Every finding on record at Jewish Home of Rochester

Based on interviews and record review conducted during a Recertification Survey completed on 09/25/2025, for two (2) (Resident #127 and #280) of two (2) residents reviewed, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment are reported immediately, but not later than two (2) hours after the allegation is made, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the State Survey Agency in accordance with State law through established procedures. Specifically, Resident #127 was physically aggressive toward other residents during several resident-to-resident altercations occurring from 05/17/2025 to 09/13/2025, and the incidents of physical abuse were not reported to the State Survey Agency. Resident #280, fell off a sidewalk curb, sustained a major injury (head strike resulting in a laceration and bleeding requiring hospitalization and sutures), and the facility did not report the incident to the State Survey Agency. The findings are:The facility policy Abuse Investigation dated 08/16/2025 included, but was not limited to, the New York State Health Department is notified when there is reasonable cause to believe abuse, neglect, or mistreatment has occurred. Reporting Requirements included: identify if abuse and other incidents have occurred, report abuse immediately to the administrator or designee and appropriate agency (i.e. New York State Department of Health) with immediately defined as within 24 hours after discovery of the incident. If serious bodily injury has occurred, report within two (2) hours of forming the suspicion of abuse and all other incidents must be reported within 24 hours. 1. Resident #127 had diagnoses including severe dementia with other behavioral disturbance, cognitive communication deficit (an impaired ability to communicate effectively), and aphasia (a language disorder that affects a person's ability to communicate). The Minimum Data Set (a resident assessment tool) dated 08/06/2025 documented the resident had severely impaired cognition, exhibited physical behaviors directed toward others, and their behaviors worsened since the previous assessment. Review of the Comprehensive Care Plan last revised on 09/09/2025 revealed Resident #127 had behaviors including involvement in 16 resident-to-resident incidents occurring from 05/17/2025 to 09/13/2025. For 12 of the 16 documented incidents, Resident #127 struck/slapped/hit residents in the face, head, or other body part, and pushed a resident causing them to fall. Interventions included, but were not limited to, document behaviors every shift, separate involved residents, redirect Resident #127 away from others with the assistance of two (2) staff, provide increased supervision, and to notify medical providers. Review of facility Incident/Accident Reports and investigations from 05/13/2025 to 09/24/2025 included Resident #127 was involved in 16 resident-to-resident incidents, 15 of which documented the physical aggression of Resident #127 directed toward another resident. One (1) incident, dated 07/13/2025, included Resident #127 pushed another resident, causing that resident to fall and sustain a skin tear to their right elbow. There was no documented evidence the facility had reported any of the resident-to-resident incidents to the New York State Department of Health.During an interview on 09/22/2025 at 8:59 AM, the Director of Neurobehavioral stated Resident #127 was behaviorally complicated due to being intrusive and unpredictable. Resident #127 would get into other resident's space and swat at them, but it was never with a closed fist. The Director of Neurobehavioral stated resident-to-resident altercations were investigated promptly, and the incidents were reported to the Administrator, families, and the interdisciplinary team.During an interview on 09/23/2025 at 10:33 AM, Certified Nurse Assistant #6 stated Resident #127 had a history of violence and did not like other residents in their space. They stated Resident #127 was unpredictable, did not like noise, and would get in the faces of other residents. If residents were to yell out, the yelling would agitate the Resident #127, resulting in them hitting or grabbing the other resident. Certified Nurse Assistant #6 stated Resident #127 had been involved in a significant number of resident-to-resident altercations, and it was hard to keep everyone safe.During an interview on 09/23/2025 at 10:53 AM, Behavioral Specialist #1 stated there were times when Resident #127 had hurt other residents during their episodes of physical aggression. During an interview on 09/23/2025 at 12:59 PM with the [NAME] President of Resident Services (Director of Nursing), Administrator, and Assistant Director of Nursing, the [NAME] President of Resident Services stated none of the resident-to-resident altercations had been reported to the New York State Department of Health because no one was injured, and the altercations were not sexual in nature. The Administrator stated the physical altercations were not reported to the New York State Department of Health because no care plan violations were involved.During an interview on 09/24/2025 at 9:38 AM, Licensed Practical Nurse #10 stated resident-to-resident altercations should be reported to the New York State Department of Health if there was an injury associated or if a resident had several incidents. 2. Resident #280 had diagnoses including dementia, difficulty walking, and weakness. The Minimum Data Set, dated [DATE] included the resident was cognitively intact.During an observation and interview on 09/17/2025 at 11:43 AM, Resident #280's left side of their face was bruised with a large bandage on their forehead. The resident stated they were outside, went to step off the curb, fell on their head, and went to the hospital for a couple of days. In a progress note dated 09/10/2025, Registered Nurse Supervisor #1 documented they were notified Resident #280 fell in the parking lot and a lot of blood was noted. The resident stated they felt dizzy, oxygen was applied, 911 was called, and the resident was transported to the hospital.Review of an undated Investigative Report revealed on 09/10/2025, Resident #280 was wheeled from Cottage 3 (residential unit) to an outside event and placed on the sidewalk by Recreation Therapy Assistant #1. Recreation Therapy Assistant #1 locked the right side of the resident's wheelchair and returned to the Cottage to retrieve paperwork they had dropped during the transport. As Recreation Therapy Assistant #1 turned to walk back to Cottage 3, Resident #280's wheelchair began to slowly roll off the curb. Recreation Therapy Assistant #1 and Security Guard #1 ran to the resident's side. Resident #280 had a laceration above their left eye with bruising, multiple staff responded to assist, emergency medical services (911) were called, and the resident was sent to the hospital. The investigation included Resident #280 usually self-propelled the wheelchair around their Cottage, leg rests were placed on the wheelchair to attend an event, and the left side of the wheelchair was not locked by Recreation Therapy Assistant #1 which may have contributed to the fall. Following review of the incident, Recreation Therapy Assistant #1 was counseled, and the recreation therapy team was educated on wheelchair safety. During an interview on 09/25/2025 at 8:42 AM, the Director of Nursing stated they did not report Resident #280's fall on 09/10/2025 to the State Survey Agency as they only report falls with major injuries to the health department if a care plan violation had been identified. 10 NYCRR 415.4 (b)(2)

Based on observations, interviews, and record review conducted during a Recertification Survey completed on 09/25/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (3) (Residents #10, #37, and #143) of eight (8) residents and one (1) (Unit 4 North East) of 15 residential units reviewed. Specifically, for Residents #10, #37, and #143 the facility did not appropriately implement the use of Enhanced Barrier Precautions (EBP, an infection control strategy that uses gloves and gowns during high contact resident care to reduce the spread of infection) and there were several observations where staff did not use personal protective equipment (PPE, equipment, such as gown and gloves, worn to protect individuals and reduce the risk of exposure to and spread of infections) as required for high-contact care. During observations of wound care for Resident #10 and of a staff and resident interaction on Floor 4 North East, staff did not perform hand hygiene during wound care and/or appropriately remove gloves and perform hand hygiene in between residents.The findings are:The facility policy Enhanced Barrier Precautions dated 06/24/2024 included, but was not limited to, enhanced barrier precautions expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gloves and gowns during high contact resident care activities that promote opportunities for transfer of multi-drug resistant organisms (MDRO) to staff's hands and clothing. In addition to standard precautions, gowns and gloves should be worn during the following high-contact resident care activities: wound care, providing hygiene, changing briefs/assisting with toileting, and device care or use. For enhanced barrier precautions, signage should clearly indicate the high-contact resident care activities that require the use of gowns and gloves, personal protective equipment including gowns and gloves should be made available immediately outside the resident's room, and a trash can positioned inside the resident's room and near the exit for discarding personal protective equipment after removal, prior to exiting the room or before providing care to another resident in the same room.1. Resident #37 had diagnoses including an unstageable right heel pressure ulcer, generalized edema, and adult failure to thrive. The Minimum Data Set (a resident assessment tool) dated 05/01/2025 documented the resident had moderately impaired cognition, had an ulcer, and required wound care. Review of Resident #37's Comprehensive Care Plan revised on 08/19/2025 revealed the resident had a right heel pressure ulcer. Interventions included, but were not limited to, perform wound care daily and as needed. The care plan did not include information related to enhanced barrier precautions. During an observation and interview on 09/17/2025 at 03:23 PM, there was no enhanced barrier precautions signage or personal protective equipment outside or near the Resident #37's room. When interviewed at that time, the Director of Neurobehavioral stated the resident had a deep tissue injury to their right great toe and a pressure ulcer on their right heel. During an observation on 09/23/2025 at 9:58 AM, there was no enhanced barrier precautions signage or personal protective equipment outside or near Resident #37's room. Licensed Practical Nurse Clinical Coordinator #11 performed wound care to the resident's right heel. The nurse wore gloves only and did not wear a gown. The nurse did not change gloves or perform hand hygiene between removing the soiled dressing and putting on a clean dressing. During an interview on 09/23/2025 at 10:19 AM, Licensed Practical Nurse Clinical Coordinator #11 stated they usually change gloves, but did not this time, and they were not taught to wear a gown for wound care if there was no bleeding.During an interview on 09/24/2025 at 01:48 PM, the Infection Preventionist stated staff must wear a gown for wound care and should change gloves before applying a clean dressing to prevent cross contamination. The Infection Preventionist stated this is covered in orientation, annual training, and as-needed education.2. Resident #10 had diagnoses including an unstageable pressure ulcer (a localized skin and soft tissue injury due to prolonged pressure), coronary artery disease (heart disease), and peripheral vascular disease (a condition of reduced blood flow to the legs or arms). The Minimum Data Set, dated [DATE], documented Resident #10 was cognitively intact, had an unhealed pressure ulcer, and received wound care. Review of Resident #10's Comprehensive Care Plan, revised 07/29/2025, revealed Resident #10 had a wound to the left toe. Interventions included, but were not limited to, perform wound care per medical orders. The care plan did not include information related to enhanced barrier precautions. During an observation on 09/22/2025 at 11:47 AM, Resident #10's room did not have enhanced barrier precautions signage and Licensed Practical Nurse #8 (LPN #8) provided wound care to the left great toe without a gown. 3. Resident #143 had diagnoses including chronic kidney disease, obstructive uropathy (urinary tract restriction which impairs the ability to urinate), and had a suprapubic catheter (a tube inserted directly into the bladder to drain urine). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact.Review of Resident #143's Comprehensive Care Plan, revised 09/17/2025, revealed the resident had a suprapubic catheter placed on 09/09/2025. Interventions included, but were not limited to, catheter care per policy and to empty the catheter bag at the end of each shift. The care plan did not include information related to enhanced barrier precautions. During an observation on 09/17/2025 at 10:16 AM, a Certified Nursing Assistant emptied Resident #143's catheter drainage bag wearing only gloves. There was no enhanced barrier precautions signage outside the resident's room and no personal protective equipment was readily available. During an interview on 09/17/2025 at 10:19 AM, Registered Nurse Manager #3 stated there were residents with wounds and indwelling catheters on the unit, and no residents on enhanced barrier precautions at that time.During an interview on 09/23/2025 at 10:02 AM with the Infection Preventionist and Director of Nursing, the Infection Preventionist stated residents with known multi-drug resistant organisms, and wounds or indwelling devices should be on enhanced barrier precautions. The Infection Preventionist stated there were no residents in the facility currently on enhanced barrier precautions. During an interview on 09/24/2025 at 1:29 PM, the Infection Preventionist stated they now understand enhanced barrier precautions is indicated for all residents with wounds or indwelling devices, because many people can have multi-drug resistant organisms and not know it. The Infection Preventionist stated all staff had since been educated on enhanced barrier precautions and personal protective equipment use.4. During an observation on 09/17/2025 at 3:27 PM, Licensed Practical Nurse Clinical Coordinator #11 exited an unknown resident's room still wearing their gloves and carrying a soiled brief when they approached Resident #222 who was wandering the hall. Licensed Practical Nurse Clinical Coordinator #11 touched the resident on their left shoulder while the soiled gloves were still on. Resident #222 then held on to the nurse's wrist, making direct contact with their gloves.During an interview on 09/17/2025 at 3:35 PM, Licensed Practical Nurse Clinical Coordinator #11 stated this was an infection control concern and said the trash bin in the room had no bag.During an interview on 09/24/2025 at 2:02 PM, the Infection Preventionist stated staff are trained to never wear gloves in hallways and to never touch a resident with contaminated gloves due to the risk of cross contamination.10 NYCRR 415.19(a)(1-4)(b)(1-4)

Based on observations, interviews, and record review conducted during a Recertification Survey completed on 09/25/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (1) (Residents #196) of one (1) resident reviewed. Specifically, Resident #196 was observed on several occasions with dark brown debris underneath multiple fingernails and long facial hair on their chin. The findings are:The facility policy Bathing dated 08/19/2025 included, but was not limited to, residents can have a shower or bath at their request and the ADIR (Certified Nursing Assistant) will provide nail care (fingers and toes) with bathing as assigned. Resident #196 had diagnoses including dementia, adult failure to thrive, and Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination). The Minimum Data Set (a resident assessment tool) dated 07/21/2025, documented the resident had severely impaired cognition, required staff assistance with showering and personal hygiene, and had no rejection of care. Review of Resident #196's Comprehensive Care Plan, revised 09/11/2025, revealed the resident had a self-care deficit related to hemiparesis (weakness and paralysis on one side of the body) and Parkinson's disease. Interventions included, but were not limited to, follow the Activities of Daily Living (ADL) sheet and encourage the resident to participate in their care to the extent possible. The care plan did not include interventions related to nail care or grooming. Review of Resident #196's current Kardex (care plan used by certified nursing assistance to guide daily care) reviewed on 09/19/2025, included showers and daily routine per the resident's preference and request, and staff were to provide total assistance daily when completing activities of daily living and hygiene care. Review of the nursing progress notes for Resident #196 from 08/26/2025 to 09/25/2025 did not include documentation of a shower, bed bath, nail care, personal grooming or rejection of care. During an observation on 09/18/2025 at 10:55 AM, Resident #196 had facial hair on their chin and brown debris underneath their right index fingernail and thumbnail.During an observation and interview on 09/22/2025 at 1:17 PM, Resident #196 had a significant amount of facial hair on their chin. Their right index fingernail and thumbnail had dark brown debris underneath, and nearly all their fingernails were broken, with sharp, jagged edges. When interviewed at that time, Licensed Practical Nurse #4 stated an unknown staff person had pointed out the resident's fingernails a few minutes prior. During an observation on 09/23/2025 at 11:50 AM, Resident #196's fingernails were trimmed, their right index fingernail and thumbnail continued with dark brown debris underneath, and there was a significant amount of facial hair on their chin, approximately one inch in length. During an interview on 09/23/2025 at 11:58 AM, ADIR/Certified Nursing Assistant #4 stated Resident #196's last shower was on the evening of 09/19/2025 but they were unsure when the resident last received nail care. They stated staff should perform nail care on the resident's shower day and each morning. ADIR/Certified Nursing Assistant #4 stated Resident #196 was unable to complete nail care independently. During an observation on 09/24/2025 at 9:22 AM, Resident #196 continued with a significant amount of facial hair on their chin. During an interview on 09/24/2025 at 11:07 AM, ADIR/Certified Nursing Assistant #5 stated personal care consisted of washing the face and body, nail, feet and hair care, and facial hair removal for men and women. ADIR/Certified Nursing Assistant #5 stated they did not notice Resident #196's facial hair and the resident did not have a history of refusing care. They said if staff noticed a resident had dirty nails, they should be cleaned while cleaning the resident's hands. During an interview on 09/24/2025 at 11:20 AM, Registered Nurse Manager #4 stated Resident #196 used to go to the salon for facial hair removal but no longer did so the ADIRs/Certified Nursing Assistants should have removed it. Registered Nurse Manager #4 stated Resident #196 was not a diabetic so the ADIRs/Certified Nursing Assistants should have cleaned underneath their fingernails.During an interview on 09/24/2025 at 11:34 AM, the Director of Nursing stated they would expect staff to have cleaned Resident #196's nails and there should not be debris under any resident's fingernails. The Director of Nursing stated the ADIRs/Certified Nursing Assistants should remove all facial hair on the resident's shower day and document once it is complete. This care should be completed for all resident, including those on hospice, since it was important to maintain the resident's comfort and dignity. 10 NYCRR 415.12(a)(3)

Based on interviews and record review conducted during a Recertification Survey completed on 09/25/2025 for one (1) (Resident #280) of two (2) residents reviewed, the facility did not ensure an incident was thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, Resident #280 fell off a sidewalk curb, sustained a major injury (head strike resulting in a laceration and bleeding requiring hospitalization and sutures), and the facility was unable to provide documented evidence of a thorough investigation to rule out potential neglect. The findings are:The facility policy Abuse Investigation dated 08/16/2025 documented reporting requirements include, but are not limited to, an incident is investigated immediately and must be completed within five (5) business days. When an alleged incident of abuse or neglect is reported, a nursing department administrator will be designated to investigate the incident. The investigation report will include, but is not limited to, an interview investigation log, witness statements, statement from the resident, and the Certified Nursing Assistant (CNA) care card for the resident involved. All documentation related to the investigation and outcome will be maintained in a confidential file in the nursing office.Resident #280 had diagnoses including dementia, difficulty walking, and weakness. The Minimum Data Set (a resident assessment tool) dated 06/19/2025 included the resident was cognitively intact, used a manual wheelchair for independent mobility for at least 50 feet and moderate assistance with mobility for distances up to 150 feet.During an observation and interview on 09/17/2025 at 11:43 AM, Resident #280's left side of their face was bruised with a large bandage on their forehead. The resident stated they were outside, went to step off the curb, fell on their head, and went to the hospital for a couple of days. Review of Resident #280's Comprehensive Care Plan, last revised 09/16/2025, revealed the resident had an alteration in their thought process related to dementia, an alteration in their mobility, and had a history of falls. Interventions included, but not limited to, resident transfers with a minimal assistance from staff and with use of a front wheeled walker as ambulation is no longer functional and safe, resident can and prefers to self-propel their wheelchair short distances on the unit, needs verbal cues to scoot back further in their chair, and foot pedals are required for off unit mobility. In a progress note dated 09/11/2025, Registered Nurse Manager #5 documented Resident #280 returned from the hospital following a fall the previous evening which resulted in a head strike and facial laceration. Several skin issues were sustained including a left forehead laceration with sutures and bruising, skin tears to the left elbow and left shoulder, and abrasions to the left knee and right hand. In a facility Incident Report Form dated 09/10/2025 (not originally included with the investigative report provided by the facility), Security Guard #1 documented Resident #280 had a fall with a head laceration and bleeding which occurred as a result of negligence. The report included Recreation Therapy Assistant #1 left Resident #280 by the curb, without locking their wheelchair in place, to go get something and while Recreation Therapy Assistant #1 had their backed turned, Resident #280 rolled off the curb and fell on the ground sustaining a head laceration. Resident #280 was transported to the hospital via ambulance. In an undated witness statement, Recreation Therapy Assistant #1 documented they brought Resident #280 to the sidewalk, locked the right wheelchair brake, and returned up the ramp to retrieve a phone and resident list that had fallen out of their pocket. Review of