Every finding on record at Iroquois Nursing Home Inc

Based on observations, record review, and interviews, the facility failed to ensure residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #8) reviewed. Specifically, Resident #8 received hemodialysis treatments at a community-based dialysis center and there was no documented evidence there was consistent ongoing communication and collaboration between the facility and the dialysis center. Findings include: The facility policy Dialysis, reviewed 01/22/2026, documented preparation for dialysis treatment included provide communication book for use by both the nursing facility and the dialysis treatment center and provide a copy of the resident's current Treatment Administration Record and Medication Administration Record.Resident #8 had diagnoses of end-stage kidney disease. The 04/09/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had moderately impaired cognition and required hemodialysis treatments.The comprehensive care plan, initiated 12/05/2025 and revised 01/02/2026, documented the resident had renal failure and required dialysis. Interventions included dialysis as ordered, monitor for edema, medications as ordered, and collaboration with dialysis.The 01/02/2026 physician orders documented dialysis communication book to go with resident to dialysis and returned from dialysis. The book was to be reviewed for any concerns and concerns were to be reported to unit/clinical manager. Dialysis appointment on Tuesday, Thursday, and Saturday. Pick up time 5:00 AM for 6:15 AM chair time and estimated return time 11:45 AMThere was no documented evidence there was consistent ongoing communication and collaboration (dialysis communication book) between the facility and the dialysis center.During an interview on 05/29/2026 at 9:17 AM, Registered Nurse Unit Manager #10 stated Resident #8 kept their dialysis communication book in their room.During an observation on 05/29/2026 at 9:18 AM, there was a yellow-colored envelope on the back of the resident's wheelchair. The envelope contained a copy of the resident's diagnoses, nursing progress notes from 04/02/2026 - 04/09/2026, physician orders as of 04/09/2026, and the April 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR). There were no communication sheets in the envelope.During an interview on 05/29/2026 at 10:31 AM, Registered Nurse Unit Manager #10 stated the dialysis communication book went with the resident to the dialysis center from the facility. There should be current communication sheets reviewed by both the dialysis center and the facility to communicate any changes with the resident, their weight, and vital signs. The licensed practical nurse was responsible for ensuring the communication book sheets were filled out prior to dialysis and went to dialysis with the resident. When the resident returned to the facility the licensed practical nurse should review the communication book and notify the registered nurse Manager or Supervisor of any changes. They stated unfortunately there was no documented communication since 04/09/2026 with the dialysis center for Resident #8.During an interview on 06/01/2026 at 11:38 AM the community-based dialysis center Registered Nurse Charge Nurse #27 stated the dialysis center created a communication sheet they sent back to the facility with the resident to ensure there was communication between the dialysis center and facility. The dialysis center expected to be notified of any changes in conditions and if the resident received their medication prior to dialysis. The communication book should also include a list of up to date physician orders. During an interview on 06/01/2026 at 10:44 AM, AM Licensed Practical Nurse #8 stated when the resident returned from dialysis the nurse would check the resident's dialysis access site to ensure it was intact. They were unsure what was in the yellow envelope the resident came back with as they did not look at it. They thought if there were any issues the dialysis center would contact the facility. 10 New York Codes, Rules and Regulations 483.25

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of one (1) resident (Resident #5) reviewed. Specifically, Resident #5 was on enhanced barrier precautions and Licensed Practical Nurse #4 did not wear appropriate personal protective equipment while they performed wound care.Findings include: The facility policy Enhanced Barrier Precautions, revised 07/2024, documented enhanced barrier precautions were an infection control intervention designed to reduce transmission of multidrug-resistant organisms. Enhanced barrier precautions involved wearing a gown and gloves during high-contact resident care, which included wound care; any skin opening that required a dressing. The facility enhanced barrier precaution sign documented that providers and staff must wear gloves and gown for the following high contact resident care activities: - Device care or use for central lines, urinary catheters, feeding tubes and tracheostomies. - Wound care for any skin opening requiring a dressing. Resident #5 had diagnoses including pasteurellosis (bacterial infection). The 05/13/2026 admission Minimum Data Set assessment documented the resident was cognitively intact, had surgical wounds or skin tears and required surgical wound care. The 05/04/2026 comprehensive care plan documented the resident had an alteration in skin integrity of an ulcer to their chest wall prior to admission and non-healing surgical wound prior to admission. The resident was on enhanced barrier precautions related to a urinary catheter and wound vacuum assisted wound closure device. Interventions included to educate the resident on the importance of maintaining precautions to contain infections until resolved and educate family and visitors on the importance of maintaining precautions and frequent hand hygiene. The 05/04/2026 Physician #6 order documented the resident was on enhanced barrier precautions. The 05/28/2026 Assistant Director of Nursing #3 progress note documented the resident was seen by the skin team and tolerated their assessment. There were no changes in treatment orders and all interventions that were in place were reviewed and remained appropriate. The 05/04/2026 physician order documented to skin abrasions on back cleanse with normal saline, pat dry, apply Xeroform (dressing), cover with gauze and secure with tape every 3 days. On 05/27/2026 wet to dry dressing to midline back change daily and as needed. During an observation on 05/27/2026 at 7:40 AM there was an enhanced barrier precaution sign outside of Resident #5's room. During an observation and interview on 05/28/2026 at 3:38 PM there was an enhanced barrier precaution sign outside of the resident's room. Licensed Practical Nurse #4 prepared to change the dressing on Resident #5's wound. At 3:42 PM Licensed Practical Nurse #4 washed their hands and put on gloves; they did not put on a gown. At 3:45 PM they started to remove the old wound dressing on the resident's back. The state surveyor stopped Licensed Practical Nurse #4 and had them put on a gown for the safety of the resident. Licensed Practical Nurse #4 asked if there was an enhanced barrier sign, put on a gown and completed the dressing change. They stated they should have put a gown on but was rushing. They needed to follow isolation precaution signs to protect residents and themselves for infection control purposes. During an interview on 06/02/2026 at 8:56 AM Infection Preventionist Registered Nurse #5 stated staff were educated on infection control practices on orientation and at least annually. They were always on the units to educate staff in real time. Enhanced barrier precautions were used for residents at risk for cross contamination from staff, this included residents with wounds. When staff provided high-contact care to a resident on enhanced barrier precautions they should wear a gown and gloves, and this included dressing changes. Residents on enhanced barrier precautions should have a sign outside their door documenting what personal protective equipment was required. In shared rooms, there was a ladybug next to the resident's name on enhanced barrier precautions. Resident #5 had a wound and when their dressing was changed the nurse should have worn a gown. 10 New York Codes, Rules and Regulations 415.19(a)(b)

Based on observations, record review, and interviews, the facility failed to ensure residents who were fed by enteral means (tube feeding, delivery of nutrition directly to the stomach or small intestine) received the appropriate treatment and services to prevent complications of enteral feeding for one (1) of one (1) resident (Resident #183) reviewed. Specifically, Resident #183 did not receive their water flushes as ordered.Findings include:The facility policy Enteral Nutrition (Tube Feeding), last reviewed 01/22/2026, documented the physician orders would specify the formula, route of administration, rate, total volume infused, additional water flushes, and calories provided per feeding. The registered dietitian assesses the rationale of the tube feeding, the appropriateness of tube feeding product, and nutrition needs, including calories, protein and free water; monitors tolerance and efficacy of feeding; and documents in the medical record. Nursing staff processed tube feeding orders in the same manner as diet orders.Resident #183 had diagnoses including congestive heart failure and dysphagia (difficulty swallowing). The 05/26/2026 Minimum Data Set Assessment was in progress and not completed.The 05/26/2026 comprehensive care plan documented the resident required tube feeding due to the potential for aspiration (inhaling foreign objects into the lungs) secondary to a diagnosis of dysphagia. Interventions included administer tube feedings per medical orders and provide adequate calories, protein, and fluids via tube feeding to meet estimated nutritional needs. Physician orders documented the following tube feeding orders:-05/26/2026 administer Glucerna 1.5 (tube feeding formula) at 52 cubic centimeters per hour for 20 hours via percutaneous endoscopic gastrostomy (feeding) tube for a total volume of 1040 cubic centimeters in 24 hours.-05/26/2026 100 cubic centimeters water flush before and after tube feeding via percutaneous endoscopic gastrostomy tube.-05/26/2025 60 cubic centimeters water flush before medication pass, 60 cubic centimeters water flush with medication pass, and 60 cubic centimeters water flush after medication pass via percutaneous endoscopic gastrostomy tube.- 05/26/2026 administer additional fluid flush of 120 cubic centimeters 4 times daily for a total of 480 cubic centimeters daily. -05/27/2026 start tube feeding at 25 milliliters an hour and advance by 15 milliliters every 4 hours until goal rate of 52 milliliters an hour is reached. Start at 2:00 PM and end at 10:00 AM.The following observations were made: -On 05/27/2026 at 8:04 AM, the resident was in their room and stated they recently had their tube feeding placed. The tube feeding container was labeled Glucerna 1.5, dated 0/5/26/2026, and was hung at 6:00 PM, and the pump was infusing at 52 milliliters an hour.-On 05/28/2026 at 11:18 AM, the resident was in their room. Their tube feeding was disconnected. At 3:33 PM, the resident was in their room, and their tube feeding was infusing at 25 milliliters an hour.-On 05/29/2026 at 10:00 AM, Licensed Practical Nurse #17 entered the resident's room. They notified the resident it was time for their tube feeding to stop and they were going to provide them with their medication. They turned off the feeding pump, disconnected the tube feeding, and checked for gastric contents. They then administered 60 milliliters of water via the tube, administered the resident's medication with 60 milliliters of water, provided 60 milliliters of water after the medication pass, and exited the room. Licensed Practical Nurse #17 did not administer 100 cubic centimeters of water prior to discontinuing the tube feeding as ordered. During an interview on 05/27/2026 at 11:00 AM, Licensed Practical Nurse #16 stated they were supposed to review the medical orders prior to disconnecting the resident's tube feeding and providing medications. The resident was supposed to receive 100 milliliters of water flush prior to administering their tube feeding and when it was disconnected. They did not see the order for the water flush and missed it. Medical orders should be followed to ensure the residents receive proper nutrition and hydration.During an interview on 06/02/2026 at 9:15 AM, Registered Nurse #5 stated nurses should review the physician orders prior to disconnecting resident's tube feeding. They expected the nurse to follow the physician orders and if they were unable to provide the water flushes as ordered they should notify the supervisor and medical as it was their source of hydration.During an interview on 06/02/2026 at 9:26 AM, Registered Dietitian #16 stated resident's tube feeding orders were based on their estimated daily nutrition and hydration needs. Nursing staff should follow medical orders to ensure the residents received proper nutrition and hydration. If a resident did not receive their water flushes as ordered they expected to be notified and the medical provider should also be notified. They were not notified the resident did not receive their water flush as ordered. 10 New York Codes, Rules and Regulations 415.12(g)(2)

Based on observations, record review, and interviews, the facility failed to ensure adequate supervision to prevent accidents for two (2) of two (2) residents (Residents #105 and #123) reviewed. Specifically, Resident #105 was on a mechanical soft diet with aspiration (inhaling food into airway) precautions with no bread and was served a whole hamburger on a bun; and Resident #123 was on a ground diet and was served a whole hamburger on a bun. Findings included: The undated facility policy Solid Food Consistency, documented the facility provided appropriate food and nutrition to residents with the correct solid food consistency as recommended by the doctor or speech therapist. Staff ensure residents were served the correct solid diet consistency as prescribed by the provider and written on the meal ticket. Solid diet consistencies were pureed, ground, mechanical soft and regular. Mechanical soft foods were made up of foods that required less chewing than a regular diet. Ground foods were soft, moist, and cohesive in texture; meats should be finely chopped, and vegetables should mash easily with a fork. 1) Resident #105 had diagnoses including Parkinson's disease (a progressive neurological disorder), dementia, and severe protein-calorie malnutrition. The 04/22/2026 Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision or touching assistance for eating, had signs and symptoms of possible swallowing disorder including holding food in mouth/cheek or residual food in mouth after meals and coughing or choking during meals or when swallowing medications, and was on a mechanically altered diet. The comprehensive care plan, initiated on 10/22/2024, documented the resident had a diet consistency of mechanical soft solids and thin liquids, was on aspiration precautions, and was at risk of malnutrition. Interventions included eating with supervision or touching assistance in the dining room; regular diet with mechanical soft solids, thin liquids; and aspiration precautions. Initiated on 10/20/2025 the resident was at risk for impaired eating abilities related to arthritis of the neck, tumors in the neck, Parkinson's, and dementia. Interventions included aspiration precautions; a regular mechanical soft solids diet; eating in the dining room and supervision or touching assistance. The 10/22/2025 physician order documented the residents was to receive a mechanical soft diet consistency. The 10/22/2025 Speech Language Pathologist #26 evaluation documented the resident presented with mild dysphagia with soft solids and thin liquids. The recommendation was a diet change to mechanical soft solids and thin liquids. Education was provided on safe swallowing strategies and signs of worsening sallow function. Family/caregivers were to inform nursing/speech language pathology of any concerns with chewing/swallowing. During an observation on 05/28/2026 at 12:38 PM a family member was sitting in the room with Resident #105 and stated that their food did not always come up as the same consistency. They were not supposed to have buns, and they received a whole hamburger. The family member cut the hamburger up and threw out the bun. They stated it was hard for the resident to swallow. The resident's lunch ticket documented mechanical soft and regular liquids and aspiration precautions. Food items included cottage cheese and fruit plate, milk, no bun or bread, Swiss cheeseburger with bun, peas, white cake with frosting, and Magic Cup (frozen nutritional supplement). The meal tray had a whole hamburger with a bun. During an interview on 05/28/2026 at 1:29 PM Certified Nurse Aide #21 stated a nurse was usually checking tickets when they took the trays from the line to the residents and the trays should also be checked by the person delivering the tray. It was a double check system but sometimes mistakes happened. During an interview on 05/28/2026 at 1:31 PM Certified Nurse Aide #23 stated Resident #105 did not usually get a whole hamburger while on a mechanical soft diet. The burger should look more like a sloppy joe. They stated there were two other residents on mechanical soft diets who received the sloppy joe type burger. During an interview on 06/02/2026 at 9:15 AM Dietary Aide #22 stated they knew what diet texture to serve to a resident by looking at the meal ticket. A mechanical soft diet meant the food was ground and if the resident was on aspiration precautions it meant they could choke. A resident on a mechanical soft diet should have received a ground burger. Resident #105 was on a mechanical soft diet and was not supposed to get a bun; they should not have been given a whole hamburger with a bun and did not know why they did. During an interview on 06/02/2026 at 9:21 AM Licensed Practical Nurse #24 stated nurses were in the dining room and checked the tickets to make sure the residents had the right consistency and meal. If a resident's meal ticket documented a mechanical soft diet with no bread or bun and they received a regular burger on a bun, it should be replaced with a mechanical soft burger. Everyone who touched the tray was responsible for making sure the ticket and the contents matched. During an interview on 06/022026 at 10:16 AM Registered Nurse Unit Manager #25 stated nurses in the dining room checked trays for accuracy and watched over residents to make sure nothing happened. Trays were double checked by whoever served the meal to the resident. Aspiration precautions usually meant the resident could not have straws and had a different food consistency. Sometimes it was a precaution, and they needed to be monitored, other times it was just to be safe. Resident #105 should not have received a whole hamburger or a bun as the meal ticket specifically said no bun. During an interview on 06/02/2026 at 10:31 AM Speech Language Pathologist #26 stated resident #105 had chronic dysphagia and if their meal ticket said no bread or bun the facility should follow that because the resident had issues with the sticky texture. Aspiration precautions meant the resident was monitored for signs of aspiration. They suspected that bread was sticking to Resident #105's throat and if they were going to cough it was typically with bread products. The resident should not have been served a bun. 2) Resident #123 had diagnoses including dementia and protein-calorie malnutrition. The 05/21/2026 Minimum Data Set assessment documented the resident had moderately impaired cognition, required supervision for eating and was on a mechanically altered diet. The comprehensive care plan, initiated 02/13/2026, documented a nutritional focus with a diet consistency of ground and thick liquids, cut up food, and aspiration precautions. Interventions included supervision or touching assistance while eating, eating in the dining room and a diet consistency of ground solids with aspiration precautions. The 03/10/2026 physician order documented the resident was to receive a ground consistency diet. The 03/12/2026 Speech Language Pathologist #11 evaluation documented a referral was received for a swallow evaluation secondary to complaints of difficulty with mastication (chewing) of regular solids and the resident was recently downgraded to a ground diet. The resident presented with mild oral dysphagia. There was prolonged mastication with multiple swallows and mild to moderate oral holding and left pocketing with soft and bite sized foods. The resident was downgraded to ground with recommendation for minced and moist foods. During an observation and interview on 05/28/2026 at 12:38 Resident #123's lunch meal ticket documented ground beef. The resident received a whole cheeseburger and bun and started to eat the burger. The surveyor asked Speech Language Pathologist #11 if the resident should have that type of burger and they stated no and took the burger away from the resident. During an interview on 05/28/2026 at 12:46 PM Dietary Aide #12 stated they plated the resident's meal. The first thing they checked on a ticket was Mighty Shakes (nutritional supplement), condiments, and then if they were on a ground or regular diet. They stated the whole hamburger Resident #123 received must have gotten by them. The speech therapist made them aware, and they had the ticket in front of them. Whoever took the tray to the resident was supposed to check it as well. During an interview on 05/28/2026 at 12:54 Speech Language Pathologist #11 stated Resident #123 had been off their service for a while, but their diet consistency was downgraded to ground solids. The resident would chew and chew and it took them a while to swallow. They made the recommendation for diet consistencies, and those recommendations should be followed. This happened to Resident #123 before. The trays should be checked by the server and then again by the person who delivered them. They expected multiple checks to occur before it got to the resident. They previously brought this concern up with the charge nurse, the Director of Rehabilitation, and the food server. During a follow up interview on 05/29/2026 at 10:51 AM Speech Language Pathologist #11 stated aspiration precautions was indicated on the meal tickets and nursing would let other staff know. It meant the resident was a choking precaution and should eat with supervision. They recommended ground meat due to the resident's slow oral phase. If they ate the whole burger rather than ground it increased their risk of aspiration. During an interview on 06/01/2026 at 10:53 AM Licensed Practical Nurse #8 stated dietary plated the meals and put them on the counter. Trays were checked over for accuracy by the nurse and the aide who delivered the tray. Resident #123 was on aspiration precautions and was on a ground diet. The resident should not have received a whole hamburger. They were not sure what happened or why it was missed. During an interview on 06/01/2026 at 11:02 AM Registered Nurse Unit Manager #10 stated when a tray was placed on the counter the tray was checked against the ticket. The first check was the dietary person; the second check was one of the nurses and the last check was the aide who served the trays. They were responsible for making sure there was a nurse in the dining room checking tray accuracy. Resident #123 was on aspiration precautions, so they had to eat in the dining room. They were also on a ground consistency diet and should not have received a whole hamburger. It should have been caught if the check system was functioning properly. 10 New York Code, Rules and Regulations 483.25(d)

Based on observations, record review, and interviews, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one (1) of five (5) residents (Resident #10) reviewed. Specifically Resident #10's treatment to the pressure ulcer on their back was not administered as ordered. Findings include:The undated facility policy Skin Care Program, documented after signs of pressure, skin breakdown, edema, or changes to the skin were noticed, staff reported findings to the unit/clinical manager. Then the manager initiated treatment measures and notified physician of any new or worsening pressure areas. The skin team was notified of the identification, assessment and treatment of any noted signs of pressure. Resident #10 had diagnoses including a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) on their upper right back. The 03/05/2026 Minimum Data Set assessment documented the resident had intact cognition, required substantial assistance for bed mobility, was at a high risk for pressure ulcers and had one Stage 4 pressure ulcer present on admission. The 01/12/2023 Comprehensive Care Plan documented a focus of skin integrity. Interventions included turning and reposition every 2-3 hours and encourage offloading the right upper back. The 05/01/2026 physician order documented cleanse the spinal wound with normal saline and pat dry; apply Triad (wound care paste) to areas surrounding the wound; and cover wound with alginate (absorbent wound dressing); cover with an abdominal dressing (thick, absorbent pad) and secure with paper tape. Change dressing twice a day and as needed for excessive drainage, missing dressing or loose dressing. The May 2026 Treatment Administration Record documented the resident refused the 4:00 PM-8:00 PM dressing changes by Licensed Practical Nurse #7 on 05/05/2026, 05/09/2026, and 05/28/2026The 4:00 PM - 8:00 PM dressing was not signed as completed on 05/14/2026, 05/16/2026, 05/19/2026, 05/23/2026, and 05/31/2026 The 05/20/2026 Nurse Practitioner #28 progress note documented the wound on Resident #10's spine was chronic and present for years. The area was improving with dressing changes twice a day. Resident #10 was interviewed at the following times:- On 05/27/2026 at 9:57 AM they stated they did not think the dressing was always changed as ordered.- On 05/28/2026 at 11:41 AM they stated the dressing was changed last night, it was usually on the evening shift when the dressing was not changed.- On 05/29/2026 at 9:38 AM they stated their dressing was not changed last evening. The nurse did not come in and offer to change or check the dressing and they did not refuse to have their dressing changed. They never refused dressing changes but, sometimes the nurse would come in and say the dressing looked clean and dry and did not think it needed to be changed. The nurses asked the resident what they thought about not changing it, but they never refused outright.- On 06/01/2026 at 8:55 AM they stated their dressing was not changed last evening and there was never a conversation with the nurse about it. During an observation on 06/01/2026 at 9:58 AM Licensed Practical Nurse #8 performed dressing changes on Resident #10's wounds. There was one large wound and two small wounds without drainage or maceration and the wound beds were pink. During an interview on 06/01/2026 at 10:31 AM Licensed Practical Nurse #8 stated Resident #10 had an area on their spine which had been there for 2 years. The resident was very agreeable to dressing changes and the only time they refused was when the evening nurse came into the room late. There should not be blanks in the treatment administration record. During an interview on 06/01/2026 at 2:53 PM Certified Nurse Aide #9 stated when a resident had a dressing they checked to see if there were initials and a date on it. If the date was more than 2 days, they asked the licensed practical nurse if it had to be changed. Resident #10 had a dressing on their back that drained, and the drainage was on the sheets. They believed they had reported the resident's dressing was dated more than 2 days but did not remember when. During an interview on 06/02/2026 at 9:18 AM Licensed Practical Nurse #7 stated when treatments were done, they signed them off in the treatment administration record. When they were short staffed treatments did not always get done. If it was busy they called the supervisor to finish the treatments. When residents refused, they would reapproach and told the registered nurse if they refused again. If they did not get to the treatment, they hoped the next shift would do it. Resident #10 did not like to have things done late at night. That was why their treatments were scheduled before they started their shift. Late at night was considered 8:00 PM - 9:00 PM. The resident was compliant with treatments if they were done before those times. Usually, the day nurse completed the treatment. If they did not and it was past 9:00 PM they checked it and would say if it looked like it needed to be changed or not. If the dressing was clean and was not coming off, they asked the resident and would do what the resident wanted. They had a very structured way they scheduled their duties during their shift, and they did not go into the resident's room first thing to complete their dressing. They reported the dressing was not changed to the supervisor but not the nurse manager. The dressing should be changed twice a day. During an interview on 06/02/2026 at 9:45 AM Registered Nurse Unit Manager #10 stated when there were two) nurses scheduled, one was on the medication cart and the other completed treatments. When residents refused, the nurse needed to let them know so the resident could be reapproached. If they continued to refuse, they documented why they refused and updated the nurse practitioner. If they refused in the evenings staff should tell the supervisor and document, and they followed up in the morning. They had numerous conversations with Resident #10 about their treatments and the resident stated they refused when the nurse came in late and they did not like that. They refused the treatment recently and it seemed to be the same nurse scheduled to do the treatments. The dressing should be changed twice a day. There should not be blanks in the treatment administration record. The resident's preference for an early dressing change should be followed, and they tended to prefer it to be done before 9:00 PM. They refused to have the dressing changed as it was not getting done before 9:00 PM. 10NYCRR 415.12(c)(1)

