sitting in their wheelchair, and a Bilevel Positive Airway Pressure machine was stored on the nightstand. During an interview on 07/13/2026 at 10:05 AM, Resident #168 stated that they had been using the Bilevel Positive Airway Pressure machine since their admission to the facility. Resident #168 stated that the nursing staff applied the Bilevel Positive Airway Pressure mask at bedtime and removed the machine during the day. During an interview on 07/16/2026 at 10:27 AM, Registered Nurse #3, the unit charge nurse, stated that there should have been a care plan for the use of the Bilevel Positive Airway Pressure machine. Registered Nurse #3 stated that the registered nurses were responsible for developing the care plans. During an interview on 07/16/2026 at 11:06 AM, Registered Nurse #4 stated that the unit has two Registered Nurses, and they did not know why they missed initiating a care plan for Resident #168's Bilevel Positive Airway Pressure machine use. During an interview on 07/16/2026 at 1:39 PM, the Director of Nursing Services stated that the unit nurses should have initiated a care plan for Resident #168's Bilevel Positive Airway Pressure usage. The Director of Nursing Services stated that they expect all registered nurses to update the care plans to reflect the resident's current clinical status and any changes in care needs.10 New York Code Rules and Regulations 415.11(c)(1)

Based on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #303) of two residents reviewed for Respiratory Care, Labeling Task, and for one (Resident #103) of six residents reviewed for Accident Hazards and one (Unit 1C Medication Room) of four medication storage rooms reviewed for the Medication Storage task. Specifically, 1) On 07/13/2026, one Spiriva inhaler (medication to increases airflow to the lungs) and one Symbicort Inhaler (a combination of two different medications used to reduce swelling and inflammation in the lungs) were observed on Resident #303's bedside table. There were no staff in the vicinity. The resident did not have a physician's order or evaluation for self-administration of any medication. 2) An unlabeled Systane Original (lubricating eye drops to relieve dry eyes) bottle was observed on Resident #103's overbed table. Resident #103 did not have a physician's order for the Systane eye drop or an order to self-administer the eye drops. Additionally, during the medication storage task a medication room in Unit One C had three unlabeled Trulicity (a glucagon like peptide (GLP)-a naturally occurring gut hormone that regulates blood sugar and appetite) pens inside the medication refrigerator. The findings include: An undated facility policy titled Medication Storage documented medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas with access limited to only authorized personnel. Storage areas may include, not limited to, drawers, cabinets, medication rooms, refrigerators, and carts. A facility policy titled, Returns-Overview last revised on 06/25/2025 documented that products that are returned and are creditable to the payor source, may be restocked for re-use by the pharmacy. Returned medications where the pharmacy cannot process returns for the payor will be destroyed or donated. 1) Resident #303 was admitted to the facility with diagnoses including chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues) and chronic obstructive pulmonary disorder (a lung condition caused by damage to the lungs). The admission Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident received oxygen therapy. A comprehensive care plan titled The Resident has Altered Respiratory Status/Difficulty Breathing initiated 05/29/2026 documented interventions including monitoring and documenting abnormal breathing patterns and administering oxygen therapy as per the physician's order. A physician's order dated 05/20/2026 documented to administer Tiotropium Bromide (generic medication name for Spiriva) inhalation solution 2.5 microgram per actuation, inhale two puffs orally, one time a day for Chronic Obstructive Pulmonary Disease. A physician's order dated 05/2026 documented to administer Symbicort Aerosol 160-4.5 microgram per actuation, inhale two puffs orally two times a day for Chronic Obstructive Pulmonary Disease. The Medication Administration Record for 07/2026 documented the Symbicort inhaler and Spiriva inhaler were administered as per the physician's orders on 07/13/2026 at 8:00 AM. A review of the resident's medical record revealed there was no documentation of an evaluation for self-administration of medication and no physician's orders to self-administer any medication. During an observation on 07/13/2026 at 10:22 AM, Resident #303 was observed sleeping in bed with a bedside table positioned in front of the resident. One Spiriva inhaler and one Symbicort inhaler were observed on the bedside table, labeled with Resident #303's information. During an interview on 07/13/2026 at 10:39 AM, Licensed Practical Nurse #1 stated they were the assigned medication nurse for Resident #303. Licensed Practical Nurse #1 stated they gave the resident medications on 07/13/2026 a little after 8:00 AM. Licensed Practical Nurse stated the resident did not have a physician's order to self-administer their own medications and they (Licensed Practical Nurse #1) gave Resident #303 the Symbicort and Spiriva inhalers. Licensed Practical Nurse #1 stated as they finished administering medications to Resident #303', they were called away for a reason they could not recall and left the two inhalers on the resident's bedside table. Licensed Practical Nurse #1 stated they should not have left the inhalers on the bedside table and should have returned them to the medication cart. During an interview on 07/13/2026 at 10:46 AM, Resident #303 stated the medication nurse gave them (Resident #303) the two inhalers in the morning on 07/13/2026. Resident #303 noticed the nurse left the room and left the inhalers on the bedside table. Resident #303 stated they did not use the inhalers after the nurse left the room. During an interview on 07/13/2026 at 11:02 AM, Registered Nurse #1 stated nursing staff should not keep medications at the resident's bedside. If a resident was evaluated to self-administer medication, they would be able to keep their medication in their room in a locked compartment. Resident #303 did not self-administer medication, and Licensed Practical Nurse #1 should not have left the inhalers on the resident's bedside table. During an interview on 07/13/2026 at 1:31 PM, the Director of Nursing Services stated no medications should have been left at Resident #303's bedside. Licensed Practical Nurse #1 should have returned the inhalers to the medication cart before being called away. 2) Resident #103 was admitted with diagnoses including type two diabetes (high blood sugar), hypertension (high blood pressure) and repeated falls. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #103 had intact cognition. The admission Minimum Data Set (MDS) assessment documented an active diagnosis of hypertension. A review of Resident #103's electronic medical record revealed that Resident #103 did not have an order for the Systane original eye drops. A review of Resident #103's electronic medical record revealed that Resident #103 did not have a self-medication evaluation. During an observation on 07/14/2026 at 9:59 AM, Resident #103 was lying in bed. A bottle of Systane original eye drops was on top of Resident #103's nightstand. There was no nursing staff within the vicinity of Resident #103's room. During an interview on 07/14/2026 at 10:00 AM, Resident #103 stated that they had been administering the eye drops for the last five years and they are more than capable of independently administering the medication. Resident #103 stated that the Nurses are aware of the eye drops that they had. During an interview on 07/14/2026 at 10:02 AM, Registered Nurse #2, Medication Nurse, stated that they (Nurses) were not aware that Resident #103 had a bottle of Systane eye drops. Registered Nurse #2 stated that all medications should be locked in the medication cart and Resident #103 did not have an order for a Systane eye drops. -During an observation on 07/14/2026 at 10:15 AM, a medication room in Unit One C was observed with three loose, unlabeled Trulicity pens inside the medication refrigerator. During an interview on 07/14/2026 at 10:22 AM, Registered Nurse #3, Charge Nurse stated that they were not aware that Resident #103 had a bottle of Systane eye drops. Registered Nurse #3 stated that Resident #103 did not have an order for the Systane eye drops. Registered Nurse #3 also stated they were not aware that unlabeled Trulicity pens were in the refrigerator in the medication room. Stated that the Trulicity pens should have been returned to the Nursing office. Registered Nurse #3 stated they were not aware who had an order for Trulicity pens. During an interview on 07/16/2026 at 1:31 PM, the Director of Nursing Services stated that all medications should be locked in the medication cart and that all discontinued medications should be returned to the Nursing office. 10 New York Code Rules and Regulations 415.18(e) (1-4)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00356442 ) initiated on 11/6/2024 and completed on 11/15/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was identified for eight of eight nursing units during the Sufficient Staffing Task. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report Quarter three, 2024 (April 1st- June 30th) and the weekend of 11/9/2024 to 11/10/2024 indicated excessively low weekend staffing; 2) a review of the daily staffing sheets revealed the facility did not provide sufficient number of Licensed Nurses as indicated in the Facility Assessment; 3) during the Resident Council meeting dated 11/7/2024, three of thirteen resident attendees verbalized concerns regarding short staffing on weekends. This is a repeat deficiency. Cross Reference: F 835 Administration F 838 Facility Assessment The findings are: The Facility does not have a Staffing Policy. 1) The Payroll-Based Journal Daily Nurse Staffing Data Report dated for Fiscal Year (FY) Quarter three 2024 (April 1st- June 30th) documented the facility triggered for the Metric of excessively low weekend staffing. The Facility Assessment, dated 2/25/2024 and last reviewed 8/2/2024 documented based on data from several sources including multiple nursing home associations, census-based staffing levels would be approximately one nurse (Registered Nurse or Licensed Practical Nurse) assigned to eight to ten residents and approximately one aide (Certified Nursing Assistant) assigned to ten to fifteen residents. The Facility Assessment further documented: -For a Census of 20 residents with low acuity, there should be two Nurses and three Certified Nurse Assistants; with medium acuity, there should be three Nurses and four Certified Nurse Assistants; and with high acuity, there should be three Nurses and five Certified Nurse Assistants assigned for the 20 residents. -For a census of 30 residents with low acuity, there should be three Nurses and four Certified Nursing Assistants; with medium acuity, there should be four Nurses and five Certified Nurse Assistants; and with high acuity, there should be five Nurses and six Certified Nurse Assistants for the 30 residents. -For a census of 40 residents with low acuity there should be four Nurses and five Certified Nursing Assistants; with medium acuity, there should be five Nurses and six Certified Nurse Assistants; and with high acuity, there should be six Nurses and seven Certified Nurse Assistants for the 40 residents. The Facility Assessment did not include a breakdown of staffing needs for each of the facility's eight units. 2) A review of the facility's Daily Census Reports from 4/1/2024 to 6/30/2024 revealed the following: Unit 1A maintained a census between 31 and 38 on the weekends Unit 1B maintained a census between 26 and 39 on the weekends Unit 1C maintained a census between 22 and 37 on the weekends Unit 1D maintained a census between 38 and 40 on the weekends Unit 2A maintained a census between 38 and 40 on the weekends Unit 2B maintained a census between 34 and 40 on the weekends Unit 2C maintained a census between 39 and 40 on the weekends Unit 2D maintained a census between 37 and 40 on the weekends A review of the daily staffing sheets from 4/1/2024 to 6/30/2024 revealed the following: During the 6:30 AM to 2:30 PM Shift: Unit 1A had one licensed nurse assigned on 5/12/2024. Unit 1B had one licensed nurse assigned on 5/5/2024 and 5/12/2024. Unit 1C had one licensed nurse assigned on 4/13/2024, 4/20/2024, 4/28/2024, 5/12/2024, and 6/9/2024. Unit 1D had one licensed nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 4/27/2024, 4/28/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/18/2024, 5/19/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/8/2024, 6/9/2024, 6/15/2024, 6/16/2024, 6/22/2024, 6/23/2024, 6/29/2024, and 6/30/2024. Unit 2A had one licensed nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 4/27/2024, 4/28/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/18/2024, 5/19/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/8/2024, 6/9/2024, 6/15/2024, 6/16/2024, 6/22/2024, 6/23/2024, 6/29/2024, and 6/30/2024. Unit 2B had one licensed nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 4/27/2024, 4/28/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/18/2024, 5/19/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/8/2024, 6/9/2024, 6/15/2024, 6/16/2024, 6/22/2024, 6/23/2024, 6/29/2024, and 6/30/2024. Unit 2C had one licensed nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 4/27/2024, 4/28/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/18/2024, 5/19/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/8/2024, 6/9/2024, 6/15/2024, 6/16/2024, 6/23/2024, 6/29/2024, and 6/30/2024. Unit 2D had one licensed nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 4/27/2024, 4/28/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/18/2024, 5/19/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/8/2024, 6/9/2024, 6/15/2024, 6/16/2024, 6/22/2024, 6/23/2024, 6/29/2024, and 6/30/2024. During the 2:30 PM to 10:30 PM Shift: Unit 1C had one licensed nurse assigned on 5/12/2024 and 6/8/2024. Unit 1D had one licensed nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 4/27/2024, 4/28/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/18/2024, 5/19/2024, 5/25/2024, 5/26/2024, 6/2/2024, 6/8/2024, 6/9/2024, 6/15/2024, 6/16/2024, 6/22/2024, 6/23/2024, 6/29/2024, and 6/30/2024. Unit 2A had one licensed nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 4/27/2024, 4/28/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/18/2024, 5/19/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/8/2024, 6/9/2024, 6/15/2024, 6/16/2024, 6/22/2024, 6/23/2024, 6/29/2024, and 6/30/2024. Unit 2B had one licensed nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 4/27/2024, 4/28/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/18/2024, 5/19/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/8/2024, 6/9/2024, 6/15/2024, 6/16/2024, 6/22/2024, 6/23/2024, 6/29/2024, and 6/30/2024. Unit 2C had one licensed nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 4/27/2024, 4/28/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/18/2024, 5/19/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/8/2024, 6/9/2024, 6/15/2024, 6/23/2024, 6/29/2024, and 6/30/2024. Unit 2D had one licensed nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 4/27/2024, 4/28/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/18/2024, 5/19/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/8/2024, 6/9/2024, 6/15/2024, 6/16/2024, 6/22/2024, 6/23/2024, 6/29/2024, and 6/30/2024. 3) A Resident Council meeting was held on 11/7/2024 with 13 residents in attendance. 3 of the 13 residents complained about staffing shortage and stated that the nursing staff members were overburdened and therefore, the call bell responses were delayed: - Resident #143 stated stated the facility had been short-staffed, especially on Sundays, and because of the short staffing, they had to wait for 40 minutes to get assistance to use the bathroom. -Resident # 157 stated when they ring their call bell, the staff turns off the call bell without responding to them. -Resident # 145 stated the facility is short-staffed on the weekends and holidays, especially the morning shift. It takes a very long time for them to receive their morning care. Resident #145 stated to use the bathroom, they must wait because they are at the mercy of the staff and this makes them feel very indignified. Resident #145 stated they are awake at 6:00 AM but must wait until 10 AM-10:30 AM to receive their morning care. During an interview on 11/06/2024 at 10:45 AM, the facility Ombudsman stated the facility has low staffing on the weekends. Staffing concern was shared with the facility Administrator and the Director of Nursing Services and they said the facility was hiring and training new staff and the administration will provide enhanced weekend supervision. Low staffing has been a consistent issue since the last survey. The Ombudsman stated the residents have reported they had to wait over two hours to receive incontinence care and the staff members do not respond to call bells in a timely manner. During an interview on 11/15/2024 at 11:09 AM, an anonymous Certified Nursing Assistant # 8 stated the facility has a staffing shortage, especially on the weekends and it is hard to provide necessary care to residents on time. There are a lot of call-outs on the weekends and there is no coverage for those call-outs. During an interview on 11/15/2024 at 11:37 AM, an anonymous Certified Nursing Assistant # 9 stated over the summer, the facility was short-staffed on weekends during the day shift. There were a lot of call-outs and the facility was not able to get staff to cover for the call-outs. During an interview on 11/14/2024 at 10:44 AM, the Staffing Coordinator stated they use the Par (set staffing) levels to staff each unit each shift. The Staffing Coordinator stated that the nursing par levels are not documented anywhere. The Staffing Coordinator stated on the morning shift (6:30 AM- 2:30 PM) Unit 1A and Unit 1B should have four Nurses (Registered Nurses and Licensed Practical Nurses) and five Certified Nursing Aides; Unit 1C should have three to four Nurses (Registered Nurses and Licensed Practical Nurses) and five Certified Nursing Assistants; Unit 1D should have two Nurses (Registered Nurses and Licensed Practical Nurses) and six Certified Nursing Assistants; Unit 2A, 2B, 2C, and 2D should have two Nurses (Registered Nurses and Licensed Practical Nurses) and five Certified Nursing Assistants. On the evening shift (2:30 PM to 10:30 PM) Units 1A, 1B, and 1C should have two Nurses and 4 Certified Nursing Assistants; Unit 1D should have one Nurse and five Certified Nursing Assistants; Units 2A, 2B, 2C, and 2D should have one Nurse and four Certified Nursing Assistants. The Staffing Coordinator stated the staffing on the weekend is lower than the staffing during the weekdays. On the day shift there should be two nurses and five Certified Nursing Assistants for the Unit 1A, 1B, and 1C. Unit 1D should have one Nurse and six Certified Nursing Assistants. Unit 2 A, 2B, 2C, and 2D should have one Nurse and five Certified Nursing Assistants. On the evening shift for Units 1A, 1B, and 1C there should be two Nurses and four Certified Nursing Assistants. Unit 1D should have one Nurse and five Certified Nursing Assistants and Units 2 A, 2B, 2C, and 2D should have one Nurse and four Certified Nursing Assistants. The Staffing Coordinator stated they only work from Monday to Friday and there is no Staffing Coordinator on the weekends. The Nursing Supervisors are supposed to find staff on the weekends when Certified Nursing Assistants or Nurses call out. The facility does not use staffing agencies for Certified Nursing Assistants; however, have contracts with staffing agencies for licensed nurses. The Staffing Coordinator stated they were not told about the required staffing levels documented in the Facility Assessments. During an interview on 11/15/2024 at 2:59 PM, the Administrator stated that the facility Ombudsman had brought staffing concerns to their attention in June 2024. The Administrator met with the Director of Nursing Services and adjusted the staffing levels. The Administrator stated the Facility Assessment does not break down the facility staffing needs per unit per shift. The Administrator stated that the Facility Assessment indicated there should be one Nurse assigned for every 8 to 10 residents and the units should be staffed as per the Facility Assessment. The number of nursing staff assigned on the weekend did not match the number of nursing staff required in the Facility Assessment and they were not aware that on the weekends the facility was staffed with fewer nursing staff than on the weekdays. The administrator stated that the facility was cited for insufficient staffing on the previous survey and therefore, staffing should have been looked into more closely in the Facility Assessment. The Administrator stated the facility does not have a policy on staffing and should be staffed based on the staffing levels documented in the Facility Assessment. The Administrator stated the Staffing Coordinator and the Director of Nursing Services should have been aware of the required staffing levels documented in the Facility Assessment. During an interview on 11/15/2024 at 3:24 PM, the Director of Nursing Services stated they were not aware of staffing levels that were documented in the Facility Assessment (one nurse for 8 to 10 residents) and were not involved in reviewing or revising the staffing portion of the Facility Assessment. The Director of Nursing Services stated that the facility Administrator was made aware of less nursing staff assigned on the weekends than on the weekdays when they discussed the adjusted staffing levels. The Director of Nursing Services stated in the summer, it was difficult to obtain staff on the weekends when the scheduled staff members called out. 10 NYCRR-415.13(a)(1)(i-iii)

Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00356442 ) initiated on 11/6/2024 and completed on 11/15/2024, the facility was not 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 was not effectively administered to ensure sufficient staffing was provided to promote the highest practicable physical mental, and psychosocial well-being of each resident. The Facility Assessment did not include the overall number of facility staff needed to ensure that each resident's needs were being met. Additionally, the Administrator did not monitor and enhance the quality of care and services by repeating the same deficiencies: F 695 Respiratory/Tracheostomy Care and Suctioning, F 725 Sufficient Nursing Staff, and F 838 Facility Assessment. Cross Reference: F 725 Sufficient Nursing Staff F 838 Facility Assessment The finding is: The Facility assessment dated [DATE] revealed that the assessment did not include a breakdown of Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA) levels by unit and by nursing shifts to ensure that each resident's needs were being met. During an interview on 11/15/2024 at 2:59 PM, the Administrator stated that the facility Ombudsman had brought staffing concerns to their attention in June 2024. The Administrator met with the Director of Nursing Services and adjusted the staffing levels. The Administrator stated the Facility Assessment does not break down the facility staffing needs per unit per shift. The Administrator stated that the Facility Assessment indicated there should be one Nurse assigned for every 8 to 10 residents and the units should be staffed as per the Facility Assessment. The number of nursing staff assigned on the weekend did not match the number of nursing staff required in the Facility Assessment and they were not aware that on the weekends the facility was staffed with fewer nursing staff than on the weekdays. The administrator stated that the facility was cited for insufficient staffing on the previous survey and therefore, staffing should have been looked into more closely in the Facility Assessment. The Administrator stated the facility does not have a policy on staffing and should be staffed based on the staffing levels documented in the Facility Assessment. The Administrator stated the Staffing Coordinator and the Director of Nursing Services should have been aware of the required staffing levels documented in the Facility Assessment. During an interview on 11/15/2024 at 3:24 PM, the Director of Nursing Services stated they were not aware of staffing levels that were documented in the Facility Assessment (one nurse for 8 to 10 residents) and were not involved in reviewing or revising the staffing portion of the Facility Assessment. The Director of Nursing Services stated that the facility Administrator was made aware of less nursing staff assigned on the weekends than on the weekdays when they discussed the adjusted staffing levels. The Director of Nursing Services stated in the summer, it was difficult to obtain staff on the weekends when the scheduled staff members called out. 10 NYCRR 415.26

Based on record review and staff interviews during the Recertification Survey initiated on 11/6/2024 and completed on 11/15/2024, the facility did not ensure its Facility Assessment considered specific staffing needs for each shift and each resident unit (first floor and second floor) in the facility. Specifically, the Facility Assessment, last updated in February 2024, did not include a breakdown of staffing needs for each of the facility's eight units for each shift. Cross Reference: F 725 Sufficient Nursing Staff F 835 Administration The finding is: The Facility Assessment, dated 2/25/2024, documented based on data from several sources including multiple nursing home associations, census-based staffing levels would be approximately one nurse (Registered Nurse or Licensed Practical Nurse) assigned to eight to ten residents and approximately one aide (Certified Nursing Aide) assigned to ten to fifteen residents. The Facility Assessment further explained: -For a Census of 20 residents with low acuity, there should be two Nurses and three Certified Nurse Assistants; with medium acuity, there should be three Nurses and four Certified Nurse Assistants; and with high acuity, there should be three Nurses and five Certified Nurse Assistants assigned for the 20 residents. -For a census of 30 residents with low acuity, there should be three Nurses and four Certified Nursing Assistants; with medium acuity, there should be four Nurses and five Certified Nurse Assistants; and with high acuity, there should be five Nurses and six Certified Nurse Assistants for the 30 residents. -For a census of 40 residents with low acuity there should be four Nurses and five Certified Nursing Assistants; with medium acuity, there should be five Nurses and six Certified Nurse Assistants; and with high acuity, there should be six Nurses and seven Certified Nurse Assistants for the 40 residents. The Facility Assessment did not include a breakdown of staffing needs for each of the facility's two units for each shift. During an interview on 11/15/2024 at 2:59 PM, the Administrator stated the Facility Assessment does not break down the facility staffing needs per unit per shift. The Administrator stated that the Facility Assessment indicated there should be one Nurse assigned for every 8 to 10 residents and the units should be staffed as per the Facility Assessment. The administrator stated that the facility was cited for insufficient staffing on the previous survey and therefore, in the Facility Assessment, nursing staffing should have been reviewed closely. The Administrator stated the facility does not have a policy on staffing and should be staffed as per the Facility Assessment. The Administrator stated the Staffing Coordinator and the Director of Nursing Services should have been aware of the required staffing levels documented in the Facility Assessment. During an interview on 11/15/2024 at 3:24 PM, the Director of Nursing Services stated they were not aware of staffing levels that were documented in the Facility Assessment (one nurse for 8 to 10 residents) and were not involved in reviewing or revising the staffing portion of the Facility Assessment. 10 NYCRR 415.26

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00331241) initiated on 11/06/2024 and completed on 11/15/2024 the facility did not ensure that all alleged violations, including injuries of unknown source, were reported not later than 24 hours if the events that cause the allegation do not include abuse or do not result in a serious bodily injury, to the New York State Department of Health. This was identified for one (Resident #54) of five residents reviewed for Abuse. Specifically, Resident #54 reported that a nurse erroneously administered an injectable medication to the resident's abdominal area. Upon assessment, the resident had a bruise on the lower left side of the abdomen. The facility investigation documented there was inconclusive evidence to determine if the resident erroneously received an injectable and the cause of the bruise was unknown. The facility did not report the injury of unknown origin incident to the New York State Department of Health. The finding is: The facility's policy titled Accident/Incident revised on 6/2024 documented the Licensed Nurse or Nurse Supervisor will complete and document the evaluation of the resident's condition including vital signs, type of injury, location on the body, and skin tear or bruise measurements. If the occurrence is an injury of unknown origin i.e., skin tear or bruise, statements from staff members on the unit will be taken to try and determine the cause of the injury. The results of the investigation will be reported to the New York State Department of Health by the Administrator or Director of Nursing Services. Resident #54 was admitted with diagnoses including Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Dementia. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 10, indicating the resident had moderate cognitive impairment. The Minimum Data Set documented no Behavioral Symptoms. The Total Body Skin assessment dated [DATE] documented skin color normal for the ethnic group, with no wounds. The facility Complaint Form dated 12/08/2023 at 8:00 PM documented the family member reported Resident #54 told them a nurse took Resident #54 away from Bingo activity and administered an injection to the resident's abdomen. Resident #54 was alert with a Brief Interview for Mental Status score of 15 (indicating intact cognition). On 12/9/2023, the Infection Preventionist assessed the resident and noted an ecchymotic area on the left lower quadrant of the abdomen. A document entitled Grievance documented on 12/8/2023 Resident #54 reported by Licensed Practical Nurse #2 that they received an injection to their abdomen on 12/8/2023 between 2:30 PM and 2:45 PM and wanted to know what it was for. The Director of Nursing Services was notified, and a Grievance form was initiated. On 12/9/2023, the Infection Preventionist reviewed the Grievance form, assessed the resident, and noted a small 2.5 x 2.5 (no unit of measurement) discoloration on the left lower quadrant of the resident's abdomen, with no open area and no swelling. The Investigation Statement written by Licensed Practical Nurse #2 dated 12/11/2023 documented on 12/8/2023 Resident #54 stated they received an injection to their stomach and wanted to know the name of the medication. The resident did not have an order for an injectable medication. The resident's abdomen was noted with an old site with multiple colors of yellow, purple, and blue. A review of the medical record revealed there were no nursing progress notes, evaluations, or skin checks that documented Licensed Practical Nurse #2's or the Infection Preventionist's observation of a bruise to Resident #54's left lower quadrant. A Nurse Practitioner's note dated 12/09/2023 at 4:51 PM written by Nurse Practitioner #1 documented the resident was seen and examined today due to the nursing staff's request as the resident has a bruise on the left side of the abdomen, the resident denies and fall or injury. The note did not document any clinical factors that may have caused the identified bruise. The undated Investigative Summary, signed by the former Director of Nursing Services, documented that the investigation could not conclusively determine if any injectable was administered to the resident at this time. During an interview on 11/12/2024 at 11:08 AM, Licensed Practical Nurse #3 stated they were the assigned medication nurse on 12/08/2023 on the day shift when Resident #54 alleged they received an injection to their abdomen. Licensed Practical Nurse #3 stated Resident #54 did not have orders for injectable medications. Licensed Practical Nurse #3 stated they went to the Bingo room and administered Tylenol to Resident #54. Licensed Practical Nurse #3 stated the resident is alert and always asks what medication is being administered to them, before taking their medications. During an interview on 11/12/2024 at 1:06 PM, the Infection Preventionist stated they were the Nurse Supervisor on 12/09/2023 when they were called to assess Resident #54. The Infection Preventionist stated the resident had a bruise to the left lower abdomen. The Infection Preventionist stated they did not where the bruise came from. During an interview on 11/12/2024 at 1:13 PM, Licensed Practical Nurse #2 stated during the medication pass on 12/8/2023, the resident stated they got an injection that afternoon and wanted to know what it was. Licensed Practical Nurse #2 read through the orders and looked at the Medication Administration Record; they could not find any injectable medications that this resident may have received. Licensed Practical Nurse #2 did not know why the resident had bruising on the abdomen. During an interview on 11/13/24 at 10:30 AM, the former Director of Nursing Services stated the bruise to the resident's abdomen was small, and they did not think the bruise was from an injection. The former Director of Nursing Services stated they were focused on the resident saying they received an injection and they did not think of the bruise as an injury. The former Director of Nursing Services stated the incident should have been reported to the New York State Department of Health as an injury of unknown origin. The Director of Nursing Services or the Assistant Director of Nursing Services was responsible for reporting the Accident and Incident to the New York State Department of Health. During a re-interview on 11/13/2024 at 11:04 AM, the Infection Preventionist Nurse stated they did not write a progress note in the medical record after they observed Resident #54's bruise on 12/9/2024. During an interview on 11/13/2024 at 12:11 PM, the Director of Nursing Services stated Resident #54's grievance was reviewed with the former Director of Nursing Services, and after the investigation, they were able to determine that the individual did not get an injection. The Director of Nursing Services stated if the facility cannot conclude where the bruise came from, then the facility should report an injury of unknown origin to the New York State Department of Health. The Director of Nursing Services stated that based on the definition of injury of unknown origin, the bruise identified on Resident #54's abdomen was an injury of unknown origin that should have been reported to the New York State Department of Health. 10 NYCRR 415.4(b)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 11/6/2024 and completed on 11/15/2023, the facility did not ensure that Residents who needed respiratory care were provided such care consistent with professional standards of practice. This was identified for one (Resident #236 ) of two residents reviewed for Respiratory care. Specifically, Resident #236 had a physician's order to receive 4 liters per minute of supplemental oxygen. The resident was observed receiving oxygen at a liter flow less than the current physician's order. The finding is: The facility's policy for Oxygen, revised on 2/2022, documented that oxygen is administered by licensed staff under a physician's order to oxygenate and provide comfort to residents' acute or chronic respiratory difficulties. The procedure includes checking the physician's orders for oxygen administration, the prescribed liter flow rate, and the frequency of oxygen administration. Resident # 236 was admitted with diagnosis that includes Chronic Obstructive Pulmonary Disease. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 11, which indicated Resident#236 had moderately impaired cognition. Resident#236 did not have any behavior concerns. The Minimum Data Set indicated Resident#236 received continuous oxygen therapy. Resident#236 required substantial/maximal assistance (Staff does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). The Comprehensive Care Plan dated 6/13/2024 documented altered respiratory status/difficulty breathing related to oxygen use. The Interventions included oxygen therapy via nasal cannula at 4 liters per minute. The physician orders dated 10/21/2024 documented to administer oxygen at 4 liters per minute via a nasal cannula (tubing used to provide external oxygen through the nose) continuously for shortness of breath. During an observation on 11/07/2024 at 01:27 PM, Resident #236 was sitting in the wheelchair in the hallway and was receiving supplemental oxygen at 2 liters per minute via a nasal cannula from a portable tank. During an observation and interview on 11/13/24 at 9:55 AM, Resident #236 was observed sitting in the wheelchair in the hallway and was receiving supplemental oxygen at 2 liters per minute via a nasal cannula from a portable tank. Resident #236 stated Certified Nursing Assistant # 6 put the oxygen on for them when they were transferred this morning to the wheelchair. During an interview on 11/13/2024 at 10:00 AM, Registered Nurse # 4 stated the resident should be receiving 4 liters of oxygen as per the physician's orders. The resident's oxygen was not checked by themselves this morning when they were transferred from the bed into the wheelchair. During an interview on 11/13/2024 at 10:05 AM, Certified Nursing Assistant # 6 stated they transferred the resident into the wheelchair; however, they did not touch the resident's oxygen. During an interview on 11/13/2024 at 01:13 PM the Director of Nursing Services stated that Certified Nurse Assistants cannot touch the residents' oxygen or adjust the flow rate. When the resident's oxygen source was changed from their oxygen concentrator to the portable oxygen canister, the Registered Nurse should have ensured the oxygen was set to the correct flow rate. 10 NYCRR 415.12(k)(6)