an undated Investigative Report revealed on 09/10/2025 Resident #280 was wheeled from Cottage 3 to an outside event and placed on the sidewalk by Recreation Therapy Assistant #1. Recreation Therapy Assistant #1 locked the right side of the resident's wheelchair and returned to the Cottage to retrieve paperwork they had dropped during the transport. As Recreation Therapy Assistant #1 turned to walk back to Cottage 3, Resident #280's wheelchair began to slowly roll off the curb. Recreation Therapy Assistant #1 and Security Guard #1 ran to the resident's side. Resident #280 had a laceration above their left eye with bruising, multiple staff responded to assist, emergency medical services (911) were called, and the resident was sent to the hospital. The investigation included Resident #280 usually self-propelled the wheelchair around their Cottage (residential unit), leg rests were placed on the wheelchair to attend an event, and the left side of the wheelchair was not locked by Recreation Therapy Assistant #1 which may have contributed to the fall. Following review of the incident, Recreation Therapy Assistant #1 was counseled, and the recreation therapy team was educated on wheelchair safety. The investigative report did not include documentation of Resident #280's plan of care (including any supervision or mobility requirements), a comprehensive listing of injuries sustained, a complete listing of witnesses and their statements, a statement from the resident, or a conclusion or determination ruling out abuse, neglect, or mistreatment. During an interview on 09/24/2025 at 11:04 AM, Registered Nurse Manager #5 stated they would start an investigation, look into things a little bit and then bring what they had found to the Director of Nursing. Registered Nurse Manager #5 stated the Director of Nursing completed the investigation for Resident #280's fall on 09/10/2025 as it involved staff they did not supervise. During an interview on 09/24/2025 at 1:39 PM with the Director of Nursing, Assistant Director of Nursing, and the Administrator who all stated they were not at the facility when Resident #280 fell on [DATE]. The Director of Nursing stated either they or the Nurse Managers investigate falls, the nurses complete the incident reports, the managers type up the investigations, and the Director of Nursing reviews them. The Director of Nursing stated Security Guard #1 was directing traffic at the time of Resident #280's fall and video footage showed the guard walking over right after the resident fell. The Director of Nursing stated the security staff complete their own incident reports with statements and the facility does not include them in their investigation files. During an interview on 09/24/2025 at 3:08 PM, Recreation Therapy Assistant #1 stated they were taking Resident #280 outside of Cottage 3 when their phone and a resident list fell out of their pocket in the doorway of the Cottage. They wheeled the resident down the ramp and around the corner, locked the right brake on the resident's wheelchair, and went to go back to the Cottage door to pick up the items they dropped. Recreation Therapy Assistant #1 stated they heard something and ran back toward Resident #280 as they were falling off the sidewalk curb onto the street. Recreation Therapy Assistant #1 stated they do not know how the resident fell because a building pillar blocked their view of the resident. During an interview on 09/25/2025 at 8:42 AM, the Director of Nursing stated they should have provided Security Guard #1 statement to the State Surveyor when asked for the complete investigation. The Director of Nursing stated they ruled out abuse and neglect based on staff statements and watching the video footage. From the video footage, the Director of Nursing stated they were unable to determine what Resident #280 was doing immediately prior to falling as full view of the resident was obstructed by a pillar. The Director of Nursing stated they should have included in their investigative report that no abuse, neglect, mistreatment, or care plan violation was determined. 10 NYCRR 415.4(b)(3)

Based on observations, interviews, and record review conducted during a Recertification Survey completed on 09/25/2025, for two (2) (Residents #85 and #280) of nine (9) residents reviewed, the facility did not ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, Resident #85 required assistance with meals, had an order for no straws, and was observed drinking from a straw. Resident #280 was left in their wheelchair on the sidewalk, fell off the curb striking their head on the street, and sustained injuries including a head laceration requiring sutures. Additionally, Resident #280's current comprehensive care plan did not include the level of supervision required for mobility while on and/or off the residential unit in their wheelchair. The findings are:The facility policy Accident Incident Reporting and Monitoring dated 08/16/2025 included an incident can be a fall, discovery of a resident on the floor, or observation of a resident in a potentially unsafe situation. The Assistant Director of Nursing reviews reports to ensure complete documentation, appropriate evaluation, and corrective actions are implemented. 1. Resident #280 had diagnoses including dementia, difficulty walking, and weakness. The Minimum Data Set (a resident assessment tool) dated 06/19/2025 included the resident was cognitively intact, used a manual wheelchair for independent mobility for at least 50 feet and moderate assistance with mobility for distances up to 150 feet.Review of Resident #280's Comprehensive Care Plan, last revised 09/16/2025, revealed the resident had an alteration in their thought process related to dementia, an alteration in their mobility, and had a history of falls. Interventions included, but not limited to, resident transfers with a minimal assistance from staff and with use of a front wheeled walker as ambulation is no longer functional and safe, resident can and prefers to self-propel their wheelchair short distances on the unit, needs verbal cues to scoot back further in their chair, and foot pedals are required for off unit mobility. The care plan did not include the level of supervision Resident #280 required for mobility while on and/or off the residential unit in their wheelchair. During an observation and interview on 09/17/2025 at 11:43 AM, Resident #280's left side of their face was bruised with a large bandage on their forehead. The resident stated they were outside, went to step off the curb, fell on their head, and went to the hospital for a couple of days. In progress note dated 09/11/2025, Registered Nurse Manager #5 documented Resident #280 returned from the hospital following a fall the previous evening which resulted in a head strike and facial laceration. Several skin issues were sustained including a left forehead laceration with sutures and bruising, skin tears to the left elbow and left shoulder, and abrasions to the left knee and right hand. During an interview on 09/24/2025 at 3:08 PM, Recreation Therapy Assistant #1 stated they were taking Resident #280 outside of Cottage 3 when their phone and a resident list fell out of their pocket in the doorway of the Cottage. They wheeled the resident down the ramp and around the corner, locked the right brake on the resident's wheelchair, and went to go back to the Cottage door to pick up the items they dropped. Recreation Therapy Assistant #1 stated they heard something and ran back toward Resident #280 as they were falling off the sidewalk curb onto the street. Recreation Therapy Assistant #1 stated they do not know how the resident fell because a building pillar blocked their view of the resident.During an interview on 09/25/2025 at 8:42 AM, the Director of Nursing stated they should have provided Security Guard #1 statement to the State Surveyor when asked for the complete investigation. The Director of Nursing stated they ruled out abuse and neglect based on staff statements and watching the video footage. From the video footage, the Director of Nursing stated they were unable to determine what Resident #280 was doing immediately prior to falling as full view of the resident was obstructed by a pillar. 2. Resident #85 had diagnoses including Alzheimer's Disease, adult failure to thrive, and seizure disorder. The Minimum Data Set, dated [DATE] documented the resident had severely impaired cognition and was dependent of staff for eating assistance.The facility policy Dysphagia/Aspiration Protocol dated 07/20/2023 included, but was not limited to, all members of the interdisciplinary team were to identify residents at risk for aspiration precautions and refer to the medical record or diet roster to determine diet orders and guidelines prior to giving food or drink.During an observation and interview on 09/17/2025 at 12:17 PM, Certified Nursing Assistant #3 was assisting Resident #85 with drinking using a cup with a straw. When interviewed at that time, Certified Nursing Assistant #3 stated Resident #85 had an order for no straws, and they had not checked Resident #85's Kardex or the Diet Roster prior to assisting the resident but should have.Review of Resident #85's current Comprehensive Care Plan last revised 09/10/2025 and current Kardex (a care plan used by certified nursing assistants to provide daily care) revealed the resident had an alteration in their nutrition and was at risk for malnutrition. Interventions included, but were not limited to, diet orders for pureed foods, nectar thick liquids, and no straws, and to maintain aspiration precautions (safety measures to prevent choking).Review of the facility's Resident Diet Roster (a tool used for staff to provide care during meals) last updated on 09/15/2025 revealed Resident #85 was on aspiration precautions with pureed foods, nectar thick liquids and no straws. During an interview on 09/23/2025 at 11:01 AM, Registered Nurse Manager #2 stated staff should read the Resident Diet Roster and Kardex before each meal. They stated Certified Nursing Assistant #3 should have checked the Resident Diet Roster before assisting Resident #85 with their meal to prevent choking. During an interview on 09/24/2025 at 9:28 AM, the Registered Dietician stated they would expect staff to be familiar with the resident they were assisting and to review the care plan, diet roster, and any dietary guidelines. They stated Resident #85 was recently downgraded to nectar thick liquids following staff request and staff may have used the straw for Resident #85's comfort, but typically straws are not used for nectar thick liquids, and a recommendation for no straws is usually in place to prevent aspiration. During an interview on 09/24/2025 at 10:00 AM, the Director of Nursing stated Certified Nursing Assistant #3 should have checked Resident #85 Kardex for dietary orders before assisting Resident #85 for safety and to prevent choking.10 NYCRR 415.12(h)(1-2)