Based on record review and interviews (iQIES intake 2971099) the facility failed to ensure that residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions were referred for a Level II Preadmission Screening and Resident Review (ensures that individuals who have a mental disorder or intellectual disabilities were not inappropriately placed in nursing homes for long term care; a Level II Preadmission Screening and Resident Review identifies the specialized services required by the resident) for one (1) of one (1) residents (Resident #140) reviewed. Specifically, Resident #140 had a known developmental disability not identified on their initial Screen, a new screen was not completed, they were not referred for a Preadmission Screening and Resident Review Level II timely when the resident's discharge plan changed to long term care; and they did not have a care plan reflecting their Level II Preadmission Screening and Resident Review determination following the completion of a Level II assessment. Findings include:The New York State Department of Health Instruction Manual for Department of Health-695 (2/2009) documented if a resident of a Residential Healthcare Facility, who was identified as having mental retardation/developmental disability on their admission SCREEN Level I Review and met the criteria for Categorical Determination (convalescent care, seriously physically ill, terminally ill, or provisional emergency admission), requires a length of stay longer than the appropriate physician documented number of days, A SCREEN and Level II Evaluation must then be completed. The facility policy Iroquois Nursing Home- admission Criteria, documented all new admissions and readmissions were screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid Pre-admission Screening and Resident Review process. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for mental disorders, intellectual disabilities, or related disorders. If the level I screen indicated that the individual may meet the criteria for mental disorders, intellectual disabilities, or related disorders they are referred for a Level II evaluation and determination. The social worker was responsible for making the referrals to the appropriate state-designated authority. Resident #140 had diagnoses including Down Syndrome (genetic condition) and hydrocephalus (water on the brain). The 11/24/2025 Minimum Data Set documented the resident had an intellectual disability of Down Syndrome, had severely impaired cognition and was dependent on activities of daily living. The 11/18/2025 comprehensive care plan documented the resident was living at their sibling's home prior to their hospitalization and was in the facility for long term care due to their sibling no longer being able to care for them and no group home availability. The SCREEN Form: DOH-695 (2/2009) completed 11/18/2025 documented the resident did not have a diagnosis of developmental disability and met the Categorical Determination of convalescent care. There was no new SCREEN Form: DOH-695 (2/2009) completed to reflect the resident's developmental disabilities or when the resident no longer met the criteria for the Categorical Determination of convalescent care. Social Worker #14 progress notes documented the following:-on 11/21/2025 they held a 72-hour discharge planning meeting with the resident's sibling and the interdisciplinary team. The family's goal was to be discharged to long term care. -on 11/26/2025 the anticipated discharge date was 12/30/2025 and the discharge destination was long term care as the resident's sibling could no longer take care of them at home. The Office of People with Developmental Disabilities was contacted. -on 12/11/2025 the anticipated discharge date was 12/30/2025. The discharge destination was long term care, preferably at the facility, as the resident's sibling could no longer take care of the resident and The Office of People with Developmental Disabilities stated the waiting list for a group home was over two years. The 02/19/2026 Preadmission Screen and Resident Review Level II Assessment documented the purpose of the assessment was for current nursing home placement and the reason for the assessment was the resident exceeded categorical determination time frame.There was no documented care plan related to the resident's Level II Preadmission Screening and Resident Assessment completed 02/19/2026. The 01/22/2026 Social Services note documented the resident was reviewed for a quarterly assessment. The resident was admitted for short term rehabilitation but transitioned to long term care. The 02/19/2026 Director of Social Work progress note documented a meeting was held for the resident to have a Level II Preadmission Screening and Resident Review and the facility would receive the assessment and determination by the end of the business day on 02/20/2026. During an interview on 06/01/2026 at 3:11 PM, Social Worker #14 stated SCREEN Forms and Preadmission Screening and Resident Review Level II assessments had to be completed prior to a resident's admittance to the facility. The Admissions Coordinator was responsible for reviewing the documents prior to the resident being admitted . The Director of Social Work handled all the Preadmission Screening and Resident Review assessments. During an interview on 06/01/2026 at 3:16 PM, the Director of Social Work stated all residents needed a SCREEN Form completed prior to admission. If the facility accepted a resident who was part of the Office of People with Developmental Disabilities, most of the time the hospitals bypassed the Preadmission Screening and Resident Review Level II assessment by stating the resident was only in the facility for convalescent care which was 120 days or less. If the facility was aware the resident was going to be in the facility for more than 120 days, they needed to initiate a Level II assessment. If a resident was admitted with a diagnosis of developmental disabilities and their SCREEN Form did not reflect it, the facility should be completing a new screen and reaching out to the Level II coordinator for developmental disabilities. Resident #140 was not referred for a Level II assessment as they came in with a categorical determination of a convalescent stay. The resident's family did state upon admission they wanted the resident to be long term care but that did not mean it was an appropriate discharge plan. The Office of People with Developmental Disabilities and the Preadmission Screening and Resident Review Level II process determined the appropriate discharge plan. After Resident #140's Level II assessment was completed, the determination should have been reflected on their care plan. 10 New York Codes, Rules and Regulation 415.11(e)

Based on record review and interviews during the abbreviated survey (#2649782) conducted 01/30/2026, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for one (1) of three (3) residents (Resident #2). Specifically, Resident #2 was administered an as needed antipsychotic medication for agitation without a documented medical rationale. There was no documented evidence that the medication was medically necessary, nor that non-pharmacological interventions were attempted prior to administering the medication. Additionally, the resident did not have a care plan to address their behaviors or personalized interventions for their behaviors.Findings include:The undated facility policy, Psychotropic Medication Use, documented a psychotropic drug was any medication that affected brain activities associated with mental processes and behavior which included anti-psychotics. The facility would not use psychotropic medications to address behaviors without first determining if there was a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. Facility staff should take a holistic approach to behavior management that involved a thorough assessment of underlying causes of behaviors and individualized person-centered non-drug and pharmaceutical interventions. Residents who exhibited new or worsening behavioral or psychological symptoms of dementia were to be evaluated by a health care professional and the care team to identify contributing factors such as treatable medical conditions, physical problems, emotional stressors, psychiatric or psychological factors, social issues or environmental factors. The physician order for an as needed psychotropic would indicate that the medication was only to be administered if non-drug approaches were ineffective, the specific symptoms that are to be exhibited for the as needed medication to be administered, and that the post-medication effects are to be documented by the nurse. Resident #2 had diagnoses including unspecified dementia with unspecified severity with other behavioral disturbance and age-related osteoporosis with current pathological fracture of the right femur. The 09/11/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, had continuously present inattention and disorganized thinking, rarely felt lonely or isolated, had no behaviors, and required partial to moderate assistance most activities of daily living.The 09/05/2025 Comprehensive Care Plan documented the resident had the potential for adverse effects from daily use of an antipsychotic with no associated diagnosis listed. Interventions included: provide the anti-psychotic per the provider's order; assess for the effectiveness of the antipsychotic medication to relieve symptoms of aggression/combativeness; document the onset, duration and characteristics of all symptoms of aggression/combativeness; inform the physician of any increase symptoms or possibility of adverse effects of the drug; monitor for the side-effects of the anti-psychotic medications; utilize gradual dose reduction to maintain the lowest effective dose; and utilize non-pharmacological interventions.There was no documented care plan for the resident's behaviors or personalized interventions for the resident's behaviors.The undated Resident Care Record (care instructions) did not include any information related to behavioral symptoms or interventions.The 09/05/2025 hospital discharge medication list documented 0.5 tablet of quetiapine (antipsychotic) 25 milligrams by mouth nightly as needed for agitation, unable to be redirected, with harm to self and others.The 09/05/2025 physician's order documented the resident was to receive 0.5 tablet (12.5 milligrams) of a quetiapine 25 milligram tablet by oral route once daily as needed, in the evening for 14 days.The 09/05/2025 History and Physical, completed by Nurse Practitioner #19, documented the resident had a diagnosis of dementia with behavior disturbances, hypertension, recurrent falls, recurrent urinary tract infections, and osteoporosis. The plan was to give quetiapine 12.5 milligrams once daily in the evening as needed for agitation. There were no documented behaviors or related diagnosis for the quetiapine.The September 2025 Medication Administration Record documented the resident received 12.5 milligrams of quetiapine on 09/05/2025 at 8:18 PM, 09/06/2025 at 7:35 PM, 09/08/2025 at 7:53 PM, and 09/11/2025 at 12:05 AM.There were no documented behaviors or evidence of non-pharmacological interventions attempted prior to the administration of the as needed quetiapine on 09/05/2025, 09/06/2025, and 09/08/2025 and there were no assessments of the effectiveness of the medication post-administration.The 09/11/2025 progress note completed by Registered Nurse #18 documented the resident exhibited restlessness and irritability and was reported to have had aggression during the 3 PM to 11 PM shift. The writer offered some snacks, but the resident refused. Redirection and incontinence care were also done. The nursing supervisor was notified, and the resident was given their as needed quetiapine 12.5 milligrams. There were no documented specific behaviors of aggression noted or outcome after redirection, incontinence care, or medication administration was completed.The 09/11/2025 progress note completed by Registered Nurse Unit Manager #15 documented the resident's health care proxy was requesting to have the resident's melatonin scheduled as they thought the as needed quetiapine was making the resident groggy during the day. Nurse Practitioner #19 was updated, and the orders were to schedule the resident's melatonin and continue with the as needed quetiapine.During an interview on 10/29/2025 at 8:56 AM, Resident #2's health care proxy stated the resident was admitted to the facility after surgery for their broken hip. They stated after the resident was admitted they had a hard time keeping the resident awake and could not coordinate getting the utensil to their mouth during meals. They had a hard time finding out what medication the resident was being given. One of the nurses had informed them the resident had received quetiapine at midnight, there was no note as to why it was given, and it was only to be given for agitation or aggression which the resident never really exhibited. They expressed concerns regarding the resident's medication, but nothing was done. The next day the resident was asleep in their chair, and they asked the nurse if the resident was given quetiapine and was told it was given at 7:45 PM and there was no note as to why. They stated the resident was trying to get out of bed at midnight, was given the medication, and the resident was sleepy for the rest of the day. They asked why the resident had not received melatonin and were told they could not give it because it was an as needed medication. They asked for the melatonin to be changed to scheduled.During an interview on 10/30/2025 at 11:31 AM, Social Worker #17 stated they were responsible for the meetings for baseline care plans, assessed for changes with mood, cognition, and behaviors, and care plan meetings with families. Resident #2 did not have behaviors to their knowledge. If Resident #2 was having behaviors, it was to be reported to themselves and Registered Nurse Unit Manager #15 so they could update their care plan to include the behaviors and update their risk tool. The risk tool assessed the potential to be an aggressor or victim, and Resident #2 was assessed to be low risk. They were unaware the resident had received their as needed quetiapine four times prior to it being discontinued.During a phone interview on 10/30/2025 at 1:21 PM, Licensed Practical Nurse #25 stated an as needed antipsychotic medication was given, if the nurse deemed the resident needed it or if the resident was alert enough to ask for it. The reason for administering the medication needed to be documented as well as what led up to using it, the results of using the medication, and what happened after the medication was administered in a progress note. They recalled giving Resident #2 their as needed antipsychotic on 09/05/2025 and 09/08/2025. The medication was given due to the way the resident was acting. The resident was aggressive, hitting, getting up, and trying to leave the facility. It was always after their family or someone they were familiar with left. The resident thought they were trying to harm them because they did not know the staff. They believed they put in a note on 09/08/2025, because they did not put in a note on 09/05/2025, and was spoken to about it. They were told they had to document what interventions were attempted prior to giving the medication. The nurse stated the resident calmed down after the quetiapine and the medication does make people sleepy but that was not the main reason it was given to the resident.During an interview on 10/30/2025 at 3:08 PM, Licensed Practical Nurse #24 stated a resident could be given an as needed antipsychotic medication if the resident was agitated after redirection, having them go to an activity, or trying to calm them down and that was not working. The medication order documented the reason the medication was given. The nurses had to document the reason the medication was given in the comment section of the medication administration record, sometimes a progress note was put into the electronic medical record. They did not remember Resident #2 or why they gave the resident the as needed antipsychotic medication on 09/06/2025. They would have documented the reason in the notes or the medication administration record.During a phone interview on 10/31/2025 at 2:22 PM, Registered Nurse Manager #15 stated the staff knew what interventions to utilize with a resident when they were having behaviors by the care plan. Behaviors, what interventions were tried, and if the interventions were effective were recorded in a progress note. Psychotropic medications and behavior care plans were usually done upon admission but if not, they were put in by the Unit Manager or the Director of Nursing. If a resident was admitted with an as needed antipsychotic medication, they should have a care plan at admission. An as needed antipsychotic was only used if a resident was harmful to themselves or others and the staff felt the resident needed it. The nursing staff did not have to document the reason for the as needed antipsychotic use, but it was good practice to do it in a progress note. Resident #2 had some behaviors while at the facility which included restlessness, irritability, and some aggression. They had a care plan for their antipsychotic use but not one for their behaviors. They stated they saw in the resident's record, Resident #2 had received their as needed antipsychotic medication on four occasions and there was no note documented for three of the four occasions as to why the resident received the medication. There should have been a note with the administration of the medication because by the third administration, they would have put in a behavior care plan to address the resident's behaviors.During a phone interview on 11/03/2025 at 10:12 AM, Nurse Practitioner #19 stated they did the history and physicals for new admissions. During the history and physical, they reviewed the resident's medication and ensured indications for use matched the medication. If a resident was admitted on as needed quetiapine, the indication for use was either for dementia with psychosis, a mood disorder, anxiety, or delirium (short-term confusion). Agitation was not an indication for as needed quetiapine, there had to be a cause of the agitation. The medical providers or the Unit Manager were responsible for finding out the background for an as needed antipsychotic and it was typically documented in a note. Non-pharmacological interventions should be tried prior to an as needed antipsychotic being utilized and they should be documented as well as if they were effective or ineffective and what happened to reach the level of medications. Resident #2 should only receive the as needed antipsychotic medication for restlessness, if they were a danger to themselves or others.During a phone interview on 11/04/2025 at 1:58 PM, Medical Director #20 stated when the Nurse Practitioner and nursing staff reconcile the medications at admission, they ensured the medications have a corresponding diagnosis or indication for use. They did not usually make changes to the medications of residents who come in for short-term rehabilitation. Resident #2 was admitted with the as needed antipsychotic medication. The hospital record stated it was for agitation, so they did not need to ask any more questions as to the reason for use. In the facility, the antipsychotic medication was used for agitation, sleep, psychosis, or behavioral problems that came with dementia which Resident #2 had as a diagnosis. Resident #2 was on the medication for agitation as needed specifically at nighttime when the resident could not sleep. Even if the resident did not have a diagnosis of insomnia, the medication was used routinely for sleep in the facility. In the evening, residents that were Resident #2's age sundown (a pattern of increased behavior late afternoon to nighttime), they are irritable, agitated, and cannot sleep. If the resident could not sleep at night, the resident could get the quetiapine, and there was nothing wrong with that. Other interventions should be utilized first such as redirection or addressing the resident's needs. However, Resident #2 was older and could not say what they needed out loud. The idea behind an as needed antipsychotic was for comfort for the patient so they could rest and sleep. The reason for the medication was given should be documented by the nurse, as needed medication should not be given without a documented reason.During an interview on 01/29/2026 at 11:37 AM, the Director of Nursing stated interventions for individual resident behaviors were in their care plans. Staff were also trained to reapproach, reattempt, and redirect for dementia residents. Specific resident behaviors were recorded in the resident's care plan, if they were known. If a resident was actively having behaviors, it should be documented in a behavior note. The Unit Managers were responsible for the behavior care plans with Social Work's assistance. If a resident had known behaviors, there should be a care plan with personalized interventions. The indication for use for an as needed antipsychotic was if the resident was a danger to themselves or others. Other interventions should be utilized prior to the resident receiving an as needed antipsychotic. It was expected that if an as needed antipsychotic was administered, there should be a corresponding nurse's note as to why. 10 New York Codes, Rules and Regulations, 415.12(I)(1)

Based on observation, record review, and interview during the recertification survey conducted 8/14/2024 -8/20/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment for 1 of 4 resident floors (Unit 1) reviewed. Specifically, Unit 1 had multiple unclean and damaged wheelchairs, positioning chairs, and positioning devices. Findings include: The facility policy, Devices and Equipment, dated 3/2028 documented all resident devices and equipment, to include wheelchairs and walkers, would be maintained on a schedule. Defective or worn devices would be repaired or replaced. The undated facility policy, Work Orders, documented all staff were responsible for submitting work orders in the electronic system and then it was to be forwarded to the maintenance director. The Director of Maintenance was responsible to ensure the work was completed in a timely manner. The following observations were made: - on 8/14/2024 at 10:06 AM, Resident #10 was sitting in a positioning chair in their room. The chair's arm rests were unclean, and the material on the right back side of the chair was ripped. - on 8/14/2024 at 10:11 AM, Resident #61 was sitting in a positioning chair in their room. Both armrests on the chair were unclean. - on 8/14/2024 at 10:52 AM, Resident #117 was sitting in a positioning chair in their room. The left, blue positioning wedge was ripped in several areas. - on 8/14/2024 at 11:00 AM, Resident #89 was sitting in a positioning chair in the unit common area. The chair's backrest was ripped on the side. - on 8/14/2024 at 11:01 AM, Resident #29 was sitting in a high-back wheelchair in the unit common area. The right arm rest had brown tape over it and the left arm rest had visible worn and soiled black foam. - on 8/14/2024 at 11:11 AM, Resident #119 was sitting in a positioning chair. The left, back side of the chair was ripped. During an interview on 8/19/2024 at 10:17 AM, Certified Nurse Aide #2 stated all unit staff were responsible for cleaning resident chairs. Housekeeping also assisted with cleaning. Any staff member was able to put in a work order. If a chair was observed to be in disrepair, maintenance was notified, and the issue was usually fixed quickly. Therapy was responsible for replacing chairs if they were broken. Resident #29's chair should not have been in the condition it was. During an interview on 8/19/2024 at 11:22 AM, Licensed Practical Nurse Manager #3 stated all unit staff were responsible for cleaning wheelchairs and positioning chairs. All staff were responsible for submitting a work order to maintenance for any chairs needing repairs. They were not aware of any recently submitted work orders for chairs. They expected staff to notify them if a chair was ripped or needed repair. If a chair was unable to be fixed by maintenance, therapy would re-issue the resident a new chair. During an interview on 8/20/2024 at 9:56 AM, the Director of Nursing stated all staff were responsible for submitting an electronic work order for any equipment needing repair to the maintenance department. They were unaware of any chairs needing repair as they were checked frequently, and most were recently cleaned. Any chairs needing cleaning or in disrepair were not considered homelike, especially those that were ripped or torn. During an interview on 8/20/2024 at 10:59 AM, the Director of Maintenance stated their department was responsible for overseeing all work orders. All staff were responsible for submitting a work order for repairs. Once the work order was received, they usually had it repaired the same day. They had not received any work orders for Unit 1 chairs. They were not aware some of the chairs were ripped. The goal was for the facility to provide a homelike environment to all residents. 10 NYCRR 415.29(b)(j)(1)

Based on observation, record review, and interview during the recertification and abbreviated (NY00318948 and NY00314795) surveys conducted 8/14/2024-8/20/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 4 residents (Resident #36) reviewed. Specifically, Resident #36 was not assisted with timely toileting. Findings include: The undated facility policy, Certified Nurse Aide Activities of Daily Living, documented the certified nurse aide who completed the resident care was responsible for documenting the level of care the resident received that shift. The undated facility policy, Toileting Schedule, documented an incontinent resident would be placed on a toileting schedule. The resident was to be toileted a minimum of 5 times within a 24-hour period and must be documented. A sign was hung on the resident's bathroom door to serve as a reminder. The resident who required supervision for bowel function was to be taken to the toilet every 2 hours as part of the bladder program. Resident #36 had diagnoses including Alzheimer's dementia and anxiety. The 5/30/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, used a wheelchair, was dependent for toileting hygiene, toilet transfers, and wheelchair mobility, was frequently incontinent of urine and always incontinent of stool, and was not on a toileting program. The undated care instructions documented the resident required 2-person physical assistance and was dependent for toileting and was to wear incontinence briefs. The resident was to be toileted every day from 12:00 AM - 6:00 AM, 8:00 AM - 2:00 PM, and 4:00 PM - 10:00 PM. The 6/12/2024 Comprehensive Care Plan documented the resident had urinary incontinence, a history of urinary tract infections, was at risk for falls, and was at risk for impaired skin integrity. Interventions included offer toileting every 2-3 hours or check and change every 2 - 3 hours, promote good hygiene practices, keep free from moisture, provide with appropriate incontinence products, and increase toileting. During an observation on 8/15/2024 at 9:07 AM, an undated sign on a wall in the nursing office documented every resident was to be toileted per their care plan and not just once per shift. During a continuous observation on 8/16/2024 from 8:59 AM-12:38 PM, Resident #36 was observed: - at 8:59 AM seated in a positioning chair in the unit dining room eating breakfast. - at 9:53 AM, being moved to the back common area TV room for a church service. - at 11:37 AM, being approached by Certified Nurse Aide #22 who asked the resident if they wanted to be moved to their assigned lunch table. Certified Nurse Aide #22 transported the resident back to the dining room table. At 12:38 PM the resident remained seated at the dining room table - at 1:22 PM, the resident remained sitting in their positioning chair in the unit dining room. At 1:25 PM they were transported to their room by Unit Aide #23. The resident was not toileted, and the last documented toileting had been signed for at 5:50 AM. During an interview on 8/16/2024 at 1:43 PM, Certified Nurse Aide #22 stated they documented provision of resident care two times during their shift: before lunch and before the end of their shift. Residents should be toileted at least 3 times a day. Most residents were toileted every 2 hours. Resident-specific care was documented in each resident's care instructions. Resident #36 required transfers by 2 with a mechanical lift. They stated they had not toileted the resident today. Depending on staffing for the shift, there were times the residents did not get toileted as often as they should, and the documentation was not always done. The 8/16/2024 toileting task for Resident #36 documented the resident was toileted by Certified Nurse Aide #22 at 2:20 PM. During an interview on 8/19/2024 at 11:22 AM, Licensed Practical Nurse Manager #3 stated unit staff were expected to toilet each resident before meals, after meals, and as needed. Cognitive residents were toileted as requested. Unit staff were expected to document resident care directly after the care was performed. Resident #36 required transferring by mechanical lift with 2 staff. They were responsible for overseeing that resident care was provided. If documentation was not done, it was assumed the care was not provided. The risk of not toileting a resident as planned was the resident could have skin breakdown in the perineal area. Resident #36 should be toileted as planned as they were at risk for skin breakdown. During an interview on 8/20/2024 at 9:56 AM, the Director of Nursing stated Resident #36 required substantial/maximum assistance with toileting; could stand and pivot and did not use a mechanical lift. They stated if the resident was not toileted per their care plan it would not be appropriate and could result in skin breakdown and/or infections. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interview during the recertification survey conducted 8/14/2024 -8/20/2024, the facility did not ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 1 resident (Resident #22) reviewed. Specifically, Resident #22 was not evaluated by therapy or care planned for the use of a scoot chair (a low-to-the-ground positioning chair that allows self-propulsion by foot and reduces the risk of falls). Findings include: The facility policy, Devices and Equipment, dated 3/2018 documented recommendations for devices, which included wheelchairs, were to be documented in the residents' plans of care. Nursing would request therapy services to evaluate a device that was not properly fitting. The undated facility policy, Comprehensive Care Planning, documented the interdisciplinary team would review the care plan with a significant change and as needed. The care plan would be individualized for each resident. Changes that resulted in a different approach must be documented in the care plan. The undated facility policy, Therapy Screenings and Referral Procedure, documented residents who had a change in status would receive a referral from nursing, recommended for a therapy evaluation, and treated as indicated. Resident #22 had diagnoses including dementia, fracture of the right femur (thigh bone), and right hip replacement. The 5/22/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, used a manual wheelchair, had impairment of one leg, required supervision to moderate assistance with transfers, was dependent for wheelchair mobility, and received physical and occupational therapy. The resident was unable to attempt walking due to medical condition or safety concerns with a discharge goal of walking 150 feet independently. The 5/16/2024 comprehensive care plan documented the resident had an alteration in activities of daily living, had a history of falls (last fall 7/27/2024), and had dementia. The plan included maintenance of levels for bed mobility, transfers, locomotion, and ambulation as possible. Interventions included hip precautions (used to avoid extra stress on the hip joint), maximum assistance of 1 with bed mobility/sitting/lying, maximum assistance of 2 for transfers, manual wheelchair with pressure-relieving cushion, bilateral anti-rollbacks on wheelchair, bilateral wheelchair leg rests, and physical and/or occupational evaluation as needed. The care plan did not document the use of a scoot chair. The 5/16/2024 at 12:33 PM Registered Nurse #13 admission progress note documented the resident had a diagnosis of left hip fracture with replacement. The resident required maximum assistance of 1 for transfers and used a wheelchair. The 5/16/2024 Physician #10 order documented weight bearing as tolerated on right lower leg. The 5/17/2024 Physician #10 order documented posterior hip precautions. The 5/20/2024 at 4:16 PM Licensed Practical Nurse #3 progress note documented therapy issued the resident a wheelchair pommel cushion (a positioning cushion for the seat) for positioning in their wheelchair. The 6/24/2024 at 2:32 PM Director of Nursing progress note documented the resident was assessed for wheelchair positioning to ensure they were in the proper wheelchair. The 6/28/2024 through 7/10/2024 physical therapy notes did not document the use of a scoot chair. The 7/1/2024 Director of Therapy progress note documented the resident was provided with a new 16-inch regular wheelchair with a gel seat cushion and leg rests. The 7/10/2024 Physical Therapist #16 progress note documented the resident received leg stretches to improve positioning in their wheelchair. The 7/26/2024 Registered Nurse #18 restraint assessment documented the resident had a positioning chair with a matrix cushion (a seat cushion for fragile skin), was unable to rise from the device, and could not rise from any seating device. The positioning chair was not considered a restraint. The 7/31/2024 Physician #10 order documented occupational therapy evaluation and treat 5 times a week for 4 weeks to include wheelchair assessment and management. The 8/14/2024 through 8/18/2024 care instructions documented the resident used a manual wheelchair with pressure relieving cushion, anti-rollback devices, and bilateral leg rests for mobility. Resident #22 was observed: - On 8/14/2024 at 11:00 AM, 12:49 PM, and 1:35 PM sitting in a scoot chair at a table in the unit dining room. - On 8/15/2024 at 9:55 AM, sitting in a scoot chair in their room. - On 8/16/2024 from 9:58 AM through 12:23 PM, sitting in a scoot chair at a table in the unit dining room. - On 8/19/2024 at 9:22 AM, sitting in a scoot chair at a table in the unit dining room. The 8/19/2024 at 2:36 PM Registered Nurse #17 progress note documented a therapy referral for proper wheelchair positioning. The 8/19/2024 Registered Nurse #17 restraint assessment for a scoot chair with matrix cushion documented the resident was unable to rise from the device, could not rise from any seating device, and therefore it was not considered a restraint. During an observation on 8/20/2024 at 10:07 AM, the resident was sitting in the unit dining room in a manual wheelchair with anti-tippers and bilateral leg rests. The resident was sliding down in the chair and was assisted by staff to a better seated position. During an interview on 8/19/2024 at 12:23 PM, Occupational Therapist #19 stated the resident was referred to therapy for a bed wedge evaluation on 7/31/2024. They did not evaluate the resident for the scoot chair. The evaluation documented the resident used a wheelchair prior to onset and not a scoot chair. The resident was using the scoot chair when they were evaluated. The resident was unable to rise by themselves from any type of chair. The process for use of a scoot chair was an order for an evaluation was obtained, nursing was consulted, a therapy referral/evaluation was obtained, the resident was assessed, and the most appropriate chair was provided per recommendation. During an interview on 8/19/2024 at 12:38 PM the Director of Therapy stated the resident was discharged from therapy on 7/10/2024 and was using a manual wheelchair. If the resident was not sitting well in a wheelchair, they would get an order for a therapy referral to assess for a different kind of chair. No referral was obtained from nursing for a scoot chair. Nursing was able to implement a scoot chair, but a therapy referral was still needed per policy. Nursing should have completed a restraint assessment for the scoot chair. The resident was unable to rise by themself from any type of chair. The care plan should have been updated by therapy or nursing. During an interview on 8/19/2024 at 1:02 PM, Certified Nurse Aide #20 stated the resident used a scoot chair since being transferred to the unit about two months ago. They did not know who gave the resident the scoot chair. The type of chair the resident used was supposed to be current in the resident's care plan, as that was how staff knew which chair to provide the resident daily. The current care plan documented the resident was to have a manual wheelchair with anti-rollbacks and leg rests. Staff should notify the Unit Manager if the resident did not have the planned equipment. During an interview on 8/20/2024 at 11:27 AM, Registered Nurse Manager #18 stated nursing and/or therapy were responsible for updating a resident's care plan when changes were made. Nursing should submit a referral to therapy and therapy evaluated and issued the most appropriate chair. In the case of a scoot chair, nursing should complete a restraint assessment. They did not know who initially issued the resident a scoot chair, but a therapy referral and restraint assessment should have been done. They were not aware the resident was not using the manual wheelchair. During an interview on 8/20/2024 at 12:05 PM, the Director of Nursing stated resident-specific care should be documented in the care plan and care instructions. The Unit Managers were responsible for updating the care plans. All scoot chairs should have a therapy evaluation and a restraint assessment completed by nursing to determine the appropriateness of the scoot chair. A progress note should also be completed by nursing and therapy. 10 NYCCR 415.11(c)(2)(iii)