Based on interviews and record review conducted during a Recertification Survey and Abbreviated Survey (NY 00350913) initiated on 11/6/2024 and completed on 11/15/2024, the facility did not ensure the Physician reviewed the resident's total program of care at each visit. This was identified for one (Resident #187) of two residents reviewed for Mood and Behavior. Specifically, Resident #187 with a diagnosis of Dementia but no prior history of physical aggression, punched another resident on 5/15/2024 and was ordered for psychiatric evaluation on 5/15/2024. The psychiatric consult was never completed. There is no documented evidence that the Physician followed up on the resident's psychiatric evaluation during their monthly visit in June 2024 and July 2024. Resident #187 subsequently bit another resident on 8/9/2024. The Psychiatrist assessed and evaluated the resident on 8/20/2024 and recommended Lexapro (Medication to treat Anxiety and Depression) 2.5 milligrams once a day. The finding is: The policy and procedure titled Attending Physician provided by the facility was issued by the National Health Care Associates dated 5/2002. The policy documented that the attending Physician shall be responsible for overseeing the medical care and treatment rendered to each resident under their direct supervision. The attending Physician will ensure that each resident's care plan identifies the individual's needs and provides for multi-disciplinary interventions to maximize resident functions. Resident #187 was admitted with diagnoses including Dementia, Hyperlipidemia, and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 8, which indicated the resident had moderately impaired cognition. The Minimum Data Set documented the resident did not exhibit any physical behavioral symptoms directed toward others. A review of an Accident and Incident report dated 5/15/2024 documented that on 5/15/2024 at 4:45 PM, the Recreation Therapist witnessed Resident #187 punching another resident on their left arm. When interviewed, Resident #187 could not recall the incident. Resident #187 did not have any behaviors and the incident seemed spontaneous and unprovoked. The care plan was revised to include safety checks every 15 minutes for 24 hours, social work follow-up, psychiatric consult, and to keep both residents separated from each other during activities. A physician's order dated 5/15/2024 documented a psychiatric consult for physical aggression. The Comprehensive Care Plan for Behavior Problems dated 5/20/2024 documented the resident punched another resident on 5/15/2024. The resident has never displayed behavior previously. Interventions included but were not limited to monitoring behavior episodes and attempts to determine the underlying cause. A review of the Physician's monthly progress note dated 5/25/2024, signed by Attending Physician #1, documented that Resident #187 was doing well at baseline cognitively. No other acute issues and concerns were offered by the nursing staff. The progress note did not include documentation related to the resident's recent incident on 5/15/2024 and pending psychiatric consultation. A review of the Physician's monthly progress note dated 7/7/2024 and 7/25/2024, signed by Attending Physician #1, documented that Resident #187 was doing well at baseline cognitively. No other acute issues and concerns were offered by the nursing staff. The progress note did not include documentation related to a follow-up on Resident #187's psychiatric evaluation ordered on 5/15/2024. A review of an Accident and Incident report dated 8/9/2024 documented that on 8/9/2024 at 11:30 AM, Resident #187 was witnessed [by Activity staff] biting another resident's right palm. Resident #187 could not recall the incident. There were no untoward/unusual incidents, or changes in behaviors in both residents before the incident. A review of the Physician's progress note dated 8/9/2024 documented that Resident #187 was examined for an incident with another resident. Resident #187 had a history of Dementia and was a poor historian. A psychiatry consult was ordered to evaluate and treat secondary to the biting incident. A physician's order dated 8/9/2024 documented a psychiatric consult for evaluation and treatment as indicated secondary to the biting incident. A review of Resident #187's medical record from 5/15/2024 to 8/20/2024 was conducted. There was no documented evidence that Resident #187 was seen and evaluated by a Psychiatrist until 8/20/2024. A Psychiatric assessment dated [DATE] documented Resident #187's agitation appeared to be secondary to Delirium. The Psychiatrist documented to consider Lexapro 2.5 milligrams once a day and explore the use of Namenda (medication used to treat Dementia associated with Alzheimer's Disease) as needed. The Comprehensive Care Plan for Psychosocial Well-being Potential related to Dementia, dated 9/3/2021 and revised 8/12/2024 documented the resident had behavioral concerns and had two incidents with other residents. The resident had mental health needs and required psychiatric evaluation as needed. Interventions included but were not limited to psychiatric/psychological consult as requested or indicated. During an interview on 11/13/2024 at 12:31 PM, Physician Assistant #1 stated they worked with Physician #1 and oversaw Resident #187's medical care. Physician Assistant #1 stated they were notified about Resident #187's altercation with another resident in May 2024 and they ordered psychiatric consultation. Physician Assistant #1 stated that it slipped their mind to follow up on Resident #187's psychiatric consult as no other behavioral problems were brought to their (Physician Assistant #1) attention after the incident in May. Physician Assistant #1 stated the psychiatric evaluation should have been completed and they (Physician Assistant #1) should have followed up on whether any recommendations were made by the Psychiatrist. During an interview on 11/13/2024 at 2:40 PM, Physician #1, who was Resident #187's attending Physician, stated they did not recall Resident #187's resident-to-resident altercation incident in May and whether a psychiatric consult was ordered. Physician #1 stated they expected to be informed if a consult was not completed. Physician #1 stated they have never observed Resident #187 exhibiting undesired behaviors. A psychiatric evaluation would be beneficial to assess the resident's sudden change in behaviors after the incident. Physician #1 stated they had not personally discussed Resident #187's condition with the Psychiatrist since they (Physician #1) never observed any behavior. During an interview on 11/13/2024 at 3:40 PM, the Medical Director stated a psychiatrist consultation was a standard intervention for all incidents involving resident-to-resident altercations. The Medical Director stated that the medical provider forgot to follow up on the result of Resident #187's psychiatric consult and they should have. 10 NYCRR 415.15(b)(2)(iii)

Based on interviews, observations, and record review conducted during a Recertification Survey and Abbreviated Survey (NY 00350913) initiated on 11/6/2024 and completed on 11/15/2024, the facility did not ensure that timely arrangements were made for outside services that met professional standards. This was identified for one (Resident #187) of two residents reviewed for Mood and Behavior. Specifically, Resident #187 with a diagnosis of Dementia but no prior history of physical aggression, punched another resident on 5/15/2024 and was ordered for psychiatric evaluation on 5/15/2024. There is no documented evidence that the psychiatric consult was completed until 8/20/2024 after Resident #187 bit another resident on 8/9/2024. The finding is: The facility did not develop policy and procedures related to outside consultant. Resident #187 was admitted with diagnoses including Dementia, Hyperlipidemia, and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 8, which indicated the resident had moderately impaired cognition. The Minimum Data Set documented the resident did not exhibit any physical behavioral symptoms directed toward others. A review of an Accident and Incident report dated 5/15/2024 documented that on 5/15/2024 at 4:45 PM, the Recreation Therapist witnessed Resident #187 punching another resident on their left arm. When interviewed, Resident #187 could not recall the incident. Resident #187 did not have any behaviors and the incident seemed spontaneous and unprovoked. The care plan was revised to include safety checks every 15 minutes for 24 hours, social work follow-up, psychiatric consult, and to keep both residents separated from each other during activities. A physician's order dated 5/15/2024 documented to refer a psychiatric consult for physical aggression. The Comprehensive Care Plan for Behavior Problem dated 5/20/2024 documented the resident punched another resident on 5/15/2024. Resident has never displayed any liked-behavior previously. Interventions included but were not limited to monitor behavior episode and attempt to determine underlying cause. A review of an Accident and Incident report dated 8/9/2024 documented that on 8/9/2024 at 11:30 AM, Resident #187 was witnessed [by Activity staff] biting another resident's right palm. Resident #187 could not recall the incident. There were no untoward/unusual incidents, or changes in behaviors in both residents before the incident. A physician's order dated 8/9/2024 documented a psychiatric consult for evaluation and treatment as indicated secondary to the biting incident. A review of Resident #187's medical record from 5/15/2024 to 8/9/2024 was conducted. There was no documented evidence that Resident #187 was seen and evaluated by a Psychiatrist during this period. There was no further documentation in the medical record regarding Psychiatric consultation arrangements or cancellations. A Psychiatrist assessment dated [DATE] documented Resident #187's agitation appeared to be secondary to Delirium. The Psychiatrist documented to consider Lexapro 2.5 milligrams once a day and explore the use of Namenda (medication used to treat Dementia associated with Alzheimer's Disease) as needed. During an interview on 11/13/2024 at 9:20 AM, Unit Clerk #1 stated they were responsible for arranging all outside consultation services as per the physician's orders. Unit Clerk #1 stated that they kept a Psychiatry appointment book at the nursing station and updated the list of residents on the appointment book. Unit Clerk #1 stated that the Psychiatrist visited every Tuesday and checked the appointment book for names of residents to be seen. Unit Clerk #1 was not unable provide documented evidence that Resident #187 was on the list to be seen by the Psychiatrist because Unit Clerk #1 did not save the data for May 2024. During an interview on 11/13/2024 at 11:51 AM, Registered Nurse Supervisor #2 stated they ordered the psychiatry consult for Resident #187 on 5/15/2024. Registered Nurse Supervisor #2 stated that the unit clerk should be informed during the day shift nursing report and complete the referral for Psychiatric consultation. During an interview on 11/13/2024 at 12:31 PM, Physician Assistant #1 stated they had ordered a psychiatric consultation for Resident #187 after a resident-to-resident altercation on 5/15/2024. Physician Assistant #1 stated Resident #187 should have been seen by the Psychiatrist no more than two weeks from the day the consultation order was placed. During an interview on 11/13/2024 at 3:40 PM, the Medical Director stated that a psychiatrist consultation was a standard intervention for all incidents involving resident-to-resident altercations. The Medical Director stated that Resident #187 should have been seen by the Psychiatrist as per the physician's order in May 2024. During an interview on 11/13/2024 at 4:14 PM, Psychiatrist #1 stated they visited the facility every Tuesday for the past 6 months including May 2024. Psychiatrist #1 stated they were not aware of the 5/15/2024 consultation order for Resident #187 and would have evaluated the resident if they had been informed by the facility. During an interview on 11/15/2024 at 10:45 AM, the Director of Nursing Services stated the facility did not have a policy and procedures for outside consultation services including psychiatry. The Director of Nursing Services stated they expected the unit manager or unit clerk to place a consultation referral for Resident #187 in May 2024 and follow up to ensure that the consultation was completed. 10 NYCRR 415.15(b)(2)(iii)