Based on observations, interviews, and record review conducted during a Recertification Survey completed on 09/25/2025, the facility did not ensure services were provided to meet professional standards of quality for one (1) (Resident #333) of five (5) residents reviewed. Specifically, Licensed Practical Nurse #9 was observed giving Resident #333 metoprolol tartrate (a heart medication used to treat high blood pressure) without checking the resident's blood pressure or heart rate before administering the medication as ordered by the medical provider. Additionally, review of the electronic medical record revealed on several days the metoprolol was documented as administered with no recorded blood pressures or heart rates from 08/01/2025 to 09/23/2025.The findings are:Resident #333 had diagnoses including atrial flutter (a condition where the heart's upper chambers beat too quickly), diabetes, and high blood pressure. The Minimum Data Set (a resident assessment tool) dated 09/04/2025 revealed the resident had severely impaired cognition.During a medication administration observation on 09/23/2025 at 8:23 AM, Licensed Practical Nurse #9 placed metoprolol tablets in a medication cup and gave them to Resident #333. The nurse did not check or document the resident's blood pressure or heart rate before giving the medication.Current medical orders for Resident #333 reviewed on 09/23/2025 included metoprolol tartrate 25 milligrams, give 1.5 tablet by mouth two times a day for hypertension. The order included to hold the medication if the systolic blood pressure (top number) was less than 100 or the heart rate was less than 60, and to notify a medical provider.Review of Resident #333's Medication and Treatment Administration Records from 08/01/2025 to 09/23/2025 revealed no documented blood pressures or heart rates.Review of the electronic health record's Vital Signs tab from 08/01/2025 to 09/23/2025 revealed no documented blood pressures or heart rates for 94 out of 107 opportunities when metoprolol was given.During an interview on 09/23/2025 at 11:35 AM, Licensed Practical Nurse #9 said nurses are supposed to check blood pressure or heart rate before giving medications with hold parameters. Licensed Practical Nurse #9 said she did not check Resident #333's blood pressure or heart rate because she did not notice any hold parameters in the order at that time.During an interview on 09/23/2025 at 12:16 PM, Registered Nurse Manager #1 said nurses must follow the doctor's orders and hold parameters tell the nurse when not to give a medication. Registered Nurse Manager #1 said the system usually requires the nurse to enter the vital signs before giving the medication, but she did not see any vital signs documented for this resident.During an interview on 09/24/2025 at 2:49 PM with the Director of Nursing and Administrator, the Director of Nursing said hold parameters tell the nurse when not to give a medication and that nurses must check and document blood pressure or heart rate before giving medications with those parameters. The Director of Nursing said giving a medication without checking the hold parameters is considered a medication error.10 NYCRR 415.11(c)(3)(i)

Based on observations, interviews and record reviews conducted during the Focused Infection Control Survey, completed on 10/14/21, it was determined that for one (Unit 4NE) of two units on Transmission Based Precautions (TBP), the facility failed to 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 infectious diseases including COVID-19. Specifically, a pharmacy staff member did not apply the appropriate personal protective equipment (PPE) prior to entering a unit that was on transmission-based precautions (TBP) due to multiple COVID-19 positive residents on the unit. The New York State Department of Health guidance, titled Health Advisory: COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and revised 7/10/20, documented that when there are confirmed COVID-19 positive cases in a nursing home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. Health Care Professional (HCP) and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e., do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. Per CDC guidance, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 3/29/21, recommended PPE when caring for residents with suspected or confirmed COVID-19 includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. CDC guidance titled Transmission-Based Precautions (undated), documented: Use PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. The facility policy, Use of PPE during COVID-19 Pandemic, dated 1/26/21, documented for a COVID-19 positive wing, Memory Care and NBRU, while on quarantine, all staff must don the following prior to entering the unit: gloves, gown, face shield and exam mask. During an observation on 10/14/21 at 1:45 p.m., on Unit 4NE, a locked unit for residents with dementia, the sign outside the unit doors read, Contact Precautions and Droplet Precautions. Keep doors closed at all times. Prior to entering apply the following personal protective equipment: Isolation gown, exam mask with face shield and gloves. The sign included photos of each item of PPE required. A table was located outside the unit doors with face shields, gloves, gowns, and hand sanitizer. At 1:48 p.m., a pharmacy delivery staff member entered the TBP locked dementia unit while wearing only a surgical mask. The pharmacy staff member proceeded to the medication cart and handed a bag of medications to the Licensed Practical Nurse (LPN) who was wearing full PPE and handed the LPN a cellular phone which they handed back and forth while signing for the delivery. At no time did the pharmacy staff member apply gown, gloves or a shield nor was observed sanitizing their hands following the interactions with the LPN, prior to leaving the TBP unit or prior to getting on the elevator. When interviewed on 10/14/21 at 1:50 p.m., the pharmacy staff member stated that they had only made a quick delivery and did not think that the floor was under COVID-19 watch and stated that they were fully vaccinated. During an interview on 10/14/21 at 1:51 p.m., LPN#1 stated that they had told the pharmacy staff member the previous week that they had to wear PPE but that the pharmacy staff member just wanted to run in and deliver the medications. LPN #1 stated that all the unit staff have informed the pharmacy staff member about precautions when the sign was put up. LPN#1 stated that they had not told the Nurse Manager or the Director of Nursing about the pharmacy delivery person not wearing PPE. LPN#1 stated that they have three COVID-19 positive residents currently on the unit with two of them currently in their rooms and one of them is wondering the unit freely. In an observation on 10/14/21 at 2:00 p.m., multiple residents were wandering the unit without any PPE on and without social distancing. In an interview on 10/14/21 at 2: 04 p.m., the Certified Nursing Assistant #1 stated that they were aware that the COVID+ residents were wandering around the unit. When interviewed on 10/14/21 at 2:32 p.m., the Director of Nursing (DON) stated that the signage going onto the locked dementia unit included full PPE masks gowns, shields and gloves as needed, were required for entry. The DON stated that any vendors entering the unit also needed to wear full PPE. 10 NYCRR 415.19(a)(1)(b)(4) 400.2

Based on interviews, observations, and record review conducted during a Recertification Survey and complaint investigation (#NY 039) completed on 8/6/21, it was determined for two (Residents #430 and #261) of three residents reviewed, the facility did not report allegations of abuse, neglect or mistreatment to the New York State Department of Health (NYSDOH) in a timely manner. Specifically, an incident of resident-to-resident physical abuse with injuries was not reported to the NYSDOH in the time frame required. This was evidenced by the following: The facility policy, Abuse Investigation, dated 3/24/21, revealed that NYSDOH would be notified when there is reasonable cause to believe abuse, neglect or mistreatment has occurred. The facility would report to the NYSDOH serious bodily injury within 2 hours after forming a suspicion, and for all other incidents within 24 hours. Resident #261 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 7/9/21, revealed the resident had severely impaired cognition. Resident #430 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 7/13/21, revealed the resident had severely impaired cognition. Review of the Resident Incident Report, dated 5/9/21, revealed that on 5/9/21 at 12:20 p.m., a Licensed Practical Nurse (LPN), reported that when Resident #430 was walking out of their room, Resident #261 grabbed Resident #430's wrists and pushed them causing Resident #430 to fall onto the floor. A Registered Nurse (RN) completed an assessment of Resident #430, medical was notified, and an x-ray was completed revealing a fracture of the left hip. An undated Incident Investigation Summary completed by the Director of Nursing (DON), included that the incident on 5/9/21 was witnessed by an LPN who recounted that when the Residents passed by one another while walking, Resident #261 impulsively turned toward Resident #430, grasping Resident #430's wrists and pushed the resident toward the wall causing Resident #430 to fall to the ground. The report included that Resident #430 was injured and sent to the hospital for treatment. The Health Electronic Response Data System (HERDS), a reporting system where facilities report incidents to NYSDOH, revealed that the incident was not submitted to NYSDOH until 5/12/21. When interviewed on 8/6/21 at 7:54 a.m., the DON stated both residents were demented and lacked intent, so the incident did not fall under the category of abuse, neglect, or mistreatment. The DON said that the facility had 5 days to report the incident to NYSDOH. [10 NYCRR 415.4(b)(2)]

Based on observations, interviews, and record reviews conducted during the COVID-19 Focused Infection Control Survey, the facility did not maintain an infection prevention and control program designed to provide a safe environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, transmission based precautions were not immediately implemented following physician orders [REDACTED].#9) with COVID-19 symptoms, housekeeping staff were observed without appropriate personal protective equipment (PPE) for residents on transmission based precautions and a blood glucose machine was not cleaned between uses. This evidenced by the following: The Centers for Disease Control and Prevention guidelines, under the section titled Contact Precautions, provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders, dated 11/21/20, included orders to confine Resident #9 to their room and contact and droplet precautions every shift. The order report included that order was confirmed by Licensed Practical Nurse (LPN) #1 on 11/21/20 at 11:22 a.m. In an observation on 11/25/20 at 9:40 a.m. Resident #9's room was not marked with any signage indicating the resident was on transmission-based precautions and no PPE bin on the door. In an interview on 11/25/20 at 9:40 a.m., the Registered Nurse/Clinical Coordinator (RN/CC) stated that Resident #9 had spiked a fever of 101.4 on 11/20/20 and a chest x-ray was completed that confirmed aspiration pneumonia. She said that the resident continued to be febrile and a COVID-19 test was done on 11/21/20 with results still pending. In an interview on 11/25/20 at 9:45 a.m., the Nurse Practitioner (NP) stated that as the resident continued to have a fever, droplet and contact precautions were ordered on [DATE] by the covering NP. She said they had not received Resident #9's COVID-19 test results yet. In an interview on 11/25/20 at 10:00 a.m., the RN/CC stated she was not certain why the PPE bins and signage for transmission-based precautions had not been placed on the door to Resident #9's room. The RN said that a work order should have been placed by LPN# 1 on the computer and housekeeping would have acted on it as soon as it was received. A review of the work order system at that time revealed only one order was placed for PPE for suspected COVID-19 in Resident #9's room and was dated 11/25/20 at 8:14 a.m. When interviewed on 11/25/20 at 4:30 p.m., the Infection Preventionist (IP) stated he was aware that Resident #9 had been placed on droplet and contact precautions and was recently tested for COVID-19 but was not aware that the PPE equipment was not present. 