Based on observation, record review, and interview during the recertification survey conducted 8/14/2024 - 8/20/2024, the facility did not ensure that residents who required dialysis services received such services consistent with professional standards of practice for 1 of 1 resident (Resident #301) reviewed. Specifically, Resident #301 received hemodialysis (a process of purifying blood when the kidneys do not work properly) treatments at a community-based dialysis center and did not have a Comprehensive Care Plan that addressed dialysis. Findings include: The undated facility policy, Dialysis, documented the purpose of the policy was to provide proper care for residents receiving dialysis at an external facility. General guidelines included nursing staff observing the resident after returning from each dialysis treatment for their tolerance of the procedure, meals taken, dressing condition, and any other pertinent information as indicated, and to notify the registered nurse of any abnormal findings. Any bleeding from external catheters and fistulas/grafts indicated a medical emergency and required notification of the medical provider. Resident #301 had diagnoses including end-stage renal (kidney) disease and dependence on renal dialysis. The 8/6/2024 Minimum Data Set assessment documented the resident was cognitively intact, received a therapeutic diet, had intravenous access, and required hemodialysis treatments. The 8/1/2024 Registered Nurse #13 Clinical Admission Assessment documented the resident had a double lumen peripherally inserted central catheter (a flexible tube inserted into a vein in the upper arm used for intravenous access for administration of medications and not used for dialysis). The assessment did not document the resident received hemodialysis or the presence of external catheters, fistulas, or grafts used for dialysis access. The 8/1/2024 physician orders documented: - Dialysis Monday, Wednesday, and Friday; transport pick-up time 6:00 AM and return time 12:00 PM. - Dialysis communication book to go with resident to dialysis and returned from dialysis. Concerns to be reported to Unit/Clinical manager. - No blood pressures or blood draws from dialysis shunt extremity. - Weights done at dialysis. - Food to be offered to resident upon returning from dialysis. - Monitor atrioventricular fistula (a connection between an artery and a vein for dialysis) left arm every shift for redness, edema, and drainage and palpate site for thrills (vibrations caused by blood flowing through the fistula)/listen for bruit (whooshing sound) over access site. If no thrill, notify Nursing Supervisor/Unit Manager immediately. The comprehensive care plan initiated on 8/1/2024 did not include the need for dialysis and interventions for care. During an observation on 8/15/2024 at 9:44 AM, Resident #301 was sitting in their room watching television. They stated they went to a community-based dialysis center on Monday, Wednesday, and Friday. They took a cab to dialysis, and it was 5 minutes away. During an interview on 8/16/24 at 10:16 AM, Registered Nurse Unit Manager #12 stated there was no dialysis care plan for Resident #301. They did updates to resident care plans, and there should have been a dialysis care plan with interventions. They thought the Assistant Director of Nursing or Director of Nursing did the admission care plan. Registered Nurse #13 had done the initial admission assessment for Resident #301, and they documented the resident had a peripherally inserted central catheter in their right upper chest (for antibiotic therapy) and a former chest tube site, but nothing about the resident having an atrioventricular fistula for dialysis. During an interview on 8/16/24 at 10:42 AM, the Assistant Director of Nursing stated Resident #301 did not have a dialysis care plan. All residents on admission had a baseline care plan. The Nurse Manager or whomever did the initial admission would put particulars in a care plan. They stated they needed to find some more information and would be back (they briefly left the interview). When they returned at 10:48 AM they stated a resident's dialysis care plan should be under the renal topic area, but Resident #301 did not have one. It meant they were not following the medical orders by not having a renal care plan. They also reviewed the certified nurse aide instructions and there was no information regarding dialysis. During an interview on 8/16/24 at 11:03 AM, Registered Nurse #13 stated they admitted Resident #301. When they did the initial admission assessment there should have been an area to address ports on the form and there were not any. They knew the resident had a port, but they did not know where to effectively document that. There should have been a renal care plan, and they should have done the updates for renal failure. A renal care plan should have interventions for monitoring the dialysis site. During an interview on 8/16/24 at 1:33 PM, the Director of Nursing stated registered nurses all worked together during an initial resident admission. The baseline care plan was done by whomever was assigned to do so, then the admissions registered nurse checked to make sure the care plan was accurate. Registered Nurse #13 should have checked the topic area that would have covered the resident's dialysis. It should be documented under renal function. It was important for the certified nurse aide care instructions to contain information about a residents' dialysis status so they would know when a resident should be ready to leave for dialysis. Resident #301 should have had a renal care plan so that interventions could have been followed. 10 NYCRR 415.12(k)

Based on observations, record review, and interviews during the recertification survey conducted 8/14/2024 - 8/20/2024, the facility did not ensure indicated restraints were used for the least amount of time and documented ongoing re-evaluation of the need for restraints for 1 of 2 residents (Resident #7) reviewed. Specifically, Resident #7 had an order for a Merry [NAME] (an enclosed frame wheeled walker) that was evaluated as a restraint and the Comprehensive Care Plan did not address parameters of use for the Merry Walker; and the restraint assessment was incomplete. Findings include: The facility policy, Restraint Policy, revised 2/2021 documented all residents who required the use of a restraint would have a care plan developed. All care plans would be updated quarterly at a minimum. All restraints were to be released at least every 2 hours to allow the resident to exercise and change position. A specific physicians' order was to be entered in the residents' medical record which identified the medical symptom related to the restraint, type of restraint and parameters of use. It was not necessary to indicate restraint release every 2 hours as this was the facility guidelines for all restraints. Devices that had the potential to be considered physical restraints and required an evaluation included seat belts, scoot chairs and Merry Walkers. Resident #7 had diagnoses including dementia with anxiety. The 6/20/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, wandered daily, was independent with walking, sitting to standing, and transfers, and did not use restraints. The 3/7/2024 at 6:42 AM Physical Therapy evaluation completed by the Director of Rehabilitation documented the resident required evaluation due to a recent fall on the unit. Recommendations were to trial a Merry [NAME] to increase independence within the facility and for safety on the unit. A 3/7/2024 Director of Rehabilitation progress note documented the resident was trialing a Merry [NAME] on the unit to address falls. The resident required moderate assistance of 1 getting in the walker due to resistive behaviors. A 3/7/2024 at 2:50 PM Licensed Practical Nurse Unit Manager #3 progress note documented the resident was evaluated after a fall and a Merry [NAME] was trialed during physical therapy sessions only for safe ambulation. The 3/14/2024 and 3/27/2024 restraint assessments completed by Assistant Director of Nursing #14 documented the assessment was necessary to determine if the restraint was or continued to be an appropriate intervention. A risk versus benefits discussion was done, the resident had a Merry [NAME] that was currently the least restrictive measure, the family representative was educated, and a restraint continued to be appropriate. The eventual goal was independent ambulation. A 3/27/2024 Physician #10 order documented a Merry [NAME] for independent ambulation due to muscular weakness and difficulty walking. A 3/27/2024 at 3:33 PM Licensed Practical Nurse Unit Manager #3 progress note documented the resident had been trialing the use of a Merry [NAME] with therapy on the unit for safe independent ambulation. Therapy recommended the use of the Merry [NAME] on the unit independently for morning only at that time. The resident would continue to work with therapy to increase tolerance. The resident's family was aware. The 3/27/2024 nursing care instructions documented the resident's ambulation was changed to ambulation with a Merry [NAME] in the AM only. The Comprehensive Care Plan initiated 3/27/2024 documented the resident required a Merry [NAME] secondary to a diagnosis of dementia with poor safety awareness, muscle weakness, and frequent falls. Interventions included ensure proper trunk and body alignment, and physical and occupational therapy evaluations and treatments as needed. The care plan did not include parameters for the least restrictive use or least restrictive time for the restraint to be used. The 5/10/2024 nursing care instructions documented ambulation in the Merry [NAME] for safety. The 6/13/2024 quarterly restraint assessment completed by Assistant Director of Nursing #14 documented the resident used a Merry Walker, was unable to rise from the device but could rise from other seating devices, and the Merry [NAME] was considered a restraint. The assessment did not document restraint use or restraint use conclusion if the restraint was indicated. The resident was observed at the following times: - on 8/14/2024 at 11:02 AM sitting in the Merry Walker. The device enclosed the resident while they sat on the seat and there was a latch lock on the front of the cross bar. - on 8/16/2024 from 9:00 AM - 1:22 PM the resident was observed during a continuously. At 9:00 AM, sitting at a dining room table eating breakfast. At 9:13 AM Certified Nurse Aide #1 assisted the resident into the Merry [NAME] after breakfast. Certified Nurse Aide #1 stated they thought the Merry [NAME] was used to assist the resident with walking. They stated the resident could not release the restraint. Certified Nurse Aide #1 demonstrated how to release the front bar and seatbelt. They asked the resident if they could release the front bar of the walker and the resident did not reply. At 10:54 AM ambulating in the hall in the Merry Walker. From 11:41 AM-12:26 PM, sitting on the seat of the Merry [NAME] in the hall across from the dining room. At 12:27 PM transported by staff in the Merry [NAME] to the dining room. At 12:37 PM removed from the Merry [NAME] by staff and placed at the dining room table for lunch. - At 1:22 PM, placed back into the Merry [NAME] by staff after lunch was completed. During an interview on 8/19/2024 at 10:25 AM, Certified Nurse Aide #2 stated the resident used to walk around independently daily and wandered all over the unit but had a couple of falls and now they used a Merry Walker. The resident currently had a hard time standing up from the walker. They did not document when the Merry [NAME] was released because there was no place to document on the resident care instructions. During an interview on 8/19/2024 at 11:22 AM Licensed Practical Nurse Unit Manager #3 stated the resident walked independently, had falls and required a Merry Walker. The resident had a physician order for the restraint, there were no parameters for use, the care plan did not list interventions, and the resident care instructions had no place for the certified nurse aides to document when it was released. During an interview on 8/19/2024 at 3:08 PM Resident #7's family representative stated they were informed by physical therapy a Merry [NAME] was needed to prevent falls as the resident would not remember to use a regular walker. The resident had two recent falls with no significant injuries and used to walk the halls independently. The resident could not release themself from the Merry [NAME] and they were concerned in the event of an emergency that it would not be safe for the resident to be in the Merry Walker. During an interview on 8/20/2024 at 9:27 AM the Director of Rehabilitation stated the resident had an evaluation on 3/7/2024 after a fall and was trialed with a Merry [NAME] to be used in the AM only. The Director of Rehabilitation stated when the resident was discharged from therapy on 5/10/2024 they changed the recommendation for the resident to use the Merry [NAME] at all times. They did not specifically document to release the Merry [NAME] every two hours. It would not be appropriate if the resident was not released after two hours. The risk could be skin breakdown and/or physical decline. During an interview on 8/20/2024 at 10:28 PM Nurse Practitioner #7 stated Merry Walkers were prescribed for a resident that had trialed all other assistive devices, had falls and continued to be injured. Resident #7 had a Merry Walker, could not release it themself, and it should be released every two hours. A physician order should document parameters for the least restrictive use and time for a resident who was unable to release the restraint themself. The risk of a resident not released from a restraint could result in skin breakdown or infection. During an interview on 8/20/2024 at 11:30 AM, the Administrator stated a restraint was any device that restrained or restricted a resident. Any restraint required a physician order, and it was the standard of care per their restraint policy to include the least restrictive use and time. Resident #7 had a Merry Walker, it was considered a restraint, and the resident could not release it themself. 10NYCRR 415.4(a)(2-7)

Based on observations and interviews during the recertification survey conducted 8/14/2024-8/20/2024, the facility did not ensure nurse staffing information was posted daily at the beginning of each shift and included the total number and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides for 4 of 5 days of survey. Specifically, daily nurse staffing was not posted daily at the beginning of the shift as required on 8/14/2024, 8/15/2024, 8/16/2024, and 8/19/2024 as required. Findings include: The facility did not have a policy on posting daily nurse staffing. The following observations were made in the main lobby: - on 8/14/2024 at 9:40 AM and 4:35 PM, the daily nurse staffing was posted in a clear plastic frame on a shelf and was dated 8/13/2024 with the day shift (7:00 AM - 3:00 PM) nurse staffing only. - on 8/15/2024 at 4:40 PM the posted daily nurse staffing was dated 8/13/2024. - on 8/16/2024 at 9:01 AM the daily nurse staffing posted was dated 8/13/2024. At 10:07 AM, the posted daily nurse staffing was dated 8/16/2024 and documented nursing staff for the day shift. - on 8/19/2024 at 8:45 AM and 10:47 AM there was no posted daily nurse staffing. At 12:16 PM the posted daily nurse staffing was for the day shift on 8/19/2024. During an interview on 8/20/2024 at 10:05 AM, Administrative Assistant/Day Staffing Coordinator #15 stated they did the day shift nurse staffing schedule every day. They were not aware the daily nurse staffing posted in the lobby on 8/14/2024, 8/15/2024 and 8/16/2024 was not current and had remained dated 8/13/2024. The evening shift staffing coordinator, who was new, might have taken the schedule out of the clear plastic frame and not put it back, or the staffing schedule may have been set aside when they took it to the front lobby desk. The night (11:00 PM - 7:00 AM) Registered Nurse Supervisor did the night shift staffing schedule but they had not been posting it in the lobby. During an interview on 8/20/2024 at 10:15 AM the Administrator stated they were not aware the posted daily nurse staffing schedule was not current on 8/14/2024, 8/15/2024 and 8/16/2024 or that the schedule was absent throughout the morning on 8/19/2024. The day and evening shift staffing schedules should have been posted before the shifts started. 10 NYCRR 415.13

Based on interview and record review during the abbreviated survey (NY00306465), the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2's order for continuous positive airway pressure therapy (a treatment that uses pressure to keep the airway open when sleeping) was not complete and when Resident #2 either refused the treatment or the machine had a missing part, there was no documentation the facility addressed the issues or that the medical provider was notified. Findings include: The 2019 Oxygen Therapy policy documented continuous positive airway pressure therapy was used for residents with sleep apnea (condition where the person stops breathing when sleeping) and a physician order was required for use of the machine. The procedures included: - residents may have personal machines or the facility rents the machine for use while at facility. - If the resident has their own machine, follow the manufacturer's instructions for care. - If the machine is rented, ensure the mask is fitted for resident and the procedure outlined the proper fit for 3 types of masks (nasal mask, full face mask, and breeze mask). - Staff were to document the use of machine in the treatment record. Resident #2 had diagnoses including COVID-19 pneumonia, sleep apnea, and chronic obstructive pulmonary disease (lung disease). The 10/26/2022, Minimum Data Set assessment documented the resident's cognition was intact, they had no behavioral symptoms, and required extensive assistance with all activities of daily living other than eating in which they required supervision. The resident used oxygen and a non-invasive mechanical ventilator (bilevel positive airway pressure or continuous positive airway pressure). The comprehensive care plan initiated on 10/21/2022, did not include documentation related to the resident's respiratory status. The 10/2022 Treatment Administration Record documented: - an order initiated 10/21/2022 for CPAP/BiPAP (continuous positive airway pressure or bilevel positive airway pressure). -The record documented the continuous positive airway pressure machine was not applied on 10/21/2022 through 10/24/2022 and 10/26/2022 through 10/31/2022. The reasons documented was refused, except on 10/21/2022 and 10/23/2022 when licensed practical nurse #2 documented, missing parts. The 11/2022 Treatment Administration Record documented Resident #2 refused the continuous positive airway pressure machine on 11/01/2022 and 11/02/2022. Resident #2 was hospitalized from 11/03/2022 to 11/09/2022. The 11/2022 Treatment Administration Record initiated on 11/09/22 documented: - an order for CPAP/BiPAP (continuous positive airway pressure or bilevel positive airway pressure). - The continuous positive airway pressure machine was documented as refused on 11/11/2022 through 11/13/2022, 11/19/2022, 11/21/2022 through 11/22/2022, 11/24/2022. 11/25/2022, 11/27/2022, and 11/28/2022. - Licensed practical nurse #2 documented the continuous positive airway pressure machine was not administered for missing parts or oxygen attachment not available on 11/09/2022, 11/18/2022, 11/19/2022, 11/23/2022, 11/26/2022, and 11/30/2022. The comprehensive care plan was updated on 11/17/2022 to include Resident #2 had the potential for respiratory distress secondary to chronic obstructive disease and COVID-19 pneumonia. Interventions included oxygen via nasal cannula and continuous positive airway pressure therapy per physician's order. The 12/2022 Treatment Administration Record documented the resident refused the continuous positive airway pressure machine from 12/02/2022 through 12/10/2022 and 12/13/2022 through 12/17/2022. The nursing and/or physician progress notes did not contain any documentation related to Resident #2 refusing the continuous positive airway pressure machine or that the machine was missing parts. During an interview with licensed practical nurse #2 on 11/29/2023 at 3:50 PM, they stated they did not recall Resident #2 but if a resident had a continuous positive airway pressure machine, they would make sure they had an order, which would come up in the Medication or Treatment Administration Record. They would ensure the resident had the machine in place before going to sleep. If the machine was missing a part, they would notify the nursing Supervisor who could notify whoever they needed to. They did not know if the facility or the families supplied the machines. If the resident refused the continuous positive airway pressure machine, they would reapproach the resident and offer it again. They would sometimes document in a nursing progress note about the refusal, how many times the resident was reapproached, and the resident's response. They would document about a missing part only if they needed to. During an interview with Assistant Director of Nursing #3 on 11/29/2023 at 4:10 PM, they stated they filled in as the Unit Manager on Resident #2's unit from 10/2022 through 2/2023. If a continuous positive airway pressure machine was missing a part or if the resident was refusing, they would expect to be notified. The machine was important for adequate oxygenation during sleep. They did not recall Resident #2 or being notified their continuous positive airway pressure machine had missing parts or they were refusing to use it. They would expect it to be reported to them so that it could be addressed. A care plan should be in place if a resident was using a continuous positive airway pressure machine and a behavioral care plan initiated if the resident was consistently refusing to use it. Sometimes the family brought in the machine and other times the facility rented one. They were not sure what type of continuous positive airway pressure machine was in place for the resident but some of the machines required an oxygen attachment. During an interview with registered nurse Supervisor #5 on 11/29/2023 at 4:35 PM, they stated they used to work as a licensed practical nurse on Resident #2's unit until 3/2023 when they passed their registered nursing boards and then worked as a Supervisor. They did not recall Resident #2. They would expect to be notified if a resident was refusing their continuous positive airway pressure therapy, the machine had a missing part or was not working. They would assess the resident to determine the reason for refusing, document in the medical record and notify the Unit Manager the next morning. During an interview with Director of Nursing #4 on 11/29/2023 at 4:45 PM, they stated an order for continuous positive airway pressure therapy should include when to apply the machine, such as at hours of sleep. Typically, the family would provide the machine. If a resident refused the continuous positive airway pressure therapy at bedtime or a machine part was missing, the Supervisor should be notified to assess the resident and then notify the medical provider. If the resident was stable, they could wait to notify the Unit Manager the next day. Both refusals and missing parts should be documented in the progress notes. It was important to address a resident not using a continuous positive airway pressure machine if ordered, to maintain proper oxygenation. During interviews on 12/11/2023 at 12:15 PM and 3:18 PM, the attending physician stated the orders for continuous positive airway pressure usually came from respiratory therapy or the provider who ordered the treatment for the resident prior to their admission to the nursing facility. The orders should include the machine settings but they did not set up the machines at the nursing facility so those settings should already be in place. They stated they believed the resident was on continuous positive airway pressure prior to admission so the facility would follow the settings previously used and the family would bring in the machine used prior to admission. The nurses at the facility would follow the settings that were previously used by the resident. They stated they would probably want to be notified if a resident refused continuous positive airway pressure, but they were not sure they would want to be notified at the time of every refusal. If they were notified of refusals, they would intervene and check with the family. If someone refused the treatment for a month or two, they would want to reassess and see if the treatment was still needed. 10NYCRR 415.12(k)(5)