Based on observation, record review, and interviews during the Recertification Survey initiated on 11/6/2024 and completed on 11/15/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for two (Resident #627 and Resident #625) of three residents reviewed for Transmission Based Precautions. Specifically, during observation of Resident #627 and Resident #625's shared room, an Isolation Droplet/Contact Precaution sign was observed outside the door for positive COVID-19 (Coronavirus-2019) infection. The precaution signage included instructions for the use of Personal Protective Equipment (PPE) including N95 respirator mask, gloves, a gown, and eye protection (face shield or goggles). Certified Nursing Assistant #1 was observed inside the room and was not wearing appropriate Personal Protective Equipment as indicated on the precaution signage. The finding is: The facility's policy titled Infection Prevention and Control last revised on 6/2024 documented that Contact Precautions are intended to prevent transmission of infectious agents including microorganisms that are spread by direct or indirect contact with the resident or the resident's environment. Donning (putting on) Personal Protective Equipment (PPE) upon entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been associated with transmission through environmental contamination. -Resident #627 was admitted with Diagnoses including Pulmonary Hypertension, COVID-19 infection, and Dementia. A Minimum Data Set (MDS) assessment dated [DATE] had not been completed. The Brief Interview for Mental Status (BIMS) dated 11/5/2024 documented that Resident #627 had a score of 3, which indicated Resident #627 was cognitively impaired. A Comprehensive Care Plan (CCP) dated 11/5/2024 for COVID-19 infection documented interventions that included assisting residents with hand hygiene, respiratory hygiene, and cough etiquette; implementing standard, contact, and droplet precautions, and notifying healthcare providers as needed for worsening conditions. A physician order dated 11/4/2024 documented Droplet/Contact Precautions: Isolation for positive COVID-19 infection every shift for infection control measures for 10 days. -Resident #625 was admitted with Diagnoses including Parkinson's Disease, Acute Pulmonary Edema, and COVID-2019 infection. A Comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating Resident #625 had moderately impaired cognition. The Minimum Data Set documented Isolation/Quarantine for active infectious disease. A Comprehensive Care Plan (CCP) dated 11/5/2024 documented confirmed COVID-19 infection with interventions that included Contact/Droplet Precaution and assisting residents with hand hygiene as needed. A physician order dated 11/5/2024 documented Droplet/Contact Precautions: Isolation for positive COVID-19 infection every shift for infection control measures for 10 days. During an observation on 11/6/2024 at 12:29 PM, a precautions sign was posted outside Resident #627 and Resident #625's shared room. The signage read: Contact/Droplet Isolation Precautions; everyone must perform hand hygiene before and after entering the room. Use Personal Protective Equipment (PPE) including a gown, N95 respirator, eye protection (face shield or goggles), and gloves before entering. Discard the gown, gloves, N95 respirator, and eye protection before exiting the room. Keep the room door closed (if not on a dedicated and physically separated unit). The room door was open and Certified Nursing Assistant #1 was observed inside the room without a gown, an N95 respirator mask, eye protection, or gloves. Certified Nursing Assistant #1 was wearing a surgical mask. During an interview on 11/6/2024 at 12:40 PM, Certified Nursing Assistant #1 stated they went to Resident #627 and Resident #625's shared room to pick up the meal trays after the residents completed their meals and forgot to put the Personal Protective Equipment (PPE). Certified Nursing Assistant #1 stated they should have put on, a gown, an N95 respirator mask, a face shield, and gloves when they entered Resident #627 and Resident #625's room. During an interview on 11/6/2024 at 1:00 PM, Registered Nurse #1 (the Unit Supervisor) stated that Certified Nursing Assistant #1 should have used appropriate Personal Protective Equipment as directed on the precautions signage and the resident's room door should also be kept closed; staff must have forgotten to close the door. During an interview on 11/7/2024 at 8:53 AM, the Infection Preventionist stated staff should wear appropriate Personal Protective Equipment (PPE) when entering the isolation rooms. The Infection Preventionist stated that Certified Nursing Assistant #1 did not follow the facility's infection control procedure. During an interview on 11/7/2024 at 3:07 PM, the Director of Nursing Services stated that Certified Nursing Assistant #1 should have put on Personal Protective Equipment (PPE) when they entered Resident #627 and Resident #625's room. The Director of Nursing Services stated their expectation included staff following proper infection control guidelines to prevent further transmission of infection. 10 NYCRR 415.19(a) (1-3)

Based on record review and staff interviews during the Recertification Survey initiated on 6/4/2023 and completed on 6/9/2023, the facility did not ensure that a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment was implemented for each resident. This was identified for one (Resident #64) of two residents reviewed for Limited Range of Motion. Specifically, Resident #64 was observed on three separate occasions to not have bilateral hand rolls applied as ordered by a Physician. The finding is: The facility's policy titled Physician Orders dated 10/2015 documented that when a Medical Doctor (MD) / Nurse Practitioner (NP) order is obtained, the Nurse is responsible to pick up the order. The order should be designated to the Medication Administration Record (MAR) or Treatment Administration Record (TAR) based on the type of order and the appropriate schedule is initiated to ensure the order is picked up for administration of the order. The facility's policy titled Baseline/Comprehensive Person Centered Care Plan (CPCCP) last revised 3/2023 documented that the interdisciplinary team will utilize the CPCCP process to address resident strengths, needs, and/or problems as identified on the admission discharge summary, as well as other professional assessments and orders from the healthcare provider, dietary team, therapy, social services and Preadmission Screening and Resident Review (PASRR) (if applicable) and the Minimum Data Set (MDS) assessment. The CPCCP is developed to include information necessary to properly care for the resident and will address the resident's preferences, goals, desired outcomes, and plan for discharge. Resident #64 has diagnoses which include Cerebral Infarction Affecting the Right Dominant Side and Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision-making. The resident was totally dependent on two people for transfers, toilet use, and bathing and totally dependent on one person for locomotion on/off the unit, dressing, eating, and personal hygiene. The Physician's Order dated 5/3/2023 documented to apply bilateral hand rolls and to check for placement and skin integrity every shift. This order was obtained by Registered Nurse (RN) Supervisor (RN #1). On 6/4/2023 at 10:35 AM, the resident was observed seated in their room, in their wheelchair, with no hand rolls in place. On 6/7/2023 at 11:40 AM, the resident was observed seated in the hallway next to the nursing station, in their wheelchair, with no hand rolls in place. On 6/7/2023 at 2:05 PM, the resident was observed seated in the hallway in front of the nursing station, in their wheelchair, with no hand rolls in place. The Certified Nursing Assistant (CNA) #1, caring for Resident #64 on the 6:30 AM - 2:30 PM shift on 6/07/2023, was interviewed on 6/07/2023 at 2:10 PM and stated that they (CNA #1) were not the resident's regularly assigned CNA and were just taking care of Resident #64 today. CNA #1 stated that when they need to care for a resident they are unfamiliar with, they (CNA #1) would look at the resident's Kardex (instructions provided to the CNAs for resident care needs) to see how to care for the resident and there was nothing documented on the resident's Kardex that indicated the resident should have bilateral hand rolls. CNA #1 stated that they (CNA #1) also did not see any hand rolls in the resident's room. On 6/7/2023 at 2:15 PM, in the presence of CNA #1, the resident's Kardex was reviewed and there was no documented evidence that the resident should have bilateral hand rolls. RN #1 was interviewed on 6/07/2023 at 4:05 PM and stated that they (RN #1) put the order in the resident's Electronic Medical Record (EMR) for the resident to have bilateral hand rolls when the resident was readmitted from the hospital on 5/3/2023. RN #1 stated that they (RN #1) do not add that information to the resident's Kardex, but instead, they (RN #1) add it to the resident's TAR. The resident's June 2023 TAR documented: Apply bilateral hand rolls and check for placement and skin integrity every shift for prophylaxis. The hand rolls were signed for by RN #3 for the 6:30 AM - 2:30 PM shift on 6/07/2023. RN #3 was interviewed on 6/07/2023 at 4:30 PM and stated that they (RN #3) had signed the resident's TAR for the use of the hand rolls. RN #3 stated that when they (RN #3) saw that Resident #64 did not have their ordered hand rolls, they (RN #3) went to the treatment cart and got rolled up gauze, and applied the rolls to the resident's hands after the surveyor's observation on 6/07/2023 at 2:05 PM. The Director of Nursing Services (DNS) was interviewed on 6/8/2023 at 11:30 AM and stated that when RN #1 readmitted the resident on 5/3/2023, they (RN #1) put the Physician's Order for the resident's hand rolls into the EMR as a treatment. The DNS stated that a basic preventative measure like a hand roll could be applied by a CNA and should have been put onto the resident's Kardex. The DNS further stated that the resident should have had their hand rolls in place as per the Physician's Orders. 10 NYCRR 415.11(c)(1)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00310491) initiated on 6/4/2023 and completed on 6/9/2023, the facility did not ensure that a Comprehensive Care Plan (CCP) was prepared by an interdisciplinary team that includes but is not limited to the participation of the resident and the resident's representative and is reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This was identified for one (Resident #64) of two residents reviewed for Limited Range of Motion and one of 39 residents reviewed for care planning. Specifically, 1) Resident # 64's Comprehensive Care Plan (CCP) was not reviewed and revised to reflect the resident's current condition following a hospitalization . The resident's CCP did not reflect the use of bilateral hand rolls as ordered by a Physician. 2) Resident # 77's representative was not invited to attend the initial comprehensive care plan meeting held after the resident's admission. The findings are: The facility's policy titled Baseline/Comprehensive Person Centered Care Plan (CPCCP) last revised 3/2023 documented that the interdisciplinary team will utilize the CPCCP process to address resident strengths, needs and/or problems as identified on the admission discharge summary, as well as other professional assessments and orders from the healthcare provider, dietary team, therapy, social services the Preadmission Screening and Resident Review (PASRR) ) (if applicable) and the Minimum Data Set (MDS) assessment. The CPCCP is developed to include information necessary to properly care for the resident and will address the resident's preferences, goals, desired outcomes, and plan for discharge. 1) Resident #64 has diagnoses which include Cerebral Infarction Affecting Right Dominant Side and Hypertension and was readmitted from the hospital on 5/3/2023. The quarterly MDS assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on two people for transfers, toilet use, and bathing and totally dependent on one person for locomotion on/off unit, dressing, eating, and personal hygiene. The Physician's Order dated 5/3/2023 documented: Apply bilateral hand rolls and check for placement and skin integrity every shift. This order was obtained by Registered Nurse (RN) Supervisor (RN #1). Review of the resident's entire CCP on 6/7/2023 at 11:30 AM revealed no documented evidence of the resident's bilateral hand rolls as ordered by the Physician. RN #1 was interviewed on 6/7/2023 at 4:05 PM and stated that they (RN #1) put the order in the resident's Electronic Medical Record (EMR) for the resident to have bilateral hand rolls when the resident was readmitted from the hospital on 5/3/2023. RN #1 stated that when they (RN #1) readmit a resident from the hospital, they (RN #1) do not have the time to go through the care plans to see what may need to be added. The Director of Nursing Services (DNS) was interviewed on 6/8/2023 at 11:30 AM and stated that when RN #1 readmitted the resident on 5/3/2023, they (RN #1) should have put the use of the resident's bilateral hand rolls on the resident's Activities of Daily Living (ADL) CCP. 17585 2) The Policy and Procedure for Comprehensive Care Planning (CCP) dated July 2015 documented the Interdisciplinary team will utilize the Comprehensive Care Planning process to address resident strengths, need and/or problems as identified on the Minimum Data Set (MDS), as well as other professional assessments. The Comprehensive Care Plan is developed to provide individualize care that will address the resident's identified needs and to assist the resident to achieve her or practicable quality of life. The MDS coordinator schedules the resident's assessments and care plan meetings in accordance with regulation and resident needs. An Initial Comprehensive Care Plan meeting will be scheduled within 21 days of admission. Resident #77 was admitted on [DATE], with diagnosis that include Dementia. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severely impaired cognition. An interdisciplinary care plan meeting was held on 12/29/2022. The facility had no documented evidence the resident's family was invited to the CCP meeting. Registered Nurse Supervisor (RNS) #2 was interviewed on 6/8/2023 at 11 AM and stated the MDS nurse is responsible to invite the resident's representatives and the residents to care plan meetings. The MDS Nurse Coordinator that was involved in Resident # 77's initial CCP meeting is no longer employed at the facility and was unavailable for interview. Social Worker (SW) # 2 was interviewed on 6/8/2023 at 11:45 AM and stated the Social Work department is not responsible to invite resident representatives to the CCP meetings, that is the responsibility of the nursing Department. The Director of Nursing Services (DNS) was interviewed on 6/08/2023 a 3:55 PM and stated the resident's initial CCP meeting was held on 12/29/2022. The DNS stated there was no documentation that resident's representative was invited to initial CCP. The residents' representatives are only invited to initial and annual CCP meetings, not the quarterly CCP unless there are changes in the resident's condition. The MDS coordinator is responsible to notify the nursing secretary when a CCP meeting will be held. The Nursing secretary is then responsible to call the residents' representatives to inform them of the meeting date. If the resident representative cannot be reached via telephone, a certified letter is sent. The DNS stated that there was no documented evidence that the Nursing secretary or the resident representative were notified of the CCP meeting related to Resident #77. 415.11(c)(2)(i-iii)