2. In an interview on 11/25/20 at 9:06 a.m., the LPN #2 stated that staff are donning and doffing PPE in every resident room on Unit 5 because a recent resident tested positive for COVID-19 in the facility. In an observation on 11/25/20 at 9:40 a.m., the Housekeeper #1 was cleaning in a resident room [ROOM NUMBER] and was wearing PPE which included a gown. Housekeeper #1 was observed exiting room [ROOM NUMBER], walk down the hall, and enter room [ROOM NUMBER] with the same gown on. Rooms #532 and #539 were both marked with signage including contact and droplet precautions in place and that prior to leaving each room staff must remove all PPE. When interviewed at that time the Housekeeper #1 stated that the residents were negative so they can wear the same gown. When asked about the signage on the door the Housekeeper #1 proceeded to remove all their PPE. In an observation on 11/25/2020 at 10:20 a.m. on the fifth floor unit rooms #581 and #588 were both marked with signage indicating droplet and contact precautions with associated PPE (gown, gloves, masks and shields) instructions posted on each door. The Housekeeper #2 was mopping the floor in room [ROOM NUMBER] and was not wearing a gown. The Housekeeper #2 then proceeded to room [ROOM NUMBER] and clean the bathroom and high touch surfaces again without donning a gown. When interviewed at that time, Housekeeper #2 stated they forgot to put a gown on. When interviewed on 11/25/20 at 12:00 p.m., the Environmental Services Supervisor (ESS) stated the expectation for housekeeping in droplet and contact precaution rooms is donning PPE before entering each room, then doffing PPE before leaving each room. The ESS then stated that he will re-educate staff. When interviewed on 11/25/20 at 4:30 p.m. the IP stated that environmental services staff are educated the same way with donning and doffing PPE and all staff need to observe precautions whether cleaning or giving care according to instructions on the door. 3. During an observation on 11/25/20 at 11:05 a.m., LPN #2 performed a Finger Stick Blood Glucose (FSBG) for Resident #10 using an 'Accu-Check Inform II'. Without cleaning or sanitizing the glucometer, LPN #2 then performed a FSBG for Resident #11. When interviewed on 11/25/20 at 11:10 a.m., LPN #2 stated the glucometer should be cleaned with individual wipes, but there were none available in the medication cart. LPN #2 stated that she did not clean the glucometer between the residents. In interviews on 11/25/20 at 4:40 p.m. and at 4:45 p.m., LPN #3 and LPN #4 both said Sani-cloth bleach wipes should be used to disinfect the glucometer between each use. The facility policy, Fingerstick Glucose Monitoring, dated 10/9/13, included to clean the monitor with Sani-cloth bleach wipe in between each resident use. When interviewed on 11/25/2020 at 4:30 p.m., the IP said he would expect the glucometer to be disinfected with a bleach-based product between each use. (10 NYCRR 415.19(a) (1-3))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #352) of six residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen remained free from unnecessary medications. Specifically, the resident received an as needed antipsychotic medication on the day of admission to the facility without documentation that the medication was used to treat a diagnosed specific condition, whether symptoms were clinically significant enough to administer an antipsychotic medication, and what non-pharmacological interventions were attempted prior to the administration of an antipsychotic medication. This is evidenced by the following: Resident #352 was admitted to the facility for rehabilitation on 12/20/18 following surgery for [REDACTED]. The Minimum Data Set Assessment, dated 12/27/18, revealed that the resident had moderately impaired cognition and symptoms of [MEDICAL CONDITION]. The hospital discharge paperwork, dated 12/20/18, revealed that the resident was alert and oriented to person, received [MEDICATION NAME] (antipsychotic) as needed (last dose documented was 12/18/18), and prior to admission the resident was independent with activities of daily living, driving and working part time without symptoms of confusion. The Registered Nurse (RN) Assessment, dated 12/20/18, included that the resident was alert, oriented to person and very confused on admission. The resident thought he was in a hotel and was dropped off by a taxi. The resident talked about leaving the facility, but then a family member arrived and he calmed down. The Physician Admission Exam, dated 12/20/18, revealed that the resident's postoperative course included [MEDICAL CONDITION] which was treated with [MEDICATION NAME]. The resident was in no acute distress and had a normal mood. The assessment and plan included a [MEDICAL CONDITION] workup, repeating lab work, a bladder scan and medications. The plan was discussed with the resident's family member. Physician orders, dated 12/20/18, included [MEDICATION NAME] every eight hours as needed for agitation. The related [DIAGNOSES REDACTED]. When interviewed on 1/4/19 at 3:19 p.m., the RN who admitted the resident to the facility and administered the IM [MEDICATION NAME] said that the resident came in on the evening shift and was extremely confused, talking combatively such as I am going to rip people's heads off, or I am going to shove this . The RN said she was not afraid of the resident. She said the resident was afraid and did not know where he was and commented my family has abandoned me here. The RN said that the resident wanted to leave and went toward the emergency exit to go out the door. The RN said initially the resident would not let the physician examine him. The RN said the physician gave her a verbal order for oral [MEDICATION NAME] which the facility did not have, so the physician changed the order to IM. The RN stated that she had mixed feelings about giving the IM [MEDICATION NAME]. She said the resident's family member arrived shortly thereafter and the resident calmed down. The RN said that initially she tried reorienting the resident which was not working. The RN said she did not write a behavior note. Interviews conducted on 1/7/19 included the following: a. At 9:30 a.m., the physician said that the resident was admitted to the facility between 4:00 and 5:00 p.m. and wanted to go home. He said the resident was delirious and unable to calm down. The physician said he called the resident's family member, ordered the [MEDICATION NAME], and removed the resident's walker and placed it outside of his room so he would not go far. The physician said that the resident was a risk to himself because he could fall and break his hip without his walker so he needed the [MEDICATION NAME]. The physician said that once the resident's family member arrived he was calm and had normal conversation. He said that the resident's diagnosed specific condition would be [MEDICAL CONDITION]. When asked about the underlying cause the physician said people with dementia are prone to [MEDICAL CONDITION] due to anesthesia and pain, however this resident's hospital record did not mention dementia. The physician said the resident's symptoms were loss of insight as he did not understand that he was at the facility for rehabilitation. The physician said that the staff did not attempt any other non-pharmacologic interventions other than calling the family member and having them with the resident. He said that is the best treatment for [REDACTED]. b. At 9:30 a.m., the Medical Director was interviewed with the physician. The Medical Director said she was called at home by the physician due to the resident being agitated and not having capacity to make decisions himself. The Medical Director said that a [MEDICAL CONDITION] workup was ordered for the following day which included blood work, urine, and a medication review which was all normal. The Medical Director said that she audited the resident's medical record after discharge (1/4/19), and he was off all antipsychotic medications. The Medical Director said that diagnoses, cause, symptoms, and the non-pharmacologic interventions attempted prior to the administration of the [MEDICATION NAME] should have been documented during the time the resident was experiencing symptoms and the [MEDICATION NAME] was administered. c. At 1:51 p.m., the Clinical Coordinator said that there should be good documentation as to why an antipsychotic is being administered and the non-pharmacologic interventions attempted beforehand. The Clinical Coordinator said if it was not documented, then it was not done. d. At 2:16 p.m., the Registered Nurse Manager said if a resident warrants IM [MEDICATION NAME] within hours of being admitted to the facility, then she would expect detailed documentation. The facility policy for [MEDICAL CONDITION] Medications, dated 10/9/17, revealed that the Medical Provider will order [MEDICAL CONDITION] medication only for treatment of [REDACTED]. They are to document [DIAGNOSES REDACTED]. (10 NYCRR 415.12(1-2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #15) of two residents reviewed for respiratory care, the facility did not ensure that the resident's care plan was reviewed or revised to reflect the resident's current condition. The issue involved the lack of care plan revisions for Continuous Positive Airway Pressure ([MEDICAL CONDITION]) therapy. This is evidenced by the following: Resident #15 was admitted to the facility on [DATE] for rehabilitation with a [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/16/18, revealed that the resident was cognitively intact. The Physician Admission Assessment, dated 4/30/18, revealed that the resident had sleep apnea and used a [MEDICAL CONDITION] machine (a person wears a face mask during sleep which is connected to a pump, [MEDICAL CONDITION] machine that forces air into the nasal passages at pressures high enough to overcome obstructions in the airway and stimulate normal breathing). Physician orders, from 4/30/18 through 10/18/18 and 12/21/18, included to provide the [MEDICAL CONDITION] protocol (put on in the evening and off in the morning, and as needed during the day) and the care of the [MEDICAL CONDITION] equipment. The Comprehensive Care Plan, initiated 5/1/18, revealed that the resident had sleep apnea. Interventions included providing the [MEDICAL CONDITION] as ordered. There were no revisions documented. During an observation and interview with the resident on 1/4/19 at 11:05 a.m. and on 1/7/19 at 12:41 p.m., the resident said that he had sleep apnea and has a [MEDICAL CONDITION] machine at home that does not work very well. The resident said that no one has asked him if he wanted a new [MEDICAL CONDITION], and he probably would not wear one anyway. There was no [MEDICAL CONDITION] machine observed in the resident's room. Progress notes from admission and throughout the record documented that the resident does not wear, refuses, or does not have the [MEDICAL CONDITION] machine. A progress note, dated 5/2/18, revealed that the resident stated he had a [MEDICAL CONDITION] at home. A progress note, dated 10/5/18, documented that the resident has been refusing [MEDICAL CONDITION] since admission. A progress note, dated 10/14/18, revealed that the resident did not have a [MEDICAL CONDITION] machine in his room. Review of the Treatment Administration Records (TARs) for (MONTH) (YEAR) and (MONTH) (YEAR) included an entry for the [MEDICAL CONDITION] protocol and the care of the [MEDICAL CONDITION] per the orders. The TAR had not been signed off as completed 86/93 opportunities, and on 12/23/18 and 12/26/18 it was signed off that care for the [MEDICAL CONDITION] machine was done. There was no documentation that education regarding the resident's decision not to use the [MEDICAL CONDITION] machine for his sleep apnea was provided. When interviewed on 1/7/19 at 12:57 p.m., the Clinical Coordinator said the resident refused to wear the [MEDICAL CONDITION] machine since the day he came in and everybody was aware. The Clinical Coordinator said that the physician orders [REDACTED]. The Clinical Coordinator said that he did not know if there was any documentation that the resident had been educated regarding his sleep apnea and the use of the [MEDICAL CONDITION] machine. When interviewed on 1/7/19 at 2:04 p.m., the Registered Nurse Manager (RNM) said she just started completing care plans for the unit. She stated if nursing was reporting that the resident was not using the [MEDICAL CONDITION] machine, someone should have had an educated conversation with the resident. The RNM said if the resident was not going to use the [MEDICAL CONDITION], then it should have been discontinued from the orders and the care plan revised. The facility policy for Comprehensive Care Plans, effective 5/30/18, revealed that the care plan will be updated, reviewed and evaluated including care plan goals, interventions and approaches on an ongoing basis. (10 NYCRR 415.11(c)(2)(iii))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 463), it was determined that for one (Resident #1) of three residents reviewed for accidents, the facility did not thoroughly investigate the resident's frequent falls in order to rule out abuse, neglect, or mistreatment. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated [DATE], included that the resident had severely impaired cognition and required limited assist of staff for walking in his room, and extensive assist of staff for locomotion on the unit The facility policy, Fall Management Program, dated as effective [DATE], included that when a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there and to put into place an intervention to prevent this from happening again. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall occurred. Review of the Comprehensive Nursing Care Plan in the electronic health record revealed that the resident had the potential for injury, was at risk for falls related to extensive assistance needed for transfers, a history of falls related to impulsivity, and poor safety awareness. Interventions included, but were not limited to, to provide a bed alarm when in bed to alert staff as to when the resident gets out of bed without calling for assistance. Under that, it includes a history to provide a bed alarm when the resident is in the bed and/or chair. It does not include that the chair alarm was discontinued. Review of a Physical Therapy (PT) discharge summary, dated [DATE], revealed that the resident was able to ambulate with a walker and contact guard assist of staff due to unsteadiness and the need for cueing for safe ambulation up to 300 feet. Discharge plans and instructions included that the resident was to receive maintenance therapy three times a week to allow him to keep his gains and remain safe with ambulation. Precautions include to continue to require a chair alarm due to poor safety awareness. A PT evaluation, dated [DATE], revealed that the resident was seen due to frequent falls. The evaluation included that therapy was not indicated at that time as the resident was at baseline and discharge plans were to continue maintenance therapy and the use of a walker and contact guard for unsteadiness. No changes to the care plan were recommended. Review of the Resident Incident Reports revealed, but was not limited to, the following: a. On [DATE], the resident was found on the bathroom floor. The bed/chair alarm was off/malfunctioning statement was checked and a new bed alarm was added to the report. The resident suffered abrasions to his head and shoulder. b. On [DATE], the resident was found sitting on the bathroom floor. Again the bed/chair alarm was off/malfunctioning line was checked. No injuries were noted. c. On [DATE], the resident was found in the bathroom. Nothing was noted regarding a bed or chair alarm. No injury was noted. d. On [DATE], the resident was found on a mat along the side of his bed and his bed alarm was sounding. No injury was noted. e. On [DATE], the resident was found on the floor in his room, and it was documented that the chair alarm malfunctioned. There was no other documentation regarding the chair alarm or if it was repaired or replaced, and there were no staff statements regarding the malfunctioning chair alarm. No injury was noted on the form. f. On [DATE], the resident was found at 1:50 p.m. on the floor of another resident's room by another resident's family member. The resident suffered a hematoma and an abrasion to the right side of his head, eye, and face. The report did not include any documentation related to the chair alarm or any staff statements regarding if it was present or not and/or functioning or not. Review of the summary, dated [DATE] and signed by the Nurse Manager (NM), revealed that the resident was able to self-propel around in his wheelchair independently, was found wearing his winter gloves, and his winter hat was nearby. The NM wrote that there was no violation of the plan of care. Review of a progress note, dated [DATE] and signed by the Registered Nurse, revealed that the resident had an unobserved fall in another resident's room and suffered a large hematoma to the right eye. She was unable to assess the right eye as it was swollen shut. The physician was notified and lab work was ordered. A progress note, dated as created on [DATE] and signed by a Licensed Practical Nurse (LPN), included that effective [DATE] at 5:30 p.m. the resident was found to be lethargic with an elevated blood pressure, nasal drainage, and a pinpoint pupil. It includes that the physician was notified at 6:15 p.m., and the resident was to be transferred to the hospital. A progress note, dated [DATE] and signed by a LPN, included that the resident was transferred to the hospital at 6:42 p.m. The autopsy report included that the resident expired on [DATE] from [MEDICATION NAME] force injuries of the head. Interviews conducted on [DATE] included the following: a. At 2:05 p.m., the NM stated that it was a year ago and difficult to remember. The NM felt that she did remember that the resident did have a chair alarm, but she could not recall if they ever discontinued it or not. She doubted they would as the resident was frequently getting up from his chair. She said that if they discontinued the chair alarm, she would have documented it. The NM said that the Incident Report should have documented if there was a chair alarm, if it alarmed, and staff should have been interviewed to make sure it was working. She stated that (referring to the late progress note) they audit the charts after a fall and if staff do not document regarding the resident's condition, they ask them to go back and write a note even if it is a few days later. b. At 2:45 p.m. and again on [DATE] at 1:00 p.m., the Director of Nursing (DON) stated that the bed alarm was implemented but she was not sure of the chair alarm. She stated that the Certified Nursing Assistant (CNA) assignment sheets are not kept when a resident is discharged so she does not know if it was on the CNA care plan or not. The DON said it was not on the Comprehensive Care Plan, therefore, she did not think there was a care plan violation so she did not investigate further. She said the facility changed computer systems around that time and it may have been dropped off but she agreed that it appeared that the resident had one at the time of the [DATE] which documented that the chair alarm malfunctioned and at the time of the therapy discharge summary. The DON was unable to find documentation that the chair alarm was discontinued. When interviewed on [DATE] at 1:00 p.m., the Administrator stated that it would probably be a good idea if they kept the CNA assignment sheets (care plan) after a resident is discharged for better understanding after an incident. When interviewed on [DATE] at 9:00 a.m., the complainant voiced concerns about why the resident's chair alarm did not alarm when the resident reached for his hat and gloves that were kept on the top shelf of his closet or when he fell from the wheelchair and was found by a visitor instead of staff, and how long he may have laid there because his eye was so swollen. They said that the complainant was under the impression that the resident had a chair alarm. (10 NYCRR 415.4(b)(3)

Based on observations and interviews conducted during the Recertification Survey, it was determined that the facility did not maintain an effective pest control program. Specifically, there was a significant amount of drain/fruit flies, floors that had food and debris build-up, and pest harborage areas were present. This is evidenced by the following: 1. Observations on 8/29/17 at 10:12 a.m. revealed approximately 24 small brown flies on the walls, ceiling, cabinets, and flying around within the fourth-floor Northeast kitchenette area. 2. Observations on 8/31/17 between approximately 9:50 a.m. and 10:20 a.m. revealed dozens of small brown flies on the walls, ceilings, cabinets, and flying around inside and outside the fourth-floor Northeast kitchenette area. Further observations revealed a cart full of dirty dishes near the door just outside the kitchenette with a tub full of a brownish liquid and small brown flies all over and around the dishes and cart. In an interview at that time, an employee working within the kitchenette stated that the fruit flies have been terrible for the past week or so. Further observations revealed greasy gray buildup of debris and crumbs on the floor around the edges of the kitchenette and beneath the dishwashing machine. There were sections of the cove molding that was peeling off near the hand washing sink. (10 NYCRR 415.29, 415.29(j)(1), 415.29 (j)(5))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for three of ten residential units, the facility did not maintain infection control procedures to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection. Issues involved a lack of appropriate personal protective equipment and hand hygiene for a resident's on-contact precautions (Residents #413 and #453), improper disinfecting of a glucometer (Resident #413), and a food tray place over a trash can (Resident #329). This is evidenced by the following: 1. Resident #413 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. diff - bacterial infection in the stool). The Minimum Data Set (MDS) Assessment, dated 8/17/17, included that the resident is cognitively intact. Review of the current physician's orders [REDACTED]. During observation of medication administration on 8/31/17 at 7:56 a.m., the resident's room door had a sign on the precautions box that directed to wear gloves, wash hands after leaving the room, and wear a gown for substantial contact with the resident and environmental surfaces. At that time, the Licensed Practical Nurse (LPN) applied gloves, entered the isolation room, and placed the lancet, alcohol swab, and gauze pad on the overbed table. She proceeded to obtain the blood sugar reading from the resident using a glucometer (machine used to test a resident's sugar level from a drop of blood) that she carried into the room in her pocket. After obtaining the blood sugar, the LPN left the room and removed her gloves. With her bare hands, the LPN cleansed the top surface of the glucometer with alcohol. The LPN then cleansed her hands with alcohol sanitizer, applied gloves, and stated she was ready to go to the next room to test another resident. The surveyor intervened and stopped the LPN from entering the next room. When interviewed at that time, the LPN said she did not need to wear a gown because taking a blood glucose is not considered substantial contact. The LPN said that she always cleans the glucometer with alcohol in between residents and only uses bleach wipes after she has completed the blood sugars on all the residents. She said she should have washed her hands when she left the room. When interviewed on 8/31/17 at 1:13 p.m., the Registered Nurse (RN)/Long Term Care Support Nurse said that a gown should have probably been worn to do the blood sugar. She said that she expects staff to wash their hands when leaving a room for a resident on contact precautions for [DIAGNOSES REDACTED]. She said only prolonged scrubbing will remove the [DIAGNOSES REDACTED]. She said that she expects staff to clean the entire glucometer with bleach wipes between every resident because alcohol is not sufficient. When interviewed on 9/1/17 at 11:01 a.m., the Employee Health/Infection Control Preventionist RN stated that the protocol for cleaning the glucometer is to clean the entire glucometer with bleach wipes before and after each use. Review of the 4/16/17 facility policy, Finger Stick Glucose Monitoring, revealed to clean the glucometer with bleach wipes in between each resident, wearing gloves, and then wash hands thoroughly with soap and water. 