Based on observation, record review, and interview during the abbreviated survey (NY 302) the facility failed to ensure residents were free from abuse and neglect for 1 of 3 residents (Resident #1) reviewed. Specifically, CNA #1 was observed in a video grabbing Resident #1 by the arm, pulling the resident roughly from behind with both arms and ignoring the resident while they sat on the floor for 10 minutes. This resulted in actual harm of mental anguish that was not immediate jeopardy to Resident #1 who became weepy and inconsolable when the incident was discussed. Findings include: The undated facility Abuse Policy documented all residents would be free from abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment that resulted in physical harm, pain, or mental anguish. Inappropriate physical contact with a resident which harmed or was likely to harm the resident included striking, pinching, kicking, shoving, or bumping. Reports of abuse were to be promptly and thoroughly investigated. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required limited assistance with locomotion, supervision with transfers and ambulating in their room, and used a walker. The comprehensive care plan (CCP) initiated on 7/20/2022 documented Resident #1 had cognitive impairment. Staff were to face the resident, make eye contact, identify themselves to minimize frustration. The resident was independent with supervision for ambulation, was at risk to be a victim of abuse and had behavioral problems. Interventions included to redirect the resident when voicing inaccuracies, if unable to be redirected make sure they were safe, if the resident became combative staff were to reapproach in a calm and reassuring manner. A video recording of the hallway on the resident's unit dated 10/3/2022 documented: - from 11:26.24 PM - 11:27.27 PM Resident #1 was sitting in a stationary chair at the end of the hallway by the kitchenette. A walker was noted on the left side of the resident. CNA #1 entered the hall, Resident #1 got up from the chair and walked in the opposite direction of the CNA without the walker. - at 11:27.41 CNA #1 walked down the long hallway in the direction of Resident #1. The CNA moved the stationary chair the resident had been sitting in, pushed the walker to the right, pointed to the walker and kept the walker in place. CNA#1 approached the resident without the walker, Resident #1 walked to the other side of the hallway away from CNA #1, stopped, pointed at the CNA then continued to the corner of the hall. CNA #1 stood in front of the resident, in the corner and pointed toward the long hall. The resident grabbed the handrail pointing at the CNA. CNA #1 grabbed the resident's right wrist and the resident pulled away and began walking towards the long hallway. - at 11:28.50 the resident walked down the long hall, hanging onto the handrail with CNA #1 following closely and pointing down the hall. The resident and CNA #1 came upon the walker, Resident #1 passed the walker and CNA #1 grabbed the resident by the left arm. The resident backed up to the wall, the CNA walked behind the resident down the hall with their arms directing the resident from behind down the hall. At no time did the CNA offer the resident their walker. - at 11:28.57 CNA #1 had their right arm interlocked with Resident #1's left arm. Resident #1 attempted to pull away, CNA #1 grabbed the resident's left arm and continued to walk behind the resident down the long hall with their hand on the residents back. - at 11:29.13 Resident #1 entered an alcove in the hall, CNA #1 grasped the resident from behind with their right arm as the resident attempted to grab the railing. CNA #1 encircled the resident's upper body and waist with their arms pulling the resident backwards then released the resident. CNA #1 then let the resident's left arm drop and pointed to the long hallway. - at 11:29.15 CNA #1 stepped forward away from the resident. Resident #1 pointed towards the hall with their left arm, and CNA #1 continued to converse with the resident. - at 11:29.55 CNA #1 grasped Resident #1's left arm and pulled the resident from the alcove. CNA #1 remained behind the resident, in a pushing motion, then released the resident. - at 11:30.11 Resident #1 was standing against the wall, holding the railing and CNA #1 was directly in front of the resident talking. - at 11:30.39 Resident #1 attempted to walk down the hall, CNA #1 roughly grasped the resident's left arm, Resident #1, attempted to pull away from CNA #1 and the resident placed themselves on the floor in a sitting position. - from 11:30.42 - 11:33.11 CNA #1 stood above the resident pointing down the hall with their left hand and had their right hand in and out of their right pants pocket. - at 11:33.12 CNA #1 walked away from the resident into the resident's room. The resident remained on the floor beside their doorway holding onto the railing with their right hand. CNA #1 exited the room, walked by the resident, walked down the long hallway, and proceeded to sit in a chair. Resident #1 remained on the floor clutching the handrail. - from 11:33.13-11:45.59 Resident #1 remained sitting on the floor, by the doorway of their room clutching the handrail. - at 12:06.49 the Associate Director of Nursing (ADON) entered the unit, spoke to CNA #1, and left the unit at 12:07.55 - at 12:14.29 CNA #1 entered the resident's room and remained in the room until 12:17.50. Statements included in the facility investigation documented: - untimed and undated by Associate Director of Nursing (ADON) #5, they met with Resident #1, asked how their night went and Resident #1 began crying and reported [they] just came in demonstrating with hand gestures, they were hit in the head and stomach with a closed fist. An assessment was completed, there were no injuries or complaints of pain. - untimed and undated by social worker (SW) #4, they met with Resident #1 on 10/4/2022. The resident reported being abused the previous night and was upset. Resident #1 was alert and weepy and reported someone slammed them on the left side of the face and demonstrated a punching gesture with their hand. The incident occurred the previous night, in their room, [they] carried [them] from the hall to [their] room. The resident could not identify the perpetrator or state what intentions they had. Resident #1 expressed the account several times and stated they wanted to run away. The SW met with other residents who denied any concerns with any staff. The undated facility synopsis report completed by the Administrator documented on 10/4/2022 around 10:00 AM Resident #1 reported being hit in the face, the stomach and carried down the hall the prior evening. Resident #1 was distressed while recounting the story and remained consistent with the account. The Administrator reviewed security footage and identified CNA #1 approaching Resident #1, attempted to redirect the resident to their room, pulled the resident by the arms, down the hall. The resident appeared to become combative towards CNA #1 and attempted to have the CNA leave them alone. CNA #1 was witnessed pulling Resident #1 towards the floor, leaving the resident on the floor, and sitting in a chair at the end of the hallway. Immediately after Resident #1 reported the allegation to nursing staff an investigation was initiated; a skin assessment was completed, and no noted injuries were identified. The Sheriff's department was notified, and a police report was filed. Skin assessments on other residents on the unit were performed and residents were interviewed. There were no other reports of mistreatment. CNA #1 was called to obtain a statement and CNA #1 refused to give a statement to the facility. A termination letter was to be sent to CNA #1 and the employee was not placed on the schedule. CNA #1 did not have other care issues or concerns during their employment. The facility concluded based on the facts, interviews, record review and internal investigation there was reasonable cause of the allegation of abuse as defined by the New York State Department of Health (NYSDOH). The family and medical provider were notified. There was no documented evidence of an assessment having been completed for of Resident #1 being completed. The undated Kardex (care instructions) documented Resident #1 was confused at times, required supervision while walking in their room and corridor using a walker for locomotion. A progress note dated 10/2/2022 at 2:56 PM by licensed practical nurse (LPN) #14 documented Resident #1 was alert and oriented to self, did not require assistance with ambulation, needed constant redirection from staff, and did not have physical behaviors. The shift assignment form dated 10/3/2022 for the 11:00 PM-7:00 AM shift, documented CNA#1 worked on 10/3/2022 and was assigned to care for Resident #1 until 4:00 AM. A progress note dated 10/4/2022 at 1:41 PM by licensed practical nurse (LPN) #2 documented they spoke with Resident #1 that morning about an incident that took place during the night and spoke to the resident's family. There was no additional documentation regarding specifics of the incident. A progress note dated 10/6/2022 at 10:02 AM by nurse practitioner (NP) #13 documented they saw Resident #1 following a reported incident and performed an examination. The resident recalled the incident, denied pain, headache, shortness of breath, abdominal pain nausea or vomiting. Resident #1 did not have acute distress; the physical exam was benign, and they would be referred to social work. CNA #1's timecard documented they worked at the facility on 10/3/2022 from 10:33 PM- 7:07 AM. CNA #1 did not have any further documentation they were in the facility after that date. On 10/6/2022 at 9:58 AM, LPN #2 stated during an interview they saw Resident #1 between 8:00 AM - 9:30 AM on 10/4/2022 while physical therapy assistant (PTA) #10 walked Resident #1 in the hall. LPN #2 was walking down the hall and the PTA reported the incident to the LPN. Resident #1 reported to the PTA they were mistreated during the night, hit in the face and stomach. The accused was described as big and had been there during the night. Registered nurse Supervisor (RNS) #5 was notified and performed an assessment with no bruising or injuries identified. The Administrator, SW and medical were notified and an investigation was initiated. After review of the staffing schedule CNA #1 was assigned to Resident #1 during the night and left the facility at 7:00 AM that morning. Staff statements were obtained. Administration took over the investigation and the police were notified at approximately 12:30 PM and took a copy of the video. The LPN stated whenever the resident talked about the incident, they became upset. On 10/6/2022 at 10:37 AM CNA #3 stated during an interview they were assigned to Resident #1 on 10/4/2022 during the 7:00 AM - 3:00 PM shift. At about 7:35 AM the resident stated during care a male with light blue scrubs (nursing staff attire) swung and hit them in the head, told them to stay in the bed and to shut up. Resident #1 was crying and upset. They assured Resident #1 the CNA was no longer in the building. They completed resident care and reported the allegation to LPN #2. On 10/5/2022 they also provided care to Resident #1 who remained upset and crying repeating the incident and still demonstrating what occurred. On 10/6/2022 at 11:03 AM SW #4 stated during an interview the resident had severe cognitive impairment however did not have any emotional issues prior to the incident. They were alerted on 10/4/2022 at 10:00 AM by LPN #2 Resident #1 reported they had been abused. They went directly to see the resident. Resident #1 was in another resident's room, was very weepy, and reported the previous night they were slammed by a male, in the face, could not identify the male and demonstrated the slap. The male carried the resident to their room and the resident did not know what the intention was. Resident #1 was weepy and stated they wanted to run away throughout the entire conversation. After the conversation the resident left the room attempted to go to an activity and remained by the activity leader. They went to see Resident #1 on 10/5/2022 at 3:00 PM to follow up and the resident did not discuss the incident. On 10/4/2022 at 12:21 PM a police report was filed and documented they arrived at the facility and interviewed CNA #1. CNA #1 reported Resident #1 was being disruptive and loud while in the hallway and they attempted to bring the resident back to their room. At first the resident was compliant and suddenly stopped in the hall and stated they were not going back to their room. The resident then let go of the walker, CNA #1 grabbed onto the resident as the resident was no longer using the walker. On the way back to the room, the resident was combative towards them, when they reached the resident's room the resident attempted to sit on the ground, and they helped the resident to the ground, so the resident did not injure themselves. The resident then crawled into their room and up in the bed without further incident. On 10/13/2022 at 11:49 AM NP #13 was interviewed via phone and stated Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 cried and told them they were hit in the face by someone. Any time the incident was discussed with the resident the resident became distressed and sobbed. NP #13 stated at the moment of the incident there was psychological harm to the resident. . On 10/13/2022 at 12:31 PM the Administrator was interviewed via phone and stated they followed the facility policy and used the incident reporting manual for guidance on abuse. On 10/4/2022 LPN #2 told them Resident #1 reported an incident had occurred. They immediately initiated an investigation, assessed the resident and other residents on the unit. No injuries were found. They obtained staff statements and reviewed video surveillance. They identified that CNA #1 mishandled Resident #1 and notified the police department. When they attempted to get a statement from CNA #1, the CNA would not talk to them as the police had conducted an interview prior to their call. They determined abuse by CNA #1 did occur however they did not feel psychological harm occurred as the resident did not remember the incident and did not have any changes in their behavior. 10NYCRR 415.4(b)

Based on observation, interview, and record review during the recertification and abbreviated (NY 303) surveys conducted 7/12/22-7/15/22, the facility failed to provide food and drinks that were palatable, attractive, and at safe and appetizing temperatures for 2 of 2 test trays (lunch trays for Residents #20 and #25). Specifically, food was not served at palatable or safe temperatures. The food service policy Critical Control Daily Temperature Log revised 2009, documented the minimal internal temperatures for cooking raw food were 165 degrees Fahrenheit (F) for poultry, 155 degrees F for ground meats (beef, pork, veal, lamb, and fish), pork (steak & chops), 155 degrees F for pork roasts, and 145 degrees F for beef, veal, and lamb roasts. The policy documented serving temperatures were to be: - under 40 degrees F for cold foods; - soups 160-180 degrees F; - meats, poultry, seafood, and eggs 145-165 degrees F; and - sauces, gravies, and vegetables 160-180 degrees F. Resident #20 had diagnoses including acute [CONDITION(S)] (a progressive neurological disorder). The 4/12/22 Minimum Data Set (MDS) quarterly assessment documented the resident had intact cognition and was able to feed themselves after set-up. Resident #25 had diagnoses including Alzheimer's dementia and malnutrition. The 4/25/22 MDS assessment documented the resident had severely impaired cognition and was independent with eating after set-up. The 10/2021 physician order documented Resident #20 was on a regular consistency no concentrated sweets/no added salt (NCS/NAS) diet with thin liquids. During the 7/13/22 Resident Council Meeting at 10:30 AM, Resident #20 stated the hot food was often cold. During an observation on 7/13/22 at 12:55 PM, the food cart arrived on the 3rd floor unit and at 1:14 PM a meal tray was delivered to Resident #25. The tray was used for testing and a replacement was provided to the resident. The hot food tasted lukewarm and was not flavorful, the cold food was warm, and both the hot and cold foods were not palatable. The following temperatures were recorded: - fried [NAME] was 129 degrees F; - potato wedges were 126 degrees F; - mixed vegetables were 122 degrees F; and - sliced oranges were 61 degrees F. During an interview on 7/14/22 at 12:47 PM, Resident #20 stated the food was usually not warm when their lunch tray arrived at their room. They stated that sometimes the staff would reheat the food if asked, but often were busy assisting other residents with eating. During an observation on 7/14/22 at 12:58 PM, the food cart arrived on the 3rd floor and at 1:07 PM a meal tray was delivered to Resident #20. The tray was used for testing and a replacement was provided to the resident. The hot food tasted lukewarm and was not flavorful, the cold food was too warm and not flavorful, and both the hot and cold foods were not palatable. The following temperatures were recorded: - 2% milk was 57 degrees F; - slice of pork was 114 degrees F; - sliced peaches were 60 degrees F; and - the can of ginger ale was 59 degrees F. When interviewed on 7/14/22 at 1:28 PM, the Food Service Director stated they had conducted weekly audits on the food trays and the last audit was conducted on 7/13/22. They were unsure how long that tray was on the cart before it went to the floor. They stated hot foods were required to be over 140 degrees F, and all cold food holding temperatures were required be 40 degrees F or under. The Food Service Director stated that they had received a week of training from the previous Director and was unaware of any food temperature issues. 10NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interview during the recertification and abbreviated (NY 995) surveys conducted 7/12/22-7/15/22, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #31) reviewed. Specifically, Resident #31 was found in a non-resident area of the facility 2 hours after a fire drill when the resident left a secured unit undetected. Additionally, the resident's absence was reported by a family member and unnoticed by staff. Findings include: The facility policy Fire Procedures revised 6/2018, documented for alarms including Secured Unit, keep/move residents to the Resident Dining/Activity Room. Following the evacuation, the charge nurse would verify that all residents/staff were accounted for, and report results to Control Station. The Nursing Director/Supervisor was responsible to verify that each unit/department had accounted for all residents/staff and report results to Command Station. Resident # 31 had diagnoses including unspecified dementia and anxiety disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, exhibited wandering behavior daily, ambulated independently in their room, required limited assistance for ambulation in the corridor and locomotion off the unit, did not use mobility devices, and did not use a wander/elopement alarm. The undated care instructions documented the resident was independent with locomotion on the unit. The comprehensive care plan (CCP) effective 6/30/21 documented the resident had a behavior problem related to dementia and enjoyed exploring the unit. Interventions included reapproach as needed and use calm reassuring manners. The CCP did not include risk for elopement. The Nursing Annual/Significant Change/Transfer elopement risk assessment created on 6/21/22 and completed on 7/6/22 by the Director of Nursing (DON), documented the resident had cognitive impairment with poor decision making skills and was independently mobile. The form documented if one or more questions above were answered yes, then the resident was an elopement risk. The elopement risk assessment summary documented the resident was not at risk for elopement at that time. The 7/7/22 nursing progress note by registered nurse (RN) #2, documented the resident was discovered missing from the locked unit at 6 PM when a family member came to visit. The resident had likely wandered off the unit during a fire drill which took place at 3:30 PM. After searching the unit, a Code Yellow (missing resident) was initiated, and maintenance located the resident in a stairwell on the 4th floor. There was no evidence of injury, the nurse practitioner, and the Director of Nursing (DON) were notified. The 7/7/22 Investigational Summary documented the resident was located in a potentially hazardous non-resident area. The resident was last observed at 3:50 PM sitting with peers in the Unit 1 B lounge during a fire drill. At 5:00 PM the resident's family member arrived at the facility, did not see the resident, and notified staff. AT 5:30 PM staff conducted a thorough search of the unit. At 5:45 PM a Code Yellow was initiated by the building supervisor, and a search of the entire building was started. At 5:48 PM the resident was located in the stairwell by a member of maintenance. A registered nurse (RN) head to toe assessment was completed and the resident did not have any injuries and was returned to their unit. The summary concluded the resident was able to open the stairwell door without the alarm sounding due to door locks being released when the fire alarm activated. The resident had not previously been identified as a high risk for elopement. As a result, an on-site in-service would be done to ensure staff monitored exit doors whenever a fire alarm was activated. The resident's CCP was updated to reflect the incident and a new elopement assessment was completed. The Fire Drill Evaluation Form dated 7/7/22 documented the drill was initiated at 3:20 PM and was completed at 3:29 PM, the location was Room 105, and all patients/residents were accounted for. During an interview on 7/15/22 at 8:58 AM, certified nurse aide (CNA) #5 stated residents did not wear Wanderguard bracelets on Unit 1as it was a secured dementia unit. The doors were always locked and required a code to open. Doors would open during a fire drill, and a staff member was to stand at the exit doors to prevent residents from leaving. Staff knew the doors were supposed to be monitored, but the CNA was not sure of the exact assignment. During an interview on 7/15/22 at 9:12 AM, housekeeper #6 stated during a fire drill someone was supposed to stand by the exit doors because they would open during an alarm. If staff did not monitor the doors, a resident might leave unnoticed. They were not aware of specific staff assigned to the doors during the drill. During an interview on 7/15/22 at 9:19 AM, CNA#7 stated there were no Wanderguard bracelets for residents on unit 1. The exit doors had keypads and were always locked. The doors unlock automatically during a fire drill. During a fire drill, staff on the unit were assigned to an exit door by a supervisor. After the alarm was cleared, staff were supposed to do a head count to make sure all residents were present. During an interview on 7/15/22 at 11:11 AM, Resident #31's family member stated they could not recall what time they visited on 7/7/22 but they usually visited on Thursdays between 4:30 PM and 5 PM. On 7/7/22 they walked around the circle on the unit because the resident was often in other resident's rooms. They looked in other rooms for 5-10 minutes. They let staff know they could not find the resident, and staff started looking for them. Then they realized the resident was not on the unit. The staff called the Code Yellow, and the resident was found very quickly on another floor in the stairwell. Staff reported there was a fire drill and the resident got off the unit via the stairwell doors. During an interview on 7/15/22 at 11:45 AM, CNA #8 stated during the first hour of their 3-11 PM shift on 7/7/22, they and another CNA made visual checks of the residents. The fire alarm went off while they were doing resident care at about 3:30 PM. They made sure the residents were safe and removed residents from the B lounge. During a fire drill, there was usually a nurse delegating tasks. The CNA was not able to remember who the nurse was on 7/7/22, because there was a lot of commotion. After the fire drill, the drill was discussed and then the CNAs went back and got the residents settled. The CNA stated they did not do a head count directly after the fire drill. At about 5:30 PM, the resident's family member told staff they could not find the resident. The unit staff looked around the unit 5 times without finding the resident. A Code Yellow was called, and it was realized the door had unlocked during the fire drill and the stairwell was searched. Someone from maintenance found the resident upstairs. The CNA stated they brought a wheelchair to the resident and the resident told them they had business to take care of. The resident would often wander the unit and go into other resident rooms. During an interview on 7/15/22 at 11:26 AM, licensed practical nurse (LPN) #11 Unit Manager stated fire safety training was done annually, and for new employees on hire. The facility contracted a company for monthly fire drills. Staff were to respond to exit doors, as they unlocked automatically during a fire alarm. Usually everybody came to the unit during an alarm, and doors were assigned by the nurse. After the fire drill, a head count was supposed to be done. The head count was to be reported to the nursing clinical manager. It was important to make sure that a head count was done, because doors unlock during a drill and residents could leave the unit. During an interview on 7/15/22 at 12:12 PM, LPN#12 stated they were working 3-11 PM on the unit on 7/7/22 during the fire drill. The fire drill lasted a couple of minutes, during which the exit doors were unlocked. Staff were supposed to monitor all the exit doors and do a head count after the fire drill. The LPN could not recall if a head count was done on 7/7/22. At approximately 5:00 PM, Resident # 31's family member reported they could not locate the resident. Staff began a search of the unit and were unable to find the resident. A Code Yellow was called, and the resident was found in the stairwell on the 4th floor. They stated they had last seen the resident before the drill sitting in a chair in the back lounge with other residents. The LPN stated during the drill they had walked with the resident to Room 10 and there were CNAs in the room with residents. The LPN could not recall seeing the resident after the drill but had not been looking for them. During an interview on 7/15/22 at 12:27 PM, the DON stated fire safety training was done on hire, annually and fire drills monthly were done by a contracted company. During a fire drill unit staff should monitor the stairwell/exit doors as they automatically unlock when the fire alarm was activated. The nurse on the unit usually assigned staff to unit doors. At the end of a drill, the expectation was a head count be done and reported to the Supervisor. The DON was not sure if a head count was performed on the resident's unit after the drill was completed. An accident and incident report was completed, and the reporting manual was followed. The facility was working on an updated policy for the prevention of elopement during a fire drill. During an interview on 7/15/22 at 12:59 PM, RN #2 Clinical Supervisor, stated they worked through a staffing agency. Their orientation was 1:1 shadowing, then working with someone for a couple of days before working independently. Fire safety training had been provided, and there was a Clinical Supervisor book with policies in the Supervisor's office. During a fire drill the Supervisor would respond to the fire location. The location of the fire was isolated, and exit doors were manned by staff because they unlock during fire alarms. They were not sure who assigned staff to monitor doors. At the end of the fire drill, a head count should be done. They were on duty on 7/7/22 during the fire drill and they did not receive any head count until after the resident was missing. The fire drill was at about 3:30 PM and they were notified of a missing resident at about 5:55 PM. A Code Yellow was initiated after a thorough search of the unit. A maintenance staff member found the resident in a stairwell on the 4th floor. An assessment of the resident was done, with no injuries were identified, and the DON was notified of the incident. During an interview on 7/15/22 at 1:08 PM, CNA #13 stated they were working on the 3 PM-11 PM shift on 7/7/22, as the building supervisor. They were receiving report when the fire alarm went off around 3:30 PM. By the time they reached the 1st floor locked unit, staff were searching for the fire and moving residents away from the fire room. They stated when the fire alarm sounded all doors unlocked. Staff were supposed to stand by the exits and monitor the doors to ensure no residents leave. After the fire alarm had been cleared the doors needed to be reset before they locked again. Staff should remain until they were notified All Clear and conduct a head count afterwards. At around 5 PM, CNA #8 reported that the resident's family member was looking for the resident, and the resident could not be found on the unit. Once they were notified the resident was missing, they had staff print a picture of the resident, and called a Code Yellow for a missing resident. The DON was notified via telephone. The resident was found in the locked stairwell on the 4th floor (closed unit) by a maintenance worker. The resident was brought downstairs and was assessed by a nurse. After the resident was located, they conducted a head count of the unit and reported the census to the DON. They stated the nurse on the unit should have completed a head count after the fire alarm was completed and the All Clear was called. 10NYCRR 483.25(d)