Based on observation, record review and interviews during the Recertification Survey initiated on 6/4/2023 and completed on 6/9/2023, the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan. This was identified for two (Resident #68 and #454) of two residents reviewed for Oxygen use. Specifically, 1) Resident #68 had a Physician's order for continuous oxygen via nasal cannula at 2 liters per minute on all shifts and on four separate occasions the resident was observed not receiving oxygen as per the Physician's orders. 2) Resident #454 was receiving oxygen therapy without a Physician's order. The findings are: The facility Oxygen Policy and Procedure dated 2/2022 documented that Oxygen is administered by licensed staff under a Physician's order to improve oxygenation and provide comfort to a resident experiencing acute or chronic respiratory difficulties. The policy further documented to check the Medical Doctor (MD) order and or Medication Administration Record (MAR) for method of oxygen administration, the prescribed liter flow rate, and the frequency of oxygen administration. 1) Resident #68 was admitted with diagnoses that included Chronic Obstructive Pulmonary Disease, Congestive Heart Disease, and Acute Respiratory Failure. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 14 which indicated the resident had intact cognition. The MDS documented the resident had no behavioral symptoms and received oxygen therapy while being a resident in the facility. A Physician's order dated 5/18/2023 documented to administer Oxygen at 2 liters per minute continuously via nasal cannula every shift for Shortness of Breath (SOB). During an initial tour of the 2-D nursing unit on 6/4/2023 at 10:15 AM Resident #68 was observed sitting in a wheelchair in their room at the bedside. An oxygen concentrator was observed in the resident's room; however, the oxygen was not being administered to the resident. At 1:15 PM during the lunch meal observation in the unit dining room Resident #68 was observed without the supplemental oxygen as ordered by the Physician, and at 3:30 PM on 6/4/2023 the resident was observed sitting in the hallway in their wheelchair without the supplemental oxygen as ordered by the Physician. Resident #68 was observed on 6/8/2023 at 11:06 AM sitting their room on the left side of the bed watching television. The Oxygen Concentrator was observed on the right side of the bed turned on and the nasal cannula tubing was observed on the floor. The resident was interviewed on 6/8/2023 at 11:06 AM, immediately after the observation of the nasal cannula on the floor. The resident stated that they get SOB at times but was not aware that they needed to have oxygen administered all the time. A Respiratory Comprehensive Care Plan (CCP) dated 5/20/2019 documented the resident has diagnoses of Emphysema, Chronic Obstructive Pulmonary Disease (COPD,) status post Exacerbation. Interventions included to elevate the head of the bed to alleviate any discomfort or SOB and to administer oxygen as per the Physician's order. Licensed Practical Nurse (LPN) #2 was interviewed on 6/8/2023 at 11:15 AM. LPN #2 stated earlier at approximately 10:30 AM when they administered medication to the resident, the resident had their nasal cannula in place. LPN #2 stated that the resident had an order for continuous oxygen and that the resident should have been wearing their nasal cannula to receive oxygen. LPN #2 stated when the resident is out of their room in a wheelchair that an oxygen holder is placed on the back of the wheelchair and oxygen is provided to the resident via the oxygen tank and nasal cannula. Certified Nursing Assistant (CNA) #4 was interviewed on 6/8/2023 at 11:42 AM. CNA #4 stated this morning when they left the resident in the room before breakfast the resident was utilizing the oxygen. The CNA stated if the resident was on continuous oxygen the resident would have an oxygen tank on the wheelchair. The CNA stated that they did not know how the oxygen tubing got on the floor. An interview was conducted on 6/8/23 at 3:59 PM with the Director of Nursing Services (DNS). The DNS stated when a resident has an order for continuous oxygen the expectation is for the resident to be provided with the oxygen as ordered by the doctor. There should be documentation in the Treatment Administration Record (TAR) indicating the resident is being administered oxygen as ordered. The DNS stated the Unit nurse was responsible for ensuring that oxygen was provided to the resident as ordered by the MD. 44925 2) Resident #454 was admitted to the facility on [DATE] with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, and Hypertension. The Hospital Patient Review Instrument (PRI), (an assessment tool developed by the New [NAME] State Department of Health to assess selected physical, medical, and cognitive characteristics of nursing home residents, as well as to document selected services that they may receive), dated 5/30/2023 documented the resident utilized a Nasal Cannula at 3 Liters /Minute for oxygen Administration. The Hospital discharge note dated 6/2/2023 documented Resident #454 was on oxygen via nasal cannula; however, did not indicate the flow rate per minute. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #454 was cognitively intact. The MDS documented that the resident was receiving oxygen therapy. The nursing progress note dated 6/3/2023 documented oxygen therapy at 2 liters per minute was in progress. Resident #454 was observed sitting in a wheelchair on 6/04/2023 at 2:37 PM wearing a nasal cannula. The oxygen gauge attached to the wall indicated the resident was receiving 2 liters of oxygen per minute via the nasal cannula. Review of Resident #454's medical record on 6/4/2023 revealed there were no orders in place for the administration of oxygen. The Physician's progress note dated 6/5/2023 did not document the use of oxygen. A Comprehensive Care Plan (CCP) for oxygen use dated 6/8/2023 documented to administer oxygen at 2 liters per minute. The Resident's CCP was reviewed on 6/04/2023, there was no CCP developed for the use of oxygen prior to 6/8/2023. Resident# 454 was interviewed on 6/04/2023 at 2:37 PM and stated they have been utilizing oxygen since they were hospitalized , and they continued to receive oxygen therapy since they were admitted to the facility. Resident #454 stated they are often short of breath and the oxygen helps. Resident#454 stated they were able to apply the nasal cannula for oxygen to themselves. Registered Nurse (RN) #4 was interviewed on 6/8/2023 and stated they could not find a Physician's order for the use of Oxygen and there should be an order in place to administer oxygen. The Director of Nursing Services (DNS) was interviewed on 6/09/2023 at 2:31 PM and stated the Hospital discharge note dated 6/2/2023 documented Resident #454 was on oxygen via nasal cannula and they did not know why Resident #454 did not have a doctor's order for oxygen. The DNS stated a Physician's order is needed to administer oxygen on both a continuous and as needed (PRN) basis. 10 NYCRR 415.12(k)(6)

Based on observations, record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00310491) initiated on 6/4/2023 and completed on 6/9/2023, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was identified on one of eight nursing units during the Sufficient Staffing Task and a review of the Payroll Based Journal (PBJ) Staffing Data Report. Specifically, on four weekend days in May 2023: 5/7/2023, 5/14/2023, 5/21/2023 and 5/28/2023, there were three Certified Nursing Assistants (CNA) rather than four CNAs on unit 2C for the 2:30 PM to 10:30 PM evening shift. The finding is: The Facility Staffing policy updated 2/2023 documented Staff assignments will be adjusted accordingly. For call ins or other situations where staffing is not in accordance with the usual staffing pattern, every effort will be made to fill the shift. If this is not possible, Nursing Administration will assign staff accordingly. If minimum safe staffing cannot be achieved, staff will be mandated accordingly. The PBJ Staffing Data Report dated for Fiscal Year (FY) Quarter one 2023 (October 1st-December 31st) documented the facility triggered for the Metric of excessively low weekend staffing. A review of the daily schedule from 5/1/2023 to 6/9/2023 revealed the following: On 5/7/2023, 5/14/2023, 5/21/2023 and 5/28/2023, the staffing sheets were reviewed and revealed there were three CNAS verses four CNAs on unit 2C during the 2:30 PM to 10:30 PM shift. The census on the 4 dates was between 39 and 40 residents on a 40 bedded unit. The Facility Assessment last reviewed on 5/2023 had not assessed the day-to-day nursing staffing requirements for the eight units by shift. A Resident Council meeting was held on 6/5/2023 with 10 residents in attendance. Some residents stated that the CNAs are overburdened and therefore sometimes the call bell response is delayed. The Staffing Coordinator was interviewed on 6/09/2023 at 12:14 PM and stated that they were short of CNAs on 5/7/2023, 5/14/2023, 5/21/2023 and 5/28/2023 on Unit 2C. The Staffing Coordinator stated Unit 2C should have four CNAs assigned on the 2:30 PM - 10:30 PM nursing shift; however, on 5/7/2023, 5/14/2023, 5/21/2023 and 5/28/2023 the 2C unit had only three CNAs. Four CNAs were scheduled however one CNA called out. The Staffing Coordinator stated they only work from Monday to Friday and there is no Staffing Coordinator on the weekends. The Nursing Supervisors are supposed to find staffing on the weekends when CNAs call out. The facility does not contract out with staffing agencies for CNAs; however, does have a contract for nurses. When a CNA calls out, we would ask other CNAs that are employed to pick up extra shifts. The Administrator was interviewed on 06/09/2023 at 3:06 PM and stated they are aware that there are weekend staffing shortages. The Administrator stated other employees, including the nurses and activity staff, do try to help the CNAs when there is a shortage. The Administrator stated that when there are only three CNAs, they do complete their tasks as needed but three CNAs cannot do four CNAs duties. The Administrator further stated they (facility) do not have an agency to recruit CNAs and that they (facility) are having a difficult time finding nurses and CNAs. 10NYCRR-415.13(a)(1)(i-iii)

Based on record review and interview during the Recertification Survey initiated on 6/4/2023 and completed on 6/9/2023 the facility did not ensure that a facility-wide assessment included what resources are necessary to care for the facility's residents competently during both day-to-day operations and emergencies. Specifically, the Facility Assessment did not include the overall number of facility staff needed, including Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants to ensure that a sufficient number of qualified staff were available to meet each resident's need during both day-to-day operations and emergencies. Additionally, the facility Assessment did not consider a review of individual staff assignments and systems for coordination and continuity of care for residents within and across these staff assignments. The finding is: The Facility assessment dated ,d+[DATE] was reviewed on 6/9/2023 at 1:50 PM. The Facility Assessment revealed that the assessment did not include a breakdown of Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA) levels by unit to ensure that resident's need were being met. The Administrator was interviewed on 6/9/2023 at 2:45 PM. The Administrator stated they were employed by the facility in February 2023 and reviewed the Facility Assessment soon afterwards in April 2023 and planned to schedule a full review in June of 2023. The Administrator stated staffing needs were assessed based on the acuity of resident's needs on each unit. The Administrator stated when they reviewed the Facility Assessment in April of 2023, they (Administrator) thought the staffing levels were broken down to a daily total, however, they would update the assessment on the scheduled review which will be conducted in June of 2023. The Administrator stated that they were not aware that the Facility Assessment should include the total number of nursing staff expected on each shift for the day-to-day operation of the care of the residents. 10 NYCRR 415.26

Based on observations, record review, and interviews during the Recertification Survey completed on 10/28/2021 the facility did not ensure that each resident was treated with respect and dignity and received care in a manner that promotes maintenance or enhancement of his or her quality of life and recognizes each resident's individuality for two (Resident #14 and #150) of two residents reviewed for Dignity. Specifically, 1) Certified Nursing Assistant (CNA) #3 was observed with Resident #14 in the resident's room after the resident's lunch and instructed the resident in a loud tone to wipe their (Resident #14) mouth and then abruptly placed a napkin on the resident's mouth; 2) CNA #3 was observed standing over and feeding Resident #150 while the resident was sitting in their (Resident #150) wheelchair in the hallway. The feeding was being done in a rushed manner, as much of the pureed food was observed spilling onto the resident's apron. The findings are: The facility's policy titled Feeding a Resident, dated 10/2011, documented the facility will provide residents with feeding assistance as necessary in a safe and dignified manner. Position yourself comfortably for feeding the resident. Sit and maintain eye contact. Do not rush the resident through a meal. The facility's Residents' Bill of Rights Policy, dated 9/2017, documented under the heading Dignity and Self Determination, you have the right to be treated with consideration, respect and full recognition of your dignity and individuality; and you have the right to receive quality care and services with reasonable accommodation of your individual needs and preferences. 1) Resident #14 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) assessment dated [DATE] documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident was rarely understood, rarely understands, and required extensive assistance for eating. On 10/25/2021 at 1:11 PM Resident #14 was observed in their (Resident #14) room in a wheelchair after finishing the lunch meal. CNA #3 was also present in the room. CNA #3 was observed instructing the resident in a rough, loud tone to wipe their (Resident #14) mouth and then abruptly placed a napkin on the resident's mouth, where the napkin stuck. After about 15 seconds Resident #14 took the napkin off of their mouth. CNA #3 was interviewed on 10/25/2021 at 1:15 PM and stated they (CNA #3) were just helping to wipe Resident #14's mouth. 2) Resident #150 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident was rarely understood, rarely understands, and required extensive assistance for eating. On 10/25/2021 at 1:19 PM CNA #3 was observed standing up and feeding Resident #150 who was seated in a wheelchair in the hallway. The food was observed falling from the resident's mouth onto the plastic apron while CNA #3 was placing the food in the resident's mouth. CNA #3 was interviewed on 10/25/2021 at 1:20 PM and stated that they (CNA #3) were supposed to sit down while feeding a resident. CNA #3 then continued to stand and feed the resident. The Assistant Director of Nursing Services (ADNS) was interviewed on 10/25/2021 at 1:31 PM. The ADNS stated all CNAs are supposed to sit down and be level with the resident when feeding a resident. The ADNS also stated that staff need to treat residents in a dignified manner. 415.3(c)(1)(i)

Based on observation, record review, and interviews during the Recertification Survey completed on 10/28/2021, the facility did not ensure that each resident had the right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for one (Resident #85) of five residents reviewed for Choices. Specifically, Resident #85 requested a change of shower days; however, the facility did not accommodate the resident's request. The finding is: The facility's policy titled Admission of a Resident, dated 5/2014, documented based on room assignment, shower or tub bath to be scheduled 1-2 times a week and when needed, or based on patient preference. The facility's Residents' Bill of Rights Policy, dated 9/2017, documented you have the right to receive quality care and services with reasonable accommodation of your individual needs and preferences; and you have the right to choose activities, schedules, and health care providers and services consistent with your interest and your assessment and plan of care. Resident #85 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented the resident required total assistance for bathing. The Significant Change MDS dated [DATE] documented that it was very important for the resident to choose between a tub bath, shower, bed bath, and sponge bath. A Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADL) Self Care Performance Deficit, last updated 9/1/2021, documented that the resident required extensive assistance of one staff member for bathing and preferred one shower a week. The Certified Nursing Assistant (CNA) Tasks (directions to CNAs regarding resident care needs) as of 10/26/2021 documented the resident required extensive assistance of one person with bathing and preferred one shower a week. The undated unit shower schedule indicated Resident #85 was scheduled for a shower on Saturdays only during the day shift. Review of the CNA Accountability Record for October 2021 documented that Resident #85 received showers only once a week, on Saturdays (10/2, 10/9, 10/16, and 10/23). Resident #85 was interviewed on 10/25/2021 at 11:55 AM and stated their (Resident #85) shower day is Saturday, and they (Resident #85) had a second shower scheduled for Monday. The resident stated they (Resident #85) asked the unit nursing coordinator to change the Monday shower day to a day later in the week, like Tuesday or Wednesday, because it was too close to the Saturday shower. The resident stated the unit nursing coordinator told the resident that the Monday shower could not be changed because there were no other available days that the resident's CNA (CNA #2) could give a shower. The resident also stated that Monday showers are difficult because the resident has rehabilitation therapy very early in the morning and the shower would have to take place before therapy, which was difficult for CNA #2. The resident stated they (Resident #85) did not want to take a shower after therapy. The Registered Nurse (RN #4) unit coordinator was interviewed on 10/26/2021 at 9:44 AM and stated Resident #85 was scheduled for showers on Mondays and Saturdays and that Resident #85 did request a change for the Monday shower, but RN #4 did not recall when the conversation took place. RN #4 stated they (RN #4) offered to change Resident #85's CNA (CNA #2) to get a shower day other than Monday, but Resident #85 did not want to change the CNA (CNA #2). RN #4 stated a different shower day would have required a different CNA. RN #4 stated that Resident #85 could not have CNA #2 give a shower on a day other than Monday because of CNA #2's assignment, which would have required CNA #2 to give two showers in one day. CNA #2 was interviewed on 10/26/2021 at 10:04 AM and stated that Resident #85 did not say they (Resident #85) would only accept showers from CNA #2. CNA #2 stated that Resident #85 will accept showers from other CNAs. RN #4 was re-interviewed on 10/26/2021 at 10:08 AM. RN #4 stated that they (RN #4) did not realize that Resident #85 would accept showers from other CNAs. RN #4 stated that they (RN #4) thought Resident #85 only liked CNA #2, that is why RN #4 updated the care plan and the CNA Tasks for once-a-week shower on Saturdays. Resident #85 was re-interviewed on 10/26/2021 at 11:46 AM. The resident stated they (Resident #85) will take a shower from any aide and would prefer a shower more than once a week. The Assistant Director of Nursing Services (ADNS) was interviewed on 10/26/2021 at 1:03 PM. The ADNS stated residents should get showers two times a week. The ADNS stated if a resident requested a change of a shower day the request can be accommodated, the staff just have to review the CNA assignments and perhaps speak to other residents about changing their shower day. The ADNS stated Resident #85's shower schedule will be reviewed to accommodate the resident's request. 415.5(b)(1-3)