2. Resident #453 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. diff. The MDS Assessment, dated 7/7/17, revealed that the resident's cognition is moderately impaired. Review of current physician's orders [REDACTED]. diff. Review of the Certified Nursing Assistant (CNA) Task Report revealed that between 8/19/17 and 8/31/17, the resident had 31 episodes of bowel incontinence and 5 episodes of loose stools/diarrhea. Observations and interviews conducted on 8/31/17 included the following a. The resident's room door had a sign posted that directed, Stop. Contact Precautions. Visitors: check with nurse before entering, wear gloves whenever entering room, wear a gown if substantial contact with resident or environment surfaces is anticipated. Please wash your hands with soap and water when leaving the room. b. At 10:37 a.m., the surveyor observed a male volunteer enter the resident's room with no gloves or gown. The volunteer held onto the resident's bedrail, and then moved the resident's walker closer to the resident. When interviewed at that time, the volunteer said no one told him what the precautions sign means on the door. The surveyor informed the volunteer that he should wash his hands. The volunteer proceeded to the elevator with the resident without washing his hands. c. At 10:55 a.m., the Registered Nurse Manager (RNM) said she was not aware of what education volunteers received regarding precaution rooms, but that Recreation Therapy would know. The Licensed Practical Nurse (LPN) and RNM both said that normally the volunteer stops and asks for the resident. They said the volunteer tells staff where the resident is going, and then staff will get the resident for the volunteer. When interviewed on 9/1/17 at 11:01 a.m., the Employee Health/Infection Control Preventionist RN stated that it is the expectation that volunteers follow the direction on the precaution signs. She said that the volunteers should wash their hands before and after handling residents and equipment. She said that residents with [DIAGNOSES REDACTED] that have loose stool should have their hands washed prior to leaving their room. 3. Resident #329 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The MDS Assessment, dated 6/13/17, revealed that the resident's skills for daily decision making are severely impaired, and is totally dependent in all activities of daily living. During an observation on 8/31/17 at 9:00 a.m., the resident was in a low bed that was positioned at a 45-degree angle. The CNA placed the resident's breakfast tray over the top of a waste paper basket, cut up the food and then proceeded to feed the resident. The CNA fed the resident the entire meal with the tray sitting on top of the trash can. When interviewed at that time, the CNA said that staff used the resident's tray table in the dining room for someone else. The CNA did not respond when asked about infection control. When interviewed on 9/1/17 at 10:00 a.m., the RNM stated that it is the expectation that staff will place the resident's food tray on a tray table when feeding a resident. (10 NYCRR 415.19(b)(4))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #121) of four residents reviewed for accidents, the facility did not ensure that the resident environment remained as free of accident hazards as possible. The issue involved a chest safety strap that was not used with a mechanical lift device. This evidenced by the following: Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/20/17, revealed that the resident's cognition is severely impaired and requires extensive assistance of one staff for transfer. The Comprehensive Care Plan, dated 4/5/17, revealed that the resident's goal is to transfer with one assist and a standing lift. The Fall Risk Assessment, dated 7/20/17, revealed that the resident is at risk for falls. Review of the 8/18/17 Certified Nursing Assistant (CNA) Assignment Sheet revealed that the resident was transferred with a Sara lift (mechanical lift with wheels that moves a resident from a sit to stand position for transfer) with one assistant. Observations and interviews conducted on 8/30/17 included the following: a. At 1:18 p.m., the resident requested to be taken to the bathroom so the CNA brought a Sara lift into the room. The CNA applied the transfer sling around the back of the resident. The CNA mentioned that there should have been a strap to buckle around the resident's chest area but she thought the resident was strong enough to hold on. The CNA transferred the resident from her bed to the toilet in the bathroom, and then back to her wheelchair in the room. When interviewed at that time, the CNA said there is a safety strap that goes around the resident's chest and is buckled in place. She said she did not know why it was not on the sling. The CNA said she was in a rush and did not want to try to find another sling. b. At 2:16 p.m., the Registered Nurse Manager said the transfer sling that was used did not have a safety strap. She said the strap was missing and she did not know why. She said that the safety strap is used to secure the resident. She stated that if the resident was weak or dizzy and could not hold on to the transfer lift, she did not know what would happen to the resident without the safety strap. c. At 2:24 p.m., the Director of Nursing (DON) said she would have to check with the therapy department and the manufacturer's recommendation as to whether the transfer sling could be used without the safety strap. At that time, the surveyor and the DON observed the Sara lift that was used in the transfer. The manufacturer's recommendation that was attached to the lift included to attach the safety strap. The DON said that was pretty clear that the safety strap should have been used. The undated Sara lift quick reference guide included to ensure the chest strap is fastened securely. (10 NYCRR 415.12(h)(1))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #493) of one resident reviewed for indwelling urinary catheters (tube inserted into the bladder to drain urine), the facility did not provide appropriate treatment and services to prevent potential catheter related complications. The issue involved the lack of a safety strap to secure the catheter to the resident's leg to prevent tension at the insertion site. This is evidenced by the following: Resident #493 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 6/16/17, revealed that the resident is cognitively intact, has an indwelling urinary catheter and requires extensive assist of staff for bed mobility (i.e.: turning from side to side). The current Comprehensive Nursing Care Plan and the Certified Nursing Assistant Assignment Sheet both included that the resident has a Foley (urinary catheter). Interventions included Foley care per policy, but did not include to secure the catheter in any way. Physician orders, dated 7/12/17, revealed orders for Foley care per facility protocol. During an observation of care on 8/31/17 at 9:50 a.m., the resident was turned from side to side by a Licensed Practical Nurse (LPN). The Foley catheter was not secured to anything and the LPN was not aware that the catheter was pulled tight across the resident's leg potentially being pulled out. After surveyor intervention, the resident was rolled back and the catheter was readjusted by the LPN. The resident stated at that time that he did not remember having any strap on his leg to prevent the catheter from being pulled. Interviews conducted on 8/31/17 include the following: a. At 10:15 a.m., the LPN stated that the facility had straps to secure the catheter. The LPN said that she did not think the resident ever had one. She said they do not always use the straps. The LPN said that she was not aware of this resident ever refusing one. b. At 10:20 a.m., the Registered Nurse stated that she was unsure of the facility policy on securing the catheters but she would expect them to be secured with straps. c. At 11:32 a.m., the Director of Nursing stated that it is a basic nursing function and the resident should have a strap to secure the Foley catheter. The facility policy, Catheterization Straight Cath Foley, Male and Female and Urinary Drainage Bag Care, dated 6/9/16, directs the RN/LPN to run the tubing over the resident's thigh and secure to the thigh with a catheter strap or tape and to make sure the catheter is secure. (10 NYCRR 415.12)

Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 352), it was determined that for one (Resident #202) of five residents reviewed for pressure sores, the facility did not provide the necessary services to prevent the development of, or promote healing of pressure sores. The issues involved the lack of a timely Registered Nurse (RN) skin assessment and lack of documented preventative skin measures. This is evidenced by the following: Resident #202 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the electronic version of the Interdisciplinary Admission Assessment, dated 5/5/17, revealed that the assessment was in progress and was electronically signed on 5/8/17 by the Registered Nurse Manager (RNM). The Skin Assessment section was blank. The Braden Scale, dated 5/5/17, identified that the resident was at a low risk for skin breakdown. The Comprehensive Care Plan for Alteration in Tissue Integrity/Potential for Injury, dated 5/18/17, documented that the goal was no skin breakdown and interventions included to check and change the resident every four hours and to apply barrier cream. A Minimum Data Set Assessment, dated 5/12/17, revealed that the resident is cognitively intact, required extensive assist of two staff with bed mobility, transfers and toileting, frequently incontinent of urine, at risk of developing pressure ulcers and has a Stage II pressure ulcer. A Medical Progress Note, dated 5/12/17, revealed that the resident was seen to assess a sacral pressure ulcer. The resident reported the area to be sore and blisters were noted. The Assessment and Plan revealed that the resident had a Stage II pressure ulcer, and directed to apply an Allevyn dressing, and to obtain a cushion for the resident's chair. A Nursing Note, dated 5/13/17, revealed that the resident had a pressure ulcer on his sacrum. The wound had no odor, no drainage, and the skin was pink. There were no signs or symptoms of infection, and the wound was dressed per the physician order. A RN Wound Care Specialist documented on the Skin and Wound Nursing Assessment, dated 5/17/17, that the resident had an unstageable pressure ulcer on the sacrum. There was no odor, with serosanguinous (water blood) drainage and a moderate amount of wet wound tissue. The pressure ulcer had 90 percent of slough (dead tissue) and 10 percent granulation (formation of tissue in the process of healing) and measured 1.0 centimeter (cm) x 1.0 cm. The resident was encouraged to follow a toileting schedule to help decrease moisture. When interviewed on 9/1/17 at 9:30 a.m., the RNM stated that the Braden Scale is just a skin risk assessment. The RNM said that there was no initial skin assessment. She said that a skin assessment should have been completed on admission. She said she takes responsibility. She said she knew the resident was at risk for skin breakdown based on his medical condition when she developed the resident's care plan. She said that she could not remember if the resident had a chair cushion. The RNM said that on 5/18/17, Physical Therapy upgraded the resident's chair cushion to a higher-grade pressure cushion, and the facility initiated an intervention to encourage and change the resident's position every two hours. The RNM said that the facility does not keep the Certified Nursing Assistant (CNA) Kardex once the resident is discharged . Review of the facility policy, Skin Care Protocol Pressure Sores Prevention and Treatment, dated 5/26/17, directed to minimize the risk of developing pressure ulcers, the staff will complete preventative skin checks at least weekly on any resident at risk for skin issues. The RN, Licensed Practical Nurse and CNAs are responsible to protect areas of pressure using one or more techniques/devices but not limited to: pressure reducing mattress and cushion in chair, changing position every two hours in and out of bed, applying barrier cream after each incontinence episode or bathing of peri area, checking and changing the resident every two to four hours, and daily skin monitoring. (10 NYCRR 415.12(c))