Based on observation, record review, and interview during the recertification survey conducted 7/12/22-7/15/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (main kitchen) reviewed. Specifically, the side of the deep fryer was soiled/unclean, the steam kettle had splattered deep fryer oil, the floor of the walk-in cooler had frozen water and melted water on it, the handwash sink near the 3-bay sink area was leaking, there were two soiled/unclean frying pans, and the walls behind the dish machine and the 3-bay sink area were soiled/unclean. Findings include: There was no documented policy or procedure for kitchen cleaning and maintenance. The following observations were made in the kitchen: - on 7/13/22 at 11:25 AM, the side of the deep fryer was soiled/unclean with food particles/debris. The back section of the steam kettle next to the deep fryer had deep fryer oil residue on it. - on 7/13/22 at 11:45 AM, the walk-in cooler had frozen water/ice along the bottom of the wall shared by the walk-in cooler and the walk-in freezer. Additionally, the walk-in cooler had water puddles on the floor. - on 7/13/22 at 11:56 AM, the handwash sink located near the 3-bay sink area was leaking water at the back of the sink and the water was dripping on to the kitchen floor. Water sprayed from the neck of the faucet towards the person using the sink when the sink was turned on. - on 7/13/22 at 11:58 AM, there were two large frying pans on the clean rack that were not clean. The cooking surface of the pans had baked-on debris. - on 7/13/22 at 12:20 PM, the walls behind the dish machine were soiled/brown/unclean. - on 7/14/22 at 2:35 PM, the wall behind the 3-bay sink was soiled/unclean. During an interview on 7/14/22 at 2:40 PM, the Food Service Director stated that the deep fryer had not been deep cleaned since they were hired a month ago. They were not aware the wall on the side of the deep fryer was unclean, or of the ice buildup/ melted water in the walk-in cooler. They stated the ice build-up appeared to be in the cooler longer than a month. The Food Service Director stated that it was not acceptable to have standing water in a walk-in cooler as unclean/dirty water could be spread throughout the walk-in cooler. None of the ice buildup/water was on food items in the walk-in cooler. They stated that they were not aware of the water dripping from the back of the handwash sink near the 3-bay sink area, and staff had not made them aware of the spraying water from part of the handwash sink. The Food Service Director stated they did not know how to make a work order for repair requests. They stated that the two identified frying pans were not acceptable as they had solid buildup of debris on the cooking area of the pans. The cook using the pans should have noticed this and discarded them and made the Director aware. The Food Service Director stated that the walls behind the 3-bay sink, and the dish machine had not been cleaned for over a month and they were considered unclean. During an interview on 7/15/22 at 11:02 AM, the Director of Maintenance stated the last work order submitted for the walk-in freezer was done in 8/2021 for ice buildup and that there were no previous work orders related to ice/water on the floor of the walk-in cooler. They stated that no staff had told them of any current problems with the walk-in cooler or freezer. All facility computers had a maintenance work sub-task icon that any staff could open and enter any issues requiring maintenance. The Director of Maintenance stated that the work order system covered all areas of the facility and that all facility staff had been trained to use the maintenance work order system. 10NYCRR 415.14(h)

Based on interview and record review during the abbreviated survey (NY 689), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were investigated for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 was found with a bruise of unknown origin and made an allegation of abuse against certified nurse aide (CNA) #1. The facility did not initiate a timely investigation after the allegation was made to rule out abuse, neglect, or mistreatment; and there was no documented evidence CNA #1 was removed from having contact with residents while the investigation was in progress. Findings include: The facility policy Abuse Prohibition dated 11/28/2016 documented residents had the right to be free from verbal, sexual, physical, and mental abuse, and corporal punishment. All reports of mistreatment, neglect, or abuse of residents would be thoroughly investigated. The internal investigation procedure included: - All staff were required to report to the Nursing Supervisor/Nurse Manager any incident resulting in possible or evidence of injury to a resident. - The Nursing Supervisor/Nurse Manager were required to complete a resident incident/accident report if they become aware of any injury sustained by a resident. - The Administrator, Director of Nursing (DON), and social worker would immediately be notified of an investigation in process. - The Supervisor and DON would interview the persons involved in the complaint and each person would write a statement of exactly what occurred. The undated Incident and Accident Reporting and Follow up Guideline documented when an incident/accident occurred, the Unit Manager/registered nurse (RN) must fill out the form. A nursing assessment would be completed and documented on the incident/accident form and in the resident's progress notes. Following the assessment and immediate interventions, the responsible party and/or the physician would be notified. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, did not have behavioral symptoms, rejected care 4-6 days of 7, and required extensive assistance of 2 for bed mobility and toilet use. The 11/13/20 comprehensive care plan (CCP) documented Resident #1 was alert and oriented and their cognition fluctuated. They were at risk for skin impairment and had fragile skin. The resident had behavioral issues and at times was inaccurate with their statements about situations. The 1/5/21 facility investigation completed by registered nurse (RN) #8 documented an incident occurred on the overnight shift from 1/3/21 to 1/4/21 at 12:00 AM, including: - Resident #1 was noted with a significant bruise to the right wrist and forearm measuring 6 centimeters (cm) x 8 cm. The area was dark purple and red in color and on the top half of the arm only. RN #8 assessed the resident on 1/5/21 and the resident denied pain. - RN #8 noted the bruised area lined up with the overbed table that the resident's lights were on; the resident last received incontinence care at 12:00 AM on 1/4/21; the resident had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Statement included with the facility investigation documented: - Resident #1 reported they rang their call bell at about midnight on 1/4/2021 asking for Tylenol and a brief change so they could go back to sleep. Certified nurse aide (CNA) #1 came into the room, used vulgar language a few times, and told the resident they were old, ugly, and needed to die. CNA #1 grabbed their arm, and the resident felt a burning in their right arm. The resident did not receive the Tylenol as requested. - The 1/6/21 (untimed) statement by CNA #1 documented they provided care for Resident #1 on 1/3/21. Resident #1 rang their call bell requesting to be changed. They changed the brief without any conversation. Once changed, the call bell was given back, and the resident requested water. While taking the cup, the resident claimed CNA #1 caused the bruise on their wrist. CNA #1 asked Resident #1 how that could have happened and tried to reassure the resident they did not cause the bruise. The resident was very insistent that CNA #1 caused the bruise. CNA #1 notified the nurse of the incident. -The 1/5/21 (untimed) document by the Director of Nursing (DON) noted they spoke with licensed practical nurse (LPN) #6 who stated on 1/3/21, they were told by CNA #1 that Resident #1 had complaints about care provided and that CNA #1 caused a bruise. LPN #6 reported they did not see the resident following that report. There was no documentation LPN #6 notified a registered nurse (RN) of the allegation of abuse made by Resident #1 on the overnight shift from 1/3/21 to 1/4/21 and no documentation an assessment was done when the bruise was identified. There was no documented evidence an investigation was initiated at the time the resident made the allegation. The 1/7/21 RN #8's progress note (noted as a late entry for 1/5/21 at 11:20 AM) documented Resident #1 had a 6 cm x 8 cm bruise on their right wrist and forearm. Nursing was monitoring and the physician and family were aware. The untimed, undated investigation overview by the DON documented: - on 1/5/2021, Resident #1's family member reported to the social worker that on 1/4/21 at midnight, the resident rang their call bell to ask for a Tylenol. CNA #1 answered the call bell, used vulgar language, and told Resident #1, they were ugly, old, and needed to die. The family member alleged CNA #1 caused a bruise to the resident's upper arms where CNA #1 pushed the resident. The social worker reported to the DON and an investigation was initiated on 1/5/21. - Resident #1 was interviewed and reported CNA #1 answered their call bell, used vulgar language, and grabbed their wrist causing the bruise. - Upon the DON's assessment Resident #1 had multiple bruises to the bilateral (both sides) upper extremities consistent with long term anticoagulant (blood thinner) use. Resident #1 was specifically concerned with the bruise to the right wrist and the top of the forearm. There was no bruising on the underside of the arm that would be consistent with a grabbing motion. The bruising measured 12 cm X 6 cm extending with an appearance of initial trauma to the wrist area. The resident was offered an x-ray and refused. The resident used their right arm independently for their needs and liked to have their bedside table near them. - The investigation concluded there was no abuse, neglect or mistreatment identified. The report was undated as to when the determination was made. CNA #1's timecards documented they worked the following shifts: - on 1/3/2021 from 7:19 PM to 7:22 AM. - On 1/4/2021 from 7:06 PM to 7:00 AM. - CNA #1 was not scheduled to work on 1/5/21, 1/6/21, or 1/7/2021. - On 1/8/2021 from 7:14 PM to 7:23 AM. - CNA #1 was not scheduled on 1/9/21, 1/10/2021 and 1/11/2021. There was no documented evidence the CNA was removed from resident care following the allegation of abuse and while the allegation was being investigated. LPN #6' s personnel file was reviewed and contained no documentation any education was provided on reporting or documenting when Resident #1 made an allegation of abuse on 1/3/21 On 5/17/22 at 9:35 AM, RN #8 stated during an interview, Resident #1 was alert during 2021 and was accurate in their statements at that time. The resident required one staff to assist with ADLs. They recalled Resident #1 complained about CNA #1 during care and the resident had a bruise on the right wrist. The bruise was reported on 1/5/21 and the facility was unable to determine how the bruise occurred. During an interview with CNA #1 on 5/17/22 at 11:14 AM they stated on 1/3/2021 they provided care to Resident #1, and they did not recall if the resident was assigned to them on 1/4/21. On 1/3/21, they did not have contact with Resident #1 until the resident rang their call bell. They entered the resident's room and asked what they needed. Resident #1 requested to be changed and wanted some Tylenol, which was not out of the ordinary for them. When they went to provide care, the resident had a bruise on their wrist. CNA #1 did not recall if they grabbed the resident's wrist during care and stated they may have when rolling them or providing care. They denied being aggressive with the resident and denied using foul language. They completed care and the resident asked for some water. They went to get water and told the nurse the resident wanted Tylenol. CNA #1 told LPN #6 about the bruise at that time. On 5/17/22 at 1:15 PM, RN #8 stated during a follow up interview they did not know why LPN #6 did not look at the bruise when they were made aware of it by CNA #1 on the night shift from 1/3/21 into 1/4/21. They were not informed of the bruise until 1/5/21 by the resident's family member. Once notified, they assessed the resident and during the assessment, the resident reported CNA #1 caused the bruise. On 5/19/21 at 1:28 PM, LPN #6 stated during a phone interview CNA #1 told them about Resident #1's bruise at the end of the shift on 1/4/21. CNA #1 told them the bruise was old, so they did not go look at it. They stated it was a very busy night and they forgot to call the Supervisor. They did not pass the information onto the next shift and did not document any information in the resident's record about the bruise. They did not initiate an investigation and that would be the Supervisor's responsibility. They did not recall if the resident asked for any Tylenol and did not recall if they received any education for not reporting the bruise timely. On 5/20/22 at 4:06 PM, the DON stated during a phone interview, if CNA #1 found a bruise the Supervisor should be made aware immediately, the area should be assessed, and a facility investigation initiated. They would expect LPN #6 to make the Supervisor aware of the bruise and document it in the resident's medical record. They did not recall if an assessment was completed when the bruise was found and there was a gap of time from the accusation and noted bruise. They expected LPN #6 to have notified the Supervisor at the time the bruise was found. 10NYCRR 415.4(b)(1)(ii)

Based on observation, record review, and interview during the abbreviated survey (NY 093) conducted on 6/10/21, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed. Specifically, on 6/1/21, Resident #1, a cognitively impaired resident, identified as at risk for elopement following exit-seeking behaviors exhibited following admission, was able to leave the facility undetected by staff through a second-story window, fell approximately 10-12 feet, and was found on the ground outside of the facility by a staff member exiting the building. The resident exhibited wandering behaviors and had made a statement that they would exit the building through a window. Staff reported the resident was attempting to open their room window that had a window restrictor on it to limit opening. The facility then further secured the window, so it opened only slightly. After observing the staff modifying their room window, the resident continued to wander undetected by staff in and out of other resident rooms and a shower room. The resident exited the shower room with a mop, entered another resident room, disabled the window restrictor, and exited the facility through the second-story window. This resulted in actual harm that was Immediate Jeopardy and Substandard Quality of Care to Resident #1 and Immediate Jeopardy to the facility's additional 45 residents who were at risk for elopement. Findings include: The Elopement Policy, revised 8/2018, documents: - Unsafe wandering is defined as wandering that is disruptive to other residents or places the wandering resident at risk for harm. - On, admission, the registered nurse (RN) or designee will assess the resident for elopement risk. - If a resident is identified at risk to wander, the following action must be taken: initiate a care plan that addresses the contributing factors to the risk of wandering or elopement and apply a wanderguard. The undated Wandering policy documents: - Wandering is defined as a resident who has poor safety awareness and moves independently in unsafe areas in the facility. - Nursing and social work will evaluate the resident based on history and behaviors on admission and as needed. Examples to ask and evaluate include: is the resident exhibiting confusion/[CONDITION(S)], anxiety, agitation, restlessness, verbalizing a desire to leave, exhibiting anger at placement or signs of transfer trauma, and level of mobility. - The care plan will be updated after attempts at unsafe wandering/elopement and be individualized to reflect specific behaviors. Interventions to consider include: a secured unit, diversional activities, 1:1 conversation, and family involvement. Certified nurse aides (CNA) were responsible for knowing the whereabouts of each of the residents on their assignment. Resident #1 had diagnoses including [CONDITION(S)]. The 6/1/21 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and received anti-anxiety medication. The 6/1/21 hospital Discharge Summary documented the resident was hospitalized for debility secondary to dehydration and missing their [CONDITION(S)] medications. The Medical Orders for Life Sustaining Treatment (MOLST) documented the resident lacked decision-making capacity and had a health care agent who made their advance directive decisions. The 6/1/21 Nursing Admission/Readmission Assessment completed by registered nurse (RN) Manager #1 documented the resident did not make their own healthcare decisions, was sometimes confused, was not at risk for elopement, and their mental function varied throughout the day. The 6/1/21 at 3:30 PM, RN Manager #1's progress note documented the resident's arrived from the hospital, was confused at baseline, oriented to person, and able to make needs known. The resident transferred with the assistance of one person, had an unsteady gait, was non-ambulatory, and had a fall in the last month. The 6/1/21 at 6:11 PM, social worker #16's progress note documented the resident was alert and oriented with some confusion, usually able to make choices and decisions, and scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The 6/1/21 at 7:48 PM, RN Manager #1's progress note documented the resident had increased confusion and disorientation, was wandering without purpose, opening the window in their room, and was difficult to redirect. The resident's family was called and reported the resident became confused at home intermittently and they agreed to a wanderguard which was applied to the resident's right ankle. The 6/1/21 at 7:43 PM physician's order documented a wanderguard to the right ankle. The 6/1/21 Elopement Assessment completed by RN Manager #1 documented: - The resident had cognitive impairment with poor decision-making skills, and/or a psychological diagnosis and was independently mobile or partially independent. - The resident repeatedly searched for exit doors or elevators or asked where they were and paced, wandered, tried to get out the door, positioned self by the door, or perceived they had to go somewhere. - The resident was at risk for elopement and potential interventions included personal safety alarm devices. - Other potential safety interventions listed and not implemented for the resident included a secured unit, frequent monitoring, behavior logs, and making staff aware of the resident's wandering risk. The 6/1/21 comprehensive care plan (CCP) documented: - The resident was at high risk for elopement; wandered without purpose; had exit seeking behavior; was unable to locate their room; was disoriented to their surroundings and displayed agitation/anxiety. - Interventions included an elopement risk assessment, reviewing risks with the family, and redirecting the resident to safer areas when wandering. - The resident displayed cognitive loss, impaired decision-making, had difficulty understanding direction, and had poor safety awareness. - Interventions included: using a calm approach, identifying self with each contact, and giving simple directions with short sentences. - The resident had alteration in transfers, locomotion, and ambulation with recent falls, recent hospitalization , or advanced age. - Interventions included extensive assistance of one person for locomotion. The 6/1/21 certified nurse's aide (CNA) Care Summary (care instructions) documented the resident required extensive assistance of one person for locomotion, dressing, and hygiene and extensive assistance of 2 people for walking in the corridor and room. There were no care instructions related to supervision, wandering, or exit-seeking behaviors. The 6/1/21 at 8:20 PM, Incident/Accident Report documented the resident was found lying on the grass outside of the facility. Staff and resident statements obtained by the facility related to the events of 6/1/21 included: - Resident #8 (the room Resident #1 exited from) recalled a person entered their room with a broomstick, was working on the window, opened the window and bent over it, and then they were gone. - Social worker #17 left the facility between 8:15 PM and 8:20 PM and saw Resident #1 lying on the grass between the building and sidewalk, a blue mop was located a few feet behind them. - CNA #2 documented the resident was exit seeking upon their arrival to the facility at 7 PM (their shift was 7 PM -11 PM) and CNA #2 helped redirect the resident. The resident commented they were going to leave the building even if that meant leaving through the window. The last time CNA #2 saw the resident was at 8:10 PM walking around the lounge with another resident. - Licensed practical nurse (LPN) #9 saw the resident wandering in the hallway during the shift. The 6/1/21 investigative summary completed by the Director of Nursing (DON) documented: - The resident was admitted at 4:00 PM with mild confusion and required assistance for transfers. - At approximately 7:30 PM, RN Manager #1 assessed resident for increased confusion and wandering without purpose. Redirection was difficult and temporary, and a wanderguard was applied. - At 7:45 PM, CNA #2 saw the resident attempting to open their room window and stated they were leaving even if it meant through the window. Maintenance was notified and the window was secured. - At 8:05 PM, security camera footage showed the resident entered a shower room and exited the room with a mop. The resident then entered Resident #7 and 8's room with the mop in hand. - At 8:11 PM, Building Supervisor #4 was seen on video footage looking into rooms for the resident. - At 8:20 PM, social worker #17 left the facility and found the resident on the ground with a mop next to them and called the Supervisor. - Upon investigation of the room the resident exited, it was noted the window and screen were mechanically broken from the window frame. The 6/1/21 at 8:20 PM, RN Supervisor (RNS) #8's progress note documented the resident fell from a window on the second floor and was outside on the grass, lying on their back. The resident had pain in their back and abdomen and was alert and confused. The resident was assisted onto a stretcher and transferred to the emergency department. The 6/1/21 Patient Care Report Summary documented the ambulance arrived at the facility at 8:55 PM and the chief complaint was a fall greater than 20 feet. The resident presented with chest, back, and pelvis pain that worsened with movement or palpation. The 6/1/21 Hospital Initial Patient Evaluation documented the resident presented with a level 1 trauma following a fall from a 2-story window, reported back, chest, and pelvic pain. The resident's injuries included laceration of the spleen, and pelvic fracture. The hospital social worker called the facility and spoke to RN Manager #1 who reported earlier, the resident was found trying to fully open their window, windows in the facility could not open wide enough to allow a grown person through, the resident was found beneath a window of a different window and was able to break the safety mechanism of the second window to escape. The resident was admitted to the hospital. The surveyor reviewed the facility's 6/1/21 video surveillance and observed the following: - from 6:30 PM to 6:39 PM, Resident #1 was dressed in a hospital gown and slipper socks, sitting in a wheelchair, self-propelling in the hallway and entered their room. The resident walked out of their room wearing pants and no shirt, entered lounge, entered another resident's room where staff redirected them, and assisted the resident to put on a hospital gown. - From 6:43 PM to 6:52 PM, the resident walked down the hallway, entering, and exiting the dining room twice, and entering and exiting other residents' rooms twice. The resident then went off camera, came back into camera view, and entered their own room. Resident #1 then walked down the hall entering another resident room where CNA #6 stopped and spoke to the resident. The resident continued to talk towards the dining room and off camera view. - at 6:58 PM, the resident self-propelled in a wheelchair, stood in the doorway of their room, and walked into their room. At 7:05 PM, the resident exited their room, entered another resident room, and stood near the window. The resident was seen moving the window up and down several inches. At 7:12 PM, CNA #6 entered the room where the resident was and redirected the resident to the hall. - at 7:16 PM, the resident walked in the hall with CNA #2 and entered their own room. RNS #8 and CNA #6 also entered the Resident #1's room, at 7:20 PM, CNAs #2 and 6 and RNS #8 exited the room. From 7:23 PM to 7:36 PM, CNAs #2, 5 and 6, and RNS #8 were in and out of the Resident #1's room. - At 7:40 PM, building supervisor #4 and maintenance staff #3 approached the resident's room. Maintenance staff #3 entered the room and exited and at 7:44 PM, maintenance staff #3 re-entered the room. - At 7:45 PM, Resident #1 exited their room, Building Supervisor #4 followed, and the resident walked around the lounge and then sat down in the lounge. At 7:47 PM, Building Supervisor #4 left the area, maintenance staff #3 exited the resident's room. - At 7:51 PM, Resident #1 approached the door of another resident's room then returned to the lounge and walked out of camera view. - At 7:54 PM, the resident walked down the hall, entered a resident room, exited, and entered a room across the hall. LPN #9 was at a medication cart in the hall and did not address the resident. No other staff were visible. - At 7:55 PM, the resident returned to the lounge, and walked out of camera view. At 7:58 PM, the resident walked down the hall, stopped at the medication cart where LPN #9 stood, and entered a resident room, exited, and entered another resident room. At 8:00 PM, the resident exited the room and walked towards the nursing station. - At 8:00 PM, the resident entered a doorway near the unit entrance and at 8:03 PM, the resident exited the doorway and walked down the hall and entered a room to their right. At 8:05 PM, the resident exited the room carrying a mop and walked across the hall and entered a resident room. No staff were visible in the area. - No other staff were visible from 7:51 PM to 8:05 PM aside from the nurse at the medication cart. - At 8:11 PM, Building Supervisor #4 walked down the hallway and was looking into rooms. At 8:17 PM, Building supervisor #4 and CNA #2 walked down the hall and were looking in rooms. - At 8:21 PM, Building Supervisor #4 exited the unit. - At 8:23 PM, CNA #2 and RN Manager #1 entered the room Resident #1 was last seen to have entered. On 6/3/21 at 8:56 AM, Resident #1's room was observed. The 2 windows in the room were able to be opened approximately 1 inch. The window frame tracks had strips placed that prevented the window from opening any further. On 6/3/21 at 10:50 AM, the Director of Maintenance was interviewed and stated the facility windows were secured on all units since window installation [AGE] years ago. On 6/1/21, maintenance staff #3 received a call that the resident was attempting to get out of the window so they placed additional plastic strips in the sides of the window so the window could only open a crack. For someone to remove the plastic window stoppers, they would need a screwdriver to pry them off. The Director stated they participated in the facility investigation and found the plastic window stoppers were essentially intact in the window the resident went out. The two sliders on top of the window were broken. The sliders allowed someone to tilt the window in for cleaning. When the resident broke them, they were able to dislodge the window allowing Resident #1 to get out. During an interview on 6/3/21 at 11:40 AM with RN Manager #1, stated they admitted Resident #1 at around 4:00 PM on 6/1/21. The resident was confused with cognitive impairment. The resident was able to answer some questions and had difficulty with other things such as the date, children's names, and processing directions. After dinner, the resident had increased anxiety and wandered without purpose and was kept in the common area for supervision. At 7:00 PM, the resident received a routine dose of [MEDICATION(S)] (anti-anxiety medication). At 7:30 PM, the resident continued to wander and at 7:45 PM, staff reported the resident opened their window and maintenance was called and secured the window. The resident was difficult to redirect and did not appear to be calming down and a wanderguard was applied. RN #1 was not aware the resident was in and out of other residents' rooms and was not aware the resident stated they wanted to leave and would go out the window. After the wanderguard was applied, RN #1 stated the staff went about their work. The resident was not exit seeking, was confused, and the wanderguard was to prevent them from going to stairwell or other unsafe area, because of aimless wandering. When interviewed on 6/3/21 at 12:02 PM, CNA #6 stated the resident was on their assignment on 6/1/21 and was admitted later in the afternoon. The resident had a shower, ate dinner in the dining room, and after dinner, was walking around, going into other residents' rooms. The resident tried to leave the unit and staff continued to redirect them. A wanderguard was applied. The resident's roommate rang their call bell and reported to CNA #6 the resident was trying to open their window. Maintenance staff came to the floor to secure the window. The resident said they wanted to go home. When CNA #6 left for their meal break, CNA #2, RNS #8, and a maintenance person were in the resident's room with the resident. During a telephone interview on 6/3/21 at 1:50 PM, the resident's HCP stated the resident had end stage [CONDITION(S)] and some limitations with activities of daily living. The resident was admitted for rehabilitation following a hospital stay to help build strength prior to returning home. Another family member was notified at 5:30 PM, the resident was confused and did not know why they were there, and a wanderguard was applied. The family member received another call from the facility at 7:43 PM, as the resident was confused, unsure of the reason they were there, walking around, and was not responding to directions. The family member was unable to complete the conversation due to poor cellular service. After 9:00 PM, the family was called by the facility to notify them the resident had tried to open their window and was found outside another window on the ground. At the time of the call, the resident remained in the hospital Intensive Care Unit (ICU) with a spleen and pelvic injury and a concussion. When interviewed on 6/3/21 at 3:00 PM, maintenance staff #3 stated on 6/1/2021, they were notified by Building Supervisor #4 to install longer stop strips on the windows of the resident's room. Maintenance staff #3 stated, the resident was present when they worked on the windows. The device they added to the window restricted it the window from a 6 inch opening to about 2 inches or less opening. After the resident was discovered outside, maintenance staff #3 went to the room the resident exited from and identified the window, stoppers, and screen were intact. On top of the bottom windowpane were latches that when released allowed the window to be pulled in for cleaning. The latches were broken off, which allowed the window to be pulled in or slid all the way up. During an interview on 6/3/21 at 4:05 PM, Building Supervisor #4 stated on 6/1/21, they received a call from the unit staff requesting window stoppers because the resident was messing with the window. Building supervisor #4 contacted maintenance staff #3 for the stoppers and brought a wanderguard to the room. After applying the wanderguard, building supervisor #4 stayed with the resident to see if they were going to tamper with other windows. The resident was in and out of residents' rooms, was not observed to tamper with any windows, and then sat in the lounge. The resident was confused, made comments about wanting to go home, and asked why there were so many doors. After observing the resident, building supervisor #4 felt they were okay, and they left the unit. Building supervisor #4 returned to the until shortly after 8:00 PM to check on the resident because the resident was a new admission and was agitated earlier. Building supervisor #4 stated, they did not see the resident in their room and looked for the resident. Building supervisor #4 stated, CNA #2 assisted with looking for the resident. RNS #8 and RN Manager #1 were on the unit and the building supervisor reported they could not locate the resident. Building supervisor #4 stated, RNS #8 and RN Manager #1 got up to look for Resident #1, then the building supervisor received a call from social worker #17 who stated they were outside with the resident who may have gone out the window. During an interview on 6/3/21 at 7:27 PM, CNA #5 stated, on 6/1/2 the resident was adamant about leaving since their arrival on the unit at 4:00PM. At first staff thought the resident could not walk but after physical therapy assessed the resident, a walker was provided, and the resident was mobile on the unit. The resident sat in the wheelchair during dinner and at some point, got themselves dressed and was walking around saying they wanted to go home. The resident continued to walk toward the unit doors and was redirected multiple times. CNA #5 stated the resident was confused and continued to state they wanted to go home. CNA #5 responded to the resident's roommate's call bell and the roommate said Resident #1 asked the roommate to open the window or how to open the window. CNA #5 said they along with Resident #1 were present when maintenance arrived to place the additional window stoppers on the resident's window. The resident continued to walk around, was in and out of rooms and needed redirecting. The resident was not observed to remain in any of the rooms, rather they wound enter, look, and go elsewhere. When redirected, the resident said things like I want to go home or how do I get out of here. CNA #5 stated, they were not told the resident made any comments about wanting to leave out of a window and no one told CNA #5 to maintain supervision; CNA #5 stated, they knew from their own experience to watch for wandering residents. When interviewed on 6/3/21 at 7:47 PM, CNA #7 stated they worked the B-side (hall opposite of the resident's room) and was not made aware of the resident's wandering, exit-seeking behavior or need to be supervised. The CNA was not advised the resident stated they would go out the window to leave. During a telephone interview on 6/4/21 at 11:12 AM, RNS #8 stated on 6/1/21, they were the evening supervisor and was informed the resident was wandering. RNS #8 stated they went to see the resident in their room, the resident would not sit still, and said the resident wanted the open the window. RNS #8 stated they called for maintenance to lock the window, applied a wanderguard, and RN Manager #1 notified the family. RNS #8 stated that no staff reported to them that the resident said they wanted to leave, would go out a window, or that the resident was wandering in and out other resident rooms. RNS #8 stated, they wanted the window secured due to feeling Resident #1 might try and go out the window due to the resident's restlessness. RNS #8 was notified the resident was missing, began looking on the unit and then received the call from the building supervisor the resident was outside. RNS #8 stated, they assessed the resident outside, while lying on the grass; RNS #8 stated the second-floor window above them was open. RNS #8 stated, the resident was awake, alert, had no visible injury, was confused, unable to state what happened and complained of hip pain. RNS #8 called 911 and waited with the resident until emergency services arrived. RNS #8 stated if staff informed them of that the Resident #1 stated they wanting to leave and verbalized that they would go out a window to do so, the RNS #8 stated, they would have had staff stay with the resident and provide 1:1 supervision. During a telephone interview on 6/4/21 at 1:13 PM, LPN #9 stated they were passing medication on the unit the evening of 6/1/21. LPN #9 stated Resident #1 was anxious, tried to leave the unit, was wandering, and that they did not see the resident entering and exiting resident rooms. LPN #9 stated a CNA (unable to name) was redirecting the resident. LPN #9 stated that no one reported to them that the resident tried to open a window, made statements about wanting to get out, or to monitor the resident for wandering. LPN #9 said they did not recall seeing the resident in the hall or going into rooms while passing medications. During a telephone interview on 6/7/21 at 7:12 PM, CNA #2 stated: - On 6/1/21, they arrived for work at 7:00 PM and other staff told them Resident #1 was exit-seeking. The CNA #2 stated: - The resident was heavily exit seeking, agitated, and repeatedly stated they wanted to go home. Diversions such as snacks, activities, or walks were unsuccessful. - CNA #2 observed the resident trying to open their window and push the screen out and said they were leaving and if they could not go out a door, they would go out a window. The resident knew how to unlock the window (the standard locks) and lift the screen, which had no locks. - CNA #2 stated they were fearful the resident would try to go out their window and asked Building Supervisor #4 to come to the room and get longer stop strips in the window because the resident was trying to get out and was determined to do so. The focus was on the resident's room out of concern for overnight, when they would be in there alone. - CNA #2 stated, they made RNS #8 aware the resident was trying to get out the window and asked RNS #8 to go the resident's room to observe. - After the longer stop strips were added to the resident's window, CNA #2 thought Building Supervisor #4 was supervising the resident and CNA #2 went to provide care to other residents. The resident continued to be exit seeking and was in and out of various resident rooms. - CNA #2 stated they received no specific directives from either RNS #8 or RN Manager #1 to monitor the resident for exit-seeking or window tampering. - The Resident #1 verbalized to everyone on the floor their intentions to leave no matter what. CNA #2 was concerned because the resident knew how to lift the screen, knew how to unlock the windows, was very adamant about leaving, and very agitated. - Building Supervisor #4 returned to the unit later and came to CNA #2 stating they had done one sweep of the floor looking for the resident, who was not found. The building supervisor asked CNA #2 to assist in doing another sweep of the unit and that was when the CNA found the open window in another resident's room on the B-hall. - The window was wide open, half of it was in the track and the other half was out of the track where the safety latch would have been but was broken off. CNA #2 stated they looked outside and saw the resident on the ground with social worker #17. - CNA #2 stated while providing care to the resident in the room next to Resident #1's (around 8:00 PM), the resident stated another resident entered the room and tried to mess with the window. The CNA stated they did not report this and did not believe the resident did. - The CNA stated they believed other staff were aware Resident #1 was trying to tamper with other windows, was exit-seeking, and verbalized they were determined to leave, even if it meant through a window. During a telephone interview on 6/8/21 at 11:45 AM, social worker #16 stated they visited the resident to do the admission paperwork and assessment. The resident was confused and unable to respond to some questions accurately and the BIMS score revealed moderate cognitive impairment. For those reasons, the social worker called the resident's Health Care Proxy (HCP) to complete the admission paperwork. The social worker was not notified by any staff of concerns regarding the resident's behaviors, exit-seeking, confusion, or agitation. When the social worker left at 6:00 PM, the resident was standing near the elevator and staff were present. During a telephone interview on 6/8/21 at 12:05 PM, social worker #17 stated when they were leaving the building at approximately 8:15 PM on 6/1/21, they found the resident lying on the ground on their right side. The resident could not state their name, was not saying much, and when asked questions, replied they did not know. Social worker #17 called Building Supervisor #4 and staff arrived. Social worker #17 stated the evening of 6/1/21, prior finding the resident outside, no staff members called social worker #17 for assistance with the resident's behaviors. During a follow-up telephone interview with maintenance staff #3 on 6/8/21 at 1:02 PM, maintenance staff #3 stated they were asked by Building Supervisor #4 to add the additional stop strips and was told the resident was trying to climb out the window. Maintenance staff #3 stated they were told someone caught the resident trying to climb out and the resident was being supervised until the longer stop strips were added. When interviewed on 6/9/21 at 12:55 PM, The Director of Nursing (DON) stated: - RN Manager #1 and RNS #8 called and reported when Resident #1 was found outside. - When CNA #2 reported in their statement the resident was trying to get out the window, the DON asked other staff and no one else reported the same. CNA #2 stated the resident verbalized it and did not attempt exiting and did not report to an RN or other staff and should have reported it. - The DON was not aware of the reasons for further restricting the resident's window from opening as all the windows could only open 6 inches and residents could have open windows if desired. RN Manager #1 and RNS #8 reported to the DON the resident was fidgeting with the window. - Other windows on the unit were not addressed due to the staff looking at the least restrictive interventions first and they had no opportunity to assess for further interventions due to how quickly everything happened. - The facility had a 1:1 supervision policy that typically was initiated for resident to resident behaviors or suicidal ideation or risk. The situation with Resident #1 was not a threat or expressed statement to do something that could result in self-harm due to the fact they were not aware of any plan the resident had in place. If a resident exhibited or verbalized unsafe behaviors or plans, the DON expected staff to report to an RN to assess and gather more information such as plan or ability to execute. - The DON was not able to state what should have been in place due to it was unknown at the time the resident made statements they intended to leave or attempted to get out their window. - The DON was not aware of any other staff who were aware of the resident's exit-seeking, expressed desire to leave, even if out of a window, or an attempt to go out a window. When interviewed on 6/9/21 at 6:20 PM, the Medical Director (who was also the attending physician) stated they had not heard anything from the facility about the resident until 6/2/21. The physician signed off on the wanderguard on 6/2/21 and was not notified of any behavioral concerns on 6/1/21. The physician was not able to state if any additional actions should have been taken on 6/1/21 after the resident began exhibiting exit-seeking behaviors as they were unaware of the context. ____________________________________________________________________________________ Immediate Jeopardy was identified, and the facility Administrator was notified on 6/3/21 at 6:51 PM. Immediate Jeopardy was removed on 6/3/21 at 9:33 PM, prior to survey exit based on the following corrective actions taken: - Resident #1 was no longer in the facility. - The facility identified 45 residents at risk for wandering or elopement, including 40 residents on the secured dementia unit. The residents will be assessed for acute change in behavior or cognition while verbalizing intent to leave the facility. - The Acute Elopement Risk Tool was created to identify a high risk of elopement and follow steps as identified, including providing 1:1 supervision when intent and a verbalized plan to leave the facility were identified, and a call to 911. - The facility updated the Elopement policy to include utilization of the Acute Elopement Risk Tool. - All staff on duty 6/3/21 were educated about the elopement policy updates. 10 NYCRR 415.12(h)(1)(2)