Based on observations, record review and interviews conducted during the Recertification Survey completed on 10/28/2021, the facility did not ensure that residents received proper assistive devices to maintain hearing for one (Resident #112) of two residents reviewed for Communication. Specifically, Resident #112, who has severe hearing impairment, was not provided services to maintain functional hearing. The finding is: The facility's Hearing Aid Policy dated 10/2020 documented to care for the hearing aid and to maintain the hearing aid in good working condition. The policy documented that if a hearing aid malfunctioned, the unit clerk would arrange for a service appointment. Resident #112 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. The MDS documented the resident had highly impaired hearing and utilized a hearing aid. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) for Communication Problem dated 12/30/2020 documented that Resident #112 has a communication problem related to hearing impairment. The intervention was to ensure hearing aids (both ears) are in place. The care plan was revised on 10/21/2021 by Registered Nurse (RN) #3 who documented that a family member of Resident #112 took the hearing aid to get fixed. Resident #112 was observed and interviewed on 10/21/2021 at 12:05 PM. Resident #112 was not wearing a hearing aid in either ear. Resident #112 stated they (Resident #112) were very hard of hearing and could not hear the surveyor's questions. The surveyor needed to write questions on paper to communicate with the resident. Resident #112 stated that they (Resident #112) would like to have a hearing aid however, the resident did not know how and where to get a hearing aid. Resident #112 was observed on 10/22/2021 at 10:12 AM. The resident was not wearing a hearing aide in either ear. The resident stated they (Resident #112) need and want to have a hearing aid and that they do not go out or participate in activities because the resident cannot hear. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #3 was interviewed on 10/25/2021 at 11:35 AM and stated that Resident #112 has impaired hearing. RN #3 stated that Resident #112 had a hearing aid but was not aware that a family member had taken the hearing aid until 10/21/2021. RN #3 stated that they (RN #3) were not aware of how long Resident #112 has been without a hearing aid until 10/21/2021. RN #3 stated that Resident #112 currently does not have any hearing aid. The family member of Resident #112 was interviewed on 10/25/2021 at 2:36 PM and stated Resident #112 has severely impaired hearing and needed to use a hearing aid. The family member stated that they (the family member) took Resident #112's hearing aid approximately three weeks ago because the facility had asked the family member in August 2021 to have the hearing aid fixed. The family member stated they requested facility assistance to address Resident #112's hearing aid problem however, the facility did not address or offer any assistance during these months. The attending Physician was interviewed on 10/25/2021 at 3:15 PM and stated Resident #112 has severely impaired hearing and required a hearing aid. The Physician stated that they (MD) were aware that Resident #112's hearing aid had malfunctioned and stated that a verbal order was given to the unit manager to schedule an audiology appointment. The MD could not recall when the MD had informed the unit manager to schedule an audiology appointment. The MD further stated that they (the MD) were not aware that the audiology consultation order was not put in place. The Licensed Practical Nurse (LPN) #2 was interviewed on 10/26/2021 at 12:28 PM and stated Resident #112 was hard of hearing and therefore needed to wear a hearing aid. LPN #2 stated that they (LPN #2) were not aware that Resident #112's hearing aid was missing. LPN #2 stated that they (LPN #2) signed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The unit manager was unavailable for interview. The Assistant Director of Nursing Services (ADNS) was interviewed on 10/26/2021 at 1:03 PM and stated that if a resident's hearing aid was malfunctioning, the facility should guide the resident on how to obtain a replacement and to schedule an audiology consult for the resident. The ADNS stated that Resident #112 did not obtain a replacement hearing aid after their (Resident #112) hearing aid malfunctioned. The ADNS stated that the facility did not arrange for an audiology consult for Resident #112. The Administrator was interviewed on 10/26/2021 at 1:49 PM and stated that the facility was responsible to evaluate and assess residents for hearing aid replacement eligibility promptly when any resident's hearing aid was reported to have malfunctioned or was lost. The Administrator stated that the facility did not arrange for Resident #112 to be re-evaluated for hearing needs after Resident #112's hearing aid had malfunctioned. The Administrator further stated the facility determined Resident #112 has a need for a new hearing aid and the facility should assist the resident in acquiring a hearing aid. 415.12(3)(b)

Based on observation, record review, and interviews during the Focused Infection Control Survey (FICS) on 1/5/2021 the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of COVID-19. Specifically, on Unit 1C, a unit where a confirmed positive COVID-19 case was identified and the unit was placed on transmission-based precautions, the Licensed Practical Nurse (LPN) was observed within inches of a resident administering oral (PO) medications to the resident. The LPN was not wearing an isolation gown. Additionally, three of eight nursing units observed (Unit 1C, 2C and 2D) did not have signs indicating that the units were on transmission-based precautions contrary to the facility's policies and procedures. The finding is: The Centers for Disease Control and Prevention (CDC) guidance titled Transmission-Based Precautions (undated), provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and properly discarding before exiting the patient room is done to contain pathogens. The NYSDOH Health Advisory titled COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities dated 3/13/2020 revised 7/10/2020, documented that if there are confirmed cases of COVID-19 in a NH, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. Health Care Personnel (HCP) and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The facility policy titled Outbreak Management, dated 9/1/2020, documented to post signs as needed with instructions about control measures. The facility Pandemic Emergency Plan dated 9/15/2020 documented that the Infection Preventionist (IP) will ensure that appropriate signage is visible in designated areas for newly emerging infectious agents. The facility policy titled Quarantine Protocol for COVID-19 Exposure, dated January 2021, documented to place signage at the entrance to the room instructing HCP on recommended Personal Protective Equipment (PPE) prior to entrance to room and while performing high contact care activities. The facility's written email communication with the NYSDOH Epidemiology on 12/30/2020 documented that seven residents were newly identified as positive COVID-19 on 12/29/2020. The NYSDOH Epidemiology advised that all units should be placed on transmission-based precautions. Laboratory test data for Resident #1 who resided on Unit 1C, was reported positive COVID-19 on 1/4/2021. The resident was transferred off Unit 1C on 1/4/2021 to another unit. An interview concurrently with the Administrator, Director of Nursing (DON), and the Assistant Director of Nursing Services (ADNS) on 1/5/2021 at 9:00 AM, revealed that all the facility units were on contact and droplet precautions and the staff should wear full PPE including the isolation gowns on each unit when providing resident care. Unit 2C was toured on 1/5/2021 at 1:15 PM. There was no signage observed on the unit indicating contact and droplet precautions. The Unit 2C Registered Nurse (RN) Unit Manager was interviewed on 1/5/2021 at 1:20 PM. The RN stated that the unit was a non-COVID unit and was not on droplet and contact precautions. The RN stated that all residents were on quarantine and were being monitored for signs and symptoms of COVID-19. Unit 2D was toured on 1/5/2021 at 2:00 PM. There was no signage observed on the unit indicating droplet and contact precautions. Unit 1C was toured on 1/5/2021 at 2:00 PM. There were double doors at the entrance to the unit. One of the doors was open. There were no signs on the doors indicating contact and droplet precautions or that the unit was on quarantine. Throughout the unit there were no signs in the hallways or on the resident room doors indicating contact and droplet precautions. The Unit 1C RN Unit Manager was interviewed on 1/5/2021 at 2:10 PM. She stated that all residents were on droplet and contact precautions. She stated there are no signs indicating droplet and contact precautions, but all staff are aware because she informed them that morning. The RN Infection Preventionist was interviewed on 1/5/2021 at 4:12 PM. She stated that the only units that were on contact and droplet precautions were units 1A, 1B, and 2A. She stated no other units were on contact and droplet precautions. The RN Assistant Director of Nursing Services (ADNS) was interviewed on 1/5/2021 at 4:31 PM. She stated the entire building was on contact and droplet precautions, but signs are only put up if the resident is positive for COVID-19 or if the resident requires isolation for another infectious agent such as Clostridioides Difficile. During a subsequent observation on 1/5/2021 at 5:15 PM on Unit 1C, one of the double doors leading to the unit was open. There were no signs on the doors at the entrance to the unit or on the resident room doors indicating contact and droplet precautions. On 1/5/2021 at 5:20 PM the LPN on Unit 1C was observed giving medications to a resident who was sitting in a wheelchair near the nurse's station. The LPN was within inches of the resident's face as the nurse was spooning the medications into the resident's mouth and assisting the resident with drinking water. The LPN was not wearing an isolation gown. On 1/5/2021 at 5:25 PM the LPN was interviewed. He stated a gown was not necessary because the unit was not on contact or droplet precautions. The Director of Nursing Services (DNS) was interviewed on 1/5/2021 at 5:34 PM. She stated that Unit 1C was on contact and droplet precautions. She stated the whole building was on quarantine, which is the same as contact and droplet precautions. She stated precaution signs on Unit 1C, 2C, and 2D were not necessary because the facility considered the whole building to be on contact and droplet precautions and all the staff were aware that the building was on quarantine. She stated precaution signs will be put up now. She further stated more in-service education is required to ensure everyone is properly educated. The Administrator was interviewed on 1/5/2021 at 6:35 PM. He stated that contact and droplet precaution signage should have been placed, at a minimum, outside of every unit. 415.19(a)(1-2)

