Every finding on record at Katherine Luther Residential HLTH Care & Rehab

Based on observations, record review, and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status for three of eight residents (Residents #10, #108, and #113) reviewed. Specifically, Resident #10 had significant weight loss from 12/17/2025-06/11/2026 and there was no documented evidence interventions were implemented to address the weight loss, weekly weights were completed as recommended by the registered dietitian, or the care plan was reviewed and revised after the significant weight loss. Resident #108 had significant weight loss from 05/07/2026-06/24/2026 and there was no documented evidence interventions were implemented to address the weight loss. Resident #113 had significant weight loss and did not receive assistance with meals as planned. Residents #10, #108, and #113 continued to lose weight resulting in actual harm that was not Immediate Jeopardy. Cross Reference F 677 for Resident #113 under F 677 Activities of Daily Living Care Provided for Dependent Residents Findings include: The facility policy Resident Weights/Height and Significant Weight Change, last reviewed 04/15/2026, documented nutritional needs and intakes of the residents with significant weight change were assessed by the dietitian and appropriate interventions/ recommendations were documented in the electronic medical record as well as on the resident's care plan. The facility policy Notification of Resident Change in Condition, last reviewed 05/22/2026, documented changes in a resident's condition or treatment were immediately shared with the resident and reported to the primary care provider to prevent a delay in treatment. 1) Resident #10 had diagnoses including heart failure, kidney disease and depression. The 04/30/2026 Minimum Data Set assessment (a resident assessment tool) documented the resident was cognitively intact, required set up or clean-up assistance with eating, had a weight loss of 5% or more in the last month or loss of 10% of more in the past 6 months, and was not on a physician prescribed weight loss regimen. The Comprehensive Care Plan initiated 12/08/2025 documented the resident had unintended weight loss related to mood. Interventions included to monitor intakes, weights, lab results and skin condition; half portions were provided at lunch per resident preference; and food preferences were provided. The resident's weight record documented:-On 12/17/2025 129.45 pounds.-On 01/05/2026 126.5 pounds.-On 02/04/2026 123.8 pounds.-On 03/20/2026 124.5 pounds.-On 04/16/2026 116.3 pounds (severe 6.59% loss in one month).-On 04/21/2026 116.25 pounds. The 04/17/2026 Registered Dietitian Clinical Nutrition Manager progress note documented the resident had significant weight loss in the past 30 days. The resident voiced their appetite was not the same as it used to be. Medical was informed of the weight loss, and the resident was placed on weekly weights. The care plan was reviewed and updated. There was no documented evidence of additional interventions to address the significant weight loss, that the care plan was reviewed or revised following significant weight loss, or that weekly weights were ordered or completed as requested after the first weekly weight on 04/21/2026. The 04/20/2026 Nurse Practitioner #20 progress note documented they were made aware of an 8 pound weight loss over the past month. The resident's mood was depressed and the resident stated they no longer had taste buds. Dietary was working on optimizing the resident's supplements and there was no indication for further intervention at this time. Close monitoring was continued. There was no documented evidence the resident received nutritional supplements as indicated by Nurse Practitioner #20's 04/20/2026 progress note. The resident's weight record documented:-On 05/04/2026 116.25 pounds.-On 06/11/2026 112.9 pounds (severe 12.78% loss in six months). There was no documentation by Registered Dietitian Clinical Nutrition Manager or a medical provider addressing the resident's continued weight loss from 05/04/2026-06/11/2026. During an interview on 06/23/2026 at 1:34 PM, Resident #10 stated they lost weight since they moved to the facility in December 2025. They did not receive any supplements at the facility, but they consumed nutritional supplements in the past. The resident consumed 50-75% of both meals. During an interview on 06/25/2026 at 10:08 AM, Certified Nurse Aide #30 stated there was a weight book they referenced at the beginning of the month, and they documented the resident's weight in it. If they were on weekly weights it was indicated in the book. The nurses checked the book. The resident did not refuse to be weighed but if they did, they documented the refusal and would tell the nurse. They stated Resident #10 had lost some weight. During an interview on 06/25/2026 at 10:29 AM, Licensed Practical Nurse #29 stated weights were done monthly on all residents and medical decided if weights needed to be done more often than that. The certified nurse aides obtained the monthly weights. If a resident was on weekly weights it popped up on their medication administration record and nursing obtained those weights. Since the resident did not have an order for weekly weights it did not show up. If there was a 3-4 pound difference, the resident was re-weighed and the dietitian got involved. They were not sure if Resident #10 lost weight. During an interview on 06/25/2026 at 11:38 AM, Registered Nurse Unit Manager #28 stated weights were completed per the physician order. The registered dietitian intervened if a resident's weight changed 4 to 5 pounds from the previous weight. Weights were written in the weight book and were reviewed and entered into the electronic medical record by the registered dietitian. They stated the Nutrition Clinical Manager was monitoring Resident #10's weight loss because they entered their weights into the electronic medical record. Resident #10 was not on any supplements because they did not have an order for any. During an interview on 06/25/2026 at 3:26 PM, the Registered Dietitian Clinical Nutrition Manager stated there were no orders for weights and they just kept track of weighing frequency by their own records. Resident #10 had significant weight loss from March 2026 to April 2026 and continued to lose weight. They discontinued the weekly weights in April after the first one because the weight was stable. It was not documented anywhere in the electronic medical record; they just kept their own record. When they met with the resident in April, the resident told them their appetite was not what it used to be, and they were not hungry. They addressed the resident's weight loss by reviewing their food preferences. They stated this population did not like supplements. They did not update the resident's care plan after significant weight loss but was not sure why. During a telephone interview on 06/26/2026 at 10:09 AM, Nurse Practitioner #20 stated they were notified of Resident #10's weight loss in April 2026. The resident told them nothing really tasted good. Supplementation was strictly done by the Clinical Nutrition Manager and medical was not responsible. They were responsible for ordering appetite stimulating medications, but the resident did not receive any because they were resistive to medication changes. They were not notified recently of the resident's continued weight loss. They stated it was hard to say if the lack of interventions caused further weight loss. They could offer supplements or medications, but they could not force the resident to eat or take medications. The resident told them nothing tasted good anymore so they were not sure if the resident would even taste the supplements. 2) Resident #108 had diagnoses including diabetes, lung disease, and chronic kidney disease. The 06/15/2026 Minimum Data Set assessment documented the resident was cognitively intact, required set up or clean-up assistance with eating, had a weight loss of 5% or more in the last month or loss of 10% of more in the past 6 months and was not on a physician prescribed weight loss regimen. The Comprehensive Care Plan initiated 12/10/2025 and revised 06/02/2026 documented the resident had unintended weight loss related to refusing to have a re-weight obtained. Interventions included the intakes, weights, lab results, and skin conditions were monitored; a double portion of eggs was provided for breakfast when it was the main item; and 8 ounces of chocolate milk with meals. The resident's weight record documented:-On 05/07/2026 163.5 pounds.-On 06/08/2026 152.0 pounds (severe 7.03% loss in one month). The 06/09/2026 Medical Director admission history and physical progress note documented the resident weighed 152 pounds on 06/08/2026 and triggered warnings of weight loss. The 06/15/2026 Registered Dietitian Clinical Nutrition Manager progress note documented the resident was readmitted to the facility following hospitalization from 06/05/2026-06/08/2026. Their re-admission weight was 11.5 pounds less than May. The resident refused a re-weight, so they were unable to determine if a true weight loss occurred and the resident was placed on weekly weights. The resident already received double eggs when they were the main item and received milk at meals. The 06/16/2026 Medical Director progress note documented the resident was seen for a 60 day federally mandated visit. The weight of 152 pounds on 06/08/2026 triggered warnings of weight loss. There was no documented evidence of a plan to address the resident's weight loss. The resident's weight record documented:-On 06/18/2026 152.6 pounds.-On 06/24/2026 148.8 pounds (2.5% loss in one week). During an observation and interview on 06/22/2026 at 10:42 AM, Resident #108 stated the food was terrible and was either overcooked or undercooked. They lost probably 20 pounds, but nothing was being done about it. Their meal ticket did not include a nutritional supplementation at meals. During an interview on 06/25/2026 at 11:38 AM, Registered Nurse Unit Manager #28 stated if a resident lost weight, the registered dietitian monitored them, looked at their intakes, and was responsible for notifying the medical provider. The Registered Dietitian Clinical Nutrition Manager decided on supplements and obtained an order for them. The Registered Dietitian Clinical Nutrition Manager was aware of Resident #108's weight loss because they documented their weights. During an interview on 06/25/2026 at 3:26 PM, the Registered Dietitian Clinical Nutrition Manager stated they should notify the medical providers if there was a significant weight loss. Resident #108 had recent weight loss and had weekly weights. The resident complained about the food, so they reviewed their preferences with them. They thought they notified a medical provider, but it was not in their progress note. During a telephone interview on 06/26/2026 at 10:26 AM, the Medical Director stated Resident #108 was medically decompensated (failure of an organ or bodily system to maintain adequate function) and that affected nutrition. The documentation of weights in their progress notes was just information the electronic system pulled over. They did not recall being notified about the resident's significant weight loss but after reviewing the chart, the resident lost a significant amount of weight. The resident needed to be actively monitored. It was very important their weight bounced back, or it would compromise them medically and meant they had not fully recovered from their illness. 3) Resident #113 had diagnoses including Alzheimer's disease, moderate protein calorie malnutrition, and difficulty swallowing. The 05/14/2026 Minimum Data Set documented the resident had severely impaired cognition, required set-up assistance for eating, and had weight loss while not on a prescribed weight-loss program.The Comprehensive Care Plan documented:-initiated 12/03/2025 and revised 05/04/2026 the resident had an eating self-performance deficit related to cognitive impairment/physical impairment. Interventions included partial/moderate assistance of one at meals.-initiated 12/04/2025 inadequate oral intakes related to dementia, significant unintended weight loss related to poor intakes, and at risk for dehydration. Interventions included providing finger foods, encouraging liquids and solids at and between meals, and encouraging drinking fluids of their choice.The 03/18/2026 physician order documented a regular, mechanical soft, thin liquid diet.The resident's weights were documented as follows: -On 12/05/2025 148.3 pounds-On 04/02/2026 141.2 pounds-On 05/26/2026 131.2 pounds-On 06/05/2026 126.7 pounds (severe 14.5% weight loss in six months)The 06/01/2026 Occupational Therapist #10 discharge summary documented a recommendation for supervision or touching assistance for eating.The Kardex (care instructions) as of 06/25/2026 documented encourage resident to drink fluids of their choice, fluid preferences provided, encourage fluids at meals and between meals, and provide partial to moderate assistance of one at meals. During meal observations on 6/23/2026 at 12:24 PM, 06/24/2026 at 12:41 PM, 06/25/2026 at 9:55 AM and 12:21 PM Resident #113 was not assisted with eating or provided cueing to consume their meals. (Please refer to F 677) During an interview on 06/26/2026 at 11:52 AM, Nurse Practitioner #18 stated a resident with advanced dementia should have ongoing encouragement and cueing to eat. They expected if a resident was not eating, they were provided hands on eating assistance if the resident was willing. If a resident had significant weight loss and was not provided with consistent encouragement to eat, they could experience a physical decline, weakness and electrolyte issues which could be harmful to that resident. 10 New York Codes, Rules, and Regulations 415.12(i)(1)

Based on record review and interviews, the facility failed to ensure residents were free from abuse and neglect for one of one resident (Resident #167) reviewed. Specifically, Resident #167 required assistance of two for transfers using a mechanical lift and on 05/19/2025, Certified Nurse Aide #21 used a stand pivot transfer without assistance resulting in a fractured right arm. This resulted in actual harm to Resident #167 that was not Immediate Jeopardy. Findings include: The facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, last reviewed 01/15/2024, documented that each resident would be free from abuse or neglect and would not be tolerated. The facility policy Interdisciplinary Care Plans, last reviewed 04/20/2026, documented the facility would develop and implement individualized care plans for each resident to meet the resident's needs.The facility policy Assistive Devices and Equipment, last reviewed 04/26/2026, documented staff were to be trained and use care planned devices for resident mobility and safety.Resident #167 had diagnoses of arthritis, osteoporosis (weak bones), and dementia. The 04/10/2025 Minimum Data Set (a resident assessment tool) documented the resident had severe cognitive impairment, limited range of motion in both arms and one leg and was dependent on transfers.The 12/26/2024 revised Comprehensive Care Plan documented the resident had self-care deficits, was resistive to care, was non-ambulatory, was at risk for pain due to osteoporosis, and was a fall risk. Interventions included Hoyer (mechanical) lift with a wedge between the legs for transfers and give clear explanation of care activities prior to performing. The 05/19/2026 resident care instructions documented the resident was non-ambulatory and transferred with assistance of two using a Hoyer lift. The 05/19/2025 at 10:50 AM, Registered Nurse #52 progress note documented they were notified by the Nurse Manager the resident was complaining of right arm pain while in the shower room. The resident was assessed and was yelling out in pain when their right arm was touched. An order for an x-ray of the right shoulder and arm was ordered, and the resident was provided with one dose of Roxanol (morphine) 1 milligram. The 05/19/2025 at 11:18 AM x-ray report documented the resident had an age-indeterminate fracture of the right arm correlating with timing of trauma and pain. The 05/19/2025 at 1:05 PM Registered Nurse Unit Manager #14 progress note documented the resident was screaming in pain and stated their arm hurt. An x-ray was completed with abnormal findings. The resident was sent to the hospital for further evaluation at 12:16 PM. Incident Summaries with Witness Statements: -The 05/19/2025 Certified Nurse Aide #22 witness statement documented they asked Certified Nurse Aide #21 for assistance transferring Resident #167 and went to get a Hoyer sheet to transfer the resident. They saw Certified Nurse Aide #21 stand the resident by themselves and pivoted the resident into the shower chair. Immediately after the resident was in the chair, the resident yelled out in pain. Certified Nurse Aide #21 stated they thought the resident's arm broke. The supervisor was notified at that time.-The undated Certified Nurse Aide #21 witness statement documented they were transferring Resident #167 into a shower chair using a Hoyer lift, the resident was closer to one side of the chair than the other, the aide did not realize the resident's arm was back, and the aide heard a snap. Registered Nurse Manager #14 was made aware. -The 5/19/2025 Registered Nurse Unit Manager #14 witness statement documented they were in their office, heard Resident #167 yell out in pain, went to assess the situation, and found the resident holding their right arm stating it hurt badly. When the right arm was assessed, the resident started screaming out in pain. Certified Nurse Aides #21 and #22 were interviewed immediately. A nurse practitioner was asked to assess the resident, the aides were told to place the resident in bed, and an x-ray was ordered. Certified Nurse Aide #21 told the manager they were transferring the resident to a shower chair using a Hoyer lift. Certified Nurse Aide #22 was brought into the office, an interview was conducted, and Certified Nurse Aide #22 stated Certified Nurse Aide #21 transferred the resident by themselves using a stand and pivot method. -The 05/20/2025 incident report summary documented Assistant Director of Nursing #23 spoke with Certified Nurse Aide #22 at 11:30 AM on 05/19/2025 post incident. Certified Nurse Aide #22 stated they asked Certified Nurse Aide #21 to assist with transferring the resident, went to get a Hoyer sheet, returned to the room, and Certified Nurse Aide #21 told them to put the pad in the chair. Certified Nurse Aide #22 lifted the resident and performed a stand-pivot transfer to place the resident into a shower chair. Upon being seated in the shower chair, Resident #167 began screaming in pain and Certified Nurse Aide #21 stated they thought the resident's arm broke. Certified Nurse Aide #22 asked the other aide if the resident was a Hoyer lift at all times or as needed. Certified Nurse Aide #21 stated at all times. Registered Nurse Unit Manager #14 was notified. Certified Nurse Aide #21 told Certified Nurse Aide #22 the family was made aware and told them to make up a story, so they did not get into trouble. When interviewed by the former Director of Nursing, Certified Nurse Aide #21 told them when the resident was transferred to the chair, they were leaning to the left. When Certified Nurse Aide #21 straightened the resident out, the aide did not notice the resident's right arm was bent behind them and heard it snap. Certified Nurse Aide #21 stated the resident was transferred via Hoyer lift. The incident was reported to the New York State Department of Health on 05/19/2025. After further investigation, it was determined that Certified Nurse Aide #21 did not transfer the resident via Hoyer lift, which was a care plan violation. Certified Nurse Aide #21 was terminated on 05/20/2025 at 02:30 PM for care plan violation resulting in injury.During an interview on 06/26/2026 at 11:23 AM, Registered Nurse Unit Manager #14 stated Resident #167 required a Hoyer lift transfer with assistance of two. On 05/19/2025, Certified Nurse Aides #21 and #22 were working together to perform Resident #167's pre-shower transfer. Registered Nurse Unit Manager #14 stated they heard a resident scream, went to Resident #167's room, saw the Hoyer lift in the room and asked what had happened. The aides stated the resident's arm got stuck in the lift. The nurse went back to their office, and the aides took the resident to the shower room. Certified Nurse Aide #22 later told them Certified Nurse Aide #21 stood the resident and pivoted them to the shower chair, and they heard the resident's arm snap. Certified Nurse Aide #22 stated they did not assist at all with the transfer. Registered Nurse Unit Manager #14 and the Director of Nursing went to talk to Certified Nurse Aide #21 who was crying. The aide was immediately suspended and did not return to work. The resident went to the hospital that day and it was determined the resident sustained an arm fracture. The Director of Nursing completed an incident report, and the outcome was the resident sustained a fractured arm due to a care plan violation. Staff education on following care plans and resident transfers was done shortly after the incident. During an interview on 06/26/2026 at 12:25 PM, Physician #2 stated they remembered the situation although Nurse Practitioner #20 was more familiar with it. They stated if there were no other comorbidities, the care plan violation contributed to the shoulder/arm fracture.During an interview on 06/26/2026 at 12:32 PM, Nurse Practitioner #20 stated the resident broke their shoulder due to the care plan violation when they were transferred via stand and pivot versus the Hoyer lift as planned. The resident had osteoporosis and was at significantly high risk for fractures. The resident sustained a broken shoulder because of the care plan violation.During a telephone interview on 06/26/2026 at 12:37 PM, Assistant Director of Nursing #23 stated they were the Director of Nursing at the time of the incident. Staff should follow each resident's care plan to prevent adverse situations. They were made aware of the incident immediately. Certified Nurse Aide #22 was assigned to the resident, asked Certified Nurse Aide #21 to assist with transferring the resident via mechanical lift, left the room to get the lift and Certified Nurse Aide #21 independently transferred the resident using a stand and pivot method before Certified Nurse Aide #22 returned to the room. Certified Nurse Aide #21 was immediately suspended, terminated shortly after that, an investigation was done timely, and the resident sustained an arm fracture due to the care plan violation. The facility provided transfer and care plan education for all nursing staff shortly after the incident. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on observations, record review, and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of seven residents (Resident #113) reviewed. Specifically, Resident #113 experienced significant weight loss and did not receive assistance with meals as planned. This resulted in actual harm to Resident #113 that was not Immediate Jeopardy.Findings include:The facility policy Supporting Activities of Daily Living, revised 10/15/2024, documented residents would receive the services necessary to maintain good nutrition including appropriate support and assistance with meals and snacks. A resident's ability to perform activities of daily living would be measured using clinical tools, including the Minimum Data Set assessment and its definitions which include the following definition; partial/moderate assistance is when a helper does less than half the effort. The helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.Resident #113 had diagnoses including Alzheimer's disease, moderate protein calorie malnutrition, and difficulty swallowing. The 05/14/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, required set-up assistance for eating, and had weight loss while not on a prescribed weight-loss program.The Comprehensive Care Plan documented:-initiated 12/03/2025 and revised 05/04/2026 the resident had an eating self-performance deficit related to cognitive impairment/physical impairment. Interventions included partial/moderate assistance of one at meals.-initiated 12/04/2025 inadequate oral intakes related to dementia, significant unintended weight loss related to poor intakes, and at risk for dehydration. Interventions included providing finger foods, encouraging liquids and solids at and between meals, and encouraging drinking fluids of their choice.The 03/18/2026 physician order documented a regular, mechanical soft, thin liquid diet.The resident's weights were documented as follows: -On 12/05/2025 148.3 pounds-On 02/03/2026 133.2 pounds (10% weight loss in two months)-On 03/03/2026 134.2 pounds (severe 9.5% weight loss in three months)-On 04/02/2026 141.2 pounds-On 05/12/2026 130.5 pounds-On 05/26/2026 131.2 pounds-On 06/05/2026 126.7 pounds (severe 14.5% weight loss in six months)The 05/04/2026 Occupational Therapist #10's treatment encounter note documented skilled interventions to facilitate independence with self-feeding abilities included initiation cues to facilitate skill performance, instruction in proper sequencing during self-feeding performance, and techniques to increase processing skills to facilitate independence in self-feeding performance. The resident's response to those skilled interventions was active participation.The 05/13/2026 Speech Language Pathologist #11 discharge summary documented recommendations for alternation of liquid/solids, rate modification, bolus size modifications and general swallow techniques/precautions. Attempts to provide the resident with feeding assistance were met with some refusal behaviors, however, at recent sessions, the resident did accept more intakes with encouragement.The 05/27/2026 Registered Dietitian Clinical Nutrition Manager progress note documented the resident triggered for a significant weight loss of 9.1% in 90 days. The resident may have further weight loss as their intakes continued to decline from 15% to 10% with 12 meals refused. The resident was now refusing their milkshakes. The plan was to provide 8 ounces of whole milk at meals. The resident refused other supplements and a Remeron (appetite stimulant) trial was ineffective. They would continue to encourage liquids and solids at meals and between meals as the resident allowed. The 06/01/2026 Occupational Therapist #10 discharge summary documented a recommendation for supervision or touching assistance for eating.The 06/16/2026 Registered Dietitian Clinical Nutrition Manager progress noted documented the resident triggered for a significant weight loss of 14.6% in 180 days. The resident was provided with 8 ounces of whole milk at meals and increased juices. Intakes were slightly improved from 10% to 21% with five meal refusals noted. The resident would at times refuse to allow staff to feed them and was provided with finger foods to promote self-feeding. The resident may have further weight loss related to dementia and poor appetite. The Kardex (care instructions) as of 06/25/2026 documented encourage resident to drink fluids of their choice, fluid preferences provided, encourage fluids at meals and between meals, and provide partial to moderate assistance of one at meals. During an observation on 06/23/2026 at 12:24 PM, the resident had a sandwich cut into quarters, a cupcake, a bowl of mixed vegetables, and three 8-ounce cups filled with a purple, white and clear colored fluid. The resident was looking around the room, not eating and no one was assisting them with their meal. At 12:31 PM, they picked up their fork, put it in the bowl of vegetables, put the utensil back down, then took one sip of the purple fluid. At 12:54 PM, they were holding and looking at their meal ticket, not eating, and did not receive any assistance. At 1:03 PM Licensed Practical Nurse #15, while standing next to the resident, asked them to eat their sandwich. When the resident did not respond, Licensed Practical Nurse #15 put one quarter of the sandwich on the fork, lifted it to the resident's mouth who readily took a bite. Licensed Practical Nurse #15 then put the sandwich back on the plate and directed the resident to pick it up. The resident touched the sandwich, looked up at Licensed Practical Nurse #15, laughed, and did not pick it up. No further assistance was provided. At 1:14 PM, Licensed Practical Nurse #15 handed the resident the cup of white fluid and the resident took one sip then put the cup back down. No further assistance was provided. The resident picked up the top slice of their sandwich, looked inside, replaced the slice, picked up their spoon, looked at it, then placed it on the plate next to the sandwich. Licensed Practical Nurse #15 stated to the resident they were not really eating and they looked at each other and laughed. Certified Nurse Aide #9 asked the resident if they were done eating, the resident's response was indiscernible, and the resident picked up the cup of white fluid and took a sip. At 1:17 PM, Licensed Practical Nurse #15 put the cupcake in front of the resident, cut it in half and asked the resident if it looked good. The resident picked up the cupcake, took a bite, put it back on the plate and began licking their fingers. At 1:22 PM, they were sipping from their cup of white fluid and began spinning the plate the cupcake was on while sticking their fingers in the frosting and licking them. At 1:29 PM, Certified Nurse Aide #9 asked the resident if they were done eating. The resident smiled and repeated the words all done and the resident was removed from the dining room. The 06/23/2026 at 1:00 PM Certified Nurse Aide #19's documentation for the activities of daily living eating task documented the resident required set-up or clean-up assistance to use suitable utensils to bring food and/or liquid to the mouth once the meal was placed before the resident; the percentage of solids consumed was 10% and the fluids drank was 120 milliliters.During an observation on 06/24/2026 at 12:41 PM, the resident had a sandwich cut in half, 8 ounces of a clear fluid, 8 ounces of an amber fluid, a mug full of a brown fluid, a fruit parfait and a bowl of vegetables. The resident was not eating and was not being assisted. At 12:58 PM, the resident was eating scant amounts of whipped cream off their parfait with a fork. At 1:06 PM, the resident picked up the parfait cup, lifted it to their mouth, hesitated, and put it back on the table without eating any. At 1:07 PM, Licensed Practical Assistant Nurse Manager #13 verbally encouraged the resident to try their sandwich, and the resident did not respond. At 1:13 PM, the resident picked up the top slice of their sandwich, looked at the contents, then put it back down. Licensed Practical Assistant Nurse Manager #13, while standing over the resident's right shoulder, asked the resident if they were done eating and the resident did not respond. They handed the resident the cup of amber fluid and the resident took a sip before placing it back on the table. At 1:22 PM, Licensed Practical Assistant Nurse Manager #13 removed the resident from the dining room. The resident only consumed a sip of the amber fluid and a small amount of whipped cream. The 06/24/2026 at 1:00 PM Certified Nurse Aide #12's documentation for the activities of daily living eating task documented the resident required set up or clean-up assistance to bring food and/or liquid to the mouth once the meal was placed before the resident; the percentage of solids consumed was 0%; and the number of fluids consumed was 0 milliliters. During an observation on 06/25/2026 at 9:55 AM, the resident was sitting in the dining room with their breakfast meal consisting of two hard-boiled eggs, a muffin, a bowl of oatmeal, all untouched. There was a half full 8-ounce cup of orange liquid and a full 8-ounce cup of white fluid. At 9:56 AM, Certified Nurse Aide #12 asked the resident if they were done eating and the resident did not answer. The resident's food was removed, and their fluids were left. No assistance or cues were provided. The 06/25/2026 at 9:00 AM Certified Nurse Aide #12's documentation for the activities of daily living eating task documented the resident required set up or clean-up assistance to bring food and/or liquid to the mouth once the meal was placed before the resident; the percentage of solids consumed was 0%; and the number of fluids consumed was 240 milliliters.During an observation on 06/25/2026 at 12:21 PM, the resident was served a ground pork sandwich and three 8-ounce cups filled with red, white and clear colored fluid each with a lid and a straw. The silverware was wrapped in a napkin. At 12:24 PM, the resident was staring at their food, making no attempt to eat. At 12:25 PM, Licensed Practical Assistant Nurse Manager #13 unwrapped the silverware, cut up the sandwich, put a piece on the fork, handed it to the resident, and the resident readily put the piece in their mouth before putting the fork back on the plate. At 12:27 PM, the resident was using their spoon to smooth out their napkin that was sitting on the table. At 12:29 PM, Licensed Practical Assistant Nurse Manager #13 offered the resident a forkful of pork sandwich which the resident accepted without hesitation. No further assistance was provided. At 12:30 PM, the resident took one sip of their red fluid. At 12:37 PM, the resident's table mate told Certified Nurse Aide #12 the resident was not eating. Certified Nurse Aide #12 placed a bowl of pudding with a spoon in front of the resident and exited the room. The resident began fiddling with the hem of their clothing protector. At 12:44 PM, the resident was not eating and did not receive assistance. At 12:58 PM, they picked up their spoon and began stirring their pudding and took one bite before putting the spoon down. They took the straw from the cup with red fluid and began poking the pork sandwich. At 1:02 PM, they picked up the cup of white fluid and took one sip then attempted to drink from the cup of red fluid but could not, because there was a lid on it and the straw was in their pork sandwich. At 1:07 PM, Certified Nurse Aide #12 approached resident, removed their clothing protector and began removing the resident from the table. The tablemate pointed out the resident did not eat, and Certified Nurse Aide #12 said it was the resident's choice to not eat. The 06/25/2026 at 1:00 PM Certified Nurse Aide #12's documentation for the activities of daily living eating task documented the resident required supervision or touching assistance to bring food and/or liquid to the mouth once the meal was placed before the resident; the percentage of solids consumed was 0%; and the number of fluids consumed was 30 milliliters. During an interview on 06/25/2026 at 1:08 PM, Certified Nurse Aide #12 stated they documented what the resident's eating performance was not what it was supposed to be. Supervision/touching assistance meant having eyes on the resident, verbal encouragement, and putting the food on the silverware. Resident #113's cognition waxed and waned and they were easily distracted. They believed the resident's assistance level for eating was supervision and could be accepting of being fed. That morning the resident did not attempt to eat their breakfast. They did not attempt to feed the resident as not eating was the resident's baseline. They stated they should have tried to feed the resident. The resident would probably eat better if someone sat with them to feed them. During an interview on 06/25/2026 at 1:30 PM, Licensed Practical Assistant Nurse Manager #13 stated set-up assistance for eating meant cutting up food, opening containers, and guiding the resident's hands to a drink. If a resident was not eating, they expected staff to assist with feeding, including feeding the resident. Before removing uneaten food, they expected staff to try to assist the resident or offer an alternative. Resident #113 had severe dementia, could not make their own decisions, was easily distracted, needed a lot of encouragement, and required partial/moderate assistance for eating. Partial/moderate assistance meant the resident could perform some of the activity and staff could assist by putting a fork in their hand, bringing the food to their mouth and even fully feeding if needed. Sometimes the resident refused to be fed but staff should always try before removing them from the table. They did not know if the resident had a significant weight loss and was not aware they had not been eating well. During an interview on 06/26/2026 11:05 AM, Registered Nurse Unit Manager #14 stated they expected staff to sit with residents, encourage them to eat, cue them, and offer something different to eat before documenting a refusal. Resident #113's intake was poor, and attention span was limited. They required partial/moderate assistance of one and could feed themselves. If the resident was not eating, staff should sit with them and provide cueing such as putting the fork and drink in their hand. If they still did not eat, an attempt to feed them should be made before removing them from the dining room. During an interview on 06/26/2026 at 11:52 AM, Nurse Practitioner #18 stated a resident with advanced dementia should have ongoing encouragement and cueing to eat. They expected if a resident was not eating, they were provided hands on eating assistance if the resident was willing. If a resident had significant weight loss and was not provided with consistent encouragement to eat, they could experience a physical decline, weakness and electrolyte issues which could be harmful to that resident. 10 New York Codes, Rules and Regulations 415.12(a)(3)

Based on observations, record review, and interviews, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one of three residents (Resident #26) reviewed. Specifically, on 05/21/2026, Resident #26 developed a pressure ulcer on the hip, and a comprehensive wound assessment, physician notification, treatment plan, and nutritional assessment were not completed timely. Subsequently, the pressure ulcer progressed to a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle). This resulted in actual harm to Resident #26 that was not Immediate Jeopardy. Findings include:The facility policy Pressure Injury Management, revised 02/15/2024, documented wound assessment and management would include determination of the type of wound, notification of the medical provider to obtain order for wound consult; and the registered dietitian would be notified for a nutritional assessment.The facility policy Wound Care, revised 11/15/2019, documented pressure injuries would be staged, and wound assessment would include location, measurements, wound bed characteristics, drainage, odor, surrounding skin, pain, and signs of healing or deterioration.Resident #26 had diagnoses including dementia, muscle weakness, and moderate protein calorie malnutrition. The 05/28/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, was dependent for most activities of daily living, was at risk for pressure ulcers, and did not have a pressure ulcer. The Comprehensive Care Plan initiated 12/04/2025 documented the resident was at risk for impaired skin integrity related to impaired mobility. Interventions included apply moisture barrier following incontinence care and pressure reduction device for wheelchair. The 05/21/2026 at 7:32 PM Registered Nurse Supervisor #17 progress note documented the resident had an open area to the left hip with a red base, no drainage, and a dressing was applied. There was no documented evidence of wound characteristics including measurements and surrounding skin; the type of dressing applied; and the presence of pain.The 05/21/2026 Unit Report Sheet documented the resident had a skin abrasion on their left hip and a dressing was applied per Registered Nurse Supervisor #17.From 05/21/2026 - 05/28/2026, there was no documented evidence in the medical record related to the wound on the resident's left hip including physician notification, treatment order, comprehensive wound and nutritional assessments, or care plan updates. The 05/28/2026 Licensed Practical Nurse #39 progress note, documented the area to the left hip persisted, the supervisor was notified, the area was cleansed, a dressing was applied, and a note was left for medical.The 05/29/2026 physician order documented cleanse left hip wound with normal saline, apply Medihoney (a wound treatment containing honey), and cover with a dry protective dressing, once a day.The 06/05/2026 Wound Consultant note documented an initial wound evaluation. The resident had an unstageable (wound base cannot be visualized due to dead tissue) pressure ulcer of the left hip. The wound measured 1.8 centimeters by 2 centimeters by 0.1 centimeters and was covered with dead tissue. The 06/19/2026 Wound Consultant note documented the left hip pressure ulcer measured 2 centimeters by 2.5 centimeters by 0.5 centimeters, was a Stage 4, was worsening, and surgical excisional debridement was performed (removal of dead tissue). The Comprehensive Care Plan, revised on 06/05/2026, included an unstageable pressure ulcer to the left hip and interventions was followed by the wound care team weekly. The 06/09/2026 Registered Dietitian Clinical Nutrition Manager progress note documented the resident had a new pressure ulcer and needs were reassessed to 1500 kilocalories, 77 grams of protein, and 1700-1900 milliliters of fluids.During an interview on 06/25/2026 at 3:25 PM, Registered Dietitian Clinical Nutrition Manager stated new wounds were usually communicated to them by nursing. They expected to be notified within 24 hours of any new wounds and typically adjusted the resident's needs, including protein needs, based on the stage of the wound. Resident #26 had an open area on their hip. They were not aware of the wound until 06/08/2026 when they reviewed the wound team note written on 06/05/2026. They were not aware the area was first noted on 05/21/2026. They should have been notified when the wound was first noted. During an interview on 06/26/2026 at 7:45 AM, Registered Nurse Supervisor #17 stated when significant findings such as new open areas, deep tissue injuries, and bruises of unknown origin were discovered, they were reported to the supervisor who then looked at it, a dressing would be placed on it, it would be added to the shift-to-shift report, a note would be placed in the physician's communication book and a progress note would be added. The nurse manager would then place the resident on the wound team rounds. They stated they did not usually take measurements or stage pressure ulcers; they let the nurse manager do that the following day. They recalled looking at Resident #26's left hip wound and putting it on the supervisor shift- to-shift report sheet. They could not recall if it was pressure related, what the size was, or if it was over a boney prominence but believed the wound bed was just pinkish/red. They thought the floor nurse put a note on the unit shift-to-shift report and in the doctor's communication book to get a treatment order. They did not have any ongoing involvement with the wound.During an interview on 06/26/2026 at 10:14 AM, Licensed Practical Assistant Nurse Manager #13 stated when a new wound was reported, that nurse called the provider to get a treatment order, the supervisor was notified, the dietitian should be notified, a note would go on both the supervisor and the unit 24-hour report sheet, and the resident would be put on the wound team's schedule. A wound treatment should be put in place that day and it was the supervisor's or the nurse manager's responsibility to make sure that happened. Resident #26's left hip wound started as a red spot and then progressed quickly. They did not remember when it was discovered as being opened or who discovered it. After referring to the medical record, they stated 05/21/2026 was the first note that there was an open wound. That should have been on the unit's 24-hour report sheet, they would have seen it, and they would have let Nurse Manager #14 know who would make sure a treatment was ordered. They were not aware of a delay in treatment but after referring to the medical record, they stated it was eight days before it was treated. That should not have happened, and they did not know why it did. During an interview on 06/26/2026 at 10:38 AM, Nurse Manager #14 stated they looked at open areas and if it was pressure related, they measured it, called the provider to get a treatment order, and added the resident to the wound rounds. Treatment orders should be obtained immediately. They did not stage pressure ulcers; that was done on wound rounds. If an open area was found on an off shift, the supervisor should get a treatment order, put it on the daily report sheet, and write a progress note that included the location and a measurement. They reviewed the 24-hour electronic report daily and would see any notes related to wounds and would make sure there was a treatment order. They did not directly notify the dietitian as the dietitian would find that information when reading notes and orders. Initially, Resident #26 had an intact reddened area on their left hip. They were first aware the area was open on 05/28/2026 when an aide asked them to look at it. They called and got an order for hydrogel (wound gel treatment). The wound was not necrotic or sloughy (no dead tissue) at that time. They looked at the wound again on 05/30/2026 and the wound had slough, so they called to get the order changed to Medihoney. They should have documented both assessments but did not as it slipped their mind. When referring to the medical record, they stated the wound was first noted on 05/21/2026. There should have been a treatment order and a documented assessment done immediately. During an interview on 06/26/2026 at 11:52 AM, Nurse Practitioner #18 stated they were notified of wounds by either a phone call or a note in the communication book. They expected to be notified quickly so treatment could be ordered. They stated they could not recall if they were notified when Resident #26's wound was discovered. Treatments usually slowed the progression of the wound and could prevent necrosis and therefore a wound should not go seven days without one. Necrosis could cause pain and infection which was harmful to a resident. 10 New York Codes, Rules and Regulations 415.12(c)(1)

Based on observations and interviews, the facility failed to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illness in one of one main kitchen. Specifically, the main kitchen had several unclean areas and there was a dented can of pudding. Findings include:The facility policy Cleanliness and Sanitation, effective 03/18/2024, documented the refrigerator and freezer walls, ceiling, and floors should be free of ice, stains, spots, food, drips, and debris. The storeroom walls, ceiling, doors, and floor should be free of dust, dirt, stains, spots, and debris. Items were stored properly, off floor and away from fire sprinklers. Corners and baseboards should be free of debris, dust, and dirt build up. Shelving and racks should be free of dirt, dust, and grease. The walls of the kitchen should be clean, free of dirt, stains, grease, food, and smooth to the touch. They should be free of dirt and grease build-up at the corners and floor junctions. The floors should be free of debris, dirt, grease, and spills. Any missing tiles and cracks on the walls or floor should be repaired.The Kitchen Staff Assignments form documented the staff assigned to Pots in the evening shift were responsible for sweeping and mopping all floors daily.The 06/15/2026 Cleaning Schedule: Main Kitchen/Units form documented the evening cook was assigned to spot clean the tile walls near the cooking areas which was additional to the daily cleaning tasks.The following observations in the main kitchen were made on 06/24/2026 from 10:54 AM to 12:32 PM:- the drain dipped under the double oven and the covered tilt skillet next to it had food debris and white scaling on the floor.- a seven pound can of vanilla pudding was dented on the bottom seam at the front of the line on the small rack.- split pea bags and boxes of oats and creamy wheat on the shelves in the dry storage were covered with little white granules; there was an individual pudding cup and a can of soda on the floor under one of the wire racks containing boxes of juice.- underneath the wire shelves in the dry storage there were particles of dried food and oats. - the main walk-in freezer had several ice shards on the floor and ice build-up along the floor jam.- the front wall and the floor of the main walk-in refrigerator had blackish specks and build- up.- the wall tiles at the bottom of the silver tread in the dish room entrance were cracked and broken.- there was dried chopped spinach on the floor under the tilt skillet facing the windows and the floor under the grill top had food debris.- the grate over the cook prep tables in front of the window had dust and build-up. - muffins for the next morning were uncovered on a tray cart in the corner by the slicer and underneath dusty ceiling tiles and wall tiles.During an interview and observation on 06/24/2026 at 11:01 AM, the Director of Food Service stated the cans were looked at for dents every time the stock came before they were placed on a rack. A dented can should not be on the rack.During an observation of the dry storage room in the main kitchen on 06/25/2026 at 10:14 AM four of five shelves on the metal storage rack were covered in whitish/tan granules, the floor in dry storage was sticky, and there were oats and other food debris on the floor behind two wire rack storage shelves.During an interview on 06/25/2026 at 10:18 AM, [NAME] #7 stated the kitchen and the dry storage room were supposed to be cleaned daily. Daily tasks were assigned to each shift to make sure the areas of the kitchen were clean.During an interview on 06/25/2026 10:20 AM Food and Nutrition Manager #8 stated they did not know how often the walls, tiles, or ceiling tiles were cleaned. Maintenance replaced ceiling tiles when they were soiled or leaked through. They were not sure how often the vents above the cook preparation station were cleaned. The evening shift was responsible for sweeping and mopping the whole kitchen, including dry storage.During an interview on 06/25/2026 at 10:30 AM, the Director of Food Services stated the evening staff should sweep and mop the dry storage every night, but it appeared the staff were just mopping the common areas, not under the racks. They were unsure who was responsible for cleaning the upper walls and tiles in the kitchen and assumed it was an outside vendor. The grates above the cook food preparation station should be cleaned by either kitchen staff or maintenance but they were not sure. Walls, ceiling tiles, and grates with dust or debris build-up had the potential to fall into food stored uncovered or prepared. 10 New York Codes Regulations Rules 483.60(i)(1)-(2)

Based on observations, record review, and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one of three residents (Resident #12) reviewed and four of five resident units ([NAME] Unit) reviewed. Specifically, Resident #12 had difficulty swallowing and their care plan and meal tickets documented no straws, the resident was provided with straws during meals and was not assisted with meals as care planned; one thermometer used for taking food temperatures on the [NAME] Unit was placed in a chemical solution and was not wiped off prior to taking food temperatures; and several thermometer chemical cleaner bottles were mislabeled with the incorrect chemical on [NAME], [NAME], [NAME], and Aspen units. Findings include: The facility policy Aspiration Precautions, last reviewed 11/25/2025, documented residents admitted to the facility on an altered consistency diet would be referred to speech therapy to determine the safest, least restrictive diet consistencies. The speech language pathologist would complete the evaluation and notify nursing and nutritional services of their recommendations. Nursing would implement the related orders and any other feeding recommendations as specified from the swallow evaluation and notify nursing staff and the interdisciplinary care planning team The facility policy Environmental Safety & Monitoring, effective 02/01/2026, documented the facility was to provide an environment that is as free from accident hazards as possible. All chemicals were to be labelled and stored in locked/secured areas. Staff received education on accident prevention and demonstrated competency in identifying and reporting hazards. Resident #12 had diagnoses including dysphagia (difficulty swallowing), feeding difficulties, and multiple sclerosis (disease that causes muscle weakness). The 06/19/2026 Minimum Data Set assessment documented the resident was cognitively intact, required supervision or touching assistance with eating, and received a mechanically altered diet. The Comprehensive Care Plan initiated 12/09/2024 and revised on 10/29/2025 documented the resident required substantial/maximal assistance for feeding tasks and to encourage the resident to be out of bed for all meals for optimal positioning. The Comprehensive Care Plan initiated on 12/10/2024 and revised on 06/22/2026 documented the resident had chewing and swallowing difficulty related to dysphagia and self-feeding difficulty related to multiple sclerosis. Interventions included regular diet with pureed consistency, two handled sip cups, and no straws. The 05/22/2026 Speech Language Pathologist #11 evaluation and plan of treatment documented the resident had dysphagia and would continue to receive pureed consistency, thin liquids, full supervision at meals, and continue to use sip cups for pacing. The current Kardex (care instructions) documented substantial/maximal assistance for feeding tasks, regular diet, pureed consistency, thin liquids, and two handled sip cups with no straws. During an observation on 06/24/2026 at 1:12 PM, Certified Nurse Aide #24 brought in the resident's lunch tray, set the tray on the bedside table in front of the resident, and exited the room. The resident's lunch meal tray ticket documented two handled sip cups, no straws. Certified Nurse Aide #25 entered the room holding a red two handled mug with a lid and a straw. They placed 4 two handled red mugs with lids and straws on the bedside table, within reach of the resident, and exited the room. No assistance was provided to the resident. At 1:20 PM, Certified Nurse Aide #25 entered the resident's room holding a two handled clear cup filled with water, with a lid and a straw, and placed it on the resident's bedside table then exited the room. During an observation and interview on 06/25/2026 at 12:13 PM, Resident #12 was lying in bed and had a two handled clear cup with a lid and a straw full of water on their bedside table. They stated they thought they were allowed to use straws because nursing staff always put them in their cups. They stated they had been using straws for a long time. During an observation on 06/25/2026 at 12:51 PM, Resident #12 was sitting up in bed eating lunch that was set up on their bedside table in front of them. The resident's lunch meal ticket documented two handled sip cups, no straws. Certified Nurse Aide #26 was seated in a chair on the left side of the resident's bed. There were five separate two handled red mugs with lids and straws. The resident stated everything on their lunch tray was put into a separate mug by Certified Nurse Aide #26. During an interview on 06/25/2026 at 1:08 PM, Certified Nurse Aide #26 stated Resident #12 required maximal assistance with meals which meant they had to stay in the room with them while they ate but if they used a cup with a handle, lid, and a straw they were able to drink by themselves if it was placed in front of them. They were not aware the resident's meal ticket and Kardex documented no straws. The resident used straws for a while. They stated they were unsure why it would say no straws because the resident did not require thickened liquids and residents who had thickened liquids were not allowed to have straws because they could choke. Resident #12 was not at risk for choking. During an interview on 06/25/2026 at 1:35 PM, Speech Language Pathologist #11 stated they evaluated Resident #12 in 05/2026. They recommended two handled sip mugs with no straws because the resident had dysphagia and was having signs of aspiration (inhalation of food, fluids, or secretions into the airway). No straws was still their current recommendation to maintain aspiration precautions. An order for aspiration precautions with no straws was not needed because they had documented no straws in their evaluation notes, it was on the resident's care plan, Kardex, and meal tickets. They were not aware Resident #12 was using straws and if they continued to use them it put them at risk for aspiration. During an interview on 06/26/2026 at 9:48 AM, Licensed Practical Nurse Unit Manager #27 stated certified nurse aides were responsible for checking the resident's care plan or Kardex to know what kind of feeding assistance the resident required. Any staff who passed a meal tray was responsible for checking the meal ticket to ensure the residents diet, food consistency, and any adaptive equipment was correct. Resident #12 was not supposed to have straws because they were at risk for aspiration. During an interview on 06/26/2026 at 10:01 AM, Certified Nurse Aide #25 stated they provided Resident #12 with straws in their drinks all week and they thought the resident only required setup assistance with meals. They stated if they looked at Resident #12's Kardex and meal ticket they would have known the resident was not allowed to use straws and required substantial/maximal assistance for feeding. During an interview on 06/26/2026 at 10:14 AM, Registered Nurse Unit Manager #14 stated Resident #12 was not supposed to get straws due to being a risk for aspiration and staff should have supervised and assisted them while eating because they required maximal assistance with meals. Thermometer and Chemical Storage: During an observation on 06/24/2026 at 12:05 PM in the [NAME] kitchenette, Dietary Services Aide #55 took an analog thermometer out of a large glass jar with holes in the top. The jar contained two thermometers with a label that read sink and surface cleaner sanitizer. Dietary Services Aide #55 placed the thermometer directly into the spinach to take the temperature and did not wipe off the thermometer. They placed the thermometer back into the jar and took a second thermometer out of the jar and took the temperature of a large pan of lasagna. They proceeded to repeat the process for the small pan of lasagna, the pureed lasagna, a hot dog and the pureed spinach. They did not wipe off the thermometer after removing it from the cleaning jar. The following observations were made on 06/24/2026 of the containers of cleaning solution containing thermometers: -at 1:27 PM in the [NAME] unit kitchenette the product label sticker documented the solution was sink and surface cleaner and sanitizer. The label had a warning label for eye irritation and clothing contact -at 1:39 PM in the [NAME] unit kitchenette there was a large plastic container with poked holes in the lid with a sink and surface cleaner and sanitizer product label sticker -at 1:43 PM in the [NAME] unit kitchenette there was a glass shaker container with a product label for a food contact sanitizer, for restaurants, food handling and process areas, wineries, federally inspected meat and poultry plants, bars and institutional kitchens. The warning label documented hazardous to humans and domestic animals due to being corrosive. It could cause irreversible eye damage, skin burns, may be fatal if inhaled and harmful if swallowed or absorbed through the skin. -at 2:55 PM in the Aspen unit kitchenette there was a container of solution with a product label sticker for surface cleaner and sanitizer During an observation on 06/25/2026 at 9:45 AM the [NAME] Unit kitchenette had a large glass shaker container with two analog thermometers and two digital thermometers, and the label read for Sani-t-10 Plus (food contact sanitizer). During an interview on 06/24/2026 at 1:30 PM Dietary Services Aide stated the solution decontaminated the thermometers, but they did not know exactly what was in it. At night they brought the whole jar down to the kitchen and it was washed and filled back up. They did not know if every unit had the solution. During an interview on 06/24/2026 at 2:55 PM, Dining Services Aide #56 stated they were supposed to be using the new digital thermometers as opposed to the analog thermometers in the solute as they were more accurate. When the thermometers in the solution were used the process was to take the thermometer out of the solution, wipe it off, take the temperature, wipe off the thermometer again and place it back into the solution. The thermometer should never be taken from the solution and stuck directly into the food. During an interview on 06/24/2026 at 3:07 PM, the Director of Dining Services stated they preferred if staff was using the new digital thermometers which were wiped off with a disposable probe wipe but if they were using the analog thermometers, they should take the thermometer out of the solution, wipe off the thermometer with a clean cloth or power towel, take the food temperature, wipe off the thermometer again and then put it back into the sanitizer solution. They did not believe the solution was safe to stick the thermometer directly into food without wiping it off. The solution in all the containers was Sani-t-10 Plus. They were not aware some of the containers did not have the correct chemical label on the containers, but they should be labeled properly. 10 New York Codes, Rules and Regulations 415.12(h)(1)(2)

Based on observations and interviews, the facility failed to ensure there was an effective pest control program for one of one main kitchen. Specifically, rodent droppings were observed in the dry storage area of the main kitchen. Findings include:The facility policy Pest Control, revised 10/25/2022, documented the facility would assure the safety and wellbeing of residents, team members, and visitors by eradicating and containing common household pests on a regular basis. A local pest control agency made monthly visits to treat the building both inside and outside for pests. If staff saw any type of pests, the pest control agency would be notified for more frequent treatment of pests until the situation was resolved.During an observation in the main kitchen on 06/25/2026 at 10:14 AM, the floor underneath the dry storage metal racks had black oblong pellet-looking debris surrounded by oats. During an interview on 06/25/2026 at 10:18 AM, [NAME] #7 stated the dry storage area was cleaned by staff daily, however it was not assigned to a specific shift. They were not aware of any pest control issues in the kitchen or dry storage area. During an observation and interview on 06/25/2026 at 10:20 AM, Food and Nutrition Manager #8 stated they were responsible for completing rounds in the kitchen and rotated throughout the kitchen. The night shift staff was responsible for sweeping and mopping the entire kitchen area including the dry storage area, and the night shift cook was responsible for ensuring the task was completed. They never saw issues with pests in the kitchen or dry storage area. Pest control came in often. After looking in the dry storage area they stated the black oblong pellet-looking debris were mouse droppings they believed came from the ceiling during an electrical repair.During an observation and interview on 06/25/2026 at 10:30 AM, the Food Service Director stated the floors were supposed to be cleaned nightly. They did not think staff were cleaning under the racks, just the exposed flooring. Oats were not stored in that area so they were unsure why they were on the floor under the racks, and the black oblong debris should not be on the floors under the wire racks. They stated about three weeks ago the facility rewired through the ceiling for maintaining heated carts and the racks were pulled away from the wall. Mice were found in the ceiling during that process, and the debris could have come from the mice located in the ceiling. 10 New York Codes Rules and Regulations: 415.29(j)(5)

Based on observations, record review, and interviews, the facility failed to ensure each resident received special eating equipment as required for one of seven residents (Resident #132) reviewed. Specifically, Resident #132 was not provided with sip cups as planned. Findings include:The facility policy Adaptive Equipment, last reviewed 11/24/2025, documented residents were provided with adaptive equipment as required or preferred. The resident's meal ticket was updated with the adaptive equipment to be provided, and the care plan was updated and linked to the Kardex (care instructions). Resident #132 had diagnoses including dementia and difficulty swallowing. The 06/11/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had severe cognitive impairment, required supervision or touching assistance with eating, and was on a mechanically altered diet. The Comprehensive Care Plan initiated 04/14/2025 and revised 05/18/2026 documented the resident had self-feeding difficulty related to decreased dexterity and need for adaptive equipment to aid with self-feeding. Interventions included food in bowls and sip cups. The 05/30/2026 Speech Language Pathologist #11 evaluation and treatment plan documented the resident was referred to speech therapy after nursing reported the resident was coughing with intakes. The resident required full supervision at meals for extensive prompting for pacing. During observations on 06/22/2026 at 12:12 PM and 06/23/2026 at 12:13 PM, the resident was eating lunch in the dining room. Their meal tickets documented food in bowls and sip cups. They were provided with regular cups and no sip cups. During an interview on 06/24/2026 at 10:48 AM, Certified Nurse Aide #12 stated they were responsible to ensure meal tickets were checked for accuracy. If a resident required adaptive equipment, it was on their meal ticket. The sip cup was different than a regular cup, it had two handles and a lid. Nursing provided the sip cups to the residents. During an interview on 06/24/2026 at 10:58 AM, Licensed Practical Nurse #15 stated if a resident required adaptive equipment, it was on their meal ticket. They stated a sip cup had two handles and a lid and food service put them on the meal trays. They did not think Resident #132 required any adaptive equipment for meals. During an interview on 06/25/2026 at 10:02 AM, Licensed Practical Nurse Assistant Unit Manager #13 stated Resident #132 required a sip cup which was a two handled mug with a spout lid. The Kardex (care instructions) told the staff if a sip cup was required as well as the meal ticket. They did not know why the resident did not get their sip cups as planned. 10 New York Codes, Rules, and Regulations 415.14(g)

Based on observations and interviews (iQIES #2730965), the facility failed to ensure a safe, clean, comfortable, and homelike environment for one of five units (Maple unit) reviewed. Specifically, the Maple Unit dining room ceiling leaked. Findings include:The facility policy Maintenance and Repairs, last reviewed 05/15/2025, documented the facility ensured all units were free of all hazards and maintained in good repair. Regular audits of the building were conducted and assured the building was in optimal condition and supported a safe and well-maintained environment.The following observations were made of the Maple unit dining room:-On 06/22/2026 at 12:17 PM, there was a ceiling tile above a table that seated eight residents and 75% of the tile was stained brown. At 4:18 PM, it was raining outside, and the stained ceiling tile was dripping. There was no receptacle to collect the drainage and no wet floor sign. There was an approximately 2 feet by 2 feet puddle on the floor. There was one resident watching television in the dining room.-On 06/23/2026 at 8:29 AM, the stained ceiling tile bowed out from the ceiling approximately 3 inches. Residents were eating breakfast at the table under the ceiling tile.-On 06/25/2026 at 1:30 PM, the stained ceiling tile bowed out from the ceiling approximately 3 inches. Residents were playing bingo at the table under the ceiling tile.During an interview on 06/26/2026 at 11:08 AM, Certified Nurse Aide #38 stated the dining room ceiling leaked sometimes when it rained. When that happened, they had to move the table under the leak and maintenance took the tile out and placed a big garbage can under it. It was a while since they had seen the ceiling leak. The residents complained about the leaks if they were during an activity or a meal. Ceiling leaks were not homelike.During an interview on 06/26/2026 at 11:30 AM, the Director of Plant Operations stated there was a leak in the Maple unit dining room after the spring thaw. The roof was old. They were not informed of a leak this week. They observed the stained ceiling tile in the dining room and stated it was the same area that previously leaked and there was a lot of ductwork and vents in that area of the roof. It was not homelike to have a leaking ceiling in the dining room. 10 New York Codes, Rules, and Regulations 415.29(i)(1)

Based on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for two of four residents (Residents #3 and #116) reviewed. Specifically, Residents #3 and #116 had diagnoses of dementia and there was no documented evidence of individualized behavioral care plans with person-centered interventions to assist staff in managing the residents' care. Findings include: The facility policy Dementia - Clinical Protocol, last reviewed 03/01/2026, documented for the individual with confirmed dementia, the interdisciplinary team will identify a resident-centered care plan to maximize remaining function and quality of life. The interdisciplinary team will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. The interdisciplinary team will adjust interventions and the overall plan depending on the individuals' responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in the resident or family wishes, etc. Nursing assistants will receive training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually. 1) Resident #3 had diagnoses including dementia, mood disturbance, and anxiety disorder. The 05/20/2026 Minimum Data Set assessment documented the resident severe cognitive impairment, wandering behaviors 4-6 of 7 days that intruded on the privacy or activities of others, was independent with mobility and needed some help in functional cognition and self-care. The Comprehensive Care Plan initiated on 05/20/2026, documented:-Resident had impaired communication related to dementia and being hard of hearing. Interventions included providing a safe environment by having call light within reach, the bed in lowest position with wheels locked, face resident and make eye contact when speaking.-Resident had Dementia. Interventions included allowing adequate time for task completion without rushing or correcting unless safety is at risk and encourage meaningful engagement, routine, and reduced frustration through Montessori-based activities (Focus on utilizing simplified tasks, visual cues, and muscle memory to foster independence and purpose).On 06/11/2026 the resident was risk for changes in mood and behaviors related to depression and anxiety. Interventions included one to one visits/conversations, listening to music, speak in a calm manner and provide a program of activities that is of interest and accommodates residents' status. Licensed Practical Nurse #32 progress notes documented the following: -the evening shift (3:00 PM to 11:00PM) on 06/08/2026, 06/09/2026 and 06/11/2026, the resident was wandering in and out of other resident rooms, upsetting and agitating other residents. The resident was very difficult to redirect. -the evening shift on 06/15/2026, the resident was exit seeking and banging on exit doors. -the evening shift on 06/16/2026 and 06/17/2026, the resident was rude and swearing at staff and other residents and was upsetting and agitating other residents. The resident was very difficult to redirect and was wandering into other resident rooms. -the evening shift on 06/18/2026, the resident was rude and swearing at staff and other residents, upsetting and agitating other residents and was difficult to redirect. They were wandering in and out of other resident rooms and was self-transferring. They reminded the resident to ask for help with transfers. The 06/20/2026 Licensed Practical Nurse #37 progress notes documented during the day shift the resident self-transferred onto toilet and was calling staff names after they were asked to stay near the nursing station so they would not self-transfer. The 06/20/2026 Licensed Practical Nurse #33 progress documented during the evening shift (3:00 AM - 11:00 PM) the resident was being rude and disruptive. They were yelling repeatedly for help, calling staff and other residents' names and asking to go to their room during the dinner hour. There was no documented evidence of person-centered interventions for Resident #3 when they exhibited behavioral symptoms. The following observations and interviews were made: -on 06/23/2026 at 12:58 PM the resident tried to find their room and asked for assistance. Certified Nurse Aide #47 stated the resident was not allowed to be in their room alone due to being a fall risk and for their safety. Certified Nurse Aide #47 brought the resident to their room to perform personal care then brought the resident back to the community area. -on 06/24/2026 at 12:47 PM, the resident asked the surveyor where their room was and stated they wanted to go to their room. Certified Nurse Aide #47 stated the resident could not be in their room alone and the resident's room door was closed. -on 06/25/2026 at 9:59 AM, the resident asked to go to their room and wanted to know where their room was. Certified Nurse Aide #47 told the resident they could not go to their room right now. At 10:07 AM, the resident asked where their room was and if they could go to their room. Registered Nurse #14 stated they could not be in there by themselves because they would end up on the floor. At 1:09 PM, the resident was in the room next to their room going through the closet. Their room door was closed. At 1:32 PM, the resident was going into their room and Unit Secretary #51 directed them to the nurses' station and told the resident they needed someone to go with them to their room. Unit Secretary #51 got the resident a cup of coffee after the resident requested one. The resident's room door was closed. During an interview on 06/26/2026 at 10:25 AM, Certified Nurse Aide #47 stated they received dementia specific training online or in person. When a resident was having behaviors, they would try to calm them down, try to redirect them, or get a nurse. They should look at the Kardex (care instructions) for guidance. They thought a resident had the right to go into their room, but they were told to keep Resident #3 out of their room for safety reasons. Registered Nurse #14 told them to keep the residents door closed. During an interview on 06/26/2026 at 10:01 AM, Licensed Practical Nurse #35 stated if a resident was having behaviors, they should try to redirect them and refer to the Kardex for interventions. The registered nurse unit manager was responsible for care plans and adding the interventions. Residents had a right to be in their room and staff cannot shut the door to keep them out. They heard other staff tell Resident #3 they could not be in their room. They had not received any dementia specific training. During an interview on 06/25/2026 at 3:41 PM, Licensed Practical Nurse #32 stated they had not received any dementia specific training. The interventions they used for behaviors such as screaming, exit seeking and resident to resident conflict included trying to get them away from other residents, and removing them from the space. They should look at the care plan, progress notes or ask the supervisor for guidance. They stated Resident #3 had typical behaviors like screaming and yelling to go to their room. They brought the resident to their room, and it calmed the resident down by looking at familiar things like pictures and a pocketbook. They stated staff should encourage the resident to stay out of their room but should not prevent them from going into their room. During an interview on 06/26/2026 at 11:43 AM, Registered Nurse #14 stated the social worker usually initiated a behavior care plan, put in behavior interventions if needed, and staff would look at them for guidance. There was a dementia training course they went to, but they had not heard anything about it in a while. Closing a resident's door was not a common intervention used for fall prevention or wandering behaviors. They thought it was against residents' rights to keep them from going into their room and they saw residents being kept out of their rooms by closing the door. They stated Resident #3 was not care planned for keeping the door closed because it was not allowed. During an interview on 06/25/2026 at 3:51 PM, Social Worker #31 stated anyone on the interdisciplinary team could initiate and develop a behavioral care plan. If a resident was having wandering behaviors, they would distract them, have them participate in an activity, or provide snacks or music. Resident doors should not be kept closed to prevent them from going into their room. They knew some residents had safety concerns so they would try to prevent falls and encourage them to engage in activities. 2) Resident #116 had diagnoses including dementia and anxiety. The 06/11/2026 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject care, required supervision or touching assistance for eating, and was dependent on all other activities of daily living. The Comprehensive Care Plan documented: -04/01/2026 the resident had a self-performance deficit related to cognitive impairment/physical impairment. Interventions included providing supervision/touching assistance for feeding and verbal cueing for initiation, sequencing, and motor planning. -04/04/2026 the resident had the potential for changes in mood/behaviors related to dementia. Interventions included explaining all procedures to the resident before starting, allowing the resident time to adjust to the changes and to speaking in a calm manner. -06/22/2026 impaired cognitive function related to dementia. Interventions included administering psychotropic medications, utilizing their therapy doll and pet, asking yes or no questions, and presenting one thought or question at a time. The following observations of Resident #116 were made on 06/22/2026. At 12:34 PM, the resident received their lunch tray. They tried to bring the spoon to their mouth but could not feed themselves due to food spilling off the utensils. No staff assistance was provided. At 12:43 PM, Certified Nurse Aid #49 sat down to assist the resident and tried to put the spoon in front of the resident's mouth. The resident yelled at them to go away. The resident was not offered additional assistance. At 12:46 PM, the resident laid their head on the table, picked up their spoon and tried to eat independently but was not successful. At 12:55 PM, Certified Nurse Aide #49 pulled the resident away from the table and tilted them back in the chair without communicating with the resident. The resident almost dropped the spoon and Certified Nurse Aide #49 stated that they did not know they had the spoon. The resident received one bite of food during lunch and had no fluid intake. The following observations of Resident #116 were made on 06/23/2026. At 12:11 PM, Licensed Practical Nurse #35 delivered the resident's lunch tray, took the food off the tray, put the food on the table, and woke the resident to tell them the food was there. The resident fell back to sleep. At 12:36 PM, Certified Nurse Aide #48 woke the resident up, sat next to them at eye level, and offered them milk and juice. The resident refused the milk and juice and stated they did not want anything. At 12:47 PM, Certified Nurse Aide #48 sat with resident and asked if they wanted to eat anything. They offered the resident a sip of their drink and the resident stated they did not want it. Certified Nurse Aide #48 got up and left the resident. The resident looked around not attempting to eat. The table was out of the resident's reach. At 1:12 PM, Licensed Practical Nurse #35 removed the resident from the dining room without offering drinks or food. The resident did not consume any food or drinks. During an observation on 06/24/2026 at 9:34 AM, the resident was in the dining room with their breakfast tray in front of them. The resident had a spoon with a small amount of cream of wheat above their head and the spoon was in their hair. Licensed Practical Nurse #35 asked if they were done eating and the resident yelled and asked why they were calling them by their name. The resident's drink cups and food bowls were untouched. During an interview on 06/26/2026 at 9:43 AM, Certified Nurse Aide #48 stated they looked at the top of the meal ticket to know what kind of assistance a resident needed. If a resident was not successful with eating independently, they should let the nurse know and request an assessment. If a resident was not feeding themselves, they should encourage them first and then offer assistance. It depended on Resident #116's mood if they would eat or drink, and some days they would eat if staff sat with them. During an interview on 06/26/2026 at 10:01 AM, Licensed Practical Nurse #35 stated they should look in the Kardex to see what level of assistance a resident needed. If a resident refused to eat, they would let them refuse after they tried to reapproach them. During an interview on 06/26/2026 at 11:43 AM, Register Nurse Unit Manager #14 stated if a resident required supervision/touching assistance for eating they expected staff to cue the resident, sit with them and keep them in a visible area. 10 New York Codes, Rules, and Regulations 415.12

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #29) reviewed. Specifically, Resident #29 was on transmission-based precautions (contact precautions) and staff were observed entering the resident's room without wearing the required personal protective equipment. Findings include:The facility policy Contact/ Droplet Precautions (Transmission Based Precautions), last reviewed 05/15/2024, documented precautions were immediately put into place upon suspicion of any communicable infection. Contact personal protective equipment was recommended for healthcare workers prior to the room being entered of suspected or confirmed infections. A sign was placed on the resident's door and indicated what types of personal protective equipment was utilized before entering the resident's room. The facility's Contact Precaution signage posted on resident room doors documented everyone must clean their hands before entering and when leaving the room, and gown and glove at the door; doctors and staff must use patient-dedicated or disposable equipment and clean and disinfect shared equipment. Resident #29 had diagnoses including extended-spectrum beta-lactamase (ESBL) resistance (an antibiotic-resistant bacteria). The 05/21/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had severe cognitive impairment, was dependent for toileting hygiene, and was frequently incontinent of urine. The Comprehensive Care Plan initiated 02/06/2026 documented the resident was on contact precautions related to extended-spectrum beta-lactamase in the urine. Interventions included contact isolation. During an observation and interview on 06/24/2026 at 9:30 AM, Certified Nurse Aide #19 entered the resident's room and picked up their breakfast tray. There was a contact precaution sign on their door. They did put on personal protective equipment prior to entering the room. They stated they knew what precautions a resident was on by reading the sign. The resident was on contact precautions, so they only needed to wear a gown and gloves when they provided patient care and did not need to if they just went in the room to grab the meal tray. During an observation on 06/24/2026 at 10:24 AM, Certified Nurse Aide #12 entered the resident's room, they picked up and rearranged items up in the room without any personal protective equipment on. There was a contact precaution sign on their door. During an interview on 06/25/2026 at 10:02 AM, Licensed Practical Nurse Assistant Unit Manager #13 stated contact precaution required a gown and gloves to be put on prior to entering the resident's room or maybe just with personal care. They were not sure what the difference was between contact precautions and enhanced barrier precautions. They stated the Infection Preventionist posted the signage for precautions. During an interview on 06/25/2026 at 10:38 AM, the Infection Preventionist stated staff knew what personal protective equipment to wear based on the sign on the resident's door. They were responsible for posting the correct signs on the doors. Extended-spectrum beta-lactamase (ESBL) required contact precautions and staff needed to put on personal protective equipment any time the room was entered. Enhanced barrier precautions only required personal protective equipment when providing hands on care. If a resident was on contact precautions, it was not acceptable to pick up a meal tray or rearrange items in a resident's room without the required personal protective equipment. They stated staff were educated annually. 10 New York Codes, Rules, and Regulations 415.19(a)(b)

Based on observations, record review, and interviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/ or prevent further decrease in range of motion and proper positioning for one of three residents (Resident #132) reviewed. Specifically, Resident #132 did not have their supportive device (wedge pillow) for their wheelchair for proper positioning as planned. Findings include: The facility policy Repositioning and Pressure Relief, last reviewed 03/25/2025, documented the interdisciplinary team developed and updated individualized repositioning interventions in the resident's care plan. Appropriate positioning devices such as pillows and wedges were used as indicated and promoted proper body alignment and enhanced resident comfort.Resident #132 had diagnoses including stroke and abnormal posture. The 06/11/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had severe cognitive impairment and was dependent on most activities of daily living.The Comprehensive Care Plan initiated 04/15/2025 and revised 03/04/2026 documented the resident had a self-performance deficit related to activity intolerance and dementia. Interventions included providing a scoot chair for locomotion and placing a wedge pillow on their right side when seated to promote proper positioning. The 03/13/2026 Occupational Therapist #10 summary of daily skilled services documented the resident had a severe right sided lean with a poorly placed wedge cushion. The resident needed to be repositioned with wedge cushion to reduce right-sided lean as resident was unable to maintain an upright position.During an observation on 06/22/2026 at 12:10 PM, Resident #132 was slumped to their right side while eating. The resident was coughing while consuming their food. At 12:20 PM, the resident was in their scoot chair in the dining room slumped to the right side and coughed eight times in 10 minutes. At 12:28 PM, Licensed Practical Nurse Assistant Unit Manager #13 brought a wedge cushion over and positioned the resident in an upright position.During an interview on 06/24/2026 at 10:48 AM, Certified Nurse Aide #12 stated they knew if a resident needed positioning cushions by the way they sat, and therapy decided what cushions were used. Residents should be seated at a 90-degree angle when eating so they did not aspirate (inhale food/fluids into lungs). Resident #132 had a wedge cushion because they favored their right side and without the cushion they did not stay upright. Adaptive equipment was listed on the care instructions and on the meal tickets for those required during mealtimes.During an interview on 06/24/2026 at 10:58 AM, Licensed Practical Nurse #15 stated if they saw a resident leaning, they called therapy and they provided a cushion. Residents should be seated upright to eat. Resident #132 used the cushion because they leaned to the side.During an interview on 06/25/2026 at 9:50 AM, Occupational Therapist #10 stated residents were positioned upright, neutral, and midline for eating because it promoted safe swallowing and increased their ability to participate in eating and self-feeding. Resident #132 had a wedge that went to the right side of the scoot chair to ensure proper positioning. 10 New York Codes, Rules, and Regulations 415.12(e)(2)

Based on observations and interviews, the facility failed to ensure each resident had the right to exercise their rights as a citizen or resident of the United States to include sending and receiving mail and to receive letters, packages, and other materials delivered to the facility for all 164 of 164 residents residing in the facility. Specifically, mail was not delivered to residents on Saturdays.Findings include: The facility policy Resident Rights, last reviewed 04/08/2024, documented the facility would assure all federal and state laws that guaranteed rights of the resident were followed. Those rights included access to a telephone, mail, and email.During an anonymous resident group meeting on 06/23/2026 at 2:04 PM, seven anonymous residents stated they did not receive mail delivery on Saturdays.During an interview on 06/25/2026 at 1:25 PM, Receptionist #36 stated they received the mail in the evening, separated it by units and put it in bins. Someone from central supply would deliver it to the residents the following morning. On Fridays they separated the mail and most of the time waited until Monday to deliver it to the residents because they did not have anyone available on the weekends to deliver it. If Monday fell on a holiday Friday's mail would not get delivered until Tuesday.During an interview on 06/25/2026 at 3:40 PM, the Administrator stated they were not aware mail was not being delivered to the residents on Saturday. They stated it was a resident right so mail should be delivered on Saturdays. 10 New York Codes, Rules and Regulations 415.23(e)(2)(i)

Based on observations and interviews, the facility failed to ensure the results of the most recent Federal and State surveys were posted in a place readily accessible where individuals who wished to examine the survey results did not have to ask for them. Specifically, the facility State survey binder located in the main lobby did not include the most recent abbreviated (complaint) survey results from 05/09/2025 and was located behind a table and chair that was not readily accessible to all residents, family members, and legal representatives of residents.Findings include: The facility policy Resident Rights, last reviewed 04/08/2024, documented the facility would assure all federal and state laws that guaranteed rights of the resident were followed. Those rights included the right to examine survey results.The following observations were made: -on 06/23/2026 at 2:46 PM, the facility state inspection binder was on the wall in the main lobby and was blocked by a table and a chair. The table had pamphlet holders and a vase full of flowers on it. The binder was difficult to reach from a standing position while having to reach over the table. The binder was not readily accessible and was missing the most recent complaint survey results from 05/09/2025. -on 06/25/2026 10:56 AM, the facility state inspection binder was on the wall in the main lobby that was blocked by a table and a chair. The table had a tall vase of flowers blocking the binder from view. The binder was difficult to reach from a standing position while having to reach over the table. The binder was not readily accessible and was missing the most recent complaint survey results from 05/09/2025.During an interview on 06/25/2026 at 10:56 AM, Receptionist #36 stated if a resident or family asked to see the State inspection binder they would send them to the Director of Nursing. They were not aware the binder in the lobby contained survey inspection results. The flowers were not normally on the table, so they thought the binder was accessible. They stated it would be difficult for residents in wheelchairs to reach the binder without asking for assistance.During an interview on 06/25/2026 at 3:40 PM, the Administrator stated they were responsible for updating the state inspection binder and they had not worked at the facility long enough to be involved in a state survey. They were not aware the most recent complaint survey results were supposed to be posted in the binder. The binder's current location was not easily accessible to all residents without having to ask for assistance. 10 New York Codes, Rules and Regulations 415.3(1)(c)(1)(v)

Based on observations, record review, and interviews, the facility failed to ensure a process was in place for residents to have their grievances addressed for 164 of 164 residents residing in the facility. Specifically, five of seven anonymous residents present at the resident group meeting stated they did not know if there were grievance forms or where they were located, their right to file grievances anonymously, or who the Grievance Officer was. Information on how to file a grievance and grievance forms were not available to the residents and the facility did not have a process for residents to file an anonymous grievance. Findings include: The facility policy Grievance Policy, last reviewed 03/27/2025, documented grievances could be expressed orally or in writing to the Grievance Officer, social workers, nursing supervisors, or unit managers. Grievance forms were available in social work offices, nursing supervisor offices, and unit manager offices. The notice on Grievances was to include how to file a grievance, the right to file orally or in writing, the right to file anonymously, contact information for the designated Grievance Official, a reasonable timeframe for completing the review of the grievance, and the resident's right to obtain a written decision regarding the grievance. Additional notices of the facility grievance process will be displayed in prominent locations throughout the facility. The 2025 grievance log documented two grievances for the year.There were no documented grievances for 2026.During a resident group meeting on 06/23/2026 at 2:03 PM, three anonymous residents stated they did not know who the grievance officer was, and five anonymous residents stated they did not know how to file a grievance or that they could do so anonymously.On 06/25/2026 from 9:29 AM to 10:05 AM resident units Maple, Aspen, [NAME], [NAME], and [NAME] were observed to have no signs on the process for filing a grievance, who the Grievance Officer was, grievance forms available to residents, or a way to file a grievance anonymously.During an interview on 06/25/2026 at 12:15 PM, Certified Nurse Aide #40 stated if a resident wanted to file a grievance, they should let the nurse supervisor, or the social worker know. They did not know of any grievance forms available on the units. They were unsure how a resident filed a grievance anonymously.During an interview on 06/25/2026 at 12:23 PM, Unit Secretary #41 stated the resident could call the Ombudsman or talk to the charge nurse to file a grievance. They were unsure where the residents obtained form to file a grievance.During an interview on 06/25/2026 at 12:32 PM Licensed Practica Nurse Unit Manager #27 stated if a resident wanted to file a grievance the numbers for the Ombudsman were posted and a facility grievance form could be obtained through social work. They believed the only way to file anonymously was to obtain the form from social work. During an interview on 06/25/2026 12:42 PM, the Director of Social Services stated grievances forms were posted throughout the units and when the grievance was filled out, the forms came to them as the Grievance Officer. The forms were usually at the nurses' station and had to be requested by the person wanting to file the grievance. They were also on the shared drive that staff had access too. Anonymous grievance forms could be completed by honoring the resident's wishes and not putting their name on the form or going through the Ombudsman program. There was nowhere in the facility for an anonymous grievance to be placed, only to hand it to a staff member. Residents and families were notified of the grievance process at admission but there was a lot of information given to them at that time.During an interview on 06/25/2026 at 3:40 PM, the Administrator stated they did not know if they had any grievance forms available for residents without talking to or asking staff. Anonymous grievances could be filed through the Ombudsman. They believed residents were informed of the grievance process through the social work department, but they did not know how often. They were aware it was a resident right to be able to file an anonymous grievance through the facility. 10 New York Codes, Rules, and Regulations 415.3(C)(1)(ii)

Based on record review and interviews during the abbreviated survey (NY00379334), the facility failed to ensure residents received treatment and care according to professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 developed abdominal distention with pain, had one bowel movement in 6 days, was provided bowel medications without a physician order, and was not assessed by a qualified professional in a timely manner. Subsequently, Resident #1 was hospitalized for a bowel obstruction requiring emergency surgery. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. Findings include: The facility policy, Bowel Management Protocol, reviewed 3/21/2021, documented certified nurse aides documented bowel movements into the electronic medical record. The licensed nurse monitored the electronic medical record dashboard for alerts of residents with no bowel movements in 72 hours and would initiate the bowel protocol. If no bowel movement for three (3) days, prune juice would be given, then milk of magnesia on the 2nd shift, then a suppository on the 3rd shift. Abnormal findings would be reported to the physician. If findings were normal, a suppository would be given rectally, and results documented in the electronic medical record. For residents with a history of chronic constipation, nursing was to consult with the physician and dietitian for bowel interventions. The facility policy, Notification of Resident Conditions to Providers reviewed 10/25/2022 documented nursing would notify the resident, resident's physician and family representative for a significant change in the resident's physical status that is a deterioration in their health, including non-immediate no bowel movements for three (3) days with a distended abdomen and other abdominal symptoms. Resident #1 had diagnoses including Parkinson's Disease, (a progressive neurological disease), dementia, and constipation. The 1/29/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, required setup/clean up assistance with eating, had no weight loss, required a therapeutic diet, and required substantial/maximum assistance for toileting, had frequent bladder incontinence and was always continent of bowel. The Comprehensive Care Plan initiated 8/5/2024 and resolved (discontinued) 12/30/2024 documented Resident #1 had a history of constipation related to Parkinson's Disease. Interventions included: follow the facility bowel protocol, monitor medications for side effects of constipation, keep the physician informed of any problems, monitor/document/report any signs or symptoms of complications related to constipation (change in mental status, sleepiness, inability to maintain posture, agitation, slow/low pulse, abdominal distension, vomiting, small or loose stools). Physician orders documented: - on 8/5/2024, bowel routine as per policy. - on 8/5/2024, MiraLAX oral powder (a laxative used for constipation), 17 grams per scoop, give 1 scoop by mouth once a day for supplement, mix with 9 ounces of juice or water. - on 8/6/2024, Senokot-S tablet, (sennosides-docusate sodium, a stool softener combined with a laxative) 8.6/50 milligrams, give 2 tablets by mouth one time a day for constipation. - on 8/6/2024, Dulcolax suppository (a laxative in suppository form), insert 1 suppository rectally once a day every 3 days to regulate bowel movements. The 1/29/2025 Registered Dietitian #13 quarterly nutritional assessment documented the resident had a decline in their meal intake and had consumed an average of 937 milliliters of fluids during meals, leaving 25% on their tray. Interventions were initiated to add more fluids. The 1/31/2025 resident care instructions documented Resident #1 required substantial/maximum assistance of one (1) staff with toilet transfers and hygiene and required toileting every two hours. The 3/2025 Documentation Survey Report (daily care log) from 3/5/2025 through 3/10/2025 documented the resident did not have a bowel movement (six days). The 3/1/2025-3/10/2025 Clinical and Order Alerts Listing Report (no bowel movement report) did not contain any documentation related to Resident #1. The 3/8/2025, at 6:00 AM Medication Administration Record documented Resident #1 received a Dulcolax suppository (scheduled) by Licensed Practical Nurse #15. There was no documented evidence a registered nurse assessment was completed, or a medical provider was notified the resident had not had a bowel movement for three days. The 3/8/2025 at 2:04 PM Licensed Practical Nurse #6 progress note documented the resident was on the bowel list, (a list generated if a resident had not had a bowel movement in three days, however the resident was not shown on this list when provided to the surveyor), the resident had some abdominal bloating, bowel sounds were active, and they were given as needed (not scheduled) Milk of Magnesia per the bowel protocol. There was no documented evidence a registered nurse assessment was completed, or the medical provider was notified related to the resident's distended abdomen and no bowel movement. There was no documented evidence the medical provider was notified for an order for the Milk of Magnesia that was provided. The March 2025 Medication Administration Record did not include documentation the Milk of Magnesia was provided, as there was no documented physician order for the medication. The following information related to Resident #1's condition was obtained from staff interviews completed 5/5/2025 to 5/7/2025: - On 3/8/2025 at 6:30 AM, Certified Nurse Aide #5 reported to Licensed Practical Nurse #15 Resident #1's abdomen was hard, bloated, and did not look right. - Licensed Practical Nurse #15 stated they were completing their shift at 6:30 AM on 3/8/2025 (overnight) and passed the information on to Licensed Practical Nurse #6 and advised Licensed Practical Nurse #6 to call a supervisor. - Licensed Practical Nurse #6 was made aware on 3/8/2025 the resident had a suppository with no results and gave the resident Milk of Magnesia. The resident's abdomen was distended, and the resident complained of pain and discomfort. They thought they notified a supervisor but was unsure if an assessment was completed. The nurse stated a physician's order was not required for Milk of Magnesia and was not necessary to document on the Medication Administration Record. - Licensed Practical Nurse #8 worked 3/8/2025 during the 7:00 AM - 3:00 PM shift. The resident's family member discussed the resident's abdomen with them, but Licensed Practical Nurse #8 did not think the resident had any issues. They did not call a supervisor to assess the resident. - Registered Nurse Supervisor #10 was the supervisor on 3/8/2025 from 7:00 AM - 3:00 PM. They were unaware Resident #1 had a change in condition and would have expected to be notified. They did not have documentation Resident #1 was assessed and did not recall being notified for an assessment on their abdomen. - Certified Nurse Aide #3 was assigned to Resident #1 on 3/8/2025 during the 2:00 PM - 10:00 PM shift. The resident's abdomen was noticeably bloated, and the resident did not have a bowel movement all shift. They could not recall if they told a nurse that day. There was no documented evidence a supervisor was notified, or assessment completed on 3/8/2025 related to Resident #1's complaints of discomfort and distended abdomen. The 3/8/2025 at 4:18 PM nursing progress note by Licensed Practical Nurse #7 documented the resident had a large bowel movement. The characteristics of the bowel movement were not documented (loose, formed). There was no documentation related to how Licensed Practical Nurse #7 received the information (per certified nurse aide report or other). The 3/2025 Documentation Survey Report (daily care log) on 3/8/2025 documented the resident did not have a bowel movement. The following information related to Resident #1's condition was obtained from family and staff interviews completed 5/2/2025 to 5/7/2025: - The family representative visited Resident #1 during the weekend of 3/8/2025 - 3/9/2025, their abdomen was bloated, distended, and hard to the touch. The resident complained of abdominal discomfort, constipation, and was squirming. The family representative communicated their concerns to Licensed Practical Nurses #7 and #8. They stated no one came to observe the resident's abdomen and no assessments were completed. - Licensed Practical Nurse #7 stated Resident #1 had a large loose bowel movement on 3/8/2025 on the 3:00 PM - 11:00 PM shift. On 3/9/2025, during the 3:00 PM - 11:00 PM shift the resident complained of discomfort and no bowel movement. The nurse gave the resident prune juice with no results and did not document it. By 11:00 PM, the resident's abdomen was more distended, the resident was complaining of discomfort, and Registered Nurse Supervisor #11 was notified. Licensed Practical Nurse #7 insisted on sending the resident to the hospital as the resident's abdomen was clearly more distended and the resident was uncomfortable, complaining they could not have a bowel movement. Registered Nurse Supervisor #11 declined to assess the resident as the resident had a recent bowel movement and did not think it was necessary based on a previous hospital transport when the diagnosis was only gas. Licensed Practical Nurse #7 disagreed and attempted to advocate for the resident to no avail. - Registered Nurse Supervisor #11 worked double evenings and overnight shifts on weekends. Resident #1 had a history of constipation and received a routine suppository. The resident had a history of complaining about gas and their bowels and the supervisor thought it was behavioral. They were not aware Resident #1 had not had a bowel movement and expected the licensed practical nurses to let them know if the resident had an issue. They would have documented a nursing progress note if they assessed the resident. There was no documented evidence nursing or medical staff addressed concerns related to Resident #1's complaints of discomfort, constipation, or abdominal distention on 3/9/2025. The 3/10/2025 at 4:29 AM progress note entered by Licensed Practical Nurse #7 documented the resident's abdomen was distended, hard to the touch, with bowel sounds, complaints of gas pain. Registered Nurse Supervisor #11 was made aware. The routine gas pill was given, and staff were to continue to monitor for changes in condition. There was no documented evidence of an assessment by a registered nurse or notification of a medical provider following the 3/10/2025 at 4:29 AM progress note. The 3/10/2025 at 8:49 AM nursing progress note by Registered Nurse #9 documented an assessment was performed on Resident #1, bowel sounds were absent, they directed an (unnamed) licensed practical nurse to give Milk of Magnesia, the medical provider was notified, and an x-ray of the kidneys, ureters, and bladder was obtained. The 3/10/2025 at 9:40 AM x-ray report documented critical findings of colonic ileus (paralysis of the large intestine) versus obstruction (blocked intestinal tract), that correlated clinically (symptoms similar, could not differentiate). The 3/10/2025 at 10:44 AM nursing progress note by Registered Nurse #9 documented Resident #1's x-ray results were abnormal, and the resident was sent to the hospital emergency room for evaluation and the family was notified. The 3/10/2025 hospital record documented: - Resident #1 arrived in the emergency room due to abdominal distention, abdominal discomfort, and an abnormal x-ray. The resident complained of constipation and a decreased appetite. - Computed Axial Tomography Scan (a type of imaging that uses X-ray technique to create detailed images of the body) results documented the resident had severe fecal impaction and a dilated (enlarged) intestine. There was evidence a cecal volvulus (a condition where the first part of the intestine twists around itself) and surgical consultation was recommended - Resident #1 was seen for a surgical consult, surgery was recommended to untwist the intestine and remove the blockage. If the surgery was not completed, a life-threatening condition would have occurred where the intestine became ischemic (loss of blood flow to the tissue) and would have also required emergency surgery. - The Surgical Operative Report documented the resident had an open sigmoid resection with an end colostomy (a surgical procedure where the sigmoid colon is removed through an open incision and the remaining portion is diverted to an artificial opening created in the abdominal wall). During an interview on 5/5/2025 at 12:00 PM with Registered Nurse Manager #9, they stated when they arrived for their shift on 3/10/2025 at 7:00 AM, they were alerted by nursing staff Resident #1 had not had a bowel movement in six days. They assessed the resident, and their abdomen was distended to the extent they appeared as if they were going to have a baby, and their abdomen was hard to the touch. Registered Nurse Manager #9 stated Licensed Practical Nurse #7 documented the resident had a large bowel movement, but it was not documented in the point of care documentation, so they questioned it. There was no bowel movement documented for the resident for six days. The facility's bowel management protocol was initiated when a resident did not have a bowel movement for three days. Bowel protocol medications (Milk of Magnesia, suppository) required a physician order. They could not understand how staff did not notice the amount of abdominal distention they had. They were unaware of any assessments on the overnight shift. They notified the medical provider, and an x-ray of their abdomen was ordered. The resident was transferred to the hospital for abnormal x-ray results. Registered Nurse Manager #9 stated the resident should have been assessed at an earlier date and sent to the hospital. It was important to do an assessment because bowel issues could be serious. During an interview on 5/5/2025 at 1:00 PM with Nurse Practitioner #12, they stated a physician order for a bowel protocol was a blanket order that meant if a resident had constipation issues, it could be implemented. Medications on the bowel protocol required a physician order and should be listed on the electronic medication administration records if/when administered. If a nurse had to administer Milk of Magnesia for constipation, they would expect to be notified first, as they would have prescribed an alternative medication such as lactulose (a synthetic sugar used to treat constipation) for Resident #1. Assessments should have been done every other day if a resident had a history of constipation and had been taking multiple bowel medications. They would expect a registered nurse to do an assessment and notify them of any concerns. Resident #1 had sennosides-sodium, Dulcolax suppositories and MiraLAX ordered routinely. There was no physician order for Milk of Magnesia and it was not shown on the electronic medication administration record. If nursing administered Milk of Magnesia, there should have been an order. They were not notified of Resident #1's change in condition and were not aware the resident had not had a bowel movement in six days. They stated Resident #1's bowel medications were not effective and the hospitalization and bowel obstruction was not a planned outcome. During an interview on 5/9/2025 at 1:20 PM, the Medical Director stated Resident #1 had constipation issues from time to time. They expected to be notified if a resident had not had a bowel movement in three days. Resident #1 should have had an abdominal assessment; they expected a registered nurse to do the assessment and report any abnormal findings. Licensed practical nurses could not assess and should have alerted a registered nurse if Resident #1 had not had a bowel movement and had abdominal distention. The Medical Director stated a volvulus occurred when the intestines twisted on itself and caused an obstruction. It could occur from constipation, or the volvulus could occur and cause constipation. The Medical Director stated it was difficult to state a cause, and that even one or two days of constipation could be life-threatening. It was important to notify a medical provider to get an x-ray to determine the seriousness of a resident's condition. 10 NYCRR 415.12

Based on observation, interview, and record review during the recertification survey conducted 8/1/2024-8/7/2024, the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 10 of 10 residents (Residents #2, #18, #53, #58, #59, #66, #67, #101, and #312) reviewed. Specifically, Residents #2, #18, #53, #58, #59, #66, #67, #101, and #312 were previously assessed for appropriate siderail use to improve functional independence and bed mobility, and their siderails were subsequently removed without explanation or replacement of an alternative positioning device. Findings included: The facility policy, Use of Side Rails, originally dated 4/10/2028 and reviewed 7/29/2024 documented the facility was siderail free. All admissions into the facility would be evaluated by the rehabilitation therapy department to assess their ability for mobility and transfer. Upon the results of the therapy evaluation, alternative methods of mobility and transfer would be put into place should the assessment determine the resident needed additional assistance. Should the Interdisciplinary Care Team deem that a siderail was the only alternative and was medically necessary for a resident, the final determination would be made by the Director of Nursing based on documentation and evaluations from the entire Interdisciplinary Care Team. 1) Resident # 53 had diagnoses of cardiomyopathy (a disease that affects the heart muscle), chronic obstructive pulmonary disease (lung disease), and diabetes. The 7/16/2024 Minimum Data Set admission assessment documented the resident had intact cognition, did not have behavioral symptoms, required substantial assistance for bed mobility and transfers, was at risk for developing pressure ulcers, and did not use side rails. The 7/9/2024 admission face sheet documented the resident was their own responsible party. The 7/9/2024 Bed Rail assessment completed by nursing and therapy documented for bed mobility and transfers the resident had bed rails that were used for positioning from side to side, pulling and holding self over, aiding in supporting self, and aiding in safe entry into bed. Therapy assessed the resident would use the bed rails for turning side to side, moving up and down in bed, holding self to one side, pulling self from lying to sitting position, for improving balance during transfers, supporting self during transfers, exiting bed safely, and entering bed safely. Bilateral quarter bed rails were recommended to enable the resident to achieve their highest level of functional. independence in bed mobility and transfers. A 7/26/2024 at 3:03 PM Director of Nursing progress note documented the Interdisciplinary Team and provider determined the use of bed rails was not medically required and the resident's bed rails would be removed. The resident's wife was spoken to and agreed with the plan. An 8/1/2024 physician order documented bilateral enablers/ 1/4 bed rails to bed were discontinued. During an interview on 8/2/2024 at 11:06 AM, Resident# 53 stated their bed rails were removed from their bed with no explanation and they had used them for independent bed mobility. Their bed was very narrow and without the bed rails it was difficult to move around in bed. Maintenance came in and removed them with no explanation. They were not offered an alternative assistive device to aid in bed mobility. They stated it would have been all right for the change to be discussed with their spouse, but they felt they should have been notified also. 2) Resident # 67 had diagnoses of rheumatoid arthritis (a chronic inflammatory disorder that can affect joints), diabetes, and depression. The 7/2/2024 quarterly Minimum Data Set assessment documented the resident had intact cognition, required partial assistance with bed mobility and transfers, was at risk for pressure ulcers, and did not use bed rails. The 7/2/2024 bed rail assessment completed by nursing and therapy documented the resident used bed rails for turning from side to side, moving self up and down in bed, pulling and holding self over, pulling self from lying to sitting position, aiding in safe entry into bed, and aiding in safe exiting from bed. Therapy assessed the resident would use the bed rails for bed mobility and transfers. Bilateral quarter bed rails were recommended to enable the resident to achieve their highest level of functional independence in bed mobility and transfers. An 8/1/2024 physician documented bilateral enablers/ 1/4 bed rails to bed were discontinued. During an interview on 8/6/2024 at 9:44 AM Resident # 67 stated they were never told their bed rails were going to be removed. The bed rails were removed about 2 weeks ago while they were out of the room. The 2 rails were always up, and they needed stand by assistance of one person with the rail. They stated without the rails, they were shaky because they were afraid of falling. Now if they wanted to reposition themself in bed it was not as easy because they had nothing firm to hold on to. Their bed mobility/side rail use was not reevaluated, and they were not offered any alternative assistive device. They stated they mentioned their concern to staff. Staff told them they heard the same complaint from everybody and that it was a State law they could not change. During an interview on 8/6/2024 at 12:07 PM, Certified Nurse Aide #29 stated residents had the bed rails taken away because of the State. There were complaints from residents almost every day, especially when they rolled residents in bed. Bed rails were used for rolling, helped with standing, and helped promote independence. Resident #67 had bed rails they used to pull themself side to side and in and out of bed. Staff now had to bear more of their weight with transfers, whereas before they did not. The resident was shakier and was fearful without the bed rails. 3) Resident #2 had diagnoses including surgical aftercare following surgery of the digestive system, paraplegia (paralysis of the legs), and pressure ulcers sacral region. The 6/26/2024 Minimum Data Set comprehensive assessment documented the resident had intact cognition, required assistance with bed mobility and transfers, was at risk for pressure ulcers, and did not use bed rails. The 6/19/2024 admission face sheet documented the resident was their own responsible party. The 6/20/2024 bed rail assessment completed by nursing and therapy documented the resident had bed rails used for turning from side to side, moving self up and down in bed, and pulling and holding self over. Therapy assessed how the resident would use the bed rails and recommended bilateral quarter bed rails to enable the resident to achieve their highest level of functional independence in bed mobility and transfers. A 7/25/2024 at 3:34 PM Director of Nursing progress note documented they met with the resident regarding removal of bed rails. The resident was assured that therapy and nursing would assess the resident to meet their comfort and safety needs. Risks versus benefits of bed rails were discussed with the resident and the resident voiced understanding. There was no documented reason for the removal of the resident's bed rails. During the resident council meeting on 8/1/2024 at 2:10 PM, Resident #2 stated they attended the meeting specifically to bring up their bed rails being removed. They stated they were reluctant to bring it up as it could cause unrest. Several residents stated their bed rails were removed without it being discussed with them. They stated they were told by the facility it was a state law they could not have bed rails. An 8/2/2024 physician order documented discontinue bilateral enablers/ 1/4 bed rails to bed. During an interview on 8/5/2024 at 2:41 PM, Resident # 2 stated maintenance just came and took the bed rails off. Maintenance said they were told to take them off. The resident stated no one talked to them about removing the bed rails before then. They were not given a choice or offered an alternative. They stated they had a trapeze since after admission and had requested it to pull up on and try to their strengthen arms. They were not able to use it to reposition themself in bed. During an interview on 8/6/2024 at 10:12 AM, Certified Nurse Aide #28 stated nobody had bed rails anymore. They were all removed because of State law. Resident #2 had bed rails previously, and they were probably the most upset about the removal. They now needed assistance to roll in bed. The trapeze only helped them to sit up, it did not help them roll independently. During an interview on 8/6/2024 at 10:17 AM, Registered Nurse Unit Manager #3 stated bed rails were used for bed mobility and transfers to assist residents that had been screened by therapy. Bed rail reduction began about 2 months ago with therapy determining safety and need. Bed rail assessments were being completed quarterly. They were not sure if assessments were done before the bed rails were removed. There were residents on the unit that benefited from bed rail use. During an interview on 8/6/2024 at 2:55 PM, the Director of Maintenance stated the Director of Nursing instructed them to remove bed rails for resident safety. They believed every resident and family members were told about the removal. They stated the use of bed rails came with risks. They performed bed rail entrapment zone checks annually. The last one was done 12/2023, with no issues identified. During an interview on 8/7/2024 at 11:02 AM, the Director of Therapy stated bed rails were used to enhance independence with bed mobility. They enhanced bed mobility from sitting/ lying and getting up to the side of the bed. A bed rail screen was done on admission and quarterly to see if they would benefit the resident. From a therapy standpoint they were good but from a safety standpoint there were risks. They stated the facility had way too many bed rails, so therapy was supposed to look at them. They were then told they were all being removed. It was not fair to residents who could use them to promote independence with bed mobility. The goal was for residents to be at their highest functional level. During an interview on 8/7/2024 at 12:49 PM, the Director of Nursing stated there was a new policy for no bed rails in the building starting on 7/29/2024. The decision was made because the bed rail use in the facility was not being monitored as it should have been. They stated Centers for Medicare and Medicaid Services guidelines were used to develop the plan. They had Interdisciplinary Team Meeting with discussions to match their sister facility bed rail free policy. There were some instances where bed rails may have benefits. Therapy evaluated residents that may benefit from bed rail use and try alternatives such as over the bed trapeze. Residents should have been told they were going to be removed and offered alternatives to the bed rails before they were removed. If a resident did not have bed rails for independence with positioning, it could lead to increased risk for pressure ulcers and loss of dignity. During an interview on 8/7/2024 at 2:40 PM, the Administrator stated the bed rail policy changed on 7/29/2024. They were attempting to remove all bed rails that were not medically necessary. The goal was making sure residents were safe. The team talked at morning report, families were called, and residents were spoken to. They were not sure if all residents were notified before the bed rails were removed. Some residents could benefit from bed rail use for bed mobility. 10NYCRR 415.5(e)(1) 49448

44838 Based on record review, observation, and interview during the recertification and abbreviated (NY00345143) surveys conducted 8/1/2024-8/7/2024, the facility did not ensure residents had a safe, clean, comfortable, and homelike environment for 3 of 3 resident units ([NAME], [NAME], and [NAME]) reviewed. Specifically, water temperatures were greater than 120 degrees Fahrenheit in shower rooms and resident bathrooms on [NAME] and [NAME] Units; The bathroom floor in room [ROOM NUMBER] on the [NAME] Unit was in disrepair and stained with a brown substance at the base of the toilet; resident wheelchairs on [NAME] and [NAME] Units were unclean; and the mechanical lifts on [NAME] and [NAME] Units were unclean with debris on the footplates. Findings include: The facility Admission Agreement documented the facility strived to provide an environment that was safe, clean, comfortable, and welcoming to its residents, families, and friends. The facility policy, Water Temperatures, dated 2/23/2022 documented water temperatures shall be maintained between 90 degrees Fahrenheit and 120 degrees Fahrenheit to assure resident safety. Building services performed daily inspections (to include weekends) of water temperatures. Any temperature that did not fall between 90 degrees Fahrenheit and 120 degrees Fahrenheit would be reported to a building service supervisor. The facility policy, Cleaning of Resident Rooms, dated 10/19/2022 documented the nursing facility would maintain clean, attractive surroundings without disrupting resident care. The facility policy, Creating a Work Order, dated 2/15/2021 documented that all team members could report needed repairs through an electronic communication system. Work orders were received and assigned to building services team members by the Building Services Director. Work orders were completed and signed off by the completing team member based on the type of repair, availability of parts, and necessity to arrange needed outside vendor services to complete the request. The facility policy, Wheelchair Safety and Care, dated 10/21/2022 documented cleaning of wheelchairs would take place when they were visibly soiled or upon a resident's request. Surface cleaning (of spills and surface dirt) should be completed using disinfectant wipes. For deeper cleaning, a wheelchair cleaning station was available in a designated location to thoroughly clean chairs. The facility policy, Use of a Mechanical Lift, dated 4/11/2024 documented lift care included: disinfection of lift surfaces after each use. The lifts should be wiped with a clean towel until dry. WATER TEMPERATURES Water temperatures (measured in degrees Fahrenheit) on the [NAME] Unit were as follows: - on 8/2/2024 at 11:22 AM the bathroom sink beside the dining room was 126 degrees. - on 8/2/2024 at 11:39 AM room [ROOM NUMBER]'s bathroom sink was 121.1 degrees - on 8/2/2024 at 11:38 AM room [ROOM NUMBER]'s bathroom sink was 122 degrees. - on 8/2/2024 at 11:41 AM the shower room near room [ROOM NUMBER] was 121 degrees, - on 8/2/2024 at 11:47 AM the shower room (across from the dining room) sink was 124 degrees. During an observation on the [NAME] Unit on 8/2/2024 at 11:39 AM room [ROOM NUMBER]' s bathroom sink was 124.2 degrees. The June 2024, July 2024, and August 2024 water temperature log did not document any recorded temperatures greater than 120 degrees. During an interview on 8/2/2024 at 12:00 PM, Maintenance Worker #32 stated a couple of maintenance workers checked the water temperatures daily, usually a little before 8:00 AM. They tested on e room on each unit and checked both the water and the air temperatures. They tried to switch the rooms checked so it was random. During an interview on 8/2/2024 at 12:21 PM, Certified Nurse Aide #9 stated no residents had complained about too hot or too cold water. They would feel the water temperature before they used it for residents, and had the residents feel it as well. If the resident could not tell them, they touched the water and watched the residents' facial expressions. They were not aware of any residents that were burned from the shower room water. They stated they also tested resident rooms sink temperatures prior to washing their hands in the sink. During an interview on 8/7/2024 at 2:21 PM, the Maintenance Director stated the boiler was set at 115 degrees Fahrenheit. It was checked with a thermometer every day in three different locations on each unit. They had measured 126 degrees on the [NAME] Unit on 8/2/2024 at 11:22 AM and did not know where that spike in temperature came from. It was important that hot water be maintained properly to keep people from getting burned. ROOMS The following observation of resident room [ROOM NUMBER] were made: - on 8/2/2024 at 9:06 AM the floor was soiled with brown spots, there were dirty dishes at the bedside, a cold full bowl of soup was on the bedside table, and there was a gauze bandage on the floor. The bathroom floor had brown stains surrounding the base of the toilet, and the flooring was ripped and loose. - on 8/5/2024 at 9:34 AM the bathroom floor had brown stains, and the tile around the toilet was stained and loose. - on 8/5/2024 at 2:29 PM the floor was spotted with brown spots, there was garbage on the floor, the bathroom toilet was leaking brown fluid around the toilet base, and the bathroom floor tiles were loose and ripped. A 4/25/2024 open work order created by Environmental Services Supervisor # 39 documented the floor was torn in resident room [ROOM NUMBER]'s bathroom. During an interview on 8/6/2024 at 10:51 AM, Housekeeper #40 stated they were responsible for cleaning the whole unit. There was no set schedule for room cleaning, and they were not able to get to each room daily. They emptied trash and cleaned each bathroom daily. They replenished toilet paper and paper towels and would put work orders in if they found a repair was needed. Sometimes they asked the Unit Secretary to call maintenance if there was a sink or toilet plugged and a response was needed right away. The resident in room [ROOM NUMBER] did not always allow housekeeping in their room. They stated they had put work orders in for the missing tile in that bathroom. During an interview on 8/6/2024 at 2:55 PM, the Director of Maintenance stated the housekeeping schedule consisted of cleaning all rooms. They partially cleaned if that was all they had time for. The work orders should be completed as timely as possible. There should have been a work order for the brown liquid seeping out at the bottom of a toilet and for loose flooring. During a follow-up interview on 8/7/2024 at 10:13 AM, they stated there was a work order placed for the damaged floor at the base of the toilet in room [ROOM NUMBER]'s bathroom. They were not sure why it had not been completed yet. The dangers of a damaged floor included difficulty keeping the floor clean and infection control issues. Bare concrete and loose flooring could increase the risk of slips, trips, or falls. They expected that work orders were completed as timely as possible. During an interview on 8/7/2024 at 10:37 AM, Environmental Services Supervisor # 39 stated housekeepers have a daily duty sheet with a space for work orders. They keep track of rooms done so they know where to pick up the next day. They received the duty sheets at day's end and entered any maintenance work orders into the computer. Maintenance took care of them when they were able. A damaged floor could be a tripping hazard or infection control issue. Especially in the bathroom moisture or other debris could get underneath which may promote mold/bacteria growth. They remembered putting a work order in for the floor in room [ROOM NUMBER] bathroom. WHEELCHAIRS The following observations of Resident #58 were made: - on 8/1/2024 at 12:09 PM in their room with their spouse visiting. Their wheelchair was unclean with food debris build up on the right side and a thick brownish substance on the frame. - on 8/2/2024 at 8:54 AM in the dining room, their wheelchair was unclean with food debris build up on the right side and a thick brownish substance on the frame. - on 8/5/2024 at 9:37 AM in the dining room, their wheelchair was unclean with food debris build up on the right side and a thick brownish substance on the frame. - on 8/6/2024 at 11:22 AM their wheelchair was unclean with food debris build up on the right side and a thick brownish substance on the frame. During an observation on 8/5/2024 at 9:34 AM Resident #43 was in their room sitting in their wheelchair. The seat was soiled with crumbs and there were scrambled eggs on the chair. The [NAME] unit wheelchair cleaning log was requested, and the facility was unable to provide a log for July/August 2024. During an interview on 8/6/2024 at 11:23 AM, Certified Nurse Aide #6 stated night shift certified nurse aides were assigned to wheelchair cleaning. Staff on any shift could clean wheelchairs if needed. Unclean wheelchairs were not homelike, dignified, and could be an infection control issue. During an interview on 8/6/24 at 11:37 AM Licensed Practical Nurse #4 stated the night shift was supposed to clean wheelchairs. There was a night shift schedule but no schedule for when there was 1 certified nurse aide scheduled. There was no July 2024 log for them to document wheelchairs were cleaned. The night nurse was supposed to make sure the log was completed. During an interview on 8/7/2024 at 11:39 AM, the Director of Nursing stated wheelchairs should be cleaned on the night shift and any time they were unclean. Clean wheelchairs provided dignity and a homelike environment. They should be clean for infection control issues. MECHANICAL LIFTS During an interview on 8/5/2024 at 9:44 AM, Resident # 59 stated the sit to stand lift they used was soiled. They stated it frequently had unidentified discolored spots present on the surface. During an observation on 8/5/2024 at 9:50 AM, the sit to stand lift on the [NAME] unit had dirt and debris on the foot plate. During an observation on 8/6/2024 at 8:59 AM, the sit to stand lift on the [NAME] unit had debris on the foot plate. During an interview on 8/7/2024 at 10:37 AM, Environmental Services Supervisor #39 stated it was not a housekeeping duty to clean mechanical lifts. It was a nursing responsibility and should be performed after each use. During an interview on 8/7/2024 at 11:27 AM, Certified Nurse Aide #23 stated mechanical lifts were cleaned by certified nurse aides after each use. They stated the sit to stand lift platform was really gross looking and should be cleaned. They used the bleach wipes in the clean utility room or on the nurse's cart to clean the lifts. During an interview on 8/7/2024 at 11:56 AM, Certified Nurse Aide #24 stated they cleaned lifts with disinfectant wipes after every use to prevent spreading germs. The foot plate was cleaned when it was visibly soiled, and crumbs on the foot plate should be cleaned off. 10 NYCRR 415.29 (f)(6), (j)(1)

43754 44838 Based on observation, interview, and record review during the recertification survey conducted 8/1/2024 - 8/7/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen and in 3 of 3 nursing unit kitchenettes ([NAME], [NAME], and [NAME] Units) reviewed. Specifically, the main kitchen walk-in cooler and walk-in freezer floor were unclean and soiled with food debris; the dishwasher in the main kitchen was not working properly; the refrigerator in the [NAME] Unit kitchenette had a broken temperature gauge and was not at an appropriate temperature; the refrigerator/freezer in the [NAME] Unit pantry was unclean with food spills; and the [NAME] Unit microwave was unclean with food debris, and the sink was leaking into the cabinet below. Findings include: The facility policy, Cleanliness and Sanitation, dated 3/18/2024 documented high standards of cleanliness and sanitation would be maintained to achieve a clean, sanitary environment. Refrigerators/freezers walls, ceilings, and floors should be free of ice, stains, spots, food, drippings, and debris. Free standing refrigerators and freezers should be clean, smooth to touch, and free of dirt and debris inside and out. Microwave oven interiors would be free of debris and grease, with no grease build up. The facility policy, Food Safety, dated 3/18/2024 documented food safety standards were maintained for the safety of all residents. Accurate food thermometers were available and used by all food employees during storage, preparation, display, service, and transportation. Thermometers must be accurate to at least +/- 2 degrees and sanitized before use. Refrigerators must maintain foods at 41 F or below. Refrigerator and freezer thermometers must be accurate to at least +/- 2 degrees. Washing, rinsing, and sanitizing procedures must be posted and adhered to at all pot washing and dish washing stations in use. The following observations were made in the main kitchen with the Food Service Director present: - on 8/1/2024 at 9:55 AM the main walk in cooler had multiple juice containers and Mighty Shake supplements directly on the floor under the shelves. The Food Service Director stated the floor should be mopped every evening and nothing should be stored on the floor. - on 8/1/2024 at 9:57 AM the walk-in freezer had 2-inch ice buildup by the door and door seal, and debris on the floor under the shelves. - on 8/1/2024 at 10:03 AM the nourishment reach in cooler contained cups of ice water with ice open to the air without lids, and a 1/4 pan on top of them. The Food Service Director stated they were cups residents would drink out of and should have lids to prevent contamination. - on 8/1/2024 10:12 AM the hot box had no thermometer inside, and the outside thermometer read 118 degrees Fahrenheit. The dishwasher temperature for the wash cycle was 139 degrees Fahrenheit, the rinse cycle was 133 degrees Fahrenheit, and the final rinse cycle was 133 degrees Fahrenheit. The dish washer final rinse log was not marked. The Food Service Director stated the final rinse should be checked 3 times daily. During an interview on 8/1/2024 at 10:23 AM, Dishwasher #37 stated dishwasher temperatures should be checked 2 times a day, once after breakfast and again after lunch. They stated they did not check the temperature that morning. During an interview on 8/1/2024 at 10:23 AM, the Food Service Director stated it was important to sanitize dishes to prevent the spread of infections. They expected it was checked when starting the cycle and not at the end of the cycle. The booster light was not on, and nobody told them it was not working. Improper sanitation could affect all the residents in the building. At 12:10 PM, the Food Service Director stated the booster was broken on the dishwasher. They were going to disposable dishware and switched to chemical sanitizer. They stated according to the temperature log, temperatures were up and down. During an observation on 8/2/2024 at 2:03 PM the [NAME] Unit kitchenette refrigerator's outside temperature gauge was not working. A probe thermometer was placed at 2:14 PM and read 54 degrees Fahrenheit. At 2:19 PM, the thermometer read 54 degrees Fahrenheit; and at 2:21 PM the thermometer read 50 degrees Fahrenheit. The temperature controlled for safety foods were discarded. During an interview on 8/2/2024 at 2:10 PM, Food Service Aide #33 stated they took the [NAME] Unit refrigerator temperature at 7:40 AM and documented on the paper it was 40 degrees Fahrenheit. There was a thermometer in the refrigerator. During an observation on 8/2/2024 at 2:27 PM the [NAME] Unit pantry refrigerator and freezer were unclean with food spills. The temperature at 2:33 PM was 48 degrees Fahrenheit, and at 2:44 PM was 43 degrees Fahrenheit. The Food Service Director stated refrigerator temperatures should be 40 degrees Fahrenheit or less. The food service aides were supposed to clean the refrigerators every shift if there were spills. During an observation on 8/2/2024 at 2:50 PM, the [NAME] Unit kitchenette microwave oven was unclean with food debris. The Food Service Director stated it should be cleaned every shift and when spills occurred. The freezer was not working, but there was no sign, and it was not locked. It was important to have the sign posted so people would not use the freezer. They stated the sink was leaking into the cabinet under the sink. During an interview on 8/6/2024 at 11:38 AM, the Food Service Director stated the dishwasher was transitioned to chemical sanitization after it was identified that it was not hitting the correct temperature on 8/1/2024. The Food Service Director and the Surveyor measured the final rinse water which did not register any sanitizer. The rinse temperature was reading 134 Fahrenheit. The Food Service Director was not sure of the machine's specifications for chemical sanitization. They stated they had been monitoring the sanitizer but had not been documenting it. 10NYCRR 415.14(h)

49448 50561 Based on observation, record review, and interview during the recertification survey conducted [DATE]-[DATE], 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 2 of 2 residents (Residents #14 and #312) reviewed and for 2 of 2 staff (Licensed Practical Nurses #1 and #2) observed. Specifically, Resident #312's and #14's urinary catheter drainage tubing was laying directly on the floor; Licensed Practical Nurse #2 provided wound care without performing appropriate hand hygiene or taking precautions to prevent contamination of the wound and clean supplies; and Licensed Practical Nurse #1 did not practice appropriate glove usage or hand hygiene during multiple resident care tasks. Findings include: The facility policy, Dressings-Dry/Clean, revised [DATE] documented scissors would be disinfected; gloves would be changed, and hands would be washed after removing soiled dressings; and gloves would be changed, and hands would be washed after cleansing the wound. The facility policy, Handwashing Technique, revised [DATE] documented hands would be washed before and after each procedure, between contact with different residents, and before serving food; the use of gloves did not eliminate the need for hand hygiene; and hand sanitizer would be used when contact had been made with people, equipment, or furniture. The facility policy Foley Catheters revised [DATE] documented the facility would assure the appropriate care of catheters and the condition of the tubing would be monitored. 1) Resident #312 had diagnoses including acute cystitis (inflamed bladder) with hematuria (blood in urine). The [DATE] Minimum Data Set documented the resident had intact cognition, required assistance required with activities of daily living, used a wheelchair for mobility, used an indwelling urinary catheter, and had a urinary tract infection in the last 30 days. The [DATE] physician order documented 16 French (size of tube) 10 milliliter bulb (used to anchor the device in the bladder) drainage device, change every 42 days, and provide device care every shift. The Comprehensive Care Plan revised [DATE] documented the resident had a urinary drainage device. Interventions included enhanced barrier precautions, monitor for pain/discomfort due to device, and monitor for signs of a urinary tract infection. The following observations of Resident #66 were made: - on [DATE] at 9:29 AM sitting on the edge of their bed with the catheter tubing directly on the floor. - on [DATE] at12:45 and 2:32 PM sitting in their wheelchair with their catheter tubing directly on the floor. - on [DATE] at 9:06 AM sitting in their wheelchair with their catheter tubing directly on the floor under their wheelchair. During an interview on [DATE] at 11:27 AM, Certified Nurse Aide #23 stated urinary drainage device care was provided at least once a shift and included switching bags, emptying bags, and documenting output. To prevent infections, the drainage bag should be positioned below the bladder and tubing should not be on the floor. During an interview on [DATE] at 11:56 AM, Certified Nurse Aide #24 stated urinary drainage device care was provided once a shift, bags should be positioned below the level of the resident's bladder in a dignity bag, and tubing and bags should not touch the floor to prevent infection. During an interview on [DATE] at 8:17 AM, Infection Preventionist Registered Nurse #25 stated catheter care was a yearly education and additional training was provided if a problem was identified. They expected staff to practice infection prevention as it was everyone's job to prevent infection. Catheter tubing should not be on the floor because the floor was dirty, and this contact could increase the risk of infection. 2) Resident #66 had diagnoses including left hip Stage 3 (full thickness tissue loss) pressure ulcer. The [DATE] Minimum Data Set documented the resident had intact cognition, required assistance with bed mobility, and had one Stage 3 pressure ulcer. The [DATE] physician order documented cleanse left hip wound with wound cleanser, pack undermining (a passageway underneath the skin's surface) with iodoform (an antiseptic gauze that removes dead tissue) soaked with wound gel (provides moisture) and collagen powder (promotes wound healing), apply moist 2 x 2 gauze, cover with absorbent dressing then dry protectant dressing twice a day. During a wound care observation on [DATE] at 10:12 AM, Licensed Practical Nurse #2 entered Resident #66's room and applied gloves and a gown. They removed the soiled wound dressing, removed their gloves, did not perform hand hygiene, and applied new gloves. They cleansed the wound, retrieved a pair of scissors from the resident's dresser drawer, cut off a strip of iodoform using the scissors, soaked the iodoform strip as ordered, used their gloved fingers to directly pack iodoform into the wound, and covered the wound with a gauze moistened with normal saline (from an undated partially used bottle), They did not change their gloves or perform hand hygiene after cleansing the wound and retrieving the scissors and before applying the new dressing. During an interview on [DATE] at 10:25 AM, Licensed Practical Nurse #2 stated hand hygiene should be performed before and after wound care and in between changing gloves only if they touched something dirty. Multi dose bottles of normal saline should be dated when opened and open dates should be checked before using wound care products. They were unsure when the bottle of normal saline was last used or originally opened as there was no date written on it. If proper hand hygiene was not performed bacteria could be spread resulting in a wound infection. During an interview on [DATE] at 2:27 PM, Registered Nurse Manager #3 stated hand hygiene should be performed in between removing soiled gloves and applying clean gloves. Hand hygiene could be either washing with soap and water or using hand sanitizer. If clean gloves touched something dirty, they could be contaminated and should be changed before touching or applying clean wound care items. Any time a small bottle of normal saline was opened it should be dated with the date it was opened. The bottle would be good for 30 days from that open date. A bottle that was opened and not dated should not be used as it could be expired and ineffective. Not properly performing hand hygiene and using supplies with unknown expiration dates could cause treatments to be less effective or cause infection. During an interview on [DATE] at 8:17 AM, Infection Preventionist Registered Nurse #25 stated gloves should be worn when providing personal care, wound care, or anytime there was the potential of encountering blood or body fluids. Gloves should be changed when soiled and in between removal of a dirty dressing and application of a clean dressing. They were initially unsure if hand hygiene should be performed in between glove changes, but after referring to the policy stated anytime gloves were removed hand hygiene should be performed. Gloves did not provide a 100% barrier and hands were not clean just because gloves had been worn. The Unit Managers completed weekly hand hygiene audits and submitted to them, and no related issues had been reported. Staff received training at least annually that included hand washing, standard/contact/droplet precautions, and the use of personal protective equipment. The most recent training was one week ago. 3) During an observation on [DATE] at 12:52 PM, Licensed Practical Nurse Assistant Manager #1 was in the dining room assisting residents with lunch wearing gloves. While wearing the same pair of gloves Licensed Practical Nurse Assistant Manager #1 provided hands on assistance to a resident attempting to sit in a chair, touched Resident #25's sandwich, provided Resident #54 hands on assistance with eating, recorded meal intakes, cleaned up dirty dishes, touched and positioned dishes with food in front of Resident #25, then removed the gloves and assisted a resident in a wheelchair to their room. During an interview on [DATE] at 1:53 PM, Licensed Practical Nurse #1 stated to prevent the spread of infection hand hygiene should be performed before resident care and before and after glove use. Gloves should be changed when visibly soiled, in between providing care to different residents, between going from one resident room to another, and after providing hands on assistance with feeding. Clean gloves should be applied if making direct contact with residents' food. During an interview on [DATE] at 8:17 AM, Infection Preventionist Registered Nurse #25 stated the same pair of gloves should not be worn to feed a resident that were previously worn to touch dirty dishes. This could result in contamination of gloves and the spread of germs from one resident to another. 10NYCRR 415.19(b)(1)

Based on record review and interview during the abbreviated and extended survey (NY00323717), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 6 residents reviewed (Resident #2 and #7. Specifically, Resident #2 had a fall with a hematoma (pooling of blood under the skin) to the back of their head and neurological checks were not completed. When the resident had a change in condition (lethargy, sluggish eye movement, slow to speak, and vomiting), a medical provider was not notified in a timely manner (approximately 2 hours after symptoms began). Additionally, a delay in transport to the hospital occurred when the facility was not able to reach Emergency Medical Services. Subsequently, the resident was sent to the hospital 3.25 hours after their change in condition was identified, diagnosed with a severe brain hemorrhage (bleed) and expired the next day. Resident #7 had a fall with a hematoma to the back of their head and was sent to the emergency room for evaluation. When Resident #7 returned to the facility approximately 4 hours later, neurological checks did not resume. The facility's failure to monitor the neurological status of Resident #2 and respond to a change in condition places all 102 residents in the facility at risk. This resulted in actual harm that was Immediate Jeopardy and Substandard Quality of Care to resident's health and safety. Findings include: The Neurological Checks Policy effective/renewed on [DATE] documented nursing staff would identify changes in a resident's neurological status based on evaluation of several factors and report changes to the physician immediately. The licensed nurse identified the need for a resident's neurological exam based on physician order and resident complaints of neurological symptoms. If a physician did not order routine neurological exams, the facility default process would be as follows: every 15 minutes x 1 hour, every 30 minutes x 1 hour, every 1-hour x 4 hours and every 4 hours until 24 hours had elapsed. The procedure included to check vital signs, check the mental status as it related to the resident's normal routine mental state (were they alert and oriented, did they respond to simple verbal commands, was their behavior within normal limits), and check the resident's pupil size, equality, and reactiveness to light. The Notification of Resident Conditions to Providers Policy effective/renewed on [DATE] documented changes in a resident's condition or treatment were to be immediately shared with the resident and/or the resident representative and reported to the primary care provider/on call practitioner to prevent delay in treatment. Nursing would immediately notify the resident's physician of a significant change in the resident's physical, mental or psychological status that was a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications including any symptom, sign, or apparent discomfort that was: acute or sudden in onset; a marked change in relation to usual symptoms and signs, or unrelieved by measures already prescribed. Examples of when to notify the medical provider immediately included any neurological changes or emesis. 1) Resident #2 had diagnoses including diabetes, cirrhosis (chronic liver damage) and dementia. The [DATE] Minimum Data Set assessment documented the resident's cognition was severely impaired, they needed assistance of one staff with bed mobility and locomotion in their room, and they were independent with transfers. The [DATE] comprehensive care plan documented the resident was alert and able to make most of their needs known. They were at risk for falls and had falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interventions included to ensure the resident wore appropriate footwear, call light within reach and encourage its' use, encourage use of a walker as resident was forgetful at times, dresser bolted to wall, and non-skid strips in room. The [DATE] 10:57 AM, Registered Nurse #2's progress note documented they were called to the resident's room by a Certified Nurse Aide (unidentified). The resident was found on the floor, seated upright, next to the closet and stated they were cleaning up their room. They had a hematoma (pooling of blood under the skin) to the back of their head and no other injury noted. Ice was applied, vital signs were stable, and the initial neurological check was within normal limits. Nurse Practitioner #8 was notified, and neurological checks were initiated per facility protocol. The [DATE] neurological check list, completed by Registered Nurse #2 documented: - at 10:30 AM and 10:45 AM, the resident was alert and oriented to person and situation and could follow a finger with their eyes. They had pain of 5 out of 10 (moderate pain) and stated their head hurt. - At 11:00 AM and 11:30 AM, the resident was oriented to person, level of consciousness was lethargic (sluggish) and they were lethargic when following a finger with their eyes. They were resting with an ice pack on their head. - At 12:30 PM, the resident continued to be oriented to person, level of consciousness was lethargic, they were lethargic when following a finger with eyes, and they were also slow to speak. There was no documented evidence neurological checks were completed at the intervals per the required facility process and no documented evidence a medical provider was notified timely after the resident had multiple documented episodes of changes in condition. The [DATE] Incident Statements obtained by the facility documented: - by Registered Nurse #2 at 10:30 AM, a Certified Nurse Aide (unidentified) alerted them the resident was on the floor and was found next to their closet. They had a hematoma to the back of their head, pupils were reactive to light, hand grip strength was equal, and speech was clear. At 10:35 AM, the medical provider was notified. At 11:45 AM, the resident was becoming more lethargic, speech was clear but slow. At 12:15 PM, the resident had emesis of undigested food. At 12:30 PM, vital signs were stable. At 1:00 PM, the on-call medical provider was notified and ordered to send the resident to the hospital. - by Registered Nurse Supervisor #3, at approximately 12:50 PM, Registered Nurse #2 updated them the resident fell at 10:30 AM. Registered Nurse #2 reported they completed the paperwork, initiated neurological checks, and the resident's vital signs were normal. Registered Nurse #2 reported the resident had one episode of emesis and they instructed them to immediately update the on-call medical provider. Registered Nurse Supervisor #3 also documented at 1:10 PM, the facility had difficulty reaching Emergency Medical Services. - A second statement from Registered Nurse #2 documented all times in their initial statement were approximate and the resident's vital signs were within normal limits. The resident started to show signs of lethargy however only slightly. The resident answered questions clearly and appropriately the entire duration. When emesis was noted, they immediately went to Registered Nurse Supervisor #3, called Nurse Practitioner #8, and began the process of sending the resident to the hospital. The [DATE] Incident Summary completed by the Director of Nursing documented: - Per interview with Certified Nurse Aide # 5, they found the resident on the floor in their room at 10:30 AM. - Per interview/statements from Registered Nurse #2, at 11:45 AM, the resident complained of a headache and acetaminophen (Tylenol) was given. The resident was slightly lethargic, and speech was slow but clear. - At 12:00 PM, the resident was given lunch in their room and at 12:15 PM, the resident vomited. - At 12:30 PM, vital signs were stable. - At 1:00 PM, per interview/statements from Registered Nurse #2 and Registered Nurse Supervisor #3, the resident was noted with increased lethargy and speech was clear but slower and softer. Registered Nurse #2 notified Registered Nurse Supervisor #3 of the fall that morning, they were now showing signs of increased lethargy and vomited once a medium amount. Registered Nurse Supervisor #3 directed Registered Nurse #2 to call the on-call medical provider and notify them of the resident's changes. An order was received to send to hospital. - At 1:45 PM, the ambulance arrived, and the resident left the facility at 2:15 PM. - At 6:25 PM, the hospital reported the resident had a severe brain hemorrhage (bleed), their family declined surgical intervention, and they had a poor prognosis. - At 6:54 AM ([DATE]), they were notified the resident expired. - Abuse and neglect were ruled out and there were no care plan violations. The [DATE] Prehospital Care Report completed by Emergency Medical Services Providers #9 and 10, at 1:41 PM documented Emergency Medical Services was contacted and dispatched, and they arrived at the facility at 1:52 PM. During a telephone interview on [DATE] at 10:02 AM, Certified Nurse Aide #4 (assigned to care for the resident on [DATE]) stated the resident was often very confused, needed help with ambulating and was non-compliant. They only saw the resident once after they fell and when Certified Nurse Aide #4 asked the resident questions, they were not their normal chatty self. They did not recall what time this was. The resident was lying in their bed with their eyes closed with an ice pack on their head. During a telephone interview on [DATE] at 10:38 AM, Certified Nurse Aide #5 stated the resident knew their own name, knew their family members names, and liked to talk. The day of the fall, they went into the resident's room about ,d+[DATE] minutes after lunch trays were served. The resident was in bed, was tired and lethargic and was not presenting per their usual self. Registered Nurse #2 mentioned to them the resident vomited during the lunch meal and Certified Nurse Aide #5 asked Registered Nurse #2 if they were going to call the physician because vomiting was a sign of a concussion. Certified Nurse Aide #5 was not sure how soon after that the physician was called. During a telephone interview on [DATE] at 11:22 AM, Registered Nurse #2 stated neurological checks were to be done every 15 minutes for 1 hour, every 30 minutes for 1 hour, and every 1 hour for 4 hours until 24 hours had passed. They stated they would be concerned if a neurological check showed a resident had unequal pupils or if they were lethargic unless that was their normal presentation, and they would call the medical provider immediately for those concerns. When they did neurological checks for the resident's [DATE] fall, they wrote all the neurological checks on a piece of paper and entered the information into the medical record later that day. They believed they completed all neurological checks however might have missed documenting some because they wrote them on a piece of paper and documented them in the electronic medical record later on. At 11:00 AM, they documented the resident was lethargic because they believed the resident wanted to take a nap and kept stating they just wanted to lie down. The resident was responding clearly at that time. At 12:15 PM, they checked on the resident, found they had vomited and that was when they had a change in condition. At 12:30 PM, the resident was slow to speak and that was a change in condition. After the resident vomited, they notified Registered Nurse Supervisor #3 about their change in neurological status. Registered Nurse Supervisor #3 assessed the resident, the medical provider was notified, and the resident was sent to the hospital. They stated that all the times they documented in the medical record were approximate as they had documented notes later in the shift. They stated they did not recall any certified nurse aides reporting concerns regarding the resident that day. During a telephone interview on [DATE] at 12:11 PM, Registered Nurse Supervisor #3 stated as the Supervisor, staff typically reported to them when someone fell or was ill and they assessed the individual in question. If there was another Registered Nurse on the unit, then the Supervisor did not have to be notified. On [DATE], Registered Nurse #2 reported to them the resident fell earlier in the shift, Registered Nurse #2 started neurological checks and started the required paperwork. Registered Nurse #2 also reported the resident vomited and they instructed them that it was a change in condition, and they needed to notify a medical provider. During a telephone interview on [DATE] at 10:22 AM, the Director of Nursing stated they expected a medical provider to be immediately notified for any alteration in mental status or for a change in neurological checks after a resident hit their head. When they completed the investigation into the resident's fall, they were not aware Registered Nurse #2 had not completed neurological checks per facility policy process. Registered Nurse #2 should have notified a medical provider on [DATE] at 11:00 AM when the resident first showed signs of being lethargic. They interviewed Registered Nurse #2 after the incident and asked them why they did not intervene, and Registered Nurse #2 stated the change in condition was very close to the resident's baseline with only a slight shift noted. At 12:15 PM, the resident was noted to vomit and at around 1:00 PM the Supervisor was notified. The Director of Nursing interviewed Registered Nurse #2 about the delay in notification and Registered Nurse #2 reported they were cleaning up vomit and doing vital signs. The Director of Nursing stated the Supervisor and medical provider were not notified timely of the resident's change in condition. That day, Certified Nurse Aide #5 reported to them concerns with the resident's care. Certified Nurse Aide #5 stated they had to tell Registered Nurse #2 to go and get the Supervisor because vomiting was a sign of a concussion. During an interview on [DATE] at 10:54 PM, former Medical Director #7 (Medical Director at the time of the resident's incident) stated after a resident hit their head, they expected a medical provider to be immediately notified for a change in cognition from their baseline or for nausea, vomiting, or headache. When the resident showed a change in their alertness at 11:00 AM, Registered Nurse #2 should have notified a medical provider. When the resident vomited, that could have indicated a worsening in their neurological status. When it took approximately 3 hours from when the first symptom began to transport to the hospital, they stated the nurse should have notified a medical provider sooner. Earlier intervention could have resulted in a different outcome for the resident however that was dependent on the resident's conditions including comorbidities. During an interview on [DATE] at 9:40 AM, Registered Nurse Supervisor #3 stated when a resident had a change in condition, the Registered Nurse completed an assessment, notified the medical provider, and completed any follow-up orders from the medical provider. Registered Nurse Supervisor #3 stated if a resident needed to be sent to the hospital because of a change in condition, the facility called the Emergency Medical Service company directly and they should call Emergency Medical Services as soon as possible once they have an order to send a resident to the hospital . On [DATE], Registered Nurse #2 notified Nurse Practitioner #8 of the resident's change in condition and Nurse Practitioner #8 ordered the resident to be sent to the hospital. Registered Nurse Supervisor #3 called the ambulance company using the first number in the book on the unit and got a voicemail. After that, they tried the company's emergency number and that did not work either. When they called the third time, they reached someone. Registered Nurse Supervisor #3 stated it could have taken them 30 minutes to reach someone at the ambulance company but they did not think to try 911 instead. They stated a head injury with vomiting was considered an emergency. They started calling Emergency Medical Services at 1:10 PM and got ahold of them at 1:41 PM and that was a delay. After this incident, they did not recall speaking to anyone in Administration about the issue with getting in contact with Emergency Medical Services. During an interview on [DATE] at 9:54 AM, the Emergency Management System Chief #11 stated the facility had a 7-digit emergency number to contact them directly or could call 911 in the event of an emergency. They stated it was their understanding that in the event of a cardiac arrest (when someone's heart stopped), the facility called 911 and for all other events, they called Emergency Medical Services directly. They stated if the facility called their 7-digit emergency number and the call was not picked up after 3 rings, it automatically forwarded to 911. They stated the company had other non-emergent numbers that go to an automated line. They stated the facility was provided literature that clearly defined who to call for emergencies. During an interview on [DATE] at 10:26 AM, Registered Nurse #2 stated in an emergency, they called Emergency Medical Services directly or called 911. They stated there was a paper posted on the wall with the number of the ambulance company. They stated on [DATE], they were aware that Registered Nurse Supervisor #3 stated it took around 20 minutes to reach Emergency Medical Services and they did not discuss calling 911. During an interview on [DATE] at 11:15 AM, the Director of Nursing stated the telephone numbers for Emergency Medical Services were posted at each nursing station. They called 911 for cardiac arrest situations. They thought this was reviewed in orientation. After the incident, they discussed with the Administrator, Registered Nurse Supervisor #3's difficulty reaching Emergency Medical Services after 3 different numbers were used. The Director of Nursing stated they discussed what the time frame they wanted nursing to reach Emergency Medical Services. Their preferred window was 10 minutes and if they did not reach them within 10 minutes, they would call 911. They questioned whether the Emergency Medical Services documentation of time frame was accurate, and they never followed up with them after this incident. After the incident, Registered Nurse Supervisor #3 called the supervisor's number for the company and whoever answered gave the correct number to call. They stated 30 minutes to reach Emergency Medical Services was not timely and they should have called 911. During an interview on [DATE] at 11:45 AM, current Medical Director #12 stated they were not sure if there was a protocol for how quickly staff should try and reach Emergency Medical Services in the event someone needed to be sent out related to a change in condition. They stated the nurse should call for Emergency Medical Services promptly after receiving an order. They stated they could not provide more specific information as they were not directly involved in the incident. 2) Resident #7 had diagnoses including Alzheimer's Disease, epilepsy (seizure disorder), and cellulitis (skin infection) of the right lower leg. The [DATE] Minimum Data Set assessment documented the resident had severe cognitive impairment and had no falls since admission or the last assessment. The [DATE] at 5:10 AM, Incident Report by Registered Nurse Supervisor #14 documented the resident had an unwitnessed fall and was found on their back between the footboard and closet in a very tight spot, with their feet facing the door. The resident stated they were trying to get to the bathroom but was found in front of the closet. The resident was last seen at 4:39 AM when checked for incontinence and was provided water. The resident stated they hit their head when landing on the floor and complained of shoulder pain. Registered Nurse Supervisor #14 palpated the resident's head and found a big bump on their posterior (back) head, with no blood. They did not move the resident, called the on-call medical provider and Emergency Medical Services and the hospital was made aware. The [DATE] at 5:10AM Registered Nurse Supervisor #14's progress note documented Emergency Medical Services was notified and arrived at the facility at 5:37 AM. The [DATE] at 7:44 AM, hospital emergency room progress note documented the resident was seen for evaluation after a fall. Laboratory results were reviewed, the resident was on medication for cellulitis (skin infection) of the right leg. The hospital care timeline included: laboratory blood tests and a change in antibiotic medication. The resident was discharged at 9:30 AM. The [DATE] hospital After Visit Summary and Discharge Recommendations documented the resident was seen for a fall and the diagnosis was bacterial skin infection of the leg. Tests completed included multiple blood tests. An antibiotic was given with a new order to start an antibiotic. The [DATE] at 8:51 AM Registered Nurse Supervisor #14's progress note documented the hospital called and the resident was being sent back to the facility. The note further documented no extensive diagnostic testing was done regarding the head injury or shoulder pain. The resident was prescribed an antibiotic for cellulitis on the right leg. The hospital's Emergency Department Provider note timeline of care documented the resident was discharged to the nursing facility on [DATE] at 9:30 AM. Per the facility's process, neurological checks were to be completed following the Emergency Department visit including: - Every 1 hour from 6:10 AM to 10:10 AM (resident returned to the facility at 9:30 AM). - Every 4 hours from 10:10 AM on [DATE] through 5:10 AM on [DATE] (neurological check was due to be done on [DATE] at 2:10 PM, 6:10 PM, 10:10 PM, and on [DATE] at 2:10 AM). The [DATE] neurological check sheet documented neurological checks were completed at 2:58 PM . A neurological check in the morning of [DATE], when the resident returned from the hospital, was not documented. The [DATE] at 10:18 PM Registered Nurse #2's progress note documented a fall follow-up; the resident was alert with confusion, they had no signs of injury , denied pain, and their vital signs were within normal limits. The [DATE] at 10:46 PM, progress note entered by Registered Nurse #15 documented the resident's vital signs at 6:00 PM and 10:00 PM, and noted they were alert, hand grips equal, moved all extremities, had clear speech, and pupils were equal, round, and reactive to light and accommodation. There was no documented evidence neurological checks were resumed per facility process when the resident returned from the hospital. During an interview with Registered Nurse Supervisor #14 on [DATE] at 11:19 AM, they stated on [DATE] they received a call from the hospital the resident would be returning, around 9:00 AM and they completed a progress note. The resident did not arrive back to the facility prior to them leaving the facility for the day. They reported to Registered Nurse #2, including the information from the hospital that no diagnostic testing related to the head injury was completed. They did not provide any specific instructions to Registered Nurse #2. During an interview with Registered Nurse #2 on [DATE] at 1:39 PM, they stated the resident returned from the hospital on [DATE] at approximately 9:30 AM. They stated they were aware the hospital did not do any head scans or testing related to the head injury. The hospital did blood work and changed the resident's antibiotic for the cellulitis on their leg. Registered Nurse #2 received report from Registered Nurse Supervisor #14 related to the resident's fall, head injury, and lack of diagnostic testing in the hospital. Registered Nurse #2 did not review the discharge paperwork from the hospital. Registered Nurse Supervisor #14 went through the hospital paperwork and called medical to clarify the antibiotic change order. Registered Nurse #2 stated the Supervisor did not provide them with instructions to resume the neurological checks. Registered Nurse #2 stated neurological checks would not need to be resumed following return from the hospital even if was within the 24 hours of the head injury, due to the resident being cleared at the hospital. If there were no tests at the hospital, that must have meant the resident was fine and testing was not needed. There were no instructions to continue the neurological checks from the hospital. At approximately 2:30 PM, Registered Nurse supervisor #13 returned to the unit to advise they should resume the neurological checks on Resident #7 to be on the safe side. Registered Nurse #2 stated they did not understand the reason for resuming the neurological checks and was not sure of the time they did them. They went to another unit at 3:00 PM and may have returned to Resident #7's unit later and did the neurological check. During an interview with Registered Nurse Supervisor #13 on [DATE] at 3:30 PM, they stated the neurological check protocol was to be implemented immediately following a head injury or unwitnessed fall. Neurological checks were to be done every 15 minutes the first hour, every 30 minutes for the next hour, then every hour for 4 hours, and every 4 hours until 24 hours had passed. If a resident went to the hospital and returned within the 24-hour period, they were considered cleared and neurological checks would not be resumed. There was no specific means to verify if the resident's head injury was cleared at the hospital , as it varied. Typically, the hospital nurse would call and provide report and possibly state if scans were completed at the hospital. If it was reported that no testing was done or no documentation the resident was cleared, Registered Nurse Supervisor #13 stated they would resume neurological checks based on the current time (number of hours since the head injury, not starting over with every 15 minutes). The decision to resume neurological checks was nursing judgment. For Resident #7, Registered Nurse Supervisor #13 stated they assumed the resident was cleared at the hospital since they did not perform any diagnostic testing. They called the medical provider regarding the medication change order and did not discuss the head injury or lack of diagnostic testing or instructions related to the head injury. Registered Nurse Supervisor #13 spoke with the Director of Nursing at approximately 3:00 PM on [DATE] and the Director of Nursing suggested they resume neurological checks for Resident #7. Registered Nurse Supervisor #13 communicated the instructions to Registered Nurse #2 after speaking to the Director of Nursing. The neurological check schedule should have been every 4 hours up to the 24-hour time (from the time of the fall) from the time the Registered Nurse Supervisor communicated it to Registered Nurse #2. Neurological checks were documented under assessments in the resident's medical record, for each time the neurological check was completed. During an interview with the Director of Nursing on [DATE] at 12:38 PM, they stated neurological checks were initiated after any known head injury or unwitnessed fall and monitored for 24 hours at preset time increments (every 15 minutes, 30 minutes, hourly, and every 4 hours). When a resident was sent to the hospital for a head injury and returned within 24 hours, it was the understanding that the resident was cleared at the hospital and neurological checks were not resumed. There was no current policy that addressed discontinuation of neurological checks upon return from the hospital if it was within 24 hours of the injury. Nursing staff typically received a verbal report from the hospital related to how the resident was cleared. If it was reported that there was no diagnostic testing or other assessment of the resident's head injury, it would be expected that neurological checks resumed. When Resident #7 returned from the hospital on [DATE] and it was reported that no diagnostic testing had been performed and it was unknown if the resident had been cleared, the neurological checks should have resumed. The receiving nurse should also have clarified the resident's status related to their head injury and any needed follow up. 10 NYCRR 415.12 ---------------------------------------------------------------------------- Immediate Jeopardy was identified, and the Administrator was notified on [DATE] at 5:53 PM. Immediate Jeopardy was removed on [DATE] at 11:07 AM prior to survey exit based on the following corrective actions taken. - 100% of staff on duty were educated according to the approved training plan. - Staff including 1 registered nurse and 7 licensed practical nurses were interviewed and confirmed participation and understanding of the education. - The facility developed a plan to educate any staff not working prior to the start of their shift. - The following from the facility's plan was verified to be implemented: - Neurological check policy revised [DATE]. - Neurological check procedure added to Registered Nurse/Licensed Practical Nurse Orientation checklist. - Neurological check sheet now included section for signs/symptoms including complaints of headache, slurred speech, and vomiting. - Incident Form was revised and now included: a section questioning if the registered nurse was notified of incident, time of registered nurse notification, time of registered nurse arrival; and a section questioning if Emergency Medical Service's was notified, time of Emergency Medical Service's notification, time Emergency Medical Service's arrived at facility and time of Emergency Medical Service's departure. - Transfer of resident in Emergency Situation Policy implemented [DATE]. - Signage with instructions for calling Emergency Medical Service's posted at all nursing stations. - Transportation procedure added to Registered Nurse/Licensed Practical Nurse Orientation checklist.

Based on observation, record review and interview during the recertification survey the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents (Resident # 158) reviewed for pressure ulcers. Specifically, Resident #158 developed a pressure ulcer that was not treated timely and there was no evidence pressure relief interventions were implemented to promote healing. Subsequently the pressure ulcer worsened, and the resident required surgical intervention to promote healing. This resulted in actual harm to Resident #158 that was not immediate jeopardy. Findings include: The facility's Pressure Injury Management Policy reviewed 6/11/19 documented a head to toe skin assessment and Braden Scale Risk for Pressure Ulcer would be completed by a registered nurse (RN) within 8 hours of admission, any resident admitted to the sub-acute rehab unit had a pressure reducing mattress and wheelchair cushion, and a licensed or registered nurse would perform a weekly skin check and document findings in the resident record. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/10/19 admission Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of 2 for bed mobility, was dependent on 2 for transfers, was frequently incontinent of urine and bowel, was at risk for developing pressure ulcers and did not have any pressure ulcers. The 7/3/2019 admission skin assessment did not document any skin alterations. The comprehensive care plan (CCP) dated 7/3/19 documented the resident was at risk for skin breakdown. The CCP did not document any interventions to prevent skin breakdown. The certified nurse aide (CNA) care instructions report dated 7/3/19 documented to inspect skin with daily care and report new or reddened areas to the nurse immediately. The care instructions also instructed to encourage the resident to change positions periodically. The CNA activities of daily living (ADL) documentation report dated 7/3/19-9/30/19 noted the resident was considered extensive assistance and at times dependent for bed mobility and required assistance of at least one staff to turn in bed. There was no documentation of a turning and positioning schedule or pressure relief interventions. A revision to the CCP dated 7/8/2019 documented a gel cushion was placed in the resident's wheelchair. A registered nurse (RN) progress note dated 8/5/2019 documented the resident had an open excoriated (superficial skin abrasion) area on the left upper buttock. The excoriation measured 0.5 centimeters (cm) x 0.5 cm. The RN documented the plan was to apply Zinc Oxide (protective cream) daily. There was no documented evidence a provider was notified of the skin alteration or that Zinc Oxide was implemented. There was no documented evidence of any treatment to the excoriated area to prevent worsening or any changes to the CCP. A nursing progress note dated 8/14/2019 documented the resident had an Unstageable (full-thickness skin and tissue loss obscured by dead tissue) pressure ulcer on the left upper buttock. The wound measured 3.0 cm x 3.0 cm and contained 100% necrotic (dead tissue). The physician was notified. There was no documentation between 8/5/19 and 8/14/19 addressing the resident's skin integrity and/or wound status. A physician order [REDACTED]. The CCP revised on 8/15/19 documented the resident had a pressure area to the left low back, top of buttock with an intervention of an alternating air mattress on his bed. There was no documentation of a turning and positioning program to address the resident's need for extensive assistance with bed mobility. The 8/28/19 weekly wound evaluation documented the wound on the left buttock remained Unstageable and measured 3 cm x 2.5 cm. The wound bed contained 10% slough (moist dead tissue) and 90% necrotic tissue. The 8/8, 8/15, 8/21 and 8/28/19 provider progress notes did not contain any documentation regarding the resident's Unstageable pressure ulcer. A 9/5/19 nursing progress note documented the resident was transferred from the rehabilitation unit to a long-term care unit at 1:30 PM. A physician order [REDACTED]. The CCP was revised on 9/5/19 and included interventions of turning and repositioning every 2 hours while in bed, side to side, back to bed for rest/off load periods when resident allows. Nursing progress notes dated 9/7/2019 and 9/8/2019 documented the wound contained a moderate amount of brown, foul smelling drainage. A physician progress notes [REDACTED]. The resident was receiving Santyl for a left sided sacral pressure ulcer. The plan was to continue with Santyl and follow closely. A weekly wound evaluation dated 9/18/19 documented an Unstageable pressure ulcer to the lower back measuring 4 cm x 3.8 cm x 1.5 cm. There was 2.5 cm of tunneling at the 11 o'clock position of the wound. The wound had 90% tan, moist slough. The wound clinic had been contacted and the facility was awaiting an appointment. A 9/21/19 nursing progress note documented the resident was transferred to the hospital secondary to a syncopal episode (loss of consciousness). A hospital discharge summary dated 10/8/19 documented the resident had a sacral wound on admission and surgery was consulted for debridement (removal of dead tissue). Under general anesthesia, the resident underwent [REDACTED]. A [MEDICAL CONDITION] was performed on 9/30/19 per surgical recommendations to promote wound healing. The resident was provided with a urinary catheter. Plastic surgery was consulted for possible flap placement over the sacral wound once the resident's physical strength and nutritional status improved. A skin/treatment observation of Resident #158 was done with LPN #43 on 10/24/2019 at 1:55 PM. The LPN removed the dressing to the pressure ulcer on the left buttock and the dressing contained a moderate amount of thick tan colored drainage. The margins of the pressure ulcer contained significant undermining at 6 and 8 o'clock and the remaining margins were pink granulation tissue. The remaining of the wound bed contained tan colored slough. During an interview with the resident on 10/22/2019 at 11:50 AM he stated he had developed a pressure ulcer on his buttock after he was admitted to the facility. At some point he was moved to the long-term care unit and they put a special mattress on his bed and special pillow for his heels. He was not repositioned regularly or had a special mattress prior to that. He had a difficult time repositioning himself since his admission. During an interview on 10/25/19 at 1:50 PM with licensed practical nurse (LPN) # 6 he stated most residents on the rehabilitation unit were mobile, so pressure reduction and prevention was not an issue. He did not recall Resident #158 having a specialty mattress. During an interview with CNA #7 on 10/25/2019 at 2:00 PM she stated the care instructions would document any special instructions for residents. She did not recall any specialty mattress for the resident. The resident did have a gel cushion on his wheelchair and at some point, they put a cushion in his chair for his back. He required assistance of two for repositioning as he was tall and was weak. She tried to reposition him when she could which was usually between 2 and 4 hours when she worked. The resident had developed a wound on his bottom and the first time she had seen it, there was a dressing on it. At some point the dressing fell off and it was black and ugly. She stated it had a dressing, so she knew someone was aware of it. During an interview with NP #9 on 10/25/2019 at 3:00 PM she stated if a resident developed a pressure ulcer it should be treated before it worsened to an Unstageable pressure ulcer. This places the resident at risk of developing infection and osteo[DIAGNOSES REDACTED] (bone infection). She would expect to be notified of a pressure ulcer immediately and she would assess the wound and reassess to ensure treatments were working. She had not evaluated the resident until after he was admitted to the long-term care unit. During an interview with physician #10 on 10/25/2019 at 3:15 PM he stated if a resident developed a pressure ulcer he would expect to be notified as he would not want the pressure ulcer to worsen. He had evaluated the resident after he was moved to the long-term care unit and his wound required an evaluation at the wound clinic which was ordered for him. The plan was to follow up with the resident after the evaluation at the clinic, but the resident was sent to the hospital. 10NYCRR 415.12(c)(1,2)

Based on record review and interview during the recertification and abbreviated surveys (NY 603) the facility did not ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for 1 of 5 residents (Residents #227) reviewed for accidents hazards. Specifically, Resident #227 sustained second [MEDICAL CONDITION](partial-thickness) from an electric fireplace (portable space heater) located in the main lobby. (See Life Safety Code recertification survey K781 Portable Space heaters.) This resulted in actual harm to Resident #227 that was not immediate jeopardy. Findings include: The 8/30/19 Electrical Safety for Residents policy documented residents will be protected from injury associated with the use of electrical devices, including electrocution,[MEDICAL CONDITION] fire. Portable space heaters are not permitted in resident areas. Resident #227 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 11/9/18 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with locomotion on and off the unit and utilized a wheelchair. The 1/11/19 at 2:45 PM investigation, initiated by registered nurse (RN) Unit Manager #29, documented the resident returned from the outside in his electric wheelchair. The resident stated his hands were cold, so he placed them on the metal grate of the fireplace in the front lobby. After removing his hands, he saw 3 fluid blister and he returned to the unit. The resident had poor sensation related to [MEDICAL CONDITIONS] and diabetes. The physician was present on the unit and assessed the areas. There were 2 blisters on the left thumb and first finger, right hand first finger, all were intact second-degree burns. The 1/11/19 investigation did not document staff interviews to determine why the electrical fireplace was in use with a functional heating element and how it had been turned on. A 1/11/19 at 3:27 PM RN Unit Manager #29 progress note documented the resident returned to the unit and stated that he had burned a couple of his fingers on the electric fireplace in the lobby area. The areas were assessed and there were 3 distinct blisters noted, 2 blisters on left hand thumb and first finger, and on the right hand first finger. The resident stated that his hands were cold, and he put his hands on the fireplace to warm them and he did not realize it was a real fire and that it would burn him. There was no pain from injured areas at this time, resident noted to have little to no sensation to his fingers. The physician was on the unit at the time of the event and assessed the area. An order was obtained for skin prep (skin protectant) to the intact blisters. A 1/11/19 at 6:45 PM RN #45 documented the resident [MEDICAL CONDITION] day resulting in blisters to right index finger and left thumb and index finger. The resident had a new physician order [REDACTED]. During an observation on 10/22/19 at 4:15 PM, the main lobby had an electric fireplace (portable space heater) that was not plugged in. During an interview on 10/22/19 at 4:26 PM, the Operations Manager stated he thought the heater element for the electric fireplace had been disabled, and he was surprised when a resident was burned on the device. He stated the fireplace had been in the facility since approximately 2014. During an interview on 10/22/19 at 4:48 PM, the Maintenance Supervisor stated he thought the electric fireplace was only for ambiance, did not know it could be used for heat, and had never seen it on before. During an interview on 10/25/19 at 1:15 PM, the Interim Director of Nursing (DON) stated incident reports should have enough information to attempt to determine a cause of an event. During an interview on 10/25/19 at 1:44 PM, RN #29 stated a receptionist would have been present in the lobby near the fireplace at the time of the event. RN #29 stated she was not aware of how the fireplace was turned on and it was not included in the investigation. 10NYCRR 415.12(h)(1)

Based on record review and interview conducted during the recertification and abbreviated surveys (NY 254), it was determined for 1 of 3 residents (Resident #539) reviewed for quality of care, the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, Resident #539 had a choking episode and was not treated according to professional standards of practice. When the resident's airway became obstructed the nursing staff did not continue attempts to relieve the obstruction after she became unresponsive. This resulted in actual harm for Resident #539. Findings include: The American Heart Association protocol for Basic Life Support for Healthcare Providers, relief of foreign-body airway obstruction for an adult, directs providers to give abdominal thrusts/[MEDICATION NAME] maneuver to a choking victim. Repeat the abdominal thrusts until the victim becomes unresponsive and then lower victim to the floor, and if the victim has no breathing or no normal breathing (i.e., agonal gasps) begin CPR. New York State Department of Health Frequently Asked Questions re: DNR's (do not resuscitate, allow natural death), policy #,[DATE], dated [DATE] includes: - If the patient is NOT in cardiac or respiratory arrest, full treatment for [REDACTED]. - Relief of choking caused by a foreign body is usually appropriate, although if breathing has stopped, ventilation should not be assisted. Resident #539 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and she required supervision with eating. The resident's Medical Orders for Life-Sustaining Treatment (MOLST) initiated on [DATE] documented Do Not Resuscitate (DNR, allow natural death). Registered nurse (RN) #45 documented on [DATE] a certified nurse aide (CNA) shouted that the resident was choking. The resident had taken another resident's sandwich and was eating it. An RN attempted the [MEDICATION NAME] maneuver and resident progressively became more dusky as the [MEDICATION NAME] was unsuccessful. The resident was removed from the dining room. A pulse was felt and oxygen was started, but agonal breathing (abnormal breath/gasping). The resident's vital signs were a pulse of 45 and blood pressure of ,[DATE]. At 1:34 PM, the resident no longer had a pulse or respirations. An investigative summary of the incident attached with the incident report documented the nurse was in the dining room when the resident choked and the [MEDICATION NAME] maneuver was immediately performed. The resident was found to have part of a sandwich in front of her and she was on a puree diet. After multiple attempts at the [MEDICATION NAME] maneuver, the resident became limp and was placed in the wheelchair and brought back to her room where she was placed in bed. Color became pinker, she had a pulse and respirations were agonal. Statements attached to the summary of investigation included: - CNA #41 documented [MEDICATION NAME] performed on the resident, the nurse in training went to the other unit to get another nurse, who ran over to assist. The resident was quickly taken to her room and 911 was called. - RN #42 documented she was alerted to the resident choking she ran over and began the [MEDICATION NAME] maneuver. Another nurse arrived and took over. By that time the resident was slumped over and dusky. We transported the resident to her room and 911 was called. - Graduate practical nurse (GN) #44 documented she heard the resident gasping and notified the RN who initiated the [MEDICATION NAME]. Another nurse arrived who took over the [MEDICATION NAME] and the resident went limp. We put her in the wheelchair, brought her back to her room and put her to bed. The resident continued to gasp for air and no success clearing her airway. We called 911 and put oxygen on the resident because she still had a pulse. By the time the ambulance arrived the resident was no longer gasping for air and no longer had a steady pulse. - RN #45 documented a nurse yelled the resident was choking and they were doing the [MEDICATION NAME]. Upon entering, the resident was slumped over, dusky and unresponsive. Two more attempts at the [MEDICATION NAME] were made and then the resident was placed in a wheelchair and taken to her room. Oxygen was applied, resident's color was improved at the time and heartbeat heard but respirations was agonal. The resident was a DNR so code protocol not initiated. - RN #46 documented she was alerted by a nurse the resident was choking and when she arrived on the unit the RN was doing the [MEDICATION NAME]. The resident was blue and unresponsive, the [MEDICATION NAME] and finger sweep was performed and the resident expelled what appeared to be bread. The nursing supervisor arrived, attempted the [MEDICATION NAME] and the resident was brought back to her room and put to bed. She had a pulse, oxygen applied and the resident had gargling sporadic breaths. The resident lost her pulse and then emergency medical technicians (EMS) arrived shortly after that. - RN #47 documented she was alerted to the resident choking, arrived on the unit and the resident was unresponsive. The [MEDICATION NAME] was done with success before her arrival on the unit. Resident put in wheelchair and put to bed in a upright position. Her pulse was strong, respirations sporadic and she remained unresponsive. Looked for food in mouth and a blind sweep with no food obtained. Shortly after that the resident was without pulse and respirations. During an interview with RN #47 on [DATE] at 1:20 PM she stated she worked as a nursing supervisor on the weekends and part of her responsibilities included responding to codes. She stated she had remembered the incident with the resident. She responded to a code call and when she arrived in the dining room the resident was unresponsive and the nurse was actively doing the [MEDICATION NAME]. The resident did not have any air movement and she was put in her wheelchair when it became evident the [MEDICATION NAME] was not successful because she did not regain spontaneous respirations and she was dusky. She was placed in bed with her head up. She did have a pulse at the time. She had taken a CPR class recently and if a resident was choking they were to do the [MEDICATION NAME] maneuver until you lose a pulse and then you would initiate CPR. The resident did still have a pulse and chest compressions were not done as they would not have helped as the resident did not have an adequate airway. During an interview with RN #46 on [DATE] at 2:16 PM she stated if a resident choked you would yell for help, activate a code blue and then initiate the [MEDICATION NAME], which were abdominal thrusts from behind, no back blows or blind finger sweep as you could further lodge the obstruction. You continued to do the [MEDICATION NAME] until the resident became unresponsive and when that happened you lie them flat and do chest compressions to attempt to dislodge the obstruction. If a DNR would not do chest compressions. Resuscitation meant to restart the heart. When she arrived on the unit the resident was blue and the RN was doing the [MEDICATION NAME]. Some bread did come out of her mouth but not enough to sustain life. [MEDICATION NAME] was continued and then the resident was taken to her room, put to bed and oxygen applied. She was gargling and was dusky color. She did not regain a normal color, was unresponsive and had a heartbeat. She stated she had not received any training or practice with codes in the facility. During an interview with RN #42 on [DATE] at 3:31 PM she stated she could recall the resident choking on [DATE] as she had never seen someone die from choking before. She was in the dining room when she was alerted the resident was choking. She initiated the [MEDICATION NAME] maneuver as the resident did not have any air exchange and she saw the sandwich in front of her. The [MEDICATION NAME] was unsuccessful and the resident became limp. She continued to not have any air movement. After it was determined the [MEDICATION NAME] was unsuccessful the resident was placed in a wheelchair and taken to her room. She was not sure if the resident had a pulse and that would not matter as the resident was a DNR so they would not have performed chest compressions. During an interview with RN #45 on [DATE] at 9:38 AM she stated part of her responsibilities included responding to codes. She stated she was both basic life support (BLS) and advanced cardiac life support (ACLS) certified and she was very familiar with the guidelines on treating a choking victim. If someone was choking they would do the [MEDICATION NAME] maneuver until food came out or they stopped breathing. Even when a resident became unresponsive you would still do the [MEDICATION NAME] from behind. She had arrived in the dining room, she was blue, they were doing the [MEDICATION NAME] and the resident did not have air movement. She directed the staff to take the resident to her room as the [MEDICATION NAME] was not successful. Oxygen was put on the resident. The resident did have a pulse. Once in her room the resident had some agonal breaths, which were not normal breaths. When the agonal breaths started there was not a lot of hope for her at that point. No chest compressions or abdominal thrusts were done as the resident was a DNR. The resident was choking as she did not have any air exchange. During an interview with the resident's physician #28 on [DATE] at 12:06 PM he stated he could not recall a choking incident with this resident. He stated he felt that if the resident was choking and did have a heartbeat they should attempt chest compressions to clear the airway. Resuscitation means to restart the heart and that is not what they would be trying to do with the chest compressions when trying to clear the airway. 10NYCRR 415.12

Based on record review and interview conducted during the abbreviated surveys (NY 199 and NY 156), it was determined for 25 of 34 residents reviewed for medications (Residents #1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 14, 15, 16, 17, 21, 22, 23, 24, 26, 27, 28, 29, 30, 33, and 34) the facility did not ensure residents were free from significant medication errors. Specifically, LPN #3 did not administer medications as ordered to Residents #14, 15, 16, 17, 21, 22, 23, 24, 26, 27, 28, 29, 30, 33, and 34 and LPN #1 did not administer medications as ordered to Residents #1, 2, 3, 4, 5, 6, 8, 9, 10, and 11. Findings include: The facility's Proper Administration and Storage of Medications policy, revised 6/24/2013, documented medications were to be administered on time and nurses were to document failures to administer ordered medications with reasons for not administering the medications in the residents' electronic medical record. 1) An Investigative packet documented on 2/26/2018 and 2/27/2018 licensed practical nurse (LPN) #3 did not administer medications as ordered to multiple residents. A medication nurse initialed and dated the multi-dose packages of medications on 2/24/2018 and 2/25/2018 and when another nurse came into work on 2/28/2018, she noticed that many medications had not been dispensed since 2/25/2018. The following residents were not administered medications as ordered: - Resident #14 did not receive [MEDICATION NAME] (anti-depressant), 20 milligrams (mg) once per day for one day (one dose). - Resident #15 did not receive [MEDICATION NAME] (diabetes medication), 500 mg once per day on 2 days (2 doses), Keflex (antibiotic), 500 mg once per day on 2 days (2 doses), [MEDICATION NAME] (blood pressure medication), 5 mg once per day on 2 days (2 doses), [MEDICATION NAME] (anti-depressant), 100 mg once per day on 2 days (2 doses), [MEDICATION NAME] (pain medication), 7.5 mg once per day on two days (2 doses), [MEDICATION NAME] (antipsychotic), 0.5 mg once per day on two days (2 doses). - Resident #16 did not receive [MEDICATION NAME], 50 mg once per day on one day (one dose). - Resident #17 did not receive [MEDICATION NAME] (diuretic), 0.5 mg once per day on 2 days (2 doses) and [MEDICATION NAME], 0.25 mg once per day on 2 days (2 doses). - Resident #21 did not receive [MEDICATION NAME] (anti-depressant), 20 mg once per day for 2 days (2 doses). - Resident #22 did not receive [MEDICATION NAME] (blood thinner), 75 mg once per day on one day (one dose). - Resident #23 did not receive Trajenta (diabetes medication), 5 mg once per day on one day (one dose). - Resident #24 did not receive [MEDICATION NAME] (anti-psychotic), 2.5 mg once per day (one dose) and [MEDICATION NAME], 75 mg once per day on one day (one dose). - Resident #26 did not receive [MEDICATION NAME] ([MEDICAL CONDITION] medication), 100 micrograms (mcg) once per day on one day (one dose). - Resident #27 did not receive [MEDICATION NAME], 0.5 mg once per day on one day (one dose), [MEDICATION NAME], 40 mg once per day on 2 days (two doses), [MEDICATION NAME], 2.5 mg once per day on one day (one dose), [MEDICATION NAME] (blood pressure medication), 25 mg once per day on 2 days (two doses), and [MEDICATION NAME], 50 mg once per day on 2 days (two doses). - Resident #28 did not receive [MEDICATION NAME] (anti-depressant), 5 mg once per day on two days (2 doses) and [MEDICATION NAME] (stomach medication), 20 mg once per day on 2 days (2 doses). - Resident #29 did not receive [MEDICATION NAME] 20 mg, once per day on 1 day (one dose), and Laxix 40 mg, once per day on one day (one dose). - Resident #30 did not receive [MEDICATION NAME] (blood pressure medication), 160 mg once per day on 2 days (2 doses), and [MEDICATION NAME], 25 mg once per day on 2 days (2 doses). - Resident #33 did not receive [MEDICATION NAME], 20 mg once per day (one dose) and [MEDICATION NAME], 80 mg once per day on 2 days (2 doses). - Resident #34 did not receive [MEDICATION NAME], 10 mg once per day (one dose) and [MEDICATION NAME], 10 mg once per day on one day (one dose). On 4/16/2018 at 9:20 AM, LPN #3 stated in an interview, the Director of Nursing (DON) called her to her office and told her she made many medication errors on 2/24 and 2/25/2018. She stated at the time of the medication errors, her practice was to go through the Medication Administration Records (MARs) and sign for administering medications prior to dispensing and administering them. She stated because that was her practice, she must have gotten pulled away and missed medications. She stated nurses were supposed to document medication administration after the medication was administered but she did it in reverse as it was faster and saved time. On 4/16/2018 at 11:05 AM, LPN #6 stated in an interview, when she came to work on 2/28/2018, she noticed many medications were not dispensed from the multi-dose packages since they were initialed and dated on 2/25/2018. She stated she reported what she noticed immediately and registered nurse (RN) Manager #7 started the investigation. In an interview with RN Manager #7 on 4/20/2018 at 3:48 PM, she stated she worked on the investigation with LPN #6 because LPN #6 noticed the errors and there was a lot to figure out. RN Manager #7 stated because some residents received medications multiple times per day, she only included the medication errors that she knew for sure were committed by LPN #3. She stated she suspected around 10 additional residents were affected by LPN #3 not administering medications over the course of 2 days but because there were other nurses involved on other shifts, she could not say that with 100% certainty. RN Manager #7 stated after this issue was brought to her attention, she started thinking about ongoing issues she had with residents on the unit and stated because of those issues, she suspected LPN #3 had been missing medications on an ongoing basis for the past few months. She stated an example was Resident #27. She stated the resident had [MEDICAL CONDITION] and it seemed like no matter how much the physician changed his medications, they did not see an improvement in his [MEDICAL CONDITION] as she would have expected. She stated she discussed that resident and a few others with LPN #3 and LPN #3 never gave her any indication she was cutting corners and not administering medications as ordered. On 5/16/2018 at 11:10 AM, the DON stated in an interview, LPN #3 should not have documented for medications until after she administered them. She also stated if LPN #3 got was not able to get her medications administered, she should have let a Supervisor know so they could find someone to help her out. 2) An Investigative Packet documented on 3/24/2018 and 3/25/2018, licensed practical nurse (LPN) #1 did not administer medications to Residents # 1, 2, 3, 4, 5, 6, 8, 9, 10, and 11 as ordered. On 3/23/2018, a medication nurse initialed the multi-dose medication packages when administering medications, LPN #1 was the medication nurse on 3/24 and 3/25/2018, and when the medication nurse came in on 3/26/2018, she observed that multiple medications had not been dispensed from the multi-dose medication packages since being initialed and dated on 3/23/2018. Review of Medication Incident Reports dated 3/26/2018 and the residents' 3/2018 Medication Administration Records (MAR) revealed LPN #1 did not administer medications as ordered and documented on each MAR that the medications were administered: - Resident #1 did not receive [MEDICATION NAME] (antidepressant), 10 milligrams (mg), once per day for 2 days (2 doses). - Resident #2 did not receive [MEDICATION NAME] (steroid), 10 mg, once per day for 2 days (2 doses). - Resident #3 did not receive [MEDICATION NAME] (blood thinner), 75 mg, once per day for 2 days (2 doses). - Resident #4 did not receive [MEDICATION NAME] (blood pressure medication), 25 mg, two tablets per day for 2 days (2 doses). - Resident #5 did not receive [MEDICATION NAME] (pain medication), 100 mg daily for two days (2 doses) and [MEDICATION NAME] (medication for nerve pain), 100 mg three times per day for one day (4 doses). - Resident #6 did not receive [MEDICATION NAME], 50 mg daily for 2 days (2 doses). - Resident #8 did not receive [MEDICATION NAME] (medication for nerve pain and antidepressant), 150 mg daily for 2 days (2 doses) and [MEDICATION NAME] (anti-psychotic medication), 2 mg daily for 2 days (2 doses). - Resident #9 did not receive [MEDICATION NAME] (diuretic), 20 mg once per day for 2 days (2 doses). - Resident #10 did not receive [MEDICATION NAME] ([MEDICAL CONDITION] medication), 500 mg twice a day for 2 days (2 doses). - Resident #11 did not receive [MEDICATION NAME], (medication for nerve pain), 25 mg once daily for 2 days (2 doses). A 3/26/2018 note written by the Assistant Director of Nursing (ADON) documented she interviewed LPN #1 who refused to provide a written statement to the facility. The ADON documented that LPN #1 told her that she did not call the Supervisor to request help with medication administration and did not notify anyone that she was not able to administer medications as ordered on [DATE] and 3/25/2018. On 4/6/2018 at 10 AM, the ADON stated in an interview, she came into the facility on [DATE] to Supervise and saw LPN #1. She stated she came in around lunchtime and LPN #1 was in the dining room feeding a resident. She stated LPN #1 did not tell her she was having issues getting medications administered. On 4/6/2018 at 12:07 PM, LPN #4 stated in an interview, she was the medication nurse on Friday 3/23/2018 and when she did her medication pass that day, she initialed and dated the multi-dose medication packages. She stated when she came to work on 3/26/2018, she noticed that many medications had not been dispensed from the multi-dose medication packages since 3/23/2018. On 4/24/2018 at 2:10 PM, registered nurse (RN) Supervisor #8 stated in an interview, she was the weekend Supervisor on 3/24/2018 and 3/25/2018 and worked the evening and night shifts on both days. She stated on both days, she saw LPN #1 and LPN #1 reported no concerns to her. She did not report she was having trouble administering medications and did not ask for help. On 4/25/2018 at 10:42 AM, LPN #1 stated in an interview she missed administering many medications on 3/24/2018 and 3/25/2018 as she got ahead of herself. LPN #1 explained her process for administering medications as follows: - Since she was new to the unit and did not know the residents, she obtained a cheat sheet which she described as a sheet that listed each resident and the manner in which they took their medications. - She then reviewed the MARs for each resident and hand wrote on the cheat sheet each residents' medication times, the names of the medications, and in some cases the dosages. - She used the handwritten cheat sheet to prepare medications and did not check the MARs during medication administration. - She wrote a line through the resident's name when she gave the medications and then later on documented on the MAR that she gave the medications if the resident had a line through their name. LPN #1 stated on these days, she must have put lines through residents' names before administering the medications because she got confused when she was called away to do other things. She stated she did not know the unit or the residents and they were a lot of medications to administer and she lost track of what she was doing. On 5/16/2018 at 11:10 AM, the Director of Nursing (DON) was interviewed and stated she was not aware of LPN #1's practice for medication administration as described by the surveyor. She stated LPN #1 should not have used the cheat sheet to administer medications, she should have referred to each residents' MAR, and should not have documented for medications until after she administered them. The DON also stated if LPN #1 was not able to get her medications administered, she should have let a Supervisor know so that they could find another nurse to assist her. 10NYCRR 415.12(m)(2)

Based on record review and interview conducted during the abbreviated survey (NY 958), it was determined for 1 of 3 residents reviewed for abuse/neglect (Resident #14), the facility did not ensure residents had the right to be free from neglect. Specifically, Resident #14 was found on the floor 4 different times by staff members and was assisted off of the floor by licensed practical nurses (LPN) and certified nurse aides (CNA) prior to assessments being done by qualified professionals. In addition, the LPNs did not notify the registered nurse (RN) timely of the resident's falls and injuries. When the assessments were completed, the resident was diagnosed with [REDACTED]. Findings include: The facility's Response to Resident Fall policy dated 5/22/2017 documented a fall was an unintentional change in position coming to rest on the ground or onto a lower surface such as a bedside mat. When a resident fell , they were to be made comfortable and should not be moved from the surface until assessed by a registered nurse (RN). Residents were not to be lifted off the floor regardless of their weight/size and should be hoyer (mechanical) lifted off the floor. Resident #14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 11/8/2017 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition. The comprehensive care plan (CCP) dated 9/6/2017 documented the resident was at risk for falls and if a fall occurred, the facility was to attempt to determine the root cause of the falls. The CCP, updated on 11/29/2017, documented the resident put herself on the floor at times when fatigued. The 12/6/2017 incident report initiated by licensed practical nurse (LPN) #1 at 11:35 PM, documented the resident was found with dried blood on her chin and a possible scratch. She cleaned up the scratch and notified the Supervisor at a later time when she rounded. The report documented LPN #1 noticed the scratch when she assisted the resident to bed and did not specify the resident had a fall. The 12/7/2017 LPN #2's progress note at 12:29 AM, documented the resident was trying to lay on the floor. The 12/7/2017 RN Supervisor #8's progress note at 1 AM documented when she was rounding, she was told by the charge LPN that the resident had a scratch on her neck. RN Supervisor #8 assessed the resident and documented the scratch was a large superficial deep scratch with dark dried blood on the left neck under the chin measuring 6 centimeters (cm). The resident also had a small bruise above the scratch measuring 1.5 cm x 1 cm and a small scratch on the collar bone with dried blood. Both scratches were cleaned and [MEDICATION NAME] (antibiotic ointment) was applied. The 12/7/2017 at 1:01 AM, RN Supervisor #8's progress note documented it was a clarification note. The note specified at 1 AM, she arrived on the unit to do rounds and the LPN told her the resident had a scratch that was found at the beginning of the shift. The RN documented she was not made aware of any falls at that time, however in passing, the LPN mentioned that the resident put herself on the floor at times. The 12/7/2017 at 4:40 AM, LPN #1's progress note documented when she assisted the resident back to bed she noticed dried blood under her chin and a larger scratch. When she cleaned the scratch up she noticed it was superficial and deep and she notified the Supervisor at a later time. The 12/7/2017 at 6:03 AM, RN Supervisor #8's progress note documented she was notified the resident had bruising on her leg. RN Supervisor #8 documented the resident had a large bruise on the left hip measuring 16 cm x 15 cm and a bruise on the upper, left inner thigh. The resident was able to move her leg and the RN Manager was present and also assessed the resident. The 12/7/2017 RN Supervisor #8's progress note at 6:05 AM, documented it was a clarification note. The note specified at 4:30 AM, Unit Helper #9 notified her of a bruise on the resident's leg. She immediately went to the unit and assessed the resident. While doing the assessment, certified nurse aide (CNA) #10 told her that when she walked by the resident's room between 11 PM and 11:30 PM, she heard a thud and found the resident on the floor. CNA #10 stated she told LPNs #1 and 2 when this occurred. RN Supervisor #8 documented she started an investigation into the resident's fall and at 5:55 AM, the RN Manager was on the unit and she updated her of the events that had occurred with the resident. The 12/7/2017 at 10:52 AM, LPN #11 's progress note documented the resident's x-ray showed a right femoral head (leg) fracture and the resident was sent to the emergency room . The 12/7/2017 at 6:26 PM, RN Manager #7's progress note documented: - At 5:45 AM, she was told by RN Supervisor #8 that the resident had a fall and an injury. - At 6 AM, she called nurse practitioner (NP) #16 and an x-ray was ordered. - At 8:25 AM, she received x-ray results and the resident sent to hospital with a femur fracture. - At 6:15 PM, she was notified by the hospital that the resident had a right femur fracture and left jaw fracture. The Investigative Packet dated 12/7/2017 documented the resident had an accident with injury and the facility obtained the following statements: - LPN #1's statement documented she arrived at the facility at 11 PM on 12/6/2017 and while she was getting report from LPN #2, CNA #10 said the resident was on the floor. LPNs #1 and 2 found nothing wrong with the resident and helped her off the floor into bed. While helping her into bed, LPN #1 saw a large scrape on the resident's chin. Approximately 15 minutes later, LPN #1 was told the resident was on the floor again and the resident was brought to the nurse's station and Unit Helper #9 did 1:1 with her. The resident fell asleep and was taken off 1:1 at 2 AM. At 2:30 AM, the Supervisor came around and LPN #1 showed the Supervisor the scratch on the resident's chin and the Supervisor took it from there. At 4:30 AM, CNA #10 saw bruising on the resident's left upper thigh and the Supervisor was notified. - CNA #10's statement documented on 12/6/2017, she walked past the resident's room, saw the resident crawling on the floor, and notified the 2 PM to 10 PM staff. CNA #10 did not specify a time when this was observed. She did not know who assisted the resident off the floor. On the 10 PM to 6 AM shift, she walked by the room, heard a thud, and saw the resident on the floor. She told the staff and later saw the marks on the resident's neck and chin. - LPN #2's statement documented on 12/6/2017 at 9:50 PM, the resident was found curled up on the dining room floor with a bathrobe under her head. LPN #2 woke the resident up and she got herself off the floor with minimal assistance from LPN #2. At 12:15 AM, the resident was found on her bedroom floor and he went to the room with the other LPN. LPNs #1 and 2 assisted the resident off the floor and back to bed. LPN #2 left the facility shortly after that. On 4/20/2018 at 2:50 PM, RN Manager #7 stated in an interview, she came into work at 5:30 AM on 12/7/2017 and RN Supervisor #8 told her the resident was found with a large bruise on her thigh and was in pain. RN Manager #7 stated she saw the resident's bruise and immediately called the medical provider to get an x-ray order. She stated she completed the staff interviews and investigation and she determined the resident fell 4 times on 12/6/2017 and 12/7/2017, was not assessed by a RN following any of the falls and the RN was not notified timely of the falls. She stated: - After dinner on 12/6/2017, CNA #10 saw the resident crawling on the floor in her room. CNA #10 told LPN #2. CNA #10 did not stay with the resident and did not know who got the resident off the floor. She stated since this was an unwitnessed event, facility policy was to call the RN for an assessment and this was not done. - Between 9:50 PM and 10 PM on 12/6/2017, LPN #2 found the resident lying on the floor in the dining room. LPN #2 woke her up and helped her to her room. A Supervisor was not called and LPN #2 should have called the Supervisor for an assessment. - At 11:30 PM on 12/6/2017, CNA #10 heard a thud, saw the resident on the floor, and told LPNs #1 and 2. CNA #10 reported the resident was on her hands and knees at that time and LPNs#1 and 2 assisted the resident off the floor and into bed. - At 12:15 AM on 12/7/2017, the resident was on the floor again. She believed LPN #2 was still in the facility at that time and both LPNs #1 and 2 had someone get the resident up and place her in a recliner near the nurse's station while Unit Helper #9 did 1:1 with her. - At 1 AM on 12/7/2017, RN Supervisor #8 rounded on the unit and saw the scratch on the resident's chin. RN Supervisor #8 was not told of any of the resident's falls. - At 4:30 AM on 12/7/2017, CNA #10 tried to do morning care on the resident and the resident could not walk and had a large bruise on her thigh. LPN #1 had Unit Helper #9 call the Supervisor and tell her about the bruise. RN Supervisor #8 came to the unit and assessed the bruise and at that time, CNA #10 said to her, that must have happened when I heard the thud. She stated RN Supervisor #8 started to try and piece everything together and notified RN Manager #7 as she was in the building. RN Manager #7 stated when she saw the resident, she had a lot of leg pain and an order was obtained for the x-rays. She stated during the x-ray, she had to hold the resident's leg in place because she was in so much pain. On 4/23/2018 at 2:05 PM, LPN #2 stated in an interview, he worked the 3 PM to 11 PM shift on 12/6/2017 and stayed later than 11 PM as the oncoming nurse (LPN #1) did not know the unit. He stated the following occurred with the resident on 12/6/2017: - after dinner, a CNA told him the resident was crawling on the floor in her room and by the time he got there, the resident was back in bed. - At around 9 PM, he found the resident sleeping on the dining room floor, he woke her up, helped her up and she went back to her room. He stated since she walked back to her room, he thought she was fine. - At around 12 AM on 12/7/2017, someone said the resident was on the floor. He stated his shift was over so he told the other nurse (LPN #1) it was her call whether to get her off the floor. The resident had a skin tear under her jaw and he lifted her off the floor on his own and placed her into a wheelchair as she was very light. He stated he left shortly after. - He did not recall the fall at around 11:30 PM on 12/6/2017 when he was giving report to LPN #1. - He stated any time a resident was on the floor he was supposed to call the Supervisor, but back in December, he thought if the resident was sitting up or able to get up on their own, then an assessment was not needed. - He stated he did not report the resident's skin tear because he had given report to LPN #1 and he thought she would follow-up on it. On 4/24/2018 at 2:10 PM RN Supervisor #8 stated in an interview, - On the evening shift on 12/6/2017, she never heard anything from the unit about the resident falling. - At 1 AM, on 12/7/2017, she saw the resident sitting in a recliner chair and LPN #1 told her about a scratch on the resident's neck found earlier in the shift. RN Supervisor #8 saw a large scratch on the resident's neck with dried blood, a small bruise above the scratch on the left chin, and a small scratch on the left collar bone with dried blood. LPN #1 told her she thought the resident scratched herself and LPN #1 did not tell her about any falls. The resident was asleep at that time. - In the morning of 12/7/2017, Unit Helper #9 called her and said they were going to have to send the resident to the hospital because they found a large bruise. RN Supervisor #8 went to the unit and saw a huge bruise on the resident's hip and noted that the neck bruise that she saw earlier was much larger. RN Manager #7 was present and took over the investigation. - CNA #10 was present and did say to her that the injuries must have happened when she heard a thud and found the resident on the floor. - The facility's policy was to assess any resident who was found on the floor and if she was told the resident fell , she would have assessed her. On 4/25/2018 at 9:56 AM, LPN #1 stated in an interview: - On 12/6/2017, she was asked to float to the resident's unit and her shift started at 11 PM. - LPN #2 stayed late to provide her with a thorough report as she did not know the residents or the unit. During report, a CNA told them the resident was on the floor. LPN #2 told her the resident was care planned to be on the floor so LPNs #1 and 2 lifted her off the floor and placed her in bed. At that time, she saw a scratch on the resident's neck and cleaned it up. It looked like a fingernail scratch and it had dried blood so she thought it had been there for a while. - Less than 15 minutes later, a little after 12 AM on 12/7/2017, she was told the resident was on the floor again. She had staff get the resident off the floor and wheel her to the nurse's station where she sat in a recliner and received 1:1. - At 1:30 AM, RN Supervisor #8 rounded and LPN #1 showed her the resident's scratch, told the RN there was an unwitnessed fall earlier in the shift, and LPN #1 and RN Supervisor #8 started the paperwork for the unwitnessed fall. - At 5 AM, the CNAs tried to get the resident up and she could not stand or bear weight and both upper thighs were black and blue. The Supervisor was called and assessed the resident. - She did not know what care planned to be on the floor meant but LPN #2 had told her that if the resident was sitting on a floor mat, they did not need to get an assessment by a RN. On 4/25/2018 at 12:21 PM, CNA #10 stated in an interview: - On 12/6/2017 after dinner, she walked past the resident's room and saw the resident crawling on the floor on her hands and knees. She went to the desk and told the nurses and CNAs who were sitting there. She was on orientation at that time so she did not know she should have stayed with the resident and made sure someone followed up. She did not know who responded and/or what they did. - On the night shift, she walked by the room and heard a thud. The resident was crouched down on her knees with her head on the floor. She told LPNs #1 and 2 and the two LPNs picked the resident up and placed her in a wheelchair. The resident was taken to a recliner chair near the nurse's station. - At 5 AM, she tried to get the resident up for the day. She did a stand and pivot transfer with the resident to get her from the recliner to the wheelchair, wheeled her to bathroom, and when they got there, the resident was unable to stand per her usual. She saw that the resident's right side was all bruised at that time and the small bruise she had on her neck was now larger. The Director of Nursing (DON) stated in an interview on 5/16/2018 at 11:10 AM, when the resident was found on the floor by LPNs #1 and 2, the RN Supervisor should have been called, told of the falls, and an assessment should have been done. She stated neither LPN called an RN any time the resident was found on the floor and when the RN rounded and saw the resident's scratch, LPN #1 did not tell the RN the resident fell . The DON stated it was not within the scope of practice for LPNs to assess residents or to get them off the floor without assessments being done. She stated the resident did have a history of lying on the floor matt next to her low bed but if she was on the floor and it was unwitnessed, the staff were told to have her assessed for injury. She stated if assessments were completed sooner, they may have obtained x-rays sooner and likely would have sent the resident to the hospital sooner. On 5/17/2018 at 2:45 PM, the NP stated in an interview, when she came on duty she was updated by RN Manager #7 that the facility had called the on-call practitioner and x-rays were pending. She stated she saw the resident prior to her going out and observed shortening and rotation in the leg that was fractured. She stated when the x-ray results came in, she was notified and the resident was sent to the hospital. She stated it was her expectation that if a resident was on the floor, a RN would be called to complete an assessment. During the interview, the NP checked the on-call notes and stated there were no calls to the provider for the resident on 12/6/2017, they were called on 12/7/2017 and the note documented that the resident had an abrasion and bruising, a fall in the evening, and x-rays were ordered. 10NYCRR 415.4(b)(1)(i)

Based on record review, observation and interview conducted during the partially extended abbreviated surveys (NY 053, NY 597, and NY 414) it was determined for 82 residents at risk to wander, including 5 of 7 residents (Residents #1, 2, 3, 4 and 5) reviewed for elopement risk, the facility: - Failed to address the effectiveness of their elopement prevention measures despite an elopement event in 5/2017 and a second event in 6/2017; - Failed to ensure staff responded to alarms alerting to potential resident elopements; - Failed to adequately implement measures to ensure residents were safe when alarms sounded; - Failed to ensure staff consistently followed planned elopement policies; - Failed to ensure all staff working in the building were trained on elopement policies; and - Failed to ensure door locks and alarms consistently functioned as planned. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. The 10/1/2016 facility Prevention of Resident Elopement Policy documented residents were to be assessed for elopement risk on admission. If identified at risk the assessment was to be completed quarterly, re-evaluated with any change in status, episode of wandering, or elopement attempt. All staff are to be educated on the identification of a resident who has been identified at risk to wander, which places them at risk for elopement. This will be done during general orientation at the facility. Findings include: RESIDENT INFORMATION 1) Resident #1 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A 3/6/2017 social services progress note documented the resident continued to talk about getting out of the facility. The 3/13/2017 comprehensive care plan (CCP) documented the resident ambulated independently, had a communication problem, periods of restlessness, anxiousness, and could be resistive to care. The resident was at risk to elope related to impaired safety awareness, and would pack his belongings and say he is getting out of here. Staff were to provide a program of activities that were of interest and accommodated the resident's status. Staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, television, or a book. A wander guard was in place to maintain the resident's safety. Staff were to engage in conversation with the resident, and stop and talk with him when he was passing by. Nursing progress notes documented: - On 3/25/2017, the resident had been found wandering into other residents' rooms, the resident was redirected twice and each time he went in to another resident's room. - On 5/22/2017, the resident was up and down during the night, going between her room and the nursing station, and attempted to go in to another resident's room. A 5/22/2017 wandering risk assessment documented the resident had wandered within the home, had wandered in the past month, was at high risk for elopement, and a wander guard was in place to maintain the resident's safety related to poor safety awareness and disorientation of place. The 5/23/2017 Minimum Data Set (MDS) assessment documented the resident was moderately cognitively impaired; had inattention, disorganized thinking, did not exhibit wandering symptoms, and required supervision to move about on and off the unit. On 6/14/2017 at 10:36 PM, a registered nurse (RN) progress note documented around 9:30 PM the nurse received a call from a 911 dispatcher stating an elderly male was found pushing an elderly female in a wheelchair on a road down the way from the facility. The units performed a head count and found Resident #1 and 2 were not in the facility. The RN, with the assistance of a licensed practical nurse (LPN), drove to the location the 911 dispatcher had stated and Resident #1 was noted to be pushing Resident #2 in her wheelchair. The residents were transported back to the facility. Resident #1's wander guard was in place on the left ankle, and upon return to the facility a new wander guard was placed. Both residents were assessed upon return to the unit and were noted without injuries. The RN documented both residents were unaware of the risk associated with wandering and elopement and unable to describe what they were doing or where they were going. Staff were to be assigned through the night in order to monitor both residents and confirm their safety and whereabouts on the unit. On 6/14/2017 at 10:43 PM, a LPN progress note documented Resident #1's wander guard was tested and did not function properly. The nurse and the supervisor were able to walk through the main door and walk past another unit without the alarm going off. A wandering risk assessment was completed on 6/14/2017 post incident and documented the resident had wandered aimlessly within the home or off the grounds, was at high risk to wander, had an actual elopement, and wandered off the grounds with another resident. A 6/15/2017 social services progress note documented the resident was noted to be leaving the facility pushing another resident in the wheelchair last evening. The resident and the other resident were found walking along a road near the facility. Both residents were returned by the nursing with no known negative effect. The resident was placed on 1:1 to maintain his safety. The social worker met with the resident, he was alert with periods of confusion and was unable to recall the events from the evening prior. Resident #2 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 3/14/2017 MDS documented the resident was severely cognitively impaired, did not wander, required supervision with movement on the unit, and extensive assistance of staff when off the unit. The CCP, last updated 3/20/2017, documented the resident ambulated throughout the unit. Staff were to be knowledgeable of resident location when off the unit and were to use the resident sign-in/sign-out elopement board when the resident left the unit. A 6/9/2017 wander risk assessment documented the resident was at risk to wander. A 6/14/2017 at 10:50 PM RN progress note documented at 9:30 PM she received a call from a 911 dispatcher that an elderly male was pushing an elderly female in a wheelchair. A head count was done by the facility and Residents #1 and 2 were not accounted for. The RN and LPN went to the location noted by the 911 dispatcher and brought the resident's back to the unit. The resident was assessed with [REDACTED]. Staff were to be assigned throughout the night in order to monitor both residents and confirm their safety and whereabouts. A 6/14/2017 wandering risk assessment post incident documented the resident was at high risk to wander, had an actual elopement, wandered aimlessly within the home or off the grounds, was ambulatory with or without staff assistance or assistive device, and wandered off grounds with another resident. A 6/15/2017 social services progress note documented the resident was noted leaving the facility with another resident last evening, the residents were found walking along a road near the facility, both residents were returned by the nursing supervisor with no known negative effects. Resident #2 was placed on 1:1 to maintain her safety and the resident was unable to recall the events from last evening and did not report any concerns. A 6/16/2017 NP progress note documented NP saw the resident and the resident did not recall leaving the facility. The resident now had a wander guard in place and was currently being monitored closely. A facility investigation dated 6/19/2017, documented on 6/14/2017 at 9:30 PM, the nursing supervisor received a call from the police department of an elderly man pushing someone in a wheelchair approximately 1 mile down the road the residents were returned to the facility without injury. The investigative packet documented: - The residents returned from an activity on the Saul Unit at 8:31 PM. - Once on the Saul Unit Resident #1 continued to push Resident #2 in a wheelchair. They immediately exited the Saul unit to the Gordon Unit, and exited to the main hallway from the Gordon Unit. - Resident #1's wander guard and the door alert system were functioning at the time of the event as the unit doors locked. A unit helper (employee who does not provide direct care to residents) entered the code, disengage the door allowing the residents and family members off the unit. - The visiting family assisted Residents #1 and 2 through the door, the alarm sounded, was disengaged by the RN supervisor without observing the location of the residents. - Resident #1 proceeded to push Resident #2 through the front entrance doors behind the visiting family and exited the building. As a result of the investigation re-education of the roam alert system (wander guard) and prevention of elopements were to begin immediately on 6/15/2017. The 6/21/2017 certified nurse aide (CNA) care instructions documented the resident had a wander guard in place. There was no documentation regarding ambulation status or the location of the wander guard on the instructions. During an interview with CNA #3 on 6/22/2017 at 3:00 PM, she stated she had seen the residents outside on 6/14/2017, did not realize they were residents as Resident #1 appeared to be a visitor, and there was not a flag on Resident #2's wheelchair. During an interview with agency CNA #11 on 6/22/2017 at 4:58 PM, she stated she was working on the unit when Resident #1 exited the facility. She stated the residents had left the unit for an activity, did not see them return to the unit and did not know they were missing until the nursing Supervisor notified their unit. She stated she was not aware Resident #1 was an elopement risk and did not know what the facility used for wander risk identifiers prior to the event. She stated since the 6/14/2017 event a coworker in passing notified her of the orange charm on the bracelet. She stated she had not received any re-education or training by the facility. She stated she had worked at the facility since 6/14/2016 and had worked on units located in the Martin Luther building. During an interview with RN Supervisor #4 on 6/22/2017 at 5:08 PM, she stated she was working the night of the 6/14/2017 elopement. She stated she received a call at 9:30 PM in the nursing supervisors' office from 911. When asked if the wander guards were tested , she stated the LPN tested the wander guard on Resident #1 and it had a delayed response. She stated the door alarm sounded, but the door did not lock. She stated when the doors were working the door locks and sounds, a code would be entered, the door would unlock and the beeping sound continued until the door was closed. During an interview with RN #13 on 6/22/2017 at 6:00 PM, he stated he was working on a medication cart the night the residents exited the building. He stated Residents #1 and 2 were on the unit talking to someone. He heard the male say he was trying to get out of here. He stated a lot of residents from the Saul Unit came over to go through the Gordon Unit. He stated he did not know they were residents as Resident #1 looked like a visitor. He stated if the doors to the unit had been opened, had not yet latched, a resident wearing a wander guard could still pass through. During an interview with unit helper #5 (employee who is a non-direct care giver) on 6/22/2017 at 6:20 PM, he stated the night of 6/14/2017 visitors were attempting to leave the unit, did not know the code, so he entered the code, opened the doors for them, and followed them to the double doors heading to the lobby. He stated neither he nor the visitors entered a code in to the second set of double doors and they and the residents were able to exit. He stated he was not trained on wandering or elopement. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The elopement risk assessment created 7/20/2016 and completed 8/3/2016, documented the resident was at risk for elopement. There was no documented evidence a wander guard bracelet (alert device which initiates alarms when nearing doorways, elevators, exits) was applied. The wandering risk assessment dated [DATE] documented the resident was being reviewed for his quarterly assessment, had a history of [REDACTED]. There was no risk score on the assessment to state if the resident was at risk for elopement or if his risk had changed from the previous assessment. There was no documented evidence the resident had a wander guard in place. The comprehensive care plan (CCP) dated 1/5/2017 and revised on 2/15/2017 documented the resident had poor safety awareness, made verbal requests to leave, and made previous attempts to jump out of the window. The CCP documented a wander guard was applied at that time. The CCP documented to assess the wander guard placement per provider order and the wander guard was applied to an extremity. There was no documented evidence where the bracelet was located, or that a physician order [REDACTED]. A wandering risk assessment dated [DATE] documented the resident was ambulatory without staff assistance or assistive devices, had a medical [DIAGNOSES REDACTED]. The form documented a roam alert wander guard bracelet was placed to maintain his safety. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, had fluctuating inattention and disorganized thinking, and required supervision and oversight for all activities of daily living (ADLs). The MDS documented the resident had no wandering behaviors. The physician's orders [REDACTED]. The medication administration record (MAR) and the treatment administration record (TAR) dated 5/1-5/31/2017 did not document the resident had a wander guard bracelet or that it was monitored for placement. The physician progress notes [REDACTED]. There was no documented evidence a physician's assessment was completed following the elopement event on 5/10/2017. A nursing progress note dated 5/10/2017 at 2:30 PM documented the resident was found outside at 8:30 AM by the housekeeping staff, wandering in front to the Martin building. The housekeeper redirected him back into the building and back to the unit, the wander guard was working as the alarm sounded at the door and elevator. There was no documented evidence an assessment was completed at the time of the incident. A facility investigative packet documented as initiated on 5/11/2017 and completed on 5/30/2017, documented on 5/10/2017 at 8:20 AM the resident was found alone outside of the Martin building by housekeeping staff member #1, who observed the resident through the window in the hallway leading from the Katherine building to the Martin building. Housekeeping staff #1 reported the resident's wander guard bracelet alarmed upon returning to the building and it was unknown how the resident was able to exit the building. The report documented the facility's video footage of the area revealed the resident exited the Martin Luther building lobby area when speech language pathologist (SLP) #2 held the door open for the resident as she entered the area. The report documented the resident was returned to the facility and did not have any injuries. The SLP was interviewed and stated she recalled opening the door for the resident, did not see him exit the building, and did not recall if the alarm sounded. The report documented it could not be determined how the resident was able to exit his floor, as the alarm system was designed to disable the elevators when a resident with a wander guard entered onto one. The SLP was counseled on maintaining resident safety, the alarm company was contacted, and there were no changes to the resident's care plan. There was no documented evidence the facility interviewed any other staff to rule out abuse, neglect, or mistreatment, or to determine how the resident was able to leave the unit. The investigative packet did not include a written statement from SLP #2, who let the resident out of the lobby. The undated resident care guide (care instructions) printed 6/2/2017 documented there was a wander guard bracelet in place. The care guide did not document where the bracelet was located or when it was to be checked. The resident was observed on 6/21/2017 at 8:30 AM in his room watching television. During the observation, Resident #3 stated he did not recall leaving the building at any time and he had a wander guard on his left wrist. He stated things were fine at the the facility and he did not have any concerns. On 6/21/2017, between 8:22 AM and 8:30 AM, the front entrance to the Martin Luther building was observed. A sign was posted on the door to the inside noting to visitors, please make sure all doors close completely behind you and that no resident is behind you. A table was just inside the Martin Luther entrance doors. There was a volunteer book on the table covering a sign documented with the same information. There was not a visitor log on the table or in the area. During an interview with social worker #7 on 6/23/2017 at 11:35 AM, she stated they reviewed the resident's care plan on a recent quarterly re-assessment and the team did not feel any further interventions were needed outside of a wander guard for resident #3. She stated a 2016 assessment identified the resident at risk for elopement. She stated when assessed at risk a wander guard would have been applied right then. She stated another assessment should have been completed in 12/2016 or 1/2017 and it was not. The social worker stated an assessment was not completed after the resident eloped from the facility and one should have been done. She stated the day of the resident's event she was working at the facility. She stated she did not update the resident's care plan after the elopement. During an interview with CNA #8 on 6/23/2017 at 12:05 PM, she stated the resident had a wander guard, and did not like to keep it on. She stated the resident had a history of [REDACTED]. She stated the day the resident eloped, the resident had an appointment, the resident went down the elevator and left the building. He stated that could have only occurred if someone entered the code. During an interview with RN Unit Manager #9 on 6/23/2017 at 12:25 PM, he stated the resident did not have the location of his wander guard on his care instructions and it should have. He reviewed the 8/3/2016 risk assessment and stated the resident should have a wander guard. He stated the 10/18/2016 assessment should have a score documented to determine risk and it did not. He stated there should have been another assessment completed after 10/2016. He stated when the resident attempted to get out the window it was brought up in the facility's morning report. There was not an incident report completed, and he would have been the one responsible to initiate it. He stated he believed the resident had a wander guard when he resided in the Katherine Luther building, prior to moving to the Martin Luther building. He stated the resident had exit seeking behavior, made attempts to leave the building, and destroyed his window screen when he was verbalizing he wanted to leave. During a follow up interview with the DON on 6/23/2017 at 8:50 AM, she stated if an alarm sounded staff should immediately respond, check the area through the doors and check if anyone is in the area. She stated staff should not be providing codes loudly in resident areas and if staff was near a door requiring a code, they could enter it for visitors. She stated PT, OT, and SLPs did not get training on elopement or wander guards. She did not know if agency staff received training. She stated they would not know if staff retained information provided at training, unless those staff asked questions. When asked what preventative measures were implemented on wandering and elopement from 12/2016-4/2017, she stated, just the sign on the door. She stated Resident #3 was moved from the Katherine Luther building to the Martin Luther building in 5/2017. She stated she was not aware of any elopement events prior to 5/2017 with the resident. She stated the resident had a wander guard as he was an elopement risk. During the interview the care plan was reviewed for Resident #3, she stated she was not aware the resident attempted to jump out the window. She stated the interventions in the residents' CCP were not correct for issues. She stated she would expect the wander guard to be on the MAR and in the physician orders. On 6/22/2017 at 1:55 PM, the Director of Information Technology stated the IT department monitored when there was a concern with the cameras, they checked the function weekly if not more. He stated he was not aware the outside camera was not working. He stated the indoor cameras were high priority, and they were motion activated. FACILITY OBSERVATIONS On 6/21/2017 between 8:57 AM and 9:20 AM, the surveyor asked an unidentified nurse if a code was needed to leave the unit. The nurse told the surveyor the code, out loud, while a resident was present and within earshot. On 6/21/2017, between 8:57 AM and 9:20 AM and at 4:55 PM, a surveyor approached the Saul Unit door and it was not latched. The surveyor entered the unit, the door closed, did not latch, and the surveyor was able to open the door without entering a code. Between 8:57 AM and 9:20 AM, the exterior exit door located outside of the Saul Unit, opened after a 15 second delayed egress. When the door was held open by the surveyor, the alarm stopped sounding while the door remained open. The alarm was faint and difficult to hear from a distance away. The door lead to an exterior side walk leading to a driveway and parking lot. On 6/22/2017 at 5:25 AM, a surveyor approached the Katherine Luther entrance doors. pressed a call button, an unidentified staff member answered, the surveyor stated she was trying to get into the building, did not identify herself. And the staff member did not ask who the surveyor was and unlocked the door from a different location. Upon entering no staff were present or visible in the lobby. The surveyor was able to go through the adjacent activity/chapel hall leading to another facility, through the hallway to the units on the Katherine Luther building, without viewing any staff. On 6/22/2017 at 5:45 AM, the stairwell door alert system near the elevator outside the Bryant Unit was sounding. The alarm was turned off by staff at 5:50 AM. The staff member did not check inside the stairwell, or look around the area to determine why the alarm was sounding. The same door alarm sounded at 5:53 AM. A CNA approached the door, entered the code to deactivate the alarm at 5:55 AM, and walked away without checking the stairwell or surrounding area. At that time the surveyor entered the Bryant Unit. A staff member was inside the entrance and stated to the surveyor, in a voice loud enough for others to hear, the code to the alert system. A resident with a wander guard was ambulating in the hallway within earshot of the staff member. On 6/22/2017 at 9:45 AM, the exterior exit door outside the Saul Unit was tested by surveyors. When entering the code, the exit door alarm sounded, the door opened, and the door alarm stopped sounding while the door remained open. At that time two staff were observed walking down the hallway outside of the Katherine Luther nursing units and did not turn around or respond to the alarm. On 6/22/2017, between 9:46 AM and 10:00 AM, the alarm was sounding by the double doors near the Bryant Unit. Staff did not respond and laundry personnel were near the doors . The alarm stopped sounding no staff responded. On 6/22/2017 at 12:30 PM, the Martin Luther interior front entrance doors were tested with a wander guard by the maintenance staff member with the surveyor present. Two of 3 trials, the alert system did not sound when tested with the wander guard. Between 12:30 PM-1:55 PM, the Mapleview Unit east staircase locked when tested , and the alarm did not sound. The Applewood Unit east and west doorways alarmed when tested . The alarm was faint and was not able to be heard near the nursing station or a distance down the unit hallways. During an interview with maintenance staff #10 on 6/22/2017 between 12:32 PM and 12:41 PM, he stated the stairwell located outside of the Bryant Unit was coded by an alarm. If someone went through those doors it leads to the outside of the building and a code was not needed to get out the exterior door. He stated some secured door alert systems sounded when a code was entered regardless if there was a resident present with a wander guard. He stated if the alarm was already sounding and a resident with a wander guard approached the tone of the alarm would change to signal the resident was in the area. On 6/22/2017 between 12:32 PM and 12:41 PM, a door at the end of the Gordon Unit toward the exterior of the building was tested with maintenance staff #10 using a wander guard device. The tone for the alarm did not change. At 12:47 PM on 6/22/2017, the Saul Unit dining room door was sounding an alarm when a surveyor and maintenance staff approached. The alarm was faint and not able to be heard at the entrance to the dining room door. The Katherine Luther double doors leading to the resident units were tested with maintenance personnel and a surveyor on 6/22/2017 between 5:40 PM and 5:45 PM. When the code was entered, the surveyor was able to walk through the door with the wander guard, the alarm continued to beep for 1 minute, then turned off with the door remaining open and the wander guard on the other side. During the observation, the RN nursing supervisor came out of the nursing office after the alarm had been sounding for 3 minutes, observed employee and surveyor, said oh and returned to her office. When asked in interview, the DON stated she would expect staff to respond immediately when any alarm was sounding, observe the area for residents on both sides of the door to ensure the residents were safe. EDUCATION During an interview with the Director of Staff Development on 6/22/2017 at 2:25 PM, she stated she provided in-service orientation to facility staff. She stated she reviewed education specific to wandering and elopement at staff's initial orientation. The education would include the use of flags on wheelchairs and orange charms on resident ID bands, to alert staff the resident was a wander risk. She stated she would update staff on the roam alert codes and process. She stated if an alarm sounded staff should check both sides of the door where the alarm is sounding. She stated staff should not be providing door codes in an area where at risk residents could hear. The Director stated they did not complete post testing or follow up with staff retention following orientation and elopement training. When asked how she would determine if staff were receptive and understanding of the training, she stated she would not. She stated only certified nurse's aides (CNAs) and nursing staff were trained on elopement during orientation and annual in-services. She stated other ancillary staff and agency staff were not trained on resident elopement/wandering. She stated agency staff received a mini orientation when starting at the facility, and elopement was not part of that orientation. She stated they had used many agency staff recently related to a need for CNAs. During an interview with CNA #3 on 6/22/2017 at 2:55 PM, she stated following the 6/2017 incident (an elopement incident involving Residents #1 and 2) they had provided education at the facility regarding elopement. She stated she and her coworkers had started their shift at 2:00 PM a day or so following the incident. At 2:15 PM, they heard there was training that needed to be done, and the training had already been started and completed before they could attend. She stated the Unit Manager ended up having to go over the training with them after. During an interview with agency CNA #11 on 6/22/2017 at 4:58 PM, she stated she was working on the unit when Residents #1 and 2 exited the facility in 6/2017. She stated she was not aware what the facility used for wander risk identifiers, prior to a 6/14/2017 elopement event. She stated since the event, a coworker in passing notified her of the orange charm on the residents' bracelets. She stated she had not received any re-education or training by the facility. She stated she had worked at the facility since 6/14/2017 and had worked on units, including Resident #3's, located in the Martin Luther building. During an interview with CNA #6 on 6/23/2017 at 7:50 AM, he stated Resident #3 had a history of [REDACTED]. He stated the last statement the resident made about getting out was about 4 weeks ago. The in service education regarding elopement provided by the facility following the 6/14/2017 event had no documentation the RN Supervisor, working the night of the event and noted as deactivating the alarm, was re-educated on the facility's elopement policy. In addition, there was no documentation agency staff were educated prior to or after the incident. In service education was reviewed on 6/22/2017 by a surveyor. There was no documentation SLP #2 received education on elopement prevention. During an interview with receptionist #14 on 6/21/2017 at 4:30 PM, she stated the doors automatically locked at 9:00 PM to the entrance of the Katherine Luther building. She stated anyone was able to exit from the inside to the outside, without using a code. She stated from the outside the doors would be locked and only those with a badge could enter without ringing the call button. During an interview with receptionist #12 on 6/22/2017 at 5:11 PM, she stated she went to an in service on 6/19/2017 regarding elopement. She stated she had worked a couple days between 6/15 and 6/19/2017 and not received any education. She stated she did not have means to identify residents at risk to wander other than a wander bracelet. She stated if they did not have a bracelet or it was covered she would not know who was a resident and who was a visitor. She stated she knew there was a lot of residents at risk to wander in the facility. She stated she was working the night of the 6/14/2017 event and she did not hear any alarms go off when the residents went through the doors. She stated Resident #1 looked like a visitor. During an interview with the acting Quality Assurance nurse on 6/22/2017 at 2:16 PM, she stated the facility had never tracked or trended elopement, they had an elopement recently, and they did not discuss the elopement at their most recent meeting. During an interview with a visitor on 6/21/2017 at 4:10 PM, the visitor stated she was not aware of a visitor log, she visited her family member in the Martin Luther building and entered through the Martin Luther door. During an interview/observation with maintenance staff #10 on 6/22/2017 at 12:41 PM, he stated some alert systems sounded when a code was entered regardless if there was a resident present with a wander guard. He stated if the alarm was already sounding and a resident with a wander guard approach(TRUNCATED)

Based on record review and staff interview conducted during the abbreviated and extended survey (NY 053, NY 597, and NY 414), it was determined for 82 residents at risk to wander, including Residents #1, 2, 3, 4 and 5, the facility did ensure Administrative staff administered the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically facility administration failed to: - address the effectiveness of their elopement prevention measures despite an elopement event in 5/2017 and a second event in 6/2017; - ensure staff responded to alarms alerting to potential resident elopements; - adequately implement measures to ensure residents were safe when alarms sounded; - ensure staff consistently followed planned elopement policies; - ensure all staff working in the building were trained on elopement policies; and - ensure door locks and alarms consistently functioned as planned. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. Findings include: Refer to F323 Free of Accident Hazards/Supervision/Devices During an interview with the acting Administrator on 6/23/2017 between 2:40 Pm and 2:50 PM, he stated all locking mechanisms were checked on 5/5/2017 and the doors were not identified of concern until 5/12/2017 when an outside company came in to check the locking mechanisms. He stated there was not a policy and procedure in place as to how the facility was to respond if locking mechanisms malfunctioned. During a follow up interview with the DON on 6/23/2017 at 8:50 AM, she stated if an alarm sounded staff should immediately respond, check the area through the doors and check if anyone is in the area. She stated staff should not be providing codes loudly in resident areas and if staff was near a door requiring a code, they could enter it for visitors. She stated PT/OT and speech did not get training on elopement or wanderguards. She did not know if agency staff received training. And unit helpers received 1 day of orientation. ------------------------------------------------------------------------------------------------------ The Immediate Jeopardy situation was removed on 6/28/2017 prior to exit based on the following corrective actions taken. The facility: - Implemented a new procedure to responding to door alarms; - Implemented a new policy and procedure on video monitoring; - Evaluated door locking mechanisms/keypads for function per manufacturer specifications; and - Developed and implemented education associated with residents at risk to wander and staff response for all disciplines; including a mechanism to monitor the effectiveness of training. 10NYCRR 415.26

Based on record review, interview, and observation conducted during the abbreviated survey (NY 233), it was determined for 3 of 7 residents reviewed for side rails/enablers (Residents #3, 6, and 7), the facility did not provide an environment free of accident hazards or adequate supervision to prevent accidents. Specifically: - for Resident #3, the facility did not reassess the resident's assistive devices (bed side rails/assist bars) timely following a decline in condition and the resident's risk factors with the assistive device were not consistently and accurately assessed, leading to injury to the resident's head when her head became entrapped between her mattress and side rail; - for Resident #6, there was a 6 inch gap between his mattress and side rail; and - for Resident #7, the bed had a non-standard square side rail at the head of the bed, with a 15 to 16 inch wide opening with no middle rails. This resulted in actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #3. Findings include: The facility policy Physical Restraint Assessment revised 2/3/2014 documented a physical restraint is any manual method, physical/mechanical device, material, or equipment attached to or adjacent to a resident's body, which the resident could not easily remove. A physical restraint is a device that limits or restricts freedom of movement or normal access to one's body. The IDCPT (Interdisciplinary Care Plan Team) will need to evaluate the effect of the restraint on the resident, as well as the intent. The policy did not include side rails/enabler bars as examples of restraints. 1) Resident #3 was admitted to the facility in 2013, and had [DIAGNOSES REDACTED]. The Fall Assessment Tool dated 4/16/2016 documented the resident was at minimal risk for falls. The resident's current physician orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The resident required extensive assistance with bed mobility and transfers. The resident had not fallen since the last assessment. The nurse practitioner (NP) progress note dated 6/8/2016 documented the resident had lost weight and declined medically. The plan was to monitor for fluid overload or unstable blood pressure. Registered nurse (RN) #1's nursing progress note dated 6/13/2016 at 6:55 AM documented that Resident #3 was found by the CNA (certified nurse aide), sitting on the floor next to her bed with her head between the mattress and the 1/4 side rail. Bruising was noted on the left side of the resident's face, her neck, and earlobe in a striped pattern. The resident also sustained a bruise on her right knee, measuring 1.0 cm (centimeter) x 0.5 cm. The resident stated she was getting out of bed. The note documented the 1/4 rail was removed from the resident's bed. The NP progress note dated 6/13/2016 documented the resident was evaluated, as staff reported the resident was found sitting on the floor next to her bed, with her head between the mattress and the 1/4 side rail. The NP documented the resident's head was wedged between the mattress and the side rail, and the resident had ecchymosis (bruising) to the left side of her face and neck, a small abrasion to her ear lobe, and ecchymosis to her right knee. The NP documented the resident stated she was getting out of bed. The comprehensive care plan (CCP) was updated on 6/13/2016, and documented that on 5/13/2016, the resident was found on the floor next to her bed. The CCP documented the resident's head was between the mattress and the side rail, which caused bruising on the left side of the resident's face, her neck, ear lobe, and a bruise to the resident's right knee. The CCP documented the resident was non-ambulatory and did not attempt to self transfer, and the 1/4 rail was removed from the resident's bed. Prior to that date, the CCP did not address side rails. The facility Incident/Accident Report dated 6/13/2016 documented the resident was found sitting on the floor, with her head wedged between the mattress and 1/4 side rail. The incident report documented bruising was noted to the left side of the resident's face, neck, and earlobe. The resident's right knee also sustained a bruise. The Post Fall Investigation attached to the Incident/Accident Report dated 6/13/2016 documented the outcome of the investigation was that the incident was an isolated event, as Resident #3 did not generally attempt to get out of bed alone. The planned intervention/recommendation was that a request was submitted to remove the 1/4 side rail from the resident's bed. The Post Fall Investigation incident report was signed by RN #1 on 6/13/2016, and had the initials of the Director of Nursing (DON) and the Administrator, also dated 6/13/2016. The Internal Investigation Section attached to the Incident/Accident Report dated 6/13/2016 documented the side rail was in the up position. The resident had the [DIAGNOSES REDACTED]. The Summary of Investigation Outcome attached to the Incident/Accident Report dated 6/13/2016 documented the resident was issued a side rail when she was admitted to the facilty, as she used them for bed mobility. The summary documented the resident no longer used the side rails, and there was no policy in place for re-evaluation. The Specific Action Taken/Assessment/Interventions/Resident Protections Put in Place section of the investigation documented: - the side rails were removed from the resident's bed immediately; - a full facilty audit of beds with side rails was done; - residents were evaluated for the need for side rails; - a new policy to be initiated to include reassessment of the need for side rails on a quarterly, and prn (as needed) basis; and - annual PM (preventative maintenance) to ensure there was no gap greater than 4 inches between the side rails and the mattress. During an interview with the DON on 6/20/2016 at 9:00 AM, she stated Resident #3 was able to use her side rails when she was admitted to the facilty. The DON stated she was not sure if the resident was able to put the side rails down at the time, and there was no policy for re-evaluation of the side rails. The DON stated the side rails were not considered restraints, as the facility policy did not identify side rails as restraints. During an interview with Physical Therapist (PT) #5 on 6/20/2016 at 10:00 AM, he stated the most important purpose of enablers, or side rails, was to assist the resident with repositioning or getting up. PT #5 stated that therapy was the department that evaluated residents for side rail usage, and if a resident could not use their arms or legs, there was no reason for side rails. During an interview with RN #1 on 6/20/2016 at 10:10 AM, she stated enabler bars, or side rails, were used to promote self mobility in bed, and to assist with getting out of bed. RN #1 stated PT assessed if a resident was to use side rails, and after the incident with Resident #3, assessments were done on all residents and all new admissions. RN #1 stated she did not believe assessments were done on residents prior to the incident with Resident #3, as she thought it was the judgment of staff on the resident's unit and what the resident requested. During an interview with the Director of Rehab Services on 6/20/2016 at 3:15 PM, he stated that since the incident with Resident #3, the facilty decided to do quarterly and annual assessments going forward, as this was not done in the past. The Director stated risk assessments had not been done in the past, and the only assessment was to look to see if the enabler, or side rail, improved the quality of life for the resident and promoted more independence and bed mobility. During a second interview with RN #1 on 6/20/2016 at 6:20 PM, she stated she saw and assessed Resident #3's head, which was stuck between the side rail of the bed and the mattress. The RN stated the resident was on the floor sitting on her knees, and her legs were tucked underneath her. One side of the resident's face was on the mattress and the side rail was against the resident's ear, the side of her face, and her earlobe. The RN stated the resident's neck was not involved. During an interview with RNA (restorative nurse aide) #6 on 6/21/2016 at 8:38 AM, she stated that she went to get Resident #3 ready for restorative nursing at approximately 6:30 AM. She found the resident with her knees on the floor, and her head between the side rail and the mattress. RNA #6 described Resident #3's position as the side rail on the left side of the resident's face, and the mattress on the right side of the resident's face. RNA #6 stated the resident rarely talked and her face was red. RNA #6 stated that the resident's mattress did not have sheets on it when she found the resident. During an interview with the resident's physician on 9/13/2016 at 1:45 PM, he stated that side rails/enabler bars were used for safety reasons, for the prevention of falls. The physician stated that he did not personally do an assessment of risks/benefits, but he would expect this to be done weekly. The physician stated he was not aware it was the practice of the facility not to re-evaluate the side rails/enabler bars after initiation, and he would have expected this to have been done, as they were considered restraints. The physician stated he did not recall if the resident's head became stuck between the mattress and the side rail/enabler bar. He stated that he did not think the resident would have required side rails/enabler bars on a daily basis. During an interview with the Administrator on 9/13/2016 at 2:10 PM, she stated that side rails/enabler bars were used for bed mobility. Prior to the incident with the resident, the facility was not assessing the bars, as they were considered a mobility device. 2) Resident #6 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 3/25/2014 documented the resident had 1/4 grab bar, as an enabler for bed mobility and self positioning. The CCP documented the 1/4 side rail was to be up while the resident was in bed, per his request. The CCP dated 4/30/2015 documented the resident had limited use of his hands due to weakness and tremors. The undated CNA (certified nurse aide) Assignments Summary (used for care guidance) documented the resident required extensive assistance of 2 or more persons. The resident used 1/4 rails as enablers for positioning. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. The resident required extensive assistance of 2 or more for bed mobility. Extensive assist of 1 person was required for personal hygiene, and the resident was dependent for transfers and toileting. The MDS documented the resident was 71 inches tall and weighed 202 pounds. The nurse practitioner (NP) progress note dated 6/6/2016 documented the resident had a decrease in his upper core and lower body strength over the last couple of months. The resident had moderate widespread muscle atrophy. His right arm strength was greater than the left, and there were no purposeful movements. A surveyor observed Resident #6's bed on 6/21/2016 between 1:40 PM and 2:00 PM. The bed was a standard size bed with an extender (device to make the bed platform wider) attached. The mattress was a standard size mattress. The bed had 2 plastic covered partial side rails at the head of the bed. There was 4 1/2 inches of space between the side rail and the mattress. The mattress slid easily to the other side of the bed when tested . When the mattress was pushed to the side rail on the opposite side of the bed, there was a 6 inch gap between the mattress and the closer side rail. The Environmental Services/Plant Operations Director was present on 6/21/2016 between 1:40 PM and 2:00 PM during the observation, and stated Resident #6's bed had an extender, which plant operations staff would remove. During interviews with 3 Saul Unit staff on 6/21/2016 between 3:40 PM and 4:00 PM, including CNA #2, licensed practical nurse (LPN) #3, and the registered nurse (RN) Unit Manager #4, all three staff stated they did not not know how long the extender had been on Resident #6's bed without a wider mattress. The RN Unit Manager stated the mattress should be sized to fit the bed. During an interview with the Administrator on 9/13/2016 at 2:10 PM, she stated she was not aware there was a problem with the resident's bed extender until it was brought to her attention by the surveyor. Per the Guidance for Industry and FDA (Food and Drug Administration) Staff document dated 3/10/2006 regarding guidance to reduce entrapment related to bed systems, the maximum distance between the side rail and the mattress should be less than 4 3/4 inches. 3) Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. The resident required supervision for bed mobility and transfers. The nurse practitioner (NP) progress note dated 6/15/2016 documented the resident had in-coordination and involuntary movements. The resident had generalized muscle atrophy, and upper and lower extremity [DIAGNOSES REDACTED]. The comprehensive care plan dated 6/21/2016 documented the resident used two 1/4 rails for bed mobility, positioning, and transfers. A surveyor observed Resident #7's bed on 6/21/2016 between 1:40 PM and 2:20 PM. The bed had a non-standard side rail at the head of the bed, with a 15 to 16 inch wide opening that was 15 to 16 inches high, with no middle rails. During an interview with the Administrator on 9/13/2016 at 2:10 PM, she stated she was not aware there was a problem with the resident's side rails, until it was brought to her attention by the DON (Director of Nursing). Per the Guidance for Industry and FDA (Food and Drug Administration) Staff document dated 3/10/2006 regarding guidance to reduce entrapment related to bed systems, the maximum distance within the side rail should be less than 4 3/4 inches. 10NYCRR 415.12(h)(1)

Based on observation, interview and record review conducted during the standard survey, it was determined for 4 of 4 residents (Residents #19, 20, 21, and 22), reviewed for independent smoking concerns, the facility failed to provide adequate supervision and assistive devices to prevent accidents and maintain a safe environment. Specifically, the facility: - failed to have systems in place to adequately monitor and supervise residents in the smoking room, to ensure safe smoking behavior (Residents #19, 20, 21 and 22); - failed to reassess residents' risk for unsafe smoking (Residents #19, 20 and 21); - failed to ensure residents and staff were educated regarding safe smoking practices and safe designated smoking areas (Residents #19, 20, 21 and 22); - failed to ensure care plans were updated when residents exhibited unsafe smoking behavior (Residents #20 and 21); - failed to clarify the role of specific staff members regarding the proper disposal of smoking debris; and - failed to ensure safe smoking waste receptacles were located in the designated smoking area. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety, and substandard quality of care, for Residents #19, 20, 21, and 22 and residents residing in that portion of the building. The facility implemented corrective measures to remove the Immediate Jeopardy prior to survey exit on 6/14/2013. Findings include: The facility Resident Smoking Area policy, dated 3/21/2007, documented the smoking area for residents was in the Saul Unit smoking lounge. The policy documented residents could smoke outside as desired, and cigarette butt cans were located at the entrance of each building. The facility Smoking Control Policy for Residents dated 2/3/2011, documented the residents were allowed to smoke only in the Saul Unit smoking lounge. The policy documented residents were assessed to determine if they had the ability to smoke safely. The policy recorded residents who smoked should be reassessed yearly, with any significant change in condition, and/or when determined as non-compliant with the smoking rules. The policy documented non-compliant residents will have "their smoking products, lighting devices, and smoking supervised" until a reassessment was completed. Unsafe Smoking Practice 1) Resident #19 had [DIAGNOSES REDACTED]. The resident's most recent Smoking Assessment, dated 3/4/2011, documented the resident had "moderate dementia." The assessment documented the resident demonstrated the ability to "safely handle" smoking implements and could smoke independently in the "Smoker's lounge." The comprehensive care plan (CCP), dated 4/9/2013, documented the resident was a "night owl" who preferred to keep his own schedule, and pursue his own leisure activities, including doing jigsaw puzzles, coloring, and visiting in the smoking room. The CCP documented the resident smoked cigarettes independently in the designated smoking area, and staff were to monitor the resident to ensure he was safe to smoke independently. The resident's Minimum Data Set (MDS) assessment, dated 3/26/2013, documented the resident had some difficulty, with daily decision making, in new situations only. The MDS documented the resident was independent with bed mobility and required supervision for transferring. The assessment documented the resident required supervision and/or the assistance of one person for locomotion in his wheelchair, and setup/supervision with eating. The CCP dated 5/19/2013 documented the resident was smoking in the Saul courtyard which was not a designated smoking area. The CCP recorded the resident was re-educated to smoke in the smoking room on Saul Unit, which was the facility's "only" designated resident smoking area. The resident's current Individualized Daily Resident Care Card (guidance for direct care staff), dated 5/19/2013, did not document the resident was a smoker and needed to be monitored to ensure safe smoking practices were followed. The social worker note dated 5/20/2013 documented the resident was found smoking in the Saul Unit courtyard, the day before, and was reminded that the designated smoking area was the Saul Unit smoking room. The social worker recorded the resident stated understanding, and would be followed related to any further incidents. The physician progress notes [REDACTED]. The note did not document the resident was smoking in an undesignated smoking area. The physician documented nursing reported no problems with caring for the resident, and the current plan of care would be continued. The CCP, dated 5/24/2013, documented the resident was an independent smoker. The CCP recorded staff were to monitor the resident to ensure his safety when smoking. When interviewed on 6/11/2013 at 5:35 PM, the registered nurse (RN) unit manager stated there were 4 residents who were assessed as independent smokers, and they were expected to keep their cigarettes/lighters in their locked drawers or with them. Observations showed: - on 6/11/2013 at 5:35 PM, the resident entered the smoking room; - on 6/12/2013 2:55 PM, the resident was laying on his bed with his back to the door; - at 3:35 PM, the resident entered the smoking room holding a metal coffee mug and exited approximately 1 minute later; and - on 6/13/2013 between 8:55 AM and 9:20 AM, the resident was smoking in the smoking room. When interviewed on 6/13/2013 at 9:10 AM, the 11 PM - 7 AM shift licensed practical nurse (LPN) stated she did not "usually" have anything to do with the resident's smoking room. She stated the resident smoked periodically during the night, and also worked on jigsaw puzzles kept in the smoking room. The LPN stated there were no other residents that smoked during the night shift. On 6/13/2013 between 8:55 AM and 9:20 AM, two surveyors, the Administrator, and the Housekeeping Director observed the smoking room. The resident was in the room, smoking at a table near the jigsaw puzzles and puzzle boxes. Two puzzle boxes were on a table top, the boxes contained pieces of the puzzle. There were cigarette ashes and a discarded, partially smoked, cigarette in one of the boxes. A significant amount of combustible material which included 58 puzzle boxes of various sizes stored on a wooden bookcase next to the table and 6 puzzle boxes on adjacent tables was observed by the surveyor During the smoking room observation on 6/13/2013 between 8:55 AM and 9:20 AM, the Administrator asked the resident if the discarded, partially smoked cigarette, found in the puzzle box was his. The resident shook his head no. The Administrator stated to the surveyors he would discard of the cigarette. The resident then made a verbal queue, gesturing to the Administrator that the partially smoked cigarette was his, and he wanted it back. During an interview on 6/13/2013 at 9:45 AM, the social worker stated, she did not know where the resident kept his smoking supplies. She said residents were assessed to determine if they were cognitively intact and safe to smoke. She said an occupational therapist determined if a resident was safe to hold a cigarette and lighter. The social worker stated residents who were determined safe, to smoke independently, were encouraged to keep their smoking supplies in a locked drawer. She said a STOP sign was placed on their door to discourage wanderers from entering their room. The social worker stated residents were reassessed for safe smoking practices yearly or when there was a decline in their condition. During an observation on 6/13/2013 at 9:55 AM, the resident did not have a STOP sign on his door. During an interview, at that time, while in the resident's room, the resident gestured to the surveyor that he kept his cigarettes and lighter in his shirt pocket or in an unlocked cupboard in his room. The resident had cigarettes and a lighter in his shirt pocket. In an interview on 6/13/2013 at 10 AM, the registered nurse (RN) unit manager stated the resident was allowed to keep extra smoking supplies in his room. In an interview on 6/13/2013 at 12:30 PM, the RN manager stated the resident kept his smoking supplies in an unlocked cupboard in his room. 2) Resident #21 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 2/7/2013 documented the resident was an independent smoker and could smoke in the designated smoking areas. The CCP documented the resident was to smoke in the designated smoking room and staff were to store the resident's lighters/matches at the nurses station. The resident's Minimum Data Set (MDS) assessment, dated 4/23/2013, documented the resident was cognitively intact, and had limitations in the range of motion of both of her arms and legs. The resident's Smoking assessment dated ,[DATE], documented the resident was cognitively intact, and "always smoked independently at home, however is spastic so may require assistance at times." The assessment documented the resident was safe to smoke independently in the smoking room, and was asked to leave her cigarettes/lighter at the nursing station. The assessment documented the resident should ask staff to assist her to the smoking room. The CCP, dated 5/2013, documented the resident was an independent smoker. The CCP did not document the resident was to leave her cigarettes and lighter at the nurses station. The Individualized Daily Resident Care Card (guidance for direct care staff), dated 5/19/2013, documented the resident was able to smoke independently in the designated smoking room. The care card did not document the resident was to leave her cigarettes and lighter at the nurses station, or ask staff for assistance to the smoking room. The CCP dated 5/31/2013 documented the resident was found smoking "in the courtyard", was redirected to the designated smoking area on Saul Unit, and was reminded the "only" area for smoking was the smoking room on Saul Unit. A nursing note on 5/31/2013 at 3:15 PM, documented the resident was observed smoking in the courtyard. The note documented the resident was counseled that the courtyard was not a designated smoking area, and the facility's designated smoking areas were reviewed with the resident. Nursing notes documented on 6/1/2013 at 9:26 PM and 6/2/2013 at 8:28 PM, the resident was found sleeping in the smoking room. Observations showed: - on 6/11/2013 at 5:35 PM, the resident exited the smoking room; - on 6/12/2013 at 10:30 AM, the resident exited the smoking room; - on 6/12/2013 at 3:50 PM, the resident entered the smoking room; and - on 6/12/2013 at 4 PM, the resident was smoking in the smoking room. When interviewed on 6/12/2013 at 4 PM, the resident stated she smoked in the smoking room, was able to light her own cigarettes, and kept her cigarettes/lighter in her purse. She stated she kept the purse on her wrist when in her room and when she was sleeping. During an observation of the Saul Unit smoking room on 6/13/2013 at 8:45 AM, the resident was seated at a table, which was covered with cigarette ashes. The resident stated, to the surveyor, the ashes were not hers. There were 2 cigarette butts and ashes on the floor near the table. The ashtray on the table, and the ashtrays on the other three tables, were partially filled with cigarette butts/ashes. The plastic trash can (approximately 5 gallons in size), was labeled with a sign that documented it was for garbage only and not for the disposal of cigarette debris. The trash can had paper, Styrofoam waste, cigarette butts and ashes in it. When interviewed on 6/13/2013 at 8:55 AM, the Administrator stated residents were assessed to determine if they required supervision when smoking. He stated the designated smoking room was cleaned by the housekeeping staff. The Administrator stated the facility may need to remove the trash can from the smoking room, and he did not think staff used the smoking room. On 6/13/2013 at 9:20 AM, the registered nurse (RN) unit manager stated the social worker determined if a resident was a safe smoker. She said a change in the resident's condition would warrant a reassessment. The manager stated she did not have a formal process to monitor the smoking room. The manager stated staff went into the smoking room with a resident who required supervision, and to encourage residents to come to their meals in the dining room. On 6/13/2013 at 9:45 AM, the social worker stated, during an interview, the resident could keep her smoking supplies in her room, under her pillow or on her arm. She stated that residents who smoked independently were encouraged to keep their smoking supplies in a locked drawer, and had a STOP sign on their door to discourage wanderers from entering their room. The social worker said residents were assessed to determine if they were cognitively intact and safe to smoke and occupational therapist determined if the residents were safe to hold a cigarette and lighter. Residents were assessed yearly for safe smoking practices, or when a decline in condition was noted. In an interview on 6/13/2013 at 10 AM, the RN unit manager stated the resident could keep extra smoking supplies in her room. An observation made on 6/14/2013 at 10:50 AM showed a sign, on the Saul unit dining room's exit door to the unit courtyard, which read "This Entrance is Not a designated smoking area for staff. Smoking is permitted to Residents and Visitors/Family members only". The Director of Housekeeping and the surveyor went out to the courtyard and observed a large covered trash can lined with plastic and partially filled with trash. There were no receptacles appropriate for cigarette debris observed in the courtyard. At that time, the Director of Housekeeping stated the courtyard was not an approved smoking area. He had no explanation for the signage on the exit door. Unsafe Storage of Smoking Supplies 3) Resident #20 had [DIAGNOSES REDACTED]. The resident's Smoking Assessment form, dated 2/23/2012, documented the resident was cognitively intact; was physically able to safely handle smoking implements; did not require supervision when smoking; and the resident's lighter would be kept at the nurses's station. The Minimum Data Set (MDS) assessment, dated 3/19/2013, documented the resident was cognitively intact, and required supervision/limited assistance with activities of daily living(ADLs). The comprehensive care plan (CCP) dated 4/2/2013, documented the resident was an independent smoker. The CCP recorded the resident would smoke only in designated smoking areas, and would remain safe while smoking. The CCP did not document the resident's lighter would be kept at the nursing station and did document the resident would retain her smoking supplies. The Individualized Daily Resident Care Card (guidance for direct care staff), dated 5/18/2013, documented the resident smoked independently in the smoking room. The resident was observed on 6/12/2013 at 10:30 AM exiting the smoking room. At 12:15 PM, the resident was seated at a table, in the smoking room, smoking a cigarette. When interviewed on 6/12/2013 at 12:15 PM, the resident stated she had a private room, and kept her door closed. The resident said she kept her smoking supplies in her bag, and held up the bag to show the surveyor what she used. On 6/13/2013 at 9:45 AM, the social worker stated the resident may have a locked drawer where she kept her supplies. In an interview on 6/13/2013 at 10 AM, the RN unit manager stated the resident could keep extra smoking supplies in her room. During an interview on 6/13/2013 at 12:05 PM, the Director of Nursing (DON) stated the unit nurse manager checked and 3 of the 4 independent smokers kept their smoking supplies in a locked drawer. On 6/13/2013 at 12:30 PM, the RN manager stated the resident kept her smoking supplies in a locked drawer. 4) Resident #22, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. The registered nurse (RN) progress note dated 6/7/2013, documented the resident was alert, oriented, and able to make his needs known to staff. The note documented the resident was cleared by social services to smoke in the designated smoking room, and the smoking rules were explained to him. Therapy notes, dated 6/7/2013, documented the resident was non ambulatory and required minimal assistance of 1 staff person for eating. On 6/13/2013 at 12:30 PM, the RN manager stated the resident kept his smoking supplies in a locked drawer in his room. When interviewed, in his room, on 6/13/2013 at 12:35 PM, the resident stated he was assessed for safe smoking, only smoked in the smoking room and was supposed to keep his smoking supplies in his locked drawer. He showed the surveyors where his smoking supplies were stored in an unlocked dresser drawer. He stated he stored his supplies in his dresser drawer because he was not able to manage the locking mechanism of his locked drawer, and demonstrated that inability for the surveyors. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to survey exit on 6/14/2013 based on the following corrective actions taken by the facility: - Developed a system to adequately monitor and supervise residents to ensure safe smoking behaviors. - Re assessed residents who smoke to determine risk for unsafe smoking. - Updated resident care plans to reflect smoking assessments. - Educated the residents who smoke independently on safe smoking practices. - Ensured there were approved receptacles for cigarette waste. - Trained the majority of staff members on safe smoking practices and remaining staff will be trained before returning to duty. - Revised policies and procedures to address safe smoking practices, and the designated smoking area. 10NYCRR 415.12(h)(1)(2)

Based on observation, record review and interviews conducted during the standard survey, it was determined for 4 of 4 residents (Residents #19, 20, 21, and 22) reviewed for unsafe smoking, the Administration failed to ensure the facility was administered in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, the Administrator failed to ensure safe smoking practices for residents assessed as safe to smoke independently; failed to ensure residents were assessed in a timely manner for safe smoking practices; failed to ensure care plans related to safe smoking practices were implemented; failed to ensure residents were educated on safe smoking practices; and failed to ensure there were approved receptacles in use to dispose of cigarette debris. Refer to F323 and K66. This resulted in no actual harm with potential for serious harm that was Immediate Jeopardy to the health and safety of Residents #19, 20, 21, 22, and to residents in that portion of the building should a fire occur. The facility implemented corrective measures to remove the Immediate Jeopardy prior to survey exit on 6/14/2013. Findings include: During an interview on 6/12/2013 between 9:25 AM and 9:30 AM, the Director of Housekeeping stated he was not aware of residents improperly disposing of cigarette debris. into a plastic trash can that contained paper and plastic waste. He stated two metal containers were provided in the Saul Unit smoking room for residents to dispose of cigarette debris, and the contents of the cans were disposed of by housekeeping staff daily. When interviewed on 6/12/2013 at 12:35 PM, the unit housekeeper stated there were 2 metal containers in the smoking room that were used for cigarette butts only, and she did not empty them. The housekeeper stated she had not observed cigarette butts in the trash can before. She stated her supervisor told her that a sign, with directions that it was not to be used for cigarette debris, had been added to the trash can. On 6/13/2013 at 9:20 AM, the registered nurse (RN) unit manager stated housekeeping staff cleaned the smoking room early in the morning. The RN manager stated the social worker made the determination if residents were safe smokers, and a change in the resident's condition would warrant a new assessment. The manager stated she did not have a formal process of monitoring the smoking room. The manager stated staff went to the smoking room with a resident who required supervision and to encourage residents to come to their meals in the dining room. On 6/13/2013 at 9:45 AM, the social worker stated residents were assessed for safe smoking practices by determining they are cognitively intact and safe to smoke; and an occupational therapist determined if the residents were safe to hold a cigarette/lighter. She stated residents who were determined safe to smoke independently were encouraged to keep their smoking supplies in a locked drawer. She stated she went in the smoking room [ROOM NUMBER]-4 times a month to talk to residents. She stated she did not know where Resident #19 kept his smoking supplies, Resident #20 may have a locked drawer that she kept her supplies in, and Resident #21 kept her supplies in her room under her pillow or on her arm. When interviewed on 6/13/2013 at 8:55 AM in his office, the Administrator stated residents were assessed to determine if they required supervision when smoking, and there was a smoker at that time who required supervision. He stated the smoking room was cleaned by housekeeping staff. When provided a description of the smoking room as observed at 8:45 AM on 6/13/2013, he stated the facility may need to remove the trash can from the smoking room. The Administrator stated he did not think staff used the smoking room. During an interview on 6/13/2013 at 12:05 PM, the Director of Nursing (DON) stated the unit nurse manager had checked and 3 of 4 residents kept their smoking supplies in their locked drawer. The DON stated that there were quality assurance audits completed when the smoking room was first used to ensure safe smoking practice, and nursing had not done any audits related to safe smoking practice recently. In a follow up interview on 6/13/2013 at 12:15 PM, the Administrator stated he should have been made aware of the cigarette butts/ashes found in the smoking room trash can; and all smokers were being re-assessed for safe smoking practice. He stated staff were not compliant all the time and was not aware staff used the smoking room to smoke or dispose of their cigarette butts/ashes. The Administrator stated there were quality assurance audits done when resident smoking assessments were initiated, and there had been no recent monitoring to ensure safe smoking practice. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to survey exit on 6/14/2013 based on the following corrective actions taken by the facility: - Developed a system to adequately monitor and supervise residents to ensure safe smoking behaviors. - Re assessed residents who smoke to determine risk for unsafe smoking. - Updated residents' care plans to reflect smoking assessments. - Educated the residents who smoke independently on safe smoking practices. - Ensured there were approved receptacles for cigarette waste. - Trained the majority of staff members on safe smoking practices and remaining staff will be trained before returning to duty; - Revised policies and procedures to address safe smoking practices, and the designated smoking area. 10NYCRR 415.26

Based on observation, record review and interviews conducted during the post survey revisit, it was determined for 1 of 2 staff smoking areas, (Martin building) the facility Administration did not ensure the facility was administered in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, the Administrator did not ensure cigarette debris was disposed in approved receptacles in the Martin building staff smoking area. Refer to the Life Safety Code survey deficiency regarding regulation K66 (smoking regulations). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. THIS IS A REPEAT DEFICIENCY FROM THE 6/14/2013 RECERTIFICATION SURVEY Findings include: On 8/19/2013 between 12:10 PM and 12:30 PM, the housekeeper responsible for emptying the trash can/ashtrays in the Martin building staff smoking area was interviewed. The housekeeper stated the cigarette debris should not be in the plastic lined, trash can. He stated he had not seen that before and had been taught that cigarette debris was not to be disposed of with "regular" trash. He stated he would not have noticed the cigarette debris in the plastic trash bag if the surveyor had not shown it to him. During an interview on 8/19/2013 at 12:35 PM, the Housekeeping Director stated the plastic lined metal trash can near the Martin building staff smoking area was emptied daily. He stated he had not done audits to determine compliance with the disposal of staff cigarette debris. During an interview on 8/19/2013 at 12:40 PM, with the facility interim Administrator and the Housekeeping Director, the Housekeeping Director stated the metal trash can in the Martin building staff smoking area had been in place for 2 weeks. The Administrator stated she did not know if the staff smoking areas were being monitored for compliance, with disposal of smoking debris. The Administrator said the metal trash can should not have a plastic liner. During an interview on 8/19/2013 at 4:50 PM, the facility's Chief Executive Officer (CEO) stated he was responsible for the trash can being placed in the Martin building staff smoking area. He stated they originally removed it, then he noticed trash on the ground, and had the trash can returned to the Martin building staff smoking area. 10NYCRR 415.26

Based on observation, staff interview, and record review conducted during the standard survey, it was determined for 3 of 9 residents reviewed for pressure ulcers (Residents #12, 15 and 16), the facility did not ensure residents with pressure ulcers received the necessary treatment and services to promote healing. Specifically for Residents #12, 15, and 16 there was no assessment of the newly developed pressure ulcers by a qualified person in a timely manner, and reassessment for pressure relieving devices was not done in a timely manner. This resulted in actual harm for Residents #12, 15, and 16, that is not immediate jeopardy. Findings include: 1) Resident #16 has [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS) dated [DATE] documented the resident had short and long term memory impairment with moderately impaired cognition. This assessment documented the resident had pressure ulcers, was frequently incontinent, and needed limited assistance of one for bed mobility. The comprehensive care plan (CCP) dated February 23, 2011, documented the resident had on open area on the left buttock, and that she was non-compliant with positioning, going back to bed, and being changed. The CCP did not address alternate pressure reduction strategies in relation to the resident's moderately impaired cognition, short term and long term memory impairment. The CCP dated March 25, 2011 documented the area on the resident's left buttock was healed. The CCP dated April 4, 2011, documented the resident was at high/moderate risk for developing pressure ulcers, and had a gel (a pressure distribution cushion) cushion in her wheelchair. An update to the CCP, dated May, 2011, documented "confusion noted on 3-11 shift periodically" there were no additional interventions related to this update. A social service progress note dated May 16, 2011 documented an entry dated May 13, 2011, "Confusion noted with resident on 3-11 shift." A licensed practical nurse (LPN) documented in the progress notes dated May 17, 2011, "Resident continues with periods of increased confusion." The licensed practical nurse's (LPN) note dated May 19, 2011, documented the resident had a new area which measured 4.3 centimeters (cm) x 2.3 cm on the left lower buttock. An order to treat with RepliCare dressing (promotes wound healing), change every 5 days and as needed was obtained from the physician by the LPN. The LPN documented on the Wound Measurement Sheet dated May 19, 2011 the area on the resident's left lower buttock was a Stage II pressure ulcer measuring 4.3 cm x 2.3 cm, with a wound bed of pink granulation tissue. The registered nurse (RN) wound nurse's note dated May 20, 2011, did not include documentation regarding the pressure ulcer on the resident's left lower buttock. A May 21, 2011 progress note entry by an LPN, documented the resident was noted with periods of increased confusion. The unit RN recorded on the Wound Measurement Sheet dated May 24, 2011, Stage II pressure ulcer on the resident's left lower buttock measuring 4.3 cm x 2.3 cm, with a wound bed of pink granulation tissue. The May 24, 2011 physician progress notes [REDACTED]. The staff revealed that family members were concerned because their mother had been increasingly confused and was no longer able to transfer from the chair to the bed and had not been cooperating with activities. "I am going to go ahead and discontinue the [MEDICATION NAME] (combination drug containing benzodiazepines- an antianxiety medication), that could have been a culprit." The physician's orders [REDACTED]. The May 26, 2011, RN wound nurse's note documented the resident had a Stage II pressure ulcer on the lower left buttock, and the treatment order changed to Solosite (a gel used to promote healing) with a [MEDICATION NAME] dressing (an absorbant dressing) every day. This note recorded the resident had a cushion (did not specify the type) in the chair, and that the resident was non-compliant at times with going back to bed in the afternoon. The RN's note did not address alternate strategies or pressure reduction interventions for when the resident refused to return to bed in the afternoon or experienced increased confusion. The Wound Measurement Guidelines form (completed by the RN) dated May 31, 2011, documented the pressure ulcer measured 5 cm x 4 cm with 10 % yellow slough (dead skin separated from surrounding tissue) and "bloody drainage." The treatment was changed to wash with normal saline and apply [MEDICATION NAME] (antibacterial cream) daily. The physician note, dated May 31, 2011, documented the resident had a 3.5 cm x 3.5 cm pressure ulcer with no slough, "clean base." This note documented the physician discussed with staff to find a cushion for her seat so the ulcer "did not get more pressure." Review of the CCP revealed no change in the cushion used in the resident's wheelchair, or any rationale for not changing the cushion. The physician order [REDACTED]. Per the RN wound care nurse's note, documented on June 3, 2011, the skin team had seen the resident on June 2, 2011. The note recorded the pressure ulcer had a scant amount of drainage, yellow slough was present (no percentage given), and the treatment was changed to Santyl, with a [MEDICATION NAME] dressing. The note recorded the resident had a cushion for her chair (no type specified) and was non-compliant at times with going back to bed in the afternoon. The RN wound nurse documented the physician had spoken with the resident regarding the importance of going back to bed in the afternoon to offload the pressure ulcer, "resident had been slightly more agreeable to this." Will continue to re-approach when she does refuse. The RN's note did not address alternate strategies or pressure reduction interventions for when the resident refused to return to bed in the afternoon or experienced increased confusion. The Wound Measurement Guidelines form dated June 6, 2011, documented the resident's left buttock pressure ulcer measured 4