Based on record review and interview conducted during the extended recertification and abbreviated (#NY 160, NY 104, and NY 342) surveys, it was determined the facility failed to effectively assess and protect 7 of 32 residents (Residents #11, 12, 20, 22, 26, 27, and 28), in the expanded sample, from residents exhibiting inappropriate sexual behaviors, sexual contact, and physical aggression. Specifically, Residents #11, 12, 20, 22, 26, 27, and 28 were subjected to inappropriate aggressive and sexually abusive behaviors from Residents #10 and 19, and the facility failed to develop or implement strategic interventions to protect them from victimization by other residents. This resulted in the potential for serious harm that was immediate jeopardy to the health and safety of the residents on Units 1 and 3. The Immediate Jeopardy was removed prior to the survey exit on 4/13/2016. Findings include: 1) Resident #20 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 9/24/2015 documented the resident was at high risk for elopement related to dementia and poor judgement. The goal included the resident would remain safe and secure within the facility unless accompanied by staff/other authorized person. Interventions included if the resident was wandering in a potentially unsafe area or situation, redirect to a safer area, leave her safe, and reassess regularly. The resident may be affectionate towards staff and peer residents, as evidenced by hugging and giving words of kindness. Interventions included to monitor for inappropriate behaviors and intervene and redirect as able. An accident/incident report dated 1/2/2016 documented a registered nurse (RN) was called to the unit to assess (male) Resident #10 who was exhibiting inappropriate sexual behaviors toward a female resident (Resident #20) on the unit. One of the statements obtained from facility staff in the facility's investigation included licensed practical nurse (LPN) #22's documentation that at approximately 11:10 AM (on 1/2/2016), she entered Resident #20's room and observed Resident #10 standing in front of Resident #20's bed, with his sweatpants down and pushing her head toward his body, with his genitals in her mouth. After LPN #22 stopped Resident #10's behavior, she turned and asked Resident #20 if she was okay. Resident #20 continued to say she was at the dentist's office, opened her mouth and said 'see'. A nursing note date 1/4/2016 at 3:40 PM documented the resident was involved in inappropriate sexual activity on 1/2/2016 and could not verbalize the events. The resident was assessed by a registered nurse and there was no evidence of injury or negative physiological effect from the incident. A social work (SW) progress note dated 1/4/2016 at 5:58 PM documented the SW was aware the resident was involved with sexually inappropriate touching/behavior by a peer resident. The resident had no recall of the event. The resident continued to wander the unit and approach peer residents to chat or give words of kindness to them. The SW would observe for changes in the resident's mood and behaviors related to the incident and would remain available. Pertinent to this event, the Director of Social Services was interviewed on 4/8/2016 at 9:41 AM. She stated she recalled the incident on 1/2/2016 when (male) Resident #20's (inappropriate sexual behaviors) affected a couple of other ladies that same day. When the behaviors occurred, for example when the resident exposed himself in front of the female residents, the female resident(s) were observed for changes in mood. A SW progress note date 1/5/2016 at 9:03 PM documented the SW met with the unit's Nurse Manager, the Director of Nursing (DON), and the resident's family, regarding care concerns for the resident. The note specified care concerns were addressed, the plan of care was discussed, and the family was in agreement with the plan. The note did not document the details of the plan to prevent future victimization. A nurse practitioner (NP) progress note dated 1/5/2016 documented the resident's weight was down a few pounds, with a decrease in intake and refusal of meals at times. The resident was involved in a resident-to-resident contact with no injuries; there was no documentation of the details of the contact. The resident had compulsive behavior and poor judgement. Treatment plans included requirement of a secured unit for wandering and significant dementia. On 1/6/2016, the CCP was updated with a SW note date 1/4/2016 that documented the SW was aware the resident was involved with sexually inappropriate touching/behavior by a peer resident. There was no documentation the CCP was revised to reflect the resident's potential for victimization or potential to victimize other residents. An accident/incident report dated 1/23/2016 documented the resident approached a male resident, who touched her breast. The residents were separated, redirected, and were seen by an RN. There was no documentation in the nursing progress notes documenting the resident-to-resident contact. A nursing progress note dated 2/1/2016 at 2:41 PM documented the resident was noted to be going in and out of residents' rooms, and was redirected successfully. A nursing progress note date 3/14/2016 at 9:04 PM documented the resident was physically struck by another resident, without injury. An accident/incident report date 3/21/2016 at 9:30 AM documented the resident was found by a certified nurse aide (CNA) in the room of a male resident. The male resident was lying in bed with a sheet over him, soiled brief and jeans were on the floor, and this female resident was sitting on the edge of the bed, with her hand on the male resident. The residents were separated immediately and redirected. There were no nursing notes that documented the resident-to-resident contact. A nursing progress note date 3/21/2016 at 10:16 AM documented the resident wandered the unit during the 11 PM - 7 AM shift, unable to sleep. The resident was redirected a lot of the night by the night staff, having seen her come in and out of two separate rooms. Staff attempted to redirect the resident. A NP progress note date 3/21/2016 at 11:11 AM documented staff reported an increase in the resident's behaviors. The resident had compulsive behavior, increased activity, mood swings, pacing, poor insight, and poor judgement. Treatment plans included to provide routine care and a safe environment; wandering with significant dementia required a secure unit; and labs were to be obtained to rule out reasons for an increase in behaviors. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, had behavioral symptoms not directed toward others for 1-3 days in a 7 day period, and wandered daily. The resident was independent with walking, required supervision with transfers, and limited assistance with bed mobility. The resident had limited ability in expressing ideas and wants and could respond adequately to simple, direct communication only. 2) Resident #12 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 5/4/2015 documented the resident had behavioral problems related to dementia. Goals included the resident would remain safe as she wandered the secure unit. Interventions included placement on a secured unit to allow for safety when wandering/exit seeking. The CCP updated 5/19/2015 documented the resident would continue to remain safe and secure within the facility unless accompanied by staff/other authorized persons. Interventions included if the resident was wandering in a potentially unsafe area or situation, staff were to redirect her to a safer area, leave her safe, and reassess regularly. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive deficits, had physical and verbal behavioral symptoms directed toward others for 1-3 days in a 7 day period, had other behavioral symptoms not directed toward others for 1-3 days in a 7 day period, and wandered daily. The resident required extensive assistance with most activities of daily living (ADLs), required supervision for locomotion on the unit, and was documented not to walk. An accident/incident report date 3/27/2016 at 11:15 AM and a nursing progress note dated 3/27/2016 at 3:55 PM documented the resident was observed by a certified nurse aide (CNA) to be in the lounge with (male) Resident #19 touching her breast on the outside of her shirt. Corrective actions taken included removal of Resident #19 from the area and an assessment by a registered nurse (RN). Measures to prevent recurrence included to continue with current safety measures, activities, and redirect as able. Interventions were in place for the peer resident. The report specified no new interventions were needed for this female resident (Resident #12). A nursing progress noted dated 3/27/2016 at 7:59 PM documented the resident's family member was called regarding the earlier incident. Nursing was to continue with ongoing monitoring and follow up with the family member the following day. There was no nursing documentation between 3/27/2016 and 4/7/2016 that there had been follow up with the family member. A note added to the CCP dated 3/28/2016 documented the resident was involved in an incident with inappropriate contact with Resident #19. There were no negative psychosocial issues and the resident had no recall of the event. The SW spoke with the resident and the resident's answers were not appropriate to the questions being asked; the resident did not appear to be affected by the incident. There was no documentation that a plan was in place of preventative measures to avoid further victimization. During an interview between the surveyor and the resident's family member on 4/8/2016 at 9:10 AM, the family member stated she was aware of the incident on 3/27/2016, but did not receive specific information. She stated the resident's room was located in a back corner of the unit and staff did not go there often. She stated other residents were in and out of the room regularly. The family member said she found a male belt under the covers of her family member's (Resident #12) bed several weeks ago, and previously had found hats and shoes. She stated on one occasion, a male resident entered the room while she was present and caressed the resident's face; the family member asked the male resident to leave. The male resident hit the family member on the arm and made her uncomfortable. She stated she reported the incident to the nursing supervisor. She had asked that the resident be moved. She stated she was offered a room on another unit, but declined, as it was also located at the end of the hall. She stated she did not feel her family member was safe. The family member stated she was told she could have a companion for the resident, but the cost would have to be covered by the resident. 3) Resident #26 had a [DIAGNOSES REDACTED]. An accident/incident report dated 1/2/2016 documented a registered nurse (RN) was called to the unit to assess (male) Resident #10, who was exhibiting inappropriate sexual behaviors toward a female resident (Resident #20) on the unit. One of the statements obtained from staff in the facility's investigation included certified nurse aide (CNA) #21's documentation that at approximately 10:30 AM (on 1/2/2016), she walked toward one of the lounges and saw Resident #10 inappropriately touching Resident #26. There was no documented evidence this female resident was assessed at the time, after she was subjected to Resident #10's sexually abusive behavior. A nursing progress note dated 1/4/2016 at 6:07 PM documented this resident witnessed inappropriate sexual activity of another resident on 1/2/2016. When interviewed, the resident could not verbalize the event. The resident had no evidence of injury or negative physiological effect from the incident. A social work (SW) progress note dated 1/4/2016 at 5:54 PM documented the SW was aware the resident was involved in an incident with sexually inappropriate touching by Resident #10. The resident appeared to have no recall of the incident and could only provide nonsensical comments. The SW planned to observe for changes in the resident ' s mood and behaviors related to the incident. There was no documentation whether measures were put into place to prevent further incidents. A nurse practitioner (NP) progress noted dated 1/12/2016 at 1:44 PM documented the resident's notes were reviewed. The NP documented the resident had poor judgement and became weepy during the NP visit. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment. The resident had physical behavioral symptoms directed toward others for 1-3 days of a 7 day period, and other behavioral symptoms not directed toward others for 1-3 days of a 7 day period. The resident required extensive assistance with transfers, dressing and personal hygiene, and supervision with location. The resident did not ambulate. The comprehensive care plan (CCP) revised on 2/13/2016 documented the resident had behaviors related to dementia, episodic mood disorder, and anxiety. The resident wandered the unit in her scoot chair, exploring her environment daily. The resident often demonstrated poor awareness and could become agitated when redirected. Goals included the resident would remain safe as she wandered the secured unit. Interventions include to monitor for inappropriate behaviors and intervene, redirect as able, monitor mood, behavior and cognition; and redirect away from exit doors and other's rooms. An accident/incident report dated 3/27/2016 documented the resident was observed with Resident #19 in the hallway and he had his hand under her shirt. There was no injury and no evidence of abuse or neglect. Measures to prevent recurrence included to continue current safety measures, activities, and redirect as able. There were no new interventions documented to be needed for resident #26. A nursing progress note dated 3/27/2016 documented a CNA observed the resident in the hall with the hand of Resident #19 under her shirt. Resident #19 was immediately removed from the area and taken to his room. The resident was assessed by an RN and no injuries were noted. The plan was to continue with current safety measures. There was no documentation what the current safety plan entailed. No new interventions were documented to be needed for the resident. A SW progress note dated 3/28/2016 at 5:03 PM documented the SW was aware the resident was involved in an incident with inappropriate contact by Resident #19. The resident had no recall of the incident and did not appear to have been affected by it. The SW planned to observe for changes in the resident's mood and behaviors related to the incident. There was no documentation that measures were put into place to prevent occurrence of future incidents. The Immediate Jeopardy situation was removed prior to survey exit of 4/13/2016 based on the following corrective actions taken. The facility: - Developed a 1:1 monitoring plan for Residents #10 and 19 to prevent their accessibility to vulnerable residents and to protect these residents from the abusive behaviors of Residents #10 and 19; - Developed a policy and procedure to define 1:1 monitoring of residents; - Developed and implemented a staff training program for the new 1:1 monitoring policy, educating the majority of staff responsible for providing this monitoring; - Assessed the risk levels of Residents #10 and 19 for aggressive, abusive, sexually inappropriate behaviors; - Developed individualized care plan interventions for staff to implement when residents begin exhibiting these behaviors. 10NYCRR 415.4(b)(1)(i)