Based on staff interview and record review during an abbreviated survey (Complaint # NY 681) the facility did not ensure the residents' rights to be free from neglect for one (Resident #1) of three residents reviewed for Resident Neglect. Specifically, a Certified Nursing Assistant (CNA #1) and a Licensed Practical Nurse (LPN #1) transferred the resident from the floor to bed without reporting to, or ensuring that the resident was assessed by, a Registered Nurse (RN), Nurse Practitioner (NP) or a physician (MD) after an unwitnessed fall. Thereafter, the resident was in pain and was unable to bear weight to the right leg. A physician or NP was not notified for 7 hours after a change in the resident's condition was identified by the facility staff. Additionally, the resident was not assessed by a qualified clinician for at least 23 hours after the fall. Subsequently, the resident was transferred to the hospital with a [DIAGNOSES REDACTED]. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The findings were: The facility policy titled Resident Abuse dated 12/2016 defined Neglect as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility policy titled Accident-Reportable Event Protocol dated 11/2018 documented it is the responsibility of all staff to report all incidents and accidents that occur at the facility, staff will notify the Nursing Supervisor immediately when an incident occurs. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident required extensive assistance of two persons with bed mobility and extensive assistance of one person for transfer and ambulation. The Comprehensive Care Plan (CCP) titled at Risk for Falls dated 01/18/2018 documented Resident #1 was at risk for falls. Interventions included; anticipate and meet the resident's needs, encourage the resident to participate in activities, Physical Therapy (PT) evaluate and treat as ordered or as needed. 02/08/2018 ensure the resident is wearing shoes when ambulating and nonskid socks only when in bed. 02/13/2018 alarmed floor mats over graduated floor mats, bilateral graduated floor mats, hip savers at all times and the resident to be first on the assignment to be provided with morning care. The resident had documented actual falls on, 02/07/2018 (no injuries), 02/13/2018 found on the floor next to the bed (no injury) and 02/20/2018 hospital transfer/right [MEDICAL CONDITION]. The medical record lacked documented evidence of an incident/accident, fall or complaints of pain from 2/14/18 - 2/19/18. The Nursing Progress Note (NPN) (authored by LPN #2) dated 02/19/2018 10:46 PM documented Resident #1 was unable to bear weight on her right leg. She denied pain or discomfort for the majority of the shift. While in bed the resident complained of pain to the right leg. [MEDICAL CONDITION] noted to the lower portion (right leg). A telephone order was obtained from the MD to get an X-ray of the right hip. X-ray Company would send a technician in the morning. The Radiology Results Report (X-ray of right hip with pelvis) dated 02/20/2018 9:02 AM documented an Intertrochanteric Right Femur Fracture. An Accident Report dated 02/20/2018 documented at 8:00 AM Resident #1 was observed with swelling and bruising to her right hip/thigh. Her right leg was shorter than the left and externally rotated. The resident had pain. The physician was notified and examined the resident on 02/20/2018 at 9:00 AM. The Medical Progress Note (MPN) dated 02/20/2018 at 9:47 AM documented; evaluated another recent fall. X-ray was done this morning, right [MEDICAL CONDITION]. Will need to transfer to the hospital for an orthopedic evaluation. The personnel file for CNA #1 included a Counseling Report dated 2/22/2018 that documented CNA #1 failed to report a fall. The CNA and Nurse transferred the resident from the floor to the bed, the supervisor was not notified. CNA #1 was suspended for two days. CNA #1's in-service record revealed an in-service dated 06/06/2017 including; Safety and Accident Prevention, Resident Abuse/Neglect/Mistreatment/Rules and Reporting. 11/17/2017 Resident Safety/Fall Prevention, 10/31/2017 reporting Accidents/Incidents The personnel file for LPN #1 included a Counseling Report dated 2/22/2018 that documented LPN #1 failed to report a fall. LPN #1 and CNA #1 assisted Resident #1 back to bed, the supervisor was never notified. She was suspended for two days. LPN #'1s in-service record revealed an in-service dated 06/08/2017 Resident Abuse/Neglect/Mistreatment and Rules and reporting, 11/30/2016 Resident Safety/Fall Prevention. The hospital discharge record dated 02/23/2018 documented patient required surgery for [REDACTED]. The Risk Manager Review (Summary of Investigation) dated 02/23/2018 documented the investigation revealed that there was no reasonable cause to believe any alleged resident abuse, mistreatment or neglect regarding this resident had occurred. The 6:30 AM - 2:30 PM LPN #1 (charge nurse) was interviewed on 01/07/2019 at 11:17 AM and stated she responded to a report of a fall at approximately 9:00 AM on 02/19/2018. Resident #1 was on the floor mat, and CNA #1 was present in the room. She asked the resident to move her legs and arms, and the resident denied pain. She asked CNA #1 to help get the resident up off the floor. CNA #1 and herself, both picked Resident #1 up off the floor. She did not notify anyone including the Registered Nurse Supervisor (RNS) or the on-coming shift. She did not fill out an incident/accident report. The 6:30 AM - 2:30 PM CNA #1 was interviewed on 01/07/2019 at 12:22 PM she and stated, in the morning she walked into Resident #1's room and found her sitting on the floor mat. She immediately called the nurse in charge (LPN #1), she came and asked the resident if she was ok. LPN #1 asked the resident to move her feet, legs and hands. Both CNA #1 and LPN #1 picked the resident up off the floor and placed her in bed. CNA #1 stated that the resident was not in pain. LPN#1 instructed her to lift the resident from the floor. CNA #1 stated that she lied and told the Assistant Director of Nursing Services (ADNS) that Resident #1 did not fall. The Nurse Practitioner was interviewed on 01/07/2019 at 2:02 PM, and stated, on 02/20/2018, she evaluated Resident #1. The right leg was noted to be shorter than the left and was externally rotated which indicated a pathological event. The resident was transferred to the hospital. The NP stated that she expected facility staff to notify her or the physician if a resident was found on the floor. The 3:00 PM - 11:00 PM LPN #2 was interviewed on 01/29/2019 at 1:30 PM and stated she was assigned to Resident #1 on 2/19/18. She did not get a report of an incident/accident or fall regarding Resident #1. LPN #2 stated at approximately 2:55 PM, CNA #3 reported to her that Resident #1 was not able to stand. The resident was sitting in her wheel chair when LPN #2 assessed the resident. The resident was able to stand up and there was no shortening of the leg. CNA #3 kept telling her something was wrong with the way the resident was standing. LPN #2 didn't think anything was wrong, therefore she did not call the RNS. At approximately 6:00-6:15 PM Resident #1 was toileted. Normally she required one person's assistance, however, two CNA's assisted her to the toilet. CNA #3 continued to tell her (LPN #2) that something was wrong with the resident. Toward the end of her shift Resident #1 was screaming for help. Resident #1 reported she was in pain. The resident had right leg pain and [MEDICAL CONDITION]. LPN #2 then called the MD and got an order for [REDACTED]. The LPN stated that she did not have an issue with the X-ray company coming to the facility in the morning because there was no indication that the resident had a fracture. If she would have noted that the resident had a fracture and she couldn't get an X-ray right away she would have sent the resident out to the hospital. LPN #2 stated that she did not notify the RNS. The nurses do the assessing of the residents including the LPN charge nurse. The RNS was made aware at the end of the shift. LPN #2's written statement provided to the facility dated 02/20/2018 documented at 2:55 PM (02/19/2018) a CNA informed her that Resident #1 was unable to stand. At 6:00 PM the resident was toileted and able to stand with assistance. At 10:25 PM the resident was in pain and unable to move her right leg. The ADNS was interviewed on 01/07/2019 at 2:57 PM, and stated she completed the ingestion investigation regarding Resident #1's fall. Initially CNA #1 and LPN #1 denied the incident. Later LPN #1 admitted that she knew the resident fell and she did not report the incident. The 2:30 PM - 10:30 PM CNA #3 was interviewed on 01/07/2019 at 3:15 PM and stated she was assigned to Resident #1 on 2/19/2018. Normally the resident required the assistance of one person for toileting. That evening the resident could not stand up, and she could not ambulate and her foot was bending under. She reported this to LPN #2 (charge nurse). LPN #2 checked her leg and then went away. After dinner the resident was toileted again and required two-person assistance. She called LPN #2 again to observe. The resident could bear weight on her leg. However, CNA #1 noted a change in the resident's transfer that was different from how she (the resident) normally transferred. The resident was uneasy during the transfer. Later that night the resident was placed in bed and CNA #5 assisted her, and they both reported to LPN #2 that the resident could not stand, and something was wrong with her leg. The 2:30 PM - 10:30 PM CNA #4 and CNA #5 were interviewed on 1/29/2019 separately via telephone. Both CNAs stated that they assisted CNA #3 in toileting Resident #1. The resident was in pain, she was frowning and grimacing. CNA #4 and CNA #5 reported the pain to LPN #2. The 7:00 AM - 3:00 PM RNS #1 was interviewed via telephone on 01/29/2019 at 11:29 AM she stated she was not made aware of any incident/accident regarding Resident #1. The MD was interviewed on 01/30/2019 at 11:33 AM, and stated he was called and ordered an x-ray for the resident however, could not recall the details of the call. He stated if a nurse called him and reported the patient could not ambulate and if there was pain he would tell them to get an X-ray, give pain medication and monitor. If the patient stable with pain medication we order the X-ray and its ok to wait until morning. He would expect the nurse to notify the supervisor. F600 (G) 415.15

Based on staff interview and record review during an abbreviated survey (Complaint # NY 805 and # NY 127), the facility did not provide the supervision and proper use of assistance devices necessary to minimize risk of avoidable accidents with serious injuries for two of four residents reviewed for accidents (Resident #1, Resident #2). Specifically, 1) Resident #1 required assistance to two persons for transfers according to the Comprehensive Care Plan (CCP). Two Certified Nursing Assistants transferred the resident using a mechanical lift (stand-up lift) without the resident having been assessed for use of a stand up lift. Resident #1's foot got caught in the bedframe resulting in an open tibia fibula (lower leg) fracture. 2) Resident #2 required use of a stand-up mechanical lift with assistance of two persons for transfer. One of two CNAs assisting the resident left the room in the middle of a transfer procedure with Resident #2 positioned in the stand-up lift. The remaining CNA continued the transfer independently. The resident fell and was diagnosed with [REDACTED]. This resulted in actual harm for Resident #1 and Resident #2 that is not Immediate Jeopardy. The findings include: The Facility Policy titled Stand Up Lift dated 4/2000 documented residents must be assessed by the unit coordinator before using the stand-up lift, two staff members must be involved in the transfer of a resident with the stand-up lift and do not use with severely comatose residents. The Facility Policy Titled Transfer Technique dated 11/2000 documented, prior to transferring the resident, staff member will check the CNA assignment/accountability/and or care plan to determine the method of lifting and transferring the resident. Disciplinary action will be taken upon employees who do not perform resident transfers according to the designated plan of care. The Facility Policy titled Resident Abuse dated 12/2016 documented the facility must ensure that all alleged violations involving neglect; including injuries of unknown source are reported immediately to the administrator and Director of Nursing Services (DNS) of the facility utilizing the chain of command. Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. Immediate action; notify administrative staff or the nursing supervisor on duty, protect the resident from alleged abuse, suspend the employee pending investigation. Investigation; immediate notification of the Administrator and Director of Nursing (DON) and/or designee, immediate investigation into alleged incident (during the shift it occurred on). 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS, a resident assessment tool) dated 06/08/2018 documented the resident had severe cognitive impairment and required extensive assistance of two persons to transfer. The untitled, undated CNA Kardex (CNA care plan) documented Resident #1 required extensive assistance of two persons to move between surfaces. The Activities of Daily Living (ADL) Comprehensive Care Plan (CCP) dated 06/01/2018 documented the resident had an ADL self-care deficit related to advanced dementia, per Physical Therapy (PT) non-ambulatory on the unit; two assists with transfers. Interventions included; extensive assist of two by staff to move between surfaces, the resident is non- ambulatory. The CCP and the CNA care plan lacked documented evidence to use a stand-up lift as an intervention for Resident #1. The Accident Report dated 08/15/2018 7:30 PM documented the Registered Nurse Supervisor (RNS) was called to evaluate Resident#1 who sustained trauma during a stand-up lift transfer into his bed. The residents' left lower leg had an open one-inch x 0.5-inch laceration/trauma with raised skin/bone area medial side of skin. Pain, swelling and change in range of motion was documented. The medical doctor (MD) was on the unit and examined the resident at 7:45 PM. Emergency care was given and the resident was transferred to the emergency room (ER). The Medical Progress Note (MPN) dated 08/17/2018 (late entry) documented the MD evaluated Resident #1 on 08/15/2018, there was blood on the floor and bed and there was bleeding on the left leg. The left leg was contracted inwards, positive wound on the left shin area. Advised to transfer the resident to the hospital for further evaluation and management. The Nursing Progress Note (NPN) dated 08/16/2018 at 8:15 AM documented Resident #1 was admitted to the hospital with [REDACTED]. The hospital untitled consultation dated 08/16/2018 documented surgical fixation was performed on 8/16/18. The Risk Manager Review (facility investigation, summary and conclusion) dated 08/16/2018 documented Resident #1 required assistance of two persons with transfers. On 08/15/2018 at 7:30 PM the resident was being transferred to his bed from his wheelchair via a stand-up lift by two CNAs (CNA #1 and #2). The resident's bed was not in low position prior to the transfer. During transfer both CNAs realized the bed was too high, it was lowered (by CNA #2) while the transfer was occurring (CNA #1 was lowering the stand-up lift). CNA #1 noticed that the resident's left leg was bent back, and bleeding and the foot was caught in the bed frame. Both CNAs were suspended for not following proper procedure for transferring the resident. The investigation also documented that there was no reasonable cause to believe any alleged resident abuse, mistreatment or neglect regarding this resident had occurred. There was no documented evidence that the resident was assessed for the use of the stand up lift. The MD was interviewed on 08/27/2018 at 11:31 AM and stated he was in the building on 8/15/18 and was called by the Registered Nurse Supervisor to assess Resident #1. The resident was lying on the bed with blood on the floor in his room. Upon assessment the resident's leg had a wound that was bleeding. A dressing was applied. The resident was noted to be sleepy and lethargic. The left leg was rotated toward the body and had pain with movement. The resident had moderate blood loss. The resident was transferred to the hospital. The 3:00 PM-11:00 PM LPN #1 was interviewed on 08/27/18 at 12:30 PM and stated that she was the assigned nurse for the resident on 8/15/18. CNA #1 informed her that the resident got injured during transfer. The resident was observed with a cut on the leg. LPN #1 stated that CNA #1 or CNA #2 did not notify her of a decline in transfer status for the Resident #1. The 2:30 PM - 10:30 PM CNA #1 was interviewed via telephone on 08/27/2018 at 12:00 PM, and stated she was the assigned CNA for Resident #1 and cared for this resident often. She did not check the Kardex for his transfer status and was not aware of the resident's transfer needs. CNA #1 stated that she had cared for this resident prior and had used the stand-up lift to transfer him. On 8/15/18 the resident was sick and was not himself, the resident looked tired and was not talking. CNA #2 assisted her with the transfer utilizing the stand-up lift. The resident was hooked up to the stand-up lift. While CNA #1 was lowering the resident onto the bed, CNA #2 went around to lower the bed as it was too high to place the resident in it. CNA #1 looked down and one of his legs was not visible. The leg was under the bed and the resident was still in the air hooked to the standup lift. She asked CNA #2 to raise the bed. The resident was lifted to the bed by both CNAs. They notified the LPN #1 after they placed the resident in bed. The resident was noted with an open wound on his leg and there was blood on the bed. CNA #2 was interviewed via telephone on 08/29/2018 at 10:15 AM and stated on 8/15/18 she assisted CNA #1 with a stand-up lift transfer for Resident #1. Prior to this incident she had also assisted CNA #1 with the stand-up lift transfer for Resident #1. The resident was hooked to the lift and his knees were against the knee support. CNA #1 lifted the resident from his wheelchair and she (CNA #2) removed the wheelchair from under the resident. The height of the bed was too high; CNA #1 stayed with the resident, CNA #2 went on the opposite side of the bed and lowered the bed. At that time CNA #1 told her to raise the bed because the resident was injured. The resident did not make any sound. CNA #2 thought the resident had a skin tear, she held the resident's shoulder while the resident was sitting at the edge of the bed. She did not see the blood. The In-service Coordinator (IC) was interviewed on 08/27/2018 at 1:30 PM and stated that she participated in the investigation related to the 08/15/2018 incident. She conducted a reenactment of the stand-up lift transfer with CNA #1 and CNA #2. CNAs were supposed to be next to the resident throughout a transfer with the stand-up lift. During the reenactment it was noted that the resident's bed was too high, CNA #2 left the resident and went on to the other side of the bed to lower the bed. CNA #1 was with the resident and was operating the lift and continued lowering the resident while CNA #2 was lowering the bed. The IC stated that the transfer was not done correctly. If the resident's feet were positioned properly on the lift the feet would not get under the bed frame. The IC stated that she was unable to discern how Resident #1's leg got under the bed frame. The IC stated that she educated the staff related to transfers and utilizing the stand-up lift. The staff was instructed of the proper procedures. The staff was also instructed to not use a lift without an assessment by the RNS or the therapist. If the resident was declining in transfer status, the CNAs were to notify the nurses. The 9:00 AM - 5:00 PM RN Risk Manager was interviewed on 08/27/2018 at 2:00 PM and stated she participated in the investigation related to the incident with Resident #1 on 8/15/18. CNA #1 and CNA #2 told her Resident #1's leg was crushed under the bed frame during a transfer. When the CNAs were transferring the resident, they realized that the bed was too high, CNA #2 lowered the bed while CNA #1 was placing the resident on the bed utilizing the stand-up lift. CNA #1 told her that she was not paying attention to the resident's legs and was looking at the intravenous pole. The Risk Manager stated that the CNAs were supposed to ensure that the bed was at the correct height prior to the transfer; the resident's limbs were secured and both CNAs were expected to be by the resident during the entire transfer process. CNA #1 and CNA #2 also told her that they used the stand-up lift for Resident #1 previously and did not make anyone aware that resident had declined in his transfer status. The Risk Manager stated that the CNAs could not use the stand-up lift without an assessment by the RNS or the physical therapy department. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 dated 05/19/2018 documented the resident's cognitive status as intact. The ADL CCP documented on 06/07/2018 stand-up lift with two assists to transfer. The Accident Report dated 06/28/2018 documented at 6:45 PM the resident was being transferred to bed with the stand-up lift, she pulled her hand out of the sling and slid out lying on her back. The CNA lowered her to the floor. The resident complained of pain to the right hip and right knee. The MD was notified and ordered an x-ray of the right hip and knee. The Radiology Results Report dated 06/28/2018 documented an acute fracture lateral tibial articular surface (a break of the upper part of the tibia (shinbone) that involves the knee joint) with slight displacement. The hospital x-ray right tibia and fibula dated 06/29/2018 documented diffuse osteopenia (bone loss is not as severe as in [MEDICAL CONDITION]) and right-sided lateral tibial fracture. The Radiology Results Report dated 06/28/2018 documented an x-ray of the right knee. Impression included an acute fracture lateral tibial articular surface (a break of the upper part of the tibia (shinbone) that involves the knee joint) with slight displacement. As compared to the study on 06/06/2018 this was not definitely identified. Severe [MEDICAL CONDITION] is present. The right hip x-ray documented mild [MEDICAL CONDITION] changes and no acute fractures noted. The Hospital History and Physical (H&P) assessment dated [DATE] documented patient had x-ray done yesterday results showing acute [MEDICAL CONDITION] lateral tibial plateau and right [MEDICAL CONDITION]. The Risk Manager Review (facility investigation summary) dated 06/29/2018 documented the investigation revealed that there may be reasonable cause to believe alleged resident abuse, mistreatment or neglect regarding this resident had occurred. On 06/28/2018 the resident was being transferred back to bed via the stand-up lift with assistance of two CNAs. CNA #5 did not stay (it was past her break time) and told CNA #4 she was leaving. CNA #4 did not insist that CNA #5 stay and assist her until the transfer was complete. While the resident was close to the bed, the resident removed her hand from the sling/strap of the lift and started to slide off the bed. The CNA put one foot against the resident to break her fall and lowered the resident to the floor in sitting position. The Nurse and MD were called and x-rays were obtained showing an acute fracture to the right lateral tibial articular surface. The MD ordered to send the resident to the hospital. The hospital Patient Discharge Instructions dated 06/30/2018 documented [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The 2:30 PM - 10:30 AM CNA #4 was interviewed via telephone on 08/31/2018 at 9:30 AM and stated CNA #5 came to the room to help transfer the resident. CNA #4 began to raise the resident while CNA #5 removed the wheelchair for her. The resident started crying, CNA #5 told her every time she was placed in the stand-up lift she cried. The resident continued to cry as she was pulled up from the wheelchair. The resident's feet were shaking and when she was lifted her heels did not lay flat on the base pedal of the machine. CNA #4 started to lower the resident and noticed the bed was too high. CNA #5 was by the door at that point and told CNA #4 that it was time for her break, CNA #5 left the room. The resident's bed was still high, CNA #4 tried to adjust it with one hand. The resident removed her hands from the machine strap. CNA #4 saw the resident was going to fall, and she slid her down in a sitting position. CNA #4 removed the belt as the resident was sliding. CNA #4 stated she did not ask CNA #5 to stay. CNA #5 was interviewed via telephone on 08/31/2018 at 1:49 PM and stated she assisted CNA #4 transfer Resident #2 using the stand-up lift. The resident said ow as she was lifting her up, the resident didn't complain anymore while she was in the air and did not cry. CNA #4 was fixing the resident's pants; the resident was at the side of the bed in the air when CNA #5 asked CNA #4 if she could go on her break and she said ok. When she left the room, the resident was still on the lift. LPN #2/Charge Nurse was interviewed on 08/28/2018 at 2:38 PM and stated CNA #4 reported that CNA #5 had left her during Resident #2's transfer. The resident was on the floor, next to her bed. She expressed pain to the right leg upon movement. The 2:30 - 10:30 PM RNS #2 was interviewed via telephone on 10/05/2018 and stated she was called to the resident's room by LPN #2. She responded to the room and saw the resident was on her back, on the floor next to the bed. Resident #2 complained of right knee and hip pain. She called the MD and he ordered x-rays that revealed right tibial fracture. Both CNAs were supposed to be with the resident during a stand-up lift transfer until the transfer was complete. CNA #5 did not follow the facility policy related to stand-up lift transfer and left the resident during the transfer. 415.12(h)(1)