Based on observations, interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY 745) completed on 6/1/17, it was determined that for one (Resident #3) of three residents reviewed for elopement, the facility did not ensure that the resident received adequate supervision to prevent potential accidents. The issue involved lack of staff response to an exit door alarm which resulted in a resident elopement from the building. This is evidenced by the following: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/21/17, revealed that the resident's cognition is moderately impaired. The Comprehensive Care Plan (CCP), dated 8/2/16, included a Wander Alert monitor to limit the resident's ability to leave the facility unsupervised. The CCP was revised on 3/5/17 to include risk for elopement with a goal that the resident will not elope. Interventions included to establish patterns and possible reasons for wandering (i.e. looking for bathroom or mate). The undated Certified Nursing Assistant (CNA) Care Guide includes that the resident has a Wander Alert and to check placement. The 8/13/16 Elopement Risk Assessment documented that the resident was at risk to wander from the facility and a Wander Alert bracelet was intact. Review of the Elopement Investigation Summary, dated 5/15/17, revealed that staff last saw the resident at 11:45 a.m. on 5/14/17. At 12:08 p.m., the resident appears in the security video ambulating with a rolling walker towards the North entrance with two visitors walking behind him. As the resident approaches the exit door, another visitor enters the building and holds the door open for the resident. The Wander Alert alarm can be heard. After the resident exits the building, a fourth visitor can be seen shutting off the alarm by entering the code. The Security Guard, who was watching the video, assumed the resident was with family and did not follow the resident outside to investigate. At 12:38 p.m., a call was received by security that two passers-by at the corner of Winton Road and Meridian Center Road found the resident. The resident was returned to the facility at 1:00 p.m., was assessed by nursing and found to be uninjured. The conclusion was that the Security Guard did not follow protocol for checking the area of the alarm but assumed the resident was with family when he exited. Review of the closed circuit television video on 6/1/17 at 9:45 a.m., revealed that on 5/14/17 the resident was observed exiting the building at 12:08 p.m. through the North Entrance exit door. One visitor was entering the building and two visitors were exiting the building at the same time and holding the door open for the resident. The Wander Alert alarm could be heard and another visitor was observed entering the code to shut off the alarm. During an observation on 6/1/17 at 10:38 a.m., the resident was sitting on a love seat in the common area by the elevators on the 3 North East Unit. The resident was sleeping and had a Wander Alert bracelet on his right wrist. Interviews conducted on 6/1/17 included the following: a. At 8:30 a.m., the Director of Nursing (DON) said since the elopement happened on Mother's Day, it was very busy with lots of visitors. She said a visitor was entering the exit door as the resident approached. She said the door did not close and lock before the resident exited. The DON stated that the Security Guard thought the resident was with visitors so he shut off the alarm. b. At 9:23 a.m., the Security Guard stated that he was working the security desk when he saw the resident on the video screen going out the North Entrance exit door. He said another visitor entered the key code because the Wander Alert alarm was going off. He said he thought that because there were two visitors near the resident, they were with him. He stated that he saw the resident exit out the door. Shortly thereafter he went to lunch without reporting this to anyone. The Security Guard said because so many visitors knew the code to the exit door, all the exit door keypad codes were changed after this incident. c. At 10:56 a.m., Licensed Practical Nurse (LPN) #1 said that at lunchtime LPN #2 told her she was looking for Resident #3 and asked me to look in every room on my hallway. Before an alert was sent out or anyone else was notified, security called and notified us that they had the resident. d. At 11:06 a.m., LPN #2 stated that she gave the resident his medications and checked his Wander Alert in the morning. She said she does not remember seeing the resident after giving him his newspaper at approximately 9:00 a.m. She stated that at lunch time she looked for the resident to give him his 1:00 p.m. medication and could not find him. LPN #2 said she, LPN #1, and the CNAs began to look in every room and bathroom and could not find the resident. She said she called the supervisor and was told the resident was found outside. Review of the 12/14/12 facility policy, Roam/Alert System revealed that when an alarm is received the guard should determine the location and the resident tag triggering the alarm. With an elopement alarm the guard should view the door by the closed circuit television system to determine if the resident is at the door and if they are safe. If the resident cannot be located with the camera, a guard will need to be dispatched immediately to the area to determine the location and status of the resident. The alarm should not be cleared until the status of the resident has been determined. (10 NYCRR 415.12(h)(1)(2))

Based on observations and interviews, it was determined that for four of five units reviewed for medication storage, the facility did not ensure that drugs and biologicals were securely stored in accordance with State and Federal laws. The issues involved undated and expired medications stored and in use. This is evidenced by the following: 1. Medication storage observations conducted on 6/8/16 on the Fourth Floor Unit included the following: a. At 1:48 p.m., the South West Zone Three medication cart contained an opened, partially used bottle of Aspirin EC 325 milligrams (mg) tablets, with the expiration date of January 2016, and a card of Carbamazepine (used to treat seizures and nerve pain) use as directed,100 mg, with the expiration date of April 2016. b. At 2:00 p.m., the South West medication room contained a box of Albuterol Sulfate Inhalation Solution nebulizer vials, (for the treatment or prevention of bronchospasm) 2.5 mg/3 milliliters (ml), with the expiration date of April 2016; Asmanex Twisthaler (control asthma), 220 micrograms (mcg), with the expiration date of April 2016; a bottle of Potassium Chloride, with the expiration date of October 2015; a bottle of Midogen vegetarian capsules, with the expiration date of September 2015; two bottles of Major Bisacodyl, 5 mg tablets, with the expiration date of May 2016; Vitamin C-500 ascorbic acid, 500 mg tablets, with the expiration date of April 2016; four bottles of Major Tab A vitamin supplement, with the expiration date of May 2016; a bottle of Major Bismatrol (used to treat diarrhea, nausea, heartburn, indigestion, and upset stomach), with the expiration date of April 2015; one bottle of liquid Citroma Magnesium Citrate lemony, (use for relief of occasional constipation) with the expiration date of September 2015; and one box of Major Loperamide Hydrochloride, (for control and symptomatic relief of acute nonspecific diarrhea and of chronic diarrhea), 2 mg tablets, with the expiration date of July 2015. 2. Medication storage observations on 6/8/16 on the Fifth Floor Unit included the following: a. At 2:13 p.m., the North East Zone One medication cart contained one vial of Lantus insulin that was opened, but not dated. When interviewed at that time, Registered Nurse (RN) #1 stated that she normally documents the date when opening the insulin vial and it is good for 28 days. b. At 2:15 p.m., the North East medication room contained an opened, partially used bottle of Top Care Antacid/Calcium Supplement 500 mg, with the expiration date of May 2016. 3. Medication storage observations on the Sixth Floor Unit on 6/8/16 at 2:30 p.m., the North East Zone One medication cart contained one opened bottle of Tracleer (used to treat high blood pressure in the lungs/pulmonary arterial hypertension) 125 mg tablets, with the expiration date of May 2012. When interviewed at that time, Licensed Practical Nurse (LPN) #1 stated the bottle had come from the resident's home supply, but now receives the medication from the facility. 4. Medication storage observations on the Third Floor Unit on 6/8/16 ay 3:32 p.m., the South West Zone Four medication cart contained one bottle of Cal.Gest Antacid 500 mg, with the expiration date of January 2016. During an interview on 6/10/16 at 10:17 a.m., the Director of Nursing (DON) stated the facility's education staff checks the medication rooms on the units for medication that is expired. This doesn't include the medication carts. The DON said the nurses share the responsibility for checking the medication carts for expired medications. (10 NYCRR 415.3(d)(e)(1-4))

Based on observations, interviews, and record reviews, it was determined that for one of one main kitchen and two (3 South West and 3 North East) of ten kitchenettes, the facility did not prepare and store food in a safe and sanitary manner. Specifically, foods were not hot held at 140 degrees Fahrenheit (*F) or above, foods were stored under an unprotected sewer pipe, and a cook did not wear a beard guard to restrain facial hair. This is evidenced by the following: 1. Interviews and observations conducted on the residential units on 6/7/16 between approximately 9:02 a.m. and 12:06 p.m. revealed the following: a. In the kitchenette on the third floor South and West wings, there were tofu patties used to make a meatless parmesan dish, which were hot holding under a heat lamp at 133*F. b. In the kitchenette on the third floor North and East wings, there were tofu patties used to make a meatless parmesan dish, which were hot holding at 133*F. In an interview during this observation, the Executive Dining Director stated that he expected the tofu to be held at 140*F or above. 2. Interviews and observations conducted in the main kitchen on 6/7/16 between approximately 9:02 a.m. and 12:06 p.m. revealed the following: a. Cook #1 was working in the food preparation area in the main kitchen. He had a beard that measured approximately 1/2 inch in length. He was not wearing a beard guard. b. In the dry storage room in the main kitchen, there was an approximately 4-inch in diameter sewer line in the corner of the ceiling. Boxes of Thick and Easy and Carbo Troll Fruit Blends peach sauce were stored directly underneath the sewer line. During an observation in the main kitchen on 6/9/16 at approximately 10:56 a.m., Cook #1 was working in the food preparation area. His beard measured approximately 1/2 inch in length. He was not wearing a beard guard. In an interview on 6/10/16 at approximately 11:16 a.m., the Executive Chef stated that beard restraints are required for people with beards longer than 1 inch. Review of the facility's policy, Employee Sanitary Practices, revealed that all employees are expected to wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. (10 NYCRR 415.14(h); 14-1.40, 14-1.43, 14-1.72)