Based on record review, observation, and interview conducted during the extended recertification and abbreviated (#NY 160 and NY 342) surveys, it was determined, for 2 of 2 sampled residents (Residents #10 and 19) identified with a history of aggressive and sexually abusive behaviors, the facility failed to identify triggers leading to their abusive behaviors; and failed to effectively manage their behaviors when they continued to be aggressive and sexually abusive to other residents. Specifically, the facility failed to manage the aggressive, sexually abusive and inappropriate behaviors of Residents #10 and 19. When Resident #10 was documented multiple times to benefit from the use of a small dose of antipsychotic medication, the facility discontinued the medication without providing successful alternative treatments to effectively prevent and/or manage his aggressive and sexually abusive behaviors towards other residents and their family members. For Resident #19, the facility failed to effectively manage his behaviors when he continued to exhibit sexually abusive behaviors towards other residents. This resulted in the potential for serious harm that was immediate jeopardy to the health and safety of the 40 residents on Units 1 and 3. The Immediate Jeopardy was removed prior to the survey exit on 4/13/2016. Findings include: 1) Resident #10 was admitted with [DIAGNOSES REDACTED]. The resident's initial care plan dated 10/3/2014 for behavior problems, documented to notify nursing if the resident was agitated. One of the interventions was that the behavior team would see the resident during monthly rounds. The resident was moved to the secured unit (Unit 1) on 10/6/2014. Review of the resident's medical record from 8/10/2015 through 12/30/2015, including interdisciplinary progress notes from nursing, the behavior team, the nurse practitioner (NP) and the attending physician, revealed the resident had a history of [REDACTED]. A NP progress note dated 10/7/2015 documented a gradual dose reduction (GDR) of [MEDICATION NAME] (antipsychotic) failed, as the resident had agitation and aggressive behaviors putting himself and others at risk and the current benefit of the medication outweighed the risk to quality of life. An NP's progress note dated 11/9/2015 documented the resident had occasional periods of agitation. The resident remained on the [MEDICATION NAME] as a result of his agitation and aggressive behaviors putting himself and others at risk. A social work progress note dated 11/12/2015 documented the physician decreased the resident's [MEDICATION NAME]. An NP's progress note dated 12/4/2015 documented the resident was anxious, agitated, delusional, fearful, and had increased activity, mood swings, poor insight, poor judgement, and poor safety awareness with periods of agitation. The NP documented the resident's [MEDICATION NAME] was recently decreased in an attempt to be compliant with the required GDR. The resident was documented as more agitated, restless, and anxious on the decreased dose. The plan was to continue to monitor the resident and if the behaviors continued, the [MEDICATION NAME] would be increased back to the previous dosage. On 12/15/2015, a nursing progress note documented the resident got up from lying down and threw a walker and lap tray table across the room. The note did not document if other residents were in the area at the time. On 12/19/2015, the physician documented the resident remained agitated, irritable, and physically aggressive toward property and also other residents. The physician documented the residents medications were reviewed and the resident was to stay on the small dose of [MEDICATION NAME] from which he has really benefited. A nursing progress note dated 12/27/2015 documented the resident was very aggressive prior to the evening meal and was throwing anything in his reach. The resident was directed away from other residents for safety. Staff provided 1:1 supervision and the resident began calming down approximately 2 hours later. On 12/27/2015, a nursing progress note documented the resident was given [MEDICATION NAME] (antipsychotic) at 7:00 PM due to behavior issues. On 12/30/2015, nursing staff documented the resident hit a staff member and was yelling help for approximately 20 minutes. Other residents were removed from the area. An accident/incident report, dated 1/2/2016, documented the registered nurse (RN) was called to the unit to assess the resident who exhibited inappropriate sexual behaviors toward a female resident on the unit. The report also documented the resident was heard to verbalize and act inappropriately toward female staff, visitors, and residents on the unit. The accident/incident report documented the reason for the incident was lack of supervision. After the incident, the report documented the resident was redirected with only momentary success. The plan was to provide frequent monitoring, observation and supervision by staff at all times. Statements obtained from staff as part of the investigation and dated 1/2/2016 were documented on the accident/incident report. These statements included: - CNA #23 documented that prior to breakfast in the dining room on 1/2/2016, she found Resident #10 inappropriately touching a female resident. - Certified nurse aide (CNA) #21 documented that at approximately 10:30 AM on 1/2/2016, she walked towards one of the lounges and saw Resident #10 inappropriately touching a different female resident. - LPN #24 documented that at approximately 11:00 AM on 1/2/2016 she saw Resident #10 exposing himself while standing next to male Resident #19 and another female resident; the resident was located in front of a different female resident's room. - Licensed practical nurse (LPN) #22's documentation that at approximately 11:10 AM on 1/2/2016, she entered a female resident room to obtain her roommate's blood pressure. LPN #22 documented she then observed Resident #10 pushing the female resident to have oral contact with his genitals. On 1/2/2016, the Director of Nursing progress notes documented the resident exhibited increased agitation, was wandering in and around rooms and was seen by staff in a female resident's room briefly touching a female. The note documented staff reported an incident of inappropriately touching another female resident in the lounge area, and upon further investigation, the resident was observed holding the hand of a female resident in an inappropriate place on his body. The resident required frequent monitoring and to be in sight of staff. The NP was made aware; orders were received to double the daily dosage of [MEDICATION NAME], dip urine and send for culture if positive, do blood work (complete blood count and basic metabolic profile), and monitor temperature every shift for 3 days. Staff were to continue close supervision of the resident. The resident's Medication Administration Record [REDACTED]. The NP documented on 1/4/2016 at 12:50 PM the resident's [MEDICATION NAME] was had to be increased as he was aggressive toward other residents and staff, putting himself and others at risk. He was not redirectable by non-pharmacologic interventions. The Minimum Data Set (MDS) assessment dated [DATE] (updated with no changes on 3/11/2016) documented the resident had severe cognitive impairment, was delusional, exhibited verbal and physical behavior symptoms directed toward others and rejected care. The resident was independent in transfers and ambulation and wandered on a daily basis. On 1/23/2016, the physician documented the resident had a lot of aggression in terms of hypersexuality. The resident was started on hormone therapy and the [MEDICATION NAME] was being gradually discontinued. The resident's MAR indicated [REDACTED]. On 12 different days from 1/3/2016 to 1/29/2016, nursing progress notes continued to document the resident exhibited inappropriate sexual and aggressive behaviors, with 1:1 supervision provided. The resident's MAR indicated [REDACTED]. The [MEDICATION NAME] was discontinued on 2/6/2016. In February 2016, 14 different days from 2/1/2016 to 2/27/2016, nursing documented the resident exhibited increased agitation and anger, wandered into other residents' rooms, and exhibited sexually inappropriate behavior toward the LPN and female residents on the 11 PM to 7 AM shift. On 2/5/2016, the NP documented she spoke with the resident's daughter and health care proxy who stated she did not understand why the resident had a room surrounded by women, and why he couldn't have a room near other men. There was no documented evidence the resident's room was changed in 2/2016 or 3/2016. Accident/incident reports, nursing notes and the resident's CCP, from 2/27/2016 to 3/28/2016, documented the resident continued with aggressive, sexually abusive and sexually inappropriate behaviors on at least 10 occasions throughout this 30 day period. These behaviors included when the resident grabbed a female staff member inappropriately in a forceful manner on the 11 PM to 7 AM shift on 2/28/2016. The LPN documented the resident was 1:1 multiple times during the night, but it was difficult to accomplish with the staffing on the unit during the shift. On 3/4/2016, nursing documented the resident was throwing objects and attempted to destroy property. Staff assistance 1:1 was provided at times. When Unit Manager licensed practical nurse (LPN) #13 was interviewed on 4/8/2016 at 8:55 AM regarding the resident's plan for supervision, she stated once the resident's medication regime stabilized, including the use of the hormone therapy, the team decided he no longer needed to be on close 1:1. When the surveyor tried to determine the specific date this change in the resident's level of supervision occurred on 4/8/2016 at 11:07 AM, LPN #13 stated the resident came off 1:1 supervision on 3/2/2016. An accident/incident reports dated 3/7/2016, documented that at 7 PM, the resident was overturning chairs in the sensory room during a period of anxiety and agitation. When the resident walked out of the room, he had removed some of his clothing and had a skin tear on his elbow. The section: Accident Reason was other. There was no documented clarification for other when the reason for the incident occurred. On 3/11/2016 at 4:18 PM, nursing documented the resident was noted to be sexually inappropriate at times this shift and was redirected. The accident/incident report dated 3/11/2016 at 7:50 PM (estimated), documented a staff member was near the sensory room and overheard the resident yelling just shut your mouth and don't talk. The staff member observed the resident holding his genitals close to a female resident's face. The staff member intervened and the resident tried to re-dress himself. During an interview with LPN Manager #13 on 4/8/2016 at 8:55 AM, she stated she was aware there were video cameras on the unit. She said she did not think she watched video of an incident involving Resident #10, but did think maybe the video was reviewed in the past. She said the resident was on 1:1 earlier in the year, and as of March 2016, the resident was on 1:1 as necessary. She said if female residents were in Resident #10's area, staff were to watch him. If the resident went into the sensory room, somebody was supposed to follow him into the room as a result of the incident that occurred in the sensory room in March 2016. There was no documented evidence the interdisciplinary team obtained a psychiatric or psychological consultation for the resident to assist in the management of this resident who was described as delusional in the MDS assessments of 1/15/2016 and 3/11/2016. A nursing progress note dated 3/13/2016 documented the resident had episodes of sexually inappropriate behaviors this shift. The CCP, updated on 3/15/2016, documented the resident was making sexually inappropriate comments or gestures, and may attempt to grab others and/or touch others inappropriately in passing. A nursing progress note on 3/15/2016 documented the resident had increased sexual behavior this shift, acting inappropriately toward female staff. An incident/accident report dated 3/21/2016 at 9:30 AM (estimated) documented the resident was found in a (female) resident's room by a CNA. The resident was lying in bed with a sheet over him. His soiled brief and jeans were on the floor. The female resident was fully clothed and sitting on the edge of the bed with her hand on Resident #10. The residents were immediately separated and redirected. The interventions remained to supervise the resident when among female peers and continue with current safety measures. Another accident/incident report, dated 3/28/2016 at 7:01 PM, documented the resident was on the floor after contact with peer resident. The interventions were to continue to supervise residents as able. On 4/6/2016 at 8:45 AM, the surveyor observed the resident ambulating in the hallway from the B dining room up the breezeway, with no staff observing the resident. A female resident (Resident #12) was observed in her scoot chair across from Resident #10 who was unobserved by staff. At 8:55 AM on 4/6/2016, the surveyor observed Resident #10 turn around, walk through the B dining room yelling someone help me please. I'm learning to be a police officer. The resident proceeded around the corner up the hallway toward the main dining room. Staff were seated with residents at the table in the B dining room and no one responded to the resident. The resident was observed by the surveyor at 8:56 AM coming out of the shower/bathing room, unobserved by staff. The resident continued yelling for help, stating he had been kidnapped. The housekeeper attempted to redirect him. At 9:05 AM, CNA #25 told the resident his daughter was coming later to get him, in attempt to calm the resident down. At 9:10 AM, the resident was observed alone in the breezeway, near Resident #12 again, and continued yelling help, help. On 4/8/2016 at 7:30 PM, the surveyor observed the resident wandering unsupervised into the sensory room. Five female residents were seated outside the sensory room at the time. At 7:35 PM, two female residents were observed wandering in wheelchairs and were attempting to open the door to Resident #10's room. During an interview at 11:45 AM on 4/7/2016, the consulting pharmacist stated she was on the Behavior Team and was not aware of any recent behavior problems with Resident #10. She said if there were any abusive behaviors, the team would have put him back on their behavior rounds. She said if you tell Resident #10 he was exhibiting inappropriate sexual behaviors, he apologized. She stated she thought it was the approach staff had with him, and he was usually very, very pleasant. During an interview with LPN #26 on 4/7/2016 at 4:05 PM, she stated it helped when they had regular staff on the unit who knew how to deal with Resident #10's behavior. When they saw signs of him exhibiting behaviors, the regular staff informed the charge LPN and the charge LPN assigned someone to do 1:1 with the resident. If the resident started any verbally inappropriate behavior, she said they would keep a close eye on him. During an interview with CNA #27 on 4/7/2016 at 4:10 PM, she stated Resident #10 had 1:1 all the time. She said the resident was different and said inappropriate things. The CNA said activities staff often did the 1:1 because they were right outside his room (doing programming). During an interview with the Director of Social Services on 4/8/2016 at 9:41 AM, she stated Resident #10 had various behaviors including sexual and aggressive behaviors. She said there was no pattern to the behavior. Staff were to watch the resident's body language to anticipate his behaviors. She said Resident #10 was placed on 1:1 after 1/2/2016 incident. If staff now observed the resident being inappropriate, staff provided 1:1 as needed when he was agitated, until he calmed down. 2) Resident #19 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderately impaired cognitive status. He had physical and verbal behavioral symptoms directed toward others for 3 of 7 days, and other behavioral symptoms not directed toward others for 6 of 7 days; the behavioral symptoms significantly disrupted care or the living environment. The resident wandered 6 days, but less than daily, and the wandering did not significantly intrude on the privacy or activities of others. The resident's behaviors had not changed since the prior assessment. The resident required extensive assistance of 2 people for transfers and limited assistance for locomotion and walking. Social work documented on 12/16/2015 the resident could be sexually inappropriate toward female staff and peer residents. The resident had not exhibited any change to his mood and behaviors related to recent medication changes: a gradual dose reduction of [MEDICATION NAME] (an antianxiety medication) and addition of [MEDICATION NAME] (an antidepressant), which could help with anxiety and decrease libido. He continue to be seen by the Behavior Team during monthly rounds, as needed. The comprehensive care plan (CCP) effective 1/20/2016 documented the resident could be sexually inappropriate toward female staff during care, had a history of [REDACTED]. The resident could call out for help to gain attention, and when asked what he needed, he may not articulate needs, but may make sexually inappropriate comments to female staff who came to assist him. Goals included the resident would have fewer sexually inappropriate, verbally and physically aggressive episodes. Interventions included to use a calm, reassuring manner; physician to monitor and adjust medications as needed; administer medications per physician order; monitor for inappropriate behaviors and intervene; redirect as able; observe mood, behavior, and cognition; and notify nurses if resident became agitated. A nursing progress note dated 12/14/2015 documented the resident was seen attempting to grab a female resident and was removed from the area. On 12/20/2015, nursing documented the resident continued with inappropriate behaviors with staff and residents, and was redirected several times. A nursing note dated 1/1/2016 documented the resident was combative with care, and pulled the dresser and the television onto the floor. Nursing documented the resident was transferred to the hospital on [DATE] for evaluation of elevated temperature and change in condition. He was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Thirteen nursing notes from 1/16/2016 through 3/1/2016 documented the resident was sexually inappropriate verbally and physically, and aggressively combative at times toward staff. He was agitated and wandered into other residents' rooms. He touched a female resident's shirt, squeezed staff's breasts, and grabbed, scratched, pinched, hit and kicked staff. The CCP updated on 3/1/2016 documented interventions included when the resident exhibited aggressive behaviors, provide him with a stress ball to provide redirection and relaxation. Nursing notes from 3/2/2016 and 3/4/2016 documented the resident had sexually inappropriate behaviors each day. A nursing note dated 3/9/2016 documented the resident had increased sexual behaviors, asking female staff to remove tops, and attempting to touch other female residents inappropriately. The resident was removed from the area, and received distractions with activities with good effect. A physician progress notes [REDACTED]. The resident was followed by the Behavior Team, who determined the resident preferred sweet foods, which could be an effective intervention to redirect negative behaviors and promote positive behaviors. On 3/10/2016, nursing documented the resident was observed by a CNA in a peer resident's room with his hands under her shirt while she was lying on the bed. The resident was independent with wheelchair mobility. The resident was immediately removed from the room. The plan was to continue current safety measures and engage the resident in activities as able. Therapy would be contacted for the use of a merry walker (a walker/chair combination to promote independent ambulation). A nursing note dated 3/10/2016 documented the resident was making attempts to grab female residents, and was redirected, yet resident was noted attempting to grab at them again. Progress notes documented the Interdisciplinary team met on 3/10/2016 to discuss resident's mobility and behaviors and decided to trial a merry walker for the resident. On 3/11/2016, the resident was able to use the merry walker with extensive assistance to propel and move around on unit. A physician progress notes [REDACTED]. There was no documentation on interventions to address the sexual inappropriateness. Nursing notes dated 3/12/2016 and 3/13/2016 documented the resident was grabbing at female residents and staff. Progress notes documented the Interdisciplinary team met on 3/14/2016 and agreed to discontinue use of the merry walker for the resident. Staff would continue to monitor and redirect as able. A nursing note dated 3/15/2016 documented the resident noted with sexually inappropriate behaviors multiple times; he was redirected often with poor effect. The social worker documented on 3/17/2016 that a family meeting was held, and the plan of care and goals were discussed. Behaviors and suggested interventions were discussed, and family was in agreement with current plan of care. (There was no documentation what the plan of care and goals were.) Five nursing notes from 3/18/2016 through 3/27/2016 documented the resident had sexually inappropriate verbalizations and behaviors, including attempting to grab at female staff and residents, and becoming physically aggressive with his roommate. A nursing note dated 3/27/2016 at 3:53 PM documented the resident was observed by a CNA with his hand under a peer resident's shirt. The resident was immediately removed from the area and taken to his room. The plan was to continue with current safety measures and engage the resident in activities as able. A nursing note dated 3/28/2016 documented the Interdisciplinary team met to discuss the resident's behaviors and current plan of care. The resident was referred to therapy for chair positioning and mobility on the unit. Resident was being trialed in a Broda scoot chair and was doing well. The resident would have increased one-to-one supervision. Nursing would continue to engage resident in activities as his attention span allowed. The CCP updated on 3/28/2016 documented interventions included one-to-one supervision; redirection to a quiet area, such as his room; and offer crossword puzzles, musicals, or old movies. When the resident wandered, staff were to attempt engagement in card games and snacks for redirection. Social work documented on 3/29/2016, the resident was transferred to Unit 3 to benefit from a quieter, less stimulating environment. Review of the resident's medical record from 3/29/2016 to 4/7/2016 revealed after his transfer to Unit 3, the resident's sexual, verbal, and physical abusive behaviors continued. When staff interviews were conducted on 4/7/2016 and 4/8/2016, staff were unaware of the abusive behavior that continued after 3/29/2016, as follows: - The registered nurse (RN) Unit Manager #11 was interviewed on 4/7/2016 at 4:10 PM. She stated the resident had been transferred from the secured dementia unit and had only been on her unit approximately one week. She stated there had been no incidents of the resident touching other residents or staff since he had been on the unit. She stated he had made a sexual comment to another RN, but nothing had been reported since then. - CNA #12 was interviewed on 4/7/2016 at 4:30 PM. He stated the resident had attempted to touch a staff member in the upper abdominal region during care in his room. He stated the resident was not to have female caregivers, only male, if possible. Two people provided care to him. He had never witnessed or been informed of any inappropriate behaviors toward other residents. - The Director of Social Services was interviewed on 4/8/2016 at 9:41 AM. She stated the resident had a history of [REDACTED]. Many interventions, including distractions such as crosswords or music, were put into place. One-to-one supervision had been used for a period of time. The resident had been moved to a different unit where there was less stimulation. She stated when a resident was moved, the care plan would be reviewed and the move would be monitored. She stated she was not aware of inappropriate behaviors since the resident had been moved. - The attending physician was interviewed on 4/8/2016 at 12:35 PM. He stated he was aware the resident had inappropriate sexual behaviors in the past with both residents and staff, and it was documented in the plan for behaviors. He stated the resident had been moved to a different unit and had not exhibited any sexual behaviors and was more medically stable on that unit. After the resident's transfer to Unit 3, a nursing note dated 3/29/2016 at 3:34 PM documented the resident was constantly trying to grab at staff during care, and made inappropriate verbalizations, with redirection several times not effective. On 3/30/2016, two nursing notes documented the resident was verbally and physically abusive towards staff, particularly women, making sexually inappropriate verbalizations. Two nursing notes on 3/31/2016 documented the resident wandered in other residents' rooms on multiple occasions, and was redirected to common areas for supervision. On 4/2/2016 at 10:40 AM, a nursing note documented the resident was removed twice from female residents when he made attempts to touch them; no contact was made, and the resident was removed to his room to watch TV. A nursing noted dated 4/4/2016 at 2:52 PM documented the resident was found wandering into other residents' rooms and was on one-to-one supervision the majority of the day to monitor his wandering. The CCP updated on 4/7/2016 documented interventions included Wanderguard placement on the back of the Broda chair. A physician progress notes [REDACTED]. He is also very sexually inappropriate. There was no documentation on interventions to effectively manage his sexually abusive behaviors. The Immediate Jeopardy situation was removed prior to survey exit of 4/13/2016 based on the following corrective actions taken. The facility: - Developed a 1:1 monitoring plan for Residents #10 and 19 to prevent their accessibility to vulnerable residents and to protect these residents from the abusive behaviors of Residents #10 and 19; - Developed a policy and procedure to define 1:1 monitoring of residents; - Developed and implemented a staff training program for the new 1:1 monitoring policy, educating the majority of staff responsible for providing this monitoring; - Assessed the risk levels of Residents #10 and 19 for aggressive, abusive, sexually inappropriate behaviors; - Developed individualized care plan interventions for staff to implement when residents begin exhibiting these behaviors. 10NYCRR 415.4(b)

Based on record review and interview conducted during the extended recertification and abbreviated (#NY 160, NY 104, and NY 342) surveys, it was determined the facility failed to develop and operationalize effective policies and procedures to ensure 9 of 32 residents (Residents #10, 11, 12, 19, 20, 22, 26, 27, and 28), in the expanded sample, were protected from Residents #10 and 19 with a history of aggressive and/or sexually abusive behaviors. Specifically, the facility failed to ensure policies and procedures were effectively implemented to prevent residents from the aggressive, sexually abusive, and sexually inappropriate behaviors of other residents. The facility failed to ensure thorough investigations of Resident #10 and 19's aggressive and sexually abusive behavior incidents were completed and reviewed to identify trends and possibly prevent repeat occurrences. This resulted in the potential for serious harm that was immediate jeopardy to the health and safety of the residents on Unit 1 and Unit 3. The Immediate Jeopardy was removed prior to the survey exit on 4/13/2016. Findings include: The facility Abuse Prohibition Policy dated 10/2011 documented: - Preventative measures included: the nursing home would continuously attempt to identify, correct and intervene in situations in which abuse or neglect were likely to occur. All clinical staff involved in the assessment and care planning of residents would closely monitor residents with needs and behaviors, which may lead to conflict or neglect. - The investigative measures included the nursing home would not permit residents to be subjected to abuse by anyone, including other residents, and all reports of mistreatment, neglect of abuse of residents would be thoroughly investigated. - The internal investigative process documented the Administrator, the Director of Nursing (DON) and the Director of Social Services would review the evidence of an investigation and determine if the case was reportable to the NYSDOH. The Abuse Prohibition Policy, dated 10/2011, did not address the involvement of the Medical Director in the development and review of policies and procedures for abuse/neglect/mistreatment, and did not address the Medical Director's review of potential abuse/neglect/mistreatment investigations. An undated policy for Behavioral Rounds, provided on 4/7/2016, documented the behavior committee included the registered nurse (RN) Manager, social worker, Consulting pharmacist, Activity Leader, licensed practical nurse (LPN) and certified nurse aide (CNA) as needed. The notes from the monthly walking rounds would be documented in the electronic medical record. RN Managers were to contact a member of the behavior team to provide a list of residents to be reviewed, to include residents with challenging behaviors that had not had successful outcomes and continued to be difficult to manage. There were no medical staff, including no psychiatric or psychological consultants as part of the behavior team to assist with the management of residents with aggressive, sexually, physically and verbally abusive behaviors. 1) Resident #10 had [DIAGNOSES REDACTED]. An accident/incident report dated 1/2/2016 documented the resident had behaviors that were sexually inappropriate toward female residents on the unit. There was no documented evidence the incident was reviewed by the Administrator or the Medical Director. The comprehensive care plan (CCP), updated 1/4/2016, documented the resident would have 1:1 supervision at all times. On 1/23/2016, the resident's CCP was updated when the intervention was added that if the resident was observed with his hand on the front of his pants in the region of his genitals, staff were to provide 1:1 supervision, as this appears to be precursor to sexually inappropriate behavior. This intervention for 1:1 supervision as needed, was in conflict with the still-current intervention of 1:1 constant supervision, which was renewed on 1/23/2016, 3/2/2016 and 3/8/2016. Nursing notes dated 2/27/2016 on the 11 PM to 7 AM shift documented the resident was on 1:1 multiple times during the night, and it was difficult to accomplish with the staffing on the unit during the shift. On 3/4/2016, nursing documented the resident was throwing objects and attempted to destroy property. Staff assistance 1:1 was provided at times. This conflicted with the resident's CCP, dated 3/8/2016, that documented the resident's behavioral interventions included 1:1 constant supervision. There was no documentation in the resident's record when constant 1:1 supervision was changed to as needed. An accident/incident report dated 3/11/2016 documented a staff member overheard the resident yelling, and when she responded, the resident was observed standing next to another resident while exposing himself near the female resident's face, yelling just shut your mouth and don't talk. The investigation was documented to be closed. There was no documented evidence the incident was reviewed by the Administrator or the Medical Director. An accident/incident report dated 3/21/2016 documented the resident was in another resident's room lying in bed with a sheet over him; soiled brief and jeans were on the floor. The peer resident was sitting on the edge of the bed with her hand on the male resident. There was no documented evidence the incident was reviewed by the Administrator or the Medical Director. The investigation was documented to be closed. During an interview with licensed practical nurse (LPN) #26 on 4/7/2016 at 4:05 PM, she stated it helped when they had regular staff o the unit who knew how to deal with Resident #10's behavior. She stated if the resident started any verbally inappropriate behavior, they would keep an eye on him. When policies were requested on 4/7 and 4/8/2016, no policy was provided that addressed the different levels of resident supervision used at the facility. There was no documented policy to guide staff on how to comply with the various terms used in resident care plans for providing different levels of supervision, including: constant 1:1 supervision; 1:1 at times; 1:1 as needed; 1:1 support; close 1:1, and keep an eye on. During an interview with both the Administrator and DON on 4/8/2016 at 12:15 PM, the Administrator stated she was not aware Resident #10 was involved in another incident after 3/2/2016, when his 1:1 supervision was changed from continuous to an as-needed basis. She stated she was not notified of all incidents, only if there was a potential that abuse, neglect or mistreatment occurred. This conflicted with the facility's Abuse Prohibition Policy that documented the Administrator, the Director of Nursing (DON) and the Director of Social Services would review the evidence of an investigation and determine if the case was reportable to the NYSDOH. During a telephone interview with the Medical Director on 4/8/2016 at 12:20 PM, he stated he was not aware of any issues regarding Resident #10's sexual behaviors. There was no documented evidence Resident #10 incidents of aggressive, sexually abusive and sexually inappropriate behavior, including those dated 1/2/2016, 3/11/2016 and 3/21/2016, were reviewed by the Administrator or the Medical Director to determine if revisions were necessary in the facility's Abuse Prohibition Policy, the Behavioral Rounds policy, or other resident care policies to prevent recurrence of, and to protect residents from, the aggressive, abusive behaviors of other residents. 2) Resident #20 had [DIAGNOSES REDACTED]. A nursing progress note dated 1/4/2016 at 3:40 PM documented the resident was involved in inappropriate sexual activity on 1/2/2016; the resident could not verbalize the events. The note specified the resident was assessed by a registered nurse (RN), with no evidence of injury or negative physiological effect for this resident observed. There were no other nursing progress notes documented between 12/31/2015 and 1/4/2016. There was no documentation the incident was investigated to rule abuse and/or neglect. An accident/incident report dated 3/21/2016 at 9:30 AM completed for Resident #10 documented Resident #20 was found by a certified nurse aide in a room with a male resident (Resident #10). The male resident was lying in bed with a sheet over him, soiled brief and jeans were on the floor, and Resident #20 was sitting on the edge of the bed with her hand on the male resident. The residents were separated immediately and redirected. There was no documentation in the resident's progress notes documenting the resident-to-resident contact. There was no documented evidence an investigation was completed for the resident to ensure she would be protected from Resident #10's sexually abusive behaviors. 3) Resident #19 had [DIAGNOSES REDACTED]. An accident/incident report dated 3/10/2016 documented the resident wheeled himself into another resident's room and was observed with his hand underneath the resident's shirt. When the Medical Director was interviewed by telephone phone on 4/8/2016 at 12:15 PM, he stated he did not oversee the care of Resident #19 and was not aware of any issues regarding Resident #19's sexual behaviors. The Medical Director stated the resident's attending physician would be able to discuss the resident more specifically. During an interview on 4/12/2016 at 8:35 AM, the DON stated she reviewed and signed off all incidents and accidents. She would review with the Administrator any incidents where there was potential for abuse and/or neglect and she would be responsible for notifying NYSDOH. The DON stated she would close out the investigation when all of the information was available, including staff and resident interviews, nursing assessments, and root cause analysis. The Immediate Jeopardy situation was removed prior to survey exit of 4/13/2016 based on the following corrective actions taken. The facility: - Developed a 1:1 monitoring plan for Residents #10 and 19 to prevent their accessibility to vulnerable residents and to protect these residents from the abusive behaviors of Residents #10 and 19; - Developed a policy and procedure to define 1:1 monitoring of residents; - Developed and implemented a staff training program for the new 1:1 monitoring policy, educating the majority of staff responsible for providing this monitoring; - Assessed the risk levels of Residents #10 and 19 for aggressive, abusive, sexually inappropriate behaviors; - Developed individualized care plan interventions for staff to implement when residents begin exhibiting these behaviors. 10NYCRR 415.4(b)

Based on interview and record review conducted during the extended recertification and abbreviated (#NY 160, NY 104, and NY 342) surveys, it was determined the facility did not ensure Administrative staff functioned in a manner that utilized its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of the 38 residents residing on Units 1 and 3. Specifically, the Administration failed to ensure staff recognized and reported Resident #10 and 19's repeated aggressive and sexually abusive behaviors towards 7 of 32 residents (Residents #11, 12, 20, 22, 26, 27 and 28), in the expanded sample, residing on their units. In addition, Administration failed to ensure these 7 residents were protected from Residents #10 and 19's abusive behaviors through the development and implementation of effective care plan interventions. The facility's Administrative staff also failed to ensure staff were provided with clarified guidance on the various levels of supervision for residents with an extensive history of aggressive, sexually abusive behaviors. Additionally, facility administration failed to address whether sufficient staffing levels were maintained to provide adequate monitoring of Residents #10 and 19, particularly on the 11 PM to 7 AM shift. This resulted in the potential for serious harm that was immediate jeopardy to the health and safety of the residents on Unit 1 and Unit 3. The Immediate Jeopardy was removed prior to the survey exit on 4/13/2016. Findings include: Refer to F 223, F 224, and F 226. During an interview on 4/8/2016 at 9:25 AM, the Administrator stated there were two residents in the facility with sexual behaviors and the facility was trying to manage them the best they could. She stated Resident #10 was medically managed and behavior plans were in place. The resident was monitored closely when in common areas and staff kept a close eye on him so he did not gravitate toward other residents. She said since the resident was taken off 1:1 monitoring, he had only exposed himself a few times. The Administrator said she was aware of the incident with Resident #10 and a female resident with dementia that occurred in early January (1/2/2016), as the facility reported it to the health department. She said she and the Director of Nursing (DON) reviewed the visual footage (video recording) of the incident. She stated she was not aware of Resident #10 exhibiting inappropriate sexual behavior toward other residents on that same day. During an interview with LPN Manager #13 on 4/8/2016 at 8:55 AM, she stated she was aware there were video cameras on the unit. She said she did not think she watched video of an incident involving Resident #10, but did think maybe the video was reviewed in the past. On 1/23/2016, Resident #10's comprehensive care plan (CCP) was updated when the intervention was added that if the resident was observed with his hand on the front of his pants in the region of his genitals, staff were to provide 1:1 supervision, as this appears to be precursor to sexually inappropriate behavior. This intervention for 1:1 supervision as needed, was in conflict with the still-current intervention of 1:1 constant supervision, which was renewed on 1/23/2016. On 2/1/2016, nursing notes documented Resident #10 was agitated on the 11 PM to 7 AM shift, wandering into other residents' rooms, and exhibiting sexually inappropriate behavior to female residents. There was no documented evidence/rationale how staff provided 1:1 supervision if the resident was able to wander into other residents' rooms and have sexually inappropriate behaviors. Resident #10's CCP was renewed on 3/2/2016 and 3/8/2016 and specified the resident remained on 1:1 constant supervision; yet nursing notes dated 3/5/2016 documented staff assistance was provided at times when the resident was throwing objects and attempting to destroy property. Accident/incident reports, nursing notes and the resident's CCP, from 2/27/2016 to 3/28/2016, documented the resident continued with aggressive, sexually abusive and sexually inappropriate behaviors on at least 10 occasions throughout this 30 day period. These behaviors included when the resident grabbed a female staff member inappropriately in a forceful manner on the 11 PM to 7 AM shift on 2/28/2016. The LPN documented the resident was 1:1 multiple times during the night, but it was difficult to accomplish with the staffing on the unit during the shift. During an interview with the Administrator and DON on 4/8/2016 at 12:15 PM, the Administrator stated she was not aware there were other incidents after 3/2/2016 involving Resident #10, when his 1:1 supervision was changed from continuous to on an as-needed basis. She stated she was not notified of all incidents, only if there was a potential that abuse, neglect, or mistreatment occurred. During an interview with the Medical Director on 4/8/2016 at 12:20 PM, he stated he did not oversee the care for Residents #10 or 19, and was not aware of any issues regarding sexual behaviors. During an interview with the Administrator on 4/8/2016 at 4:50 PM, she stated all incident and accident reports were initiated by the Nursing Supervisor or the Assistant Director of Nursing, and the DON reviewed all incident and accident reports on a daily basis. The Administrator stated she would only see the reports if they were reportable to NYSDOH. The Immediate Jeopardy situation was removed prior to survey exit of 4/13/2016 based on the following corrective actions taken. The facility: - Developed a 1:1 monitoring plan for Residents #10 and 19 to prevent their accessibility to vulnerable residents and to protect these residents from the abusive behaviors of Residents #10 and 19; - Developed a policy and procedure to define 1:1 monitoring of residents; - Developed and implemented a staff training program for the new 1:1 monitoring policy, educating the majority of staff responsible for providing this monitoring; - Assessed the risk levels of Residents #10 and 19 for aggressive, abusive, sexually inappropriate behaviors; - Developed individualized care plan interventions for staff to implement when residents begin exhibiting these behaviors. 10NYCRR 415.26(a)

Based on record review and interview conducted during the abbreviated survey (NY 750), it was determined the facility did not ensure 1 of 3 sampled residents (Resident #1) received the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically, the facility did not ensure Resident #1's repeated elevated fingerstick blood glucose (BG) levels and changes in status were assessed timely and communicated to the attending physician in a timely manner. This resulted in actual harm that was not immediate jeopardy for Resident #1, as he required hospitalization for septic shock secondary to UTI (urinary tract infection) and hyperosmolar non-ketotic [MEDICAL CONDITION] (metabolic complication of diabetes mellitus with high blood glucose levels and extreme dehydration). Findings include: The facility Glucose Monitoring-Insulin Policy dated 5/15/2015 documented the policy was to provide a standard protocol for the treatment of [REDACTED]. The policy documentation included the standard sliding scale for insulin coverage based on blood glucose results was as follows: - 200 or below = no units; - 201-250 = 2 units [MEDICATION NAME][MEDICATION NAME] SQ (subcutaneously); - 251-300 = 4 units [MEDICATION NAME][MEDICATION NAME] SQ; - 301-350 = 6 units [MEDICATION NAME][MEDICATION NAME] SQ; - 351-400 = 8 units [MEDICATION NAME][MEDICATION NAME] SQ; and - greater than 400 = call the physician. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Physician's orders, dated 11/18/2015, documented the resident was to receive 5 mg (milligrams) [MEDICATION NAME] (oral diabetes medication) twice a day and fingerstick BG monitoring every day at 7:30 AM. The physician's order did not include the use of a sliding scale insulin, or provide parameters when to notify the physician for certain fingerstick BG levels. The Minimum Data Set (MDS) assessment, dated 11/27/2015, documented the resident required assistance with activities of daily living (ADLs), had moderately impaired cognition, did not have a significant weight loss or gain in the previous 6 months; and had a history of [REDACTED]. The MDS assessment documented the resident usually was able to make himself understood and usually understood others. The CCP (comprehensive care plan), dated 12/9/2015, identified that the resident was at risk for [MEDICAL CONDITION] related to the diabetes diagnosis. The planned interventions included to monitor the resident's blood sugars, per physician's orders, and to monitor for the signs of [MEDICAL CONDITION], including increased thirst, frequent urination, and poor wound healing. The licensed practical nurse (LPN) progress notes, dated 12/11/2015, Resident #1 was found on the floor and it was s/p (status [REDACTED]. The registered nurse (RN) progress note, dated 12/11/2015 at 11:10 AM, documented the resident was found on the floor in the bathroom by a housekeeper. The RN documented the resident had no apparent injuries. Review of the resident's December 2015 Medication Administration Record (MAR) from 12/1/2015 to 12/12/2015 revealed the resident's BG readings at 7:30 AM ranged from 183 mg/dl to 312 mg/dl, for an average BG reading of 235 mg/dl for the first 12 days of the month. There was no documented evidence the facility policy for sliding scale insulin coverage was transcribed onto the MAR. On 12/14/2015, at 12:33 PM, an RN note documented the resident's scrotum was red and swollen; ointment was applied. At 10:39 PM, an LPN documented the resident was noted to yell out several times that shift. From 12/13/2015, December 2015 MAR documented the resident's 7:30 AM fingerstick BG reading was rising and was greater than 375 mg/dl on 12 of the remaining 18 days when fingersticks were obtained that month, including on: - 12/16/2015, when the resident's BG level was 433 mg/dl; - 12/18/2015, when the resident's BG level was 412 mg/dl; - 12/20/2015, when the resident's BG level was 410 mg/dl; - 12/22/2015, when the resident's BG level was 439 mg/dl; - 12/25/2015, when the resident's BG level was 446 mg/dl; and - 12/26/2015, was 425 mg/dl. There was no documented evidence the physician was notified of the resident's elevated BG levels. There was no documented evidence Resident #1 received sliding scale insulin and there was no documented evidence the facility policy for sliding scale insulin coverage was transcribed onto the MAR. From 12/19/2015 to 12/26/2015, nursing notes documented the resident was found yelling for help after a fall, or from rolling onto the floor mat 5 times. The resident was unable to express his needs. (No injuries were noted.) The MAR documented the resident's BG level was 382 mg/dl on 12/27/2015, at 7:30 AM. On 12/28/2015 at 7:21 AM, nursing progress notes documented the resident was administered Tylenol for a temperature of 100.0 degrees Fahrenheit (F). The note specified the resident's temperature is currently 99.5 F and nursing will continue to monitor. Review of the resident's medical record, including the December 2015 MAR revealed there was no documented evidence the resident's BG level was obtained on 12/28/2015 at 7:30 AM as ordered. When LPN #1 was interviewed on 2/25/2016 at 11:25 AM, she stated she cared for the resident on 12/28/2015. She stated she did not know why the resident's fingerstick BG reading was not documented. Nursing notes at 9:10 PM on 12/28/2015 documented the resident's temperature was 100.5 degrees F. at 3:50 PM; Tylenol and 360 cc fluids were administered. A recheck of the resident's temperature was documented to be 100.3 degrees F. After dinner, nursing documented the resident's temperature was 97.7 degrees F. On 12/29 at 7:30 AM, the MAR documented the resident's BG level was 500 mg/dl. There was no documented evidence the physician was notified, or that Resident #1 received insulin coverage. LPN #2's nursing progress note, dated 12/29/2015, documented the resident's temperature was 101.3 degrees F. at 7:30 AM; Tylenol was administered, and the resident's temperature decreased to 98.8 degrees F. The note specified the resident was calling out for help numerous times throughout the shift, but did not voice complaints when approached. LPN #2 documented the nurse manager was aware and assessed the resident. There was no documented evidence of the Nurse Manager's assessment. RN Unit Manager #4 was interviewed on 2/25/2016 at 12:15 PM. She stated she believed she notified the physician of the resident's elevated BG level on 12/29/2015. She stated she recalled this, as she notified the physician that the resident had an area on his scrotum at the same time, and his response was to apply zinc oxide to the resident's scrotum and to continue to monitor the resident's BG levels. RN #4 stated she did not inform the physician of the actual numerical value of the resident's fingerstick BG levels. There was no documented evidence in the resident's medical record of RN Unit Manager #4's communication with the physician and the presented information. The MAR, dated 12/30/2015 at 7:30 AM, documented the resident's BG level was 500 mg/dl; there was no documented evidence the physician was notified of the elevated BG reading, or that the resident received insulin coverage. LPN #2 was interviewed on 2/25/2016 at 10:55 AM and said she cared for the resident on 12/16, 12/19, 12/20, 12/22, 12/23, 12/24, 12/29, and 12/30/2015. She stated her initials were documented on the MAR for the resident's fingerstick BG levels on those dates. LPN #2 said she notified, whoever was in charge, of the resident's elevated BG reading; she did not know who she told. LPN #2 stated she did not recall if she administered insulin to the resident, or if we were only monitoring and not giving insulin. LPN #2 stated she would have written a nursing note if she was in charge, as typically the charge nurse wrote the nursing notes. LPN #2 did not recall if she was in charge on those dates At 2:04 PM on 12/30/2015, the RN documented the resident was found lying on the floor, on the pad next to his bed. The progress note documented the resident stated he wanted to lie on the floor, because it makes him feel better. The RN noted the resident said he had a headache. The RN documented the resident's incontinence brief was dry. The resident's MAR, dated 12/30/2015 (untimed) documented the resident was administered Tylenol. During an interview with LPN #1 on 2/11/2016 at 11:05 AM, she stated she was a float LPN on the resident's unit. She said the resident was a diabetic and his fingerstick BGs usually ran around 200 mg/dl. She stated she did not administer insulin to the resident. LPN #1 told the surveyor the glucometer used in the facility would read HI if the BG reading was greater than 600 mg/dl. She stated the glucometer controls were run on the 11 PM - 7 AM shift. LPN #1 stated if the BG reading was HI, it would need to be rechecked; the Supervisor or Nurse Manager would be notified, and fluids would be encouraged. LPN #1 stated the physician would be notified by the Nursing Supervisor or Nurse Manager. RN #4 was interviewed on 2/11/2016 at 11:40 AM. She stated the resident was a diabetic with behaviors. RN #4 stated when the resident was found on the floor (on 12/30/2015), she told the resident's daughter his elevated BG suggested something might be up and placed the resident on the UTI (urinary tract infection) protocol. RN #4 stated the resident did not complain of the signs or symptoms of [MEDICAL CONDITION]; the resident's only complaint was that he had a headache when he wanted to lie on the floor. RN #4 said the resident's urine was not foul smelling and he did not have an elevated temperature. She stated she notified the physician of the resident's change in condition, as he had to sign off on the UTI protocol. RN #4 stated she notified the physician of the resident's change in condition, as he had to sign off on the UTI protocol. There was no documentation in nursing notes that RN #4 called the physician or what information was given to the physician. The facility Protocol for Symptomatic Urinary Tract Infections dated 8/2011, documented its purpose was to have a simplified and uniform format for treating UTIs. The protocol documented the nurse should suspect that a resident may have a symptomatic UTI if 2, or more, of the following criteria were met: - fever, or chills; - new, or increased, incontinence; - new urgency, or hematuria; - new flank, or suprapubic, pain or tenderness; or - new onset of non-specific symptoms, (e.g., change in mental status, functional new status). The steps to be implemented when a resident displayed with signs and symptoms, as defined above, included 120 cc TID x 14 days. On 12/30/2015 at 10:27 PM, the LPN documented the resident was found on the floor mat next to his bed at 10:15 PM. No injuries were noted. The resident's temperature was documented to be 97.4 degrees F. At 1:38 AM on 12/31/2015, the RN documented at 10:00 PM (on 12/30/2015), the resident was found lying on his left side on the mat on the floor next to his bed. The RN noted the resident's brief was dry and he was assisted back to bed. The MAR documented the resident's BG level was 490 mg/dl on 12/31/2015 at 7:30 AM. There was no documented evidence the physician was notified, or that the resident received insulin coverage. A nursing progress note, dated 12/31/2015 at 11:15 PM, documented they would continue to monitor the resident. Review of the facility's 24 hour reports, dated 12/1/2015 through 1/1/2016 revealed no documentation the resident's elevated BG levels were reported to the interdisciplinary team. The MAR, dated 1/1/2016 at 7:30 AM, documented the resident's BG level was 600 mg/dl. There was no documented evidence the physician was notified, or that Resident #1 received insulin coverage. When LPN #1 was interviewed on 2/25/2016 at 11:25 AM, she stated she cared for the resident on 1/1/2016; and said those were her initials for the resident's fingerstick BG readings on the 1/1/2016 MAR. She said she would have notified the Nursing Supervisor; she was unable to recall who the Nursing Supervisor was at the time. LPN #1 stated she would have written a nursing note, unless the Supervisor said she would do the note. A physician's order, dated 1/1/2016 at 1:55 PM, documented the resident's temperatures were to be monitored each shift for 3 days, and he was to receive 120 cc (cubic centimeters) fluids of his choice, 3 times a day for 14 days. When the 1/1/2016 nursing notes were reviewed, there was no documented evidence of the time and date the physician was called, nor of any specific information conveyed regarding the resident's change in status, including the abnormally elevated blood glucose levels. During an interview with RN Unit Manager #4 on 2/11/2016 at 11:40 AM, she stated when the glucometer read HI, the process was to notify the physician and cover the resident with insulin coverage. At 3:34 PM on 1/1/2016, nursing notes documented the resident was combative with staff during care and pulled the dresser and television onto the floor of his room. The note documented the resident was on the UTI (urinary tract infection) protocol. The resident's temperature was recorded at 98.6 degrees F. and fluids were encouraged. On 1/2/2016, the MAR documented the resident's BG level was 600 mg/dl, at 7:30 AM. There was no documented evidence the physician was notified of this abnormally elevated blood glucose level, or the resident received insulin coverage. LPN #1's progress note, dated 1/2/2016 at 7:41 PM, documented the resident continued to be confused; remains on UTI protocol, and fluids were encouraged throughout the shift. The LPN documented per glucometer, the resident's BS remained HI. The Nursing Supervisor was made aware. LPN #1 documented the resident continued to complain of pain, [MEDICAL CONDITION] and drainage at his scrotal area. The resident's blood pressure was 105/71 and his temperature was 98.8 degrees F. The facility's 24-hour Report, dated 1/2/2016, documented the resident's BG levels remained HI per the glucometer and the Nursing Supervisor was made aware. LPN #7 nursing progress note, dated 1/2/2016 at 11:12 PM, documented the resident continued to call out through out the shift and was unable to express himself. This was a change from the MDS assessment, dated 11/27/2015, that documented the resident usually was able to make himself understood and usually understood others. On 1/2/2016, the resident's blood pressure during the 4 PM to 10 PM shift was documented to be 103/64 on the MAR. The RN Supervisor #5 progress note, dated 1/2/2016 at 11:25 PM, documented the resident's blood sugar was rechecked and continued to read HI. The resident was alert, at baseline, and had no signs or symptoms of [MEDICAL CONDITION]. A telephone order was taken from on-call physician #6 to administer the resident 6 units regular insulin for a one time dose and to obtain an Hgb A1C (blood test to determine the blood sugar concentration for the previous 2-3 months). A recheck of the resident's blood sugar was done that read HI; and the resident's blood sugar was tested with another glucometer. The resident's blood sugar continued to read HI. A telephone call was placed to physician #6 at 11:12 PM, with a message was left to call the RN Supervisor. RN supervisor #5 documented the resident would continue to be monitored for signs and symptoms of [MEDICAL CONDITION]. RN supervisor #5's 1/2/2016 progress note did not document the information she told the on-call physician #6 regarding the resident's change in status (recent low blood pressure, complaints of pain, recent increase in falls, and recent elevated temperatures.) When RN Supervisor #5 was interviewed on 2/24/2016 at 10:19 AM, she stated she did not recall this resident. When the surveyor read RN Supervisor #5 her own nursing note dated 1/2/2016, she stated she vaguely recalled the incident. She said she did not know, or recall, if physician #6 returned the phone call she made on 1/2/2016 at 11:12 PM. On 1/3/2016, the MAR documented the resident's BG was 600 mg/dl, at 7:30 AM. On 1/3/2016 at 8:01 AM, LPN #2 nursing progress note documented the resident was moaning out in pain; blood glucose monitoring was done, and showed a reading of HI indicating blood sugar elevated above 600. The resident was unable to swallow fluids, or crushed medications, and he let water and medications pool out of his mouth. The resident was in the wheel chair and unable to hold his body up. LPN #2 documented the nursing supervisor was made aware of the change of events in the resident's status, and a call was pending from the physician. LPN #2 was interviewed on 2/11/2016 at 11:25 AM and stated she was assigned to the resident's unit as a nurse on 1/3/3016. LPN #2 said she notified RN Supervisor #3 of the resident's HI BG reading. RN Unit Manager #4's progress note, dated 1/3/2016 at 8:41 AM, documented the resident's daughter was notified of the change in condition, and she requested the resident transfer to the hospital. The RN #4 documented the physician was made aware and and the order was obtained to send the resident to the hospital. The resident's hospital discharge summary, dated 1/14/2016, documented the resident was found to be to have septic shock secondary to UTI (urinary tract infection) and was in a hyperosmolar hyperglycemic non-ketotic state, with a blood sugar of greater than 900 when he presented to the hospital on [DATE]. During an interview with physician #6, on 2/24/2016 at 11:30 AM, he stated he was an on-call physician for the facility roughly every third day. When asked, physician #6 did not recall if he was on call on 1/2/2016 and did not recall the resident. When the surveyor read the 1/2/2016 nursing note to physician #6, he restated he did not recall the incident, or the resident. Physician #6 also stated he had no recollection of a second call at 11:12 PM on 1/2/2016. He said the facility would call him on his personal cell phone, and there was no way to check to see if he was called on 1/2/2016 at 11:15 PM. He stated he got many phone calls, and he cleared them from his phone monthly. During an interview with the physician #10 on 2/29/2016 at 12:05 PM, he stated he was the resident's attending physician in the facility. He said he did not recall being notified of the resident's elevated fingerstick BG levels on 12/16, 12/18, 12/19, 12/20, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/29, 12/30/2015, or on 1/1 or 1/2/2016. The attending physician stated he expected to be notified of the resident's elevated blood glucose levels with no insulin coverage. Additionally, physician #10 stated he did not recall placing the resident on the UTI protocol on 1/1/2016. 10NYCRR 415.12