Based on observation, interviews and record reviews during an abbreviated survey, the facility did not ensure that each resident was provided with adequate supervision and assistive devices to prevent accidents. Specifically, one (Resident #1) of six residents reviewed for aspiration precaution physician ordered a diet consistency as ground. The Comprehensive Care Plan (CCP) documented aspiration precaution; ground meat only. At a lunch meal, the physician's orders [REDACTED]. Resident #1 was served a cut hot dog, which resulted in choking and she expired. This resulted in actual harm that is not immediate jeopardy. CASE#: NY 157 Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set Assessment ((MDS) dated [DATE] documented Resident #1 was cognitively intact. The Comprehensive Care Plan (CCP) dated [DATE] for eating documented aspiration precautions; nutritional status dated [DATE] documented ground meat only. The Physician order [REDACTED]. The Resident Nursing Instructions Certified Nurses Aide (CNA) Accountability Record dated [DATE], for eating, documented limited assistance for Resident #1. The Speech Therapy (ST) Progress Notes dated [DATE] documented the resident was evaluated, recommended regular consistency with extra gravy, aspiration precautions. The resident had oral weakness and restricted range of motion secondary to the collar. The Interim Physician order [REDACTED]. The Progress Note dated [DATE] documented the ST evaluated the resident, the diet was modified to regular solids, ground meat only and speech therapy was discontinued. The meal ticket dated [DATE] for supper documented extra gravy, aspiration precautions, ground meat only, no starch or vegetables, hamburger OK, green tray only. The Progress Note dated [DATE] at 5:55PM, the resident was observed coughing and choking in the dining room by the nurse in charge. Code blue was called and 911 staff arrived at 6:05PM, CPR (cardio pulmonary resuscitation) was performed and the resident was sent to the hospital at 6:10PM. The Progress Note dated [DATE] at 6:03 PM documented the RN assessed the resident for choking during dinner. Resident #1 was eating a hotdog, turning blue, the RN was not able to obtain blood pressure, Pulse 102, respirations 22, temperature 98.2 Fahrenheit, the resident was alert. The ambulance report dated [DATE] documented the resident was breathing, went into cardiac arrest and CPR started. The resident was transported to the hospital. The Progress Note dated [DATE] at 9:15PM documented the facility was made aware that the resident expired at the hospital. The Accident Report dated [DATE] documented at 5:50 PM the nurse observed Resident #1 choking in the 2A/B dining room while eating a hot dog, did the Heimlich maneuver, code blue was called and the resident was sent to the hospital via 911. The resident was unresponsive. The policy for resident meal service in the dining room dated ,[DATE] documented nursing is to double check to see that food served agrees with dietary slip, and the correct consistency; dysphagia management aspiration precautions documented residents must be supervised while eating and make sure the tray has the prescribed diet. The Director of Nursing (DON), was interviewed on [DATE] at 9:00AM, the DON stated that the wrong food consistency was identified on the Resident's tray. The resident was reported to choke was transferred to the hospital where she expired on [DATE]. The DON further stated on [DATE] it was not required that a nurse check the meal ticket to the items on the tray. Supervision for a resident identified as being on aspiration precautions requires an employee to be present in the area that the resident is eating and observes the residents for coughing or choking. The Speech Therapist (ST) was interviewed on [DATE] at 11:00AM. The ST stated that she evaluated the resident for swallowing ability. On [DATE] the ST assessed Resident #1 recommended small bites, ground diet, aspiration precautions. The ST stated that the hotdog for a ground diet would need to have the consistency of chop meat for residents with swallowing issues, "hot dogs are a problem ". During an observation of lunch in the 2A/B dining room on [DATE] at 12:25PM-12:45 PM, 5 residents at risk for aspiration/green trays were observed with no discrepancy between the tickets or the items on the trays. The 2B unit 2:30 PM -10:30PM shift, Licensed Practical Nurse, (LPN) #16 who was on duty on [DATE] was interviewed on [DATE] at 2:00PM, LPN #16, stated she was getting ready to give out trays for the B side of the dining room at about 6:00PM and heard Resident #1 make a funny sound, she asked the resident, " Are you OK?" Resident #1, was trying to catch her breath. The LPN stated she observed a cut up hotdog on Resident#1's tray. The Director of Food Service (DOFS) was interviewed on [DATE] at 1:30PM. The DOFS stated that when a tray is prepared for a meal, a caller calls out the foods, the tray passes various staff and stations before the tray is placed on the food truck for the unit. The supervisor checks the trays, meal tickets and the food for accuracy. The DOFS stated on [DATE], the supervisor did not check the food items for Resident #1 prior to the food tray being placed on the food truck. The Dietary Supervisor (DS) was interviewed on [DATE] at 2:15PM, the DS stated she checked the ticket to the items on the tray for Resident #1 the tray contained a ground hot dog on a bun, the meal ticket documented no starch, no vegetables. The DS removed the hot plate from the tray, returned the dish and called out " hot dog only " . The DS did not recheck Resident #1's tray for accuracy when it was returned to her. The 2A unit 2:30 PM -10:30PM shift LPN#15 who was on duty on [DATE] was interviewed on [DATE] at 2:45PM, the LPN stated that he was not in the dining room when the trays arrived. There was another LPN in the dining room. About 5:40PM he went to the dining room, heard a resident coughing, choking, and puffing. The 2A unit 2:30 PM -10:30PM shift CNA #13 who was on duty on [DATE] was interviewed on [DATE] at 3:05PM. CNA#13 stated she removed the food tray from the truck, but did not compare the items on the tray to the meal ticket for Resident #1. CNA#13 stated she was trained to check the meal ticket to the food items on the tray but she did not do this check. Resident#1 had a whole hot dog on her tray. CNA#13 cut the hotdog into pieces for Resident#1 who was able to eat on her own. CNA#13 left the 2A/2B dining room and when she returned another staff member told CNA #13 the resident was choking. The 2:30 PM -10:30PM shift Registered Nurse Supervisor (RNS)#20 who was on duty [DATE] was interviewed on [DATE] at 4:00 PM. RNS#20 stated that at 5:55PM she heard a stat overhead page and went to the 2A dining room. She observed the resident was gasping for air, choking on a hot dog and her face was discolored, a code blue was called. RNS#20 stated the resident did not have a palpable pulse but did have a pulse oximeter reading of more than 90%.Chest compression were done until 911 arrived. The 2:30 PM -10:30PM shift RNS #17who was on duty [DATE] was interviewed on [DATE] at 4:25PM, the RNS#17 stated she heard an overhead stat call to the 2A/ dining room and she responded to the area, the resident was choking. 415.12(h)(,[DATE])

Based on observations, interviews and record review during the abbreviated survey, the facility did not ensure that each resident was provided food prepared in a form designated to meet the resident's need as ordered by the physician. Specifically, one (Resident #1) of six residents reviewed for aspiration precaution, the physician prescribed a ground diet for the Resident. During a lunch meal, the resident was served a whole hotdog. Subsequently, the resident choked was sent to the hospital and expired. This resulted in actual harm that is not immediate jeopardy. Case#: NY 157 Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set Assessment ((MDS) dated [DATE] documented Resident #1 was cognitively intact. The Comprehensive Care Plan (CCP) dated 4/2/13 for eating documented aspiration precautions; nutritional status dated 4/7/13 documented ground meat only. The Physician order [REDACTED]. The Resident Nursing Instructions Certified Nurses Aide (CNA) Accountability Record dated 5/1/13, for eating, documented limited assistance for Resident #1. The Progress Notes for Speech Therapy (ST) dated 5/24/13 documented the resident was evaluated and recommended regular consistency with extra gravy and aspiration precautions. The resident had oral weakness and restricted range of motion secondary to the collar. The Interim Physician order [REDACTED]. The Progress Note dated 5/28/13 documented the ST evaluated the resident, the diet was modified to regular solids, ground meat only. The meal ticket dated 5/30/13 for supper, documented extra gravy, aspiration precautions, ground meat only, no starch or vegetables, hamburger OK, green tray only. The Progress Note dated 5/30/13 at 6:03 PM documented Resident #1 was eating a hotdog, and turned blue. The ambulance report dated 5/30/13 documented the resident went into [MEDICAL CONDITION], CPR was started and the resident was transported to the hospital. The Progress Note dated 5/30/13 at 9:15PM the facility was made aware that the resident expired at the hospital. The Director of Nursing (DON), was interviewed on 7/1/13 at 9:00AM, the DON stated the wrong food consistency was identified on the Resident's tray. The resident was choking and was transferred to the hospital where she expired on 5/31/13. During an observation of lunch in the 2A/B dining room on 7/1/13 at 12:25PM-12:45PM, 5 residents at risk for aspiration/green trays were observed; the food was prepared and designed to meet the individual resident's needs. The Director of Food Service (DOFS) was interviewed on 7/1/13 at 1:30PM. The DOFS stated that when a tray is prepared for a meal, a caller calls out the foods, the tray passes various staff and stations before the tray is placed on the food truck for the unit. At the end of the food conveyor line, there is a supervisor who checks the tray meal tickets and the food on the tray for accuracy. The supervisor did not check the food items or diet for Resident #1 prior to the food tray being placed on the food truck. The Dietary Supervisor (DS) was interviewed on 7/1/13 at 2:15PM, the DS stated that she checked the ticket to the items on the tray for Resident #1 the tray contained a ground hot dog on a bun, the meal ticket documented no starch, no vegetables, she removed the hot plate from the tray, returned the dish and called out "hot dog only". The DS did not recheck Resident #1's tray for accuracy when it was returned to her. 415.14(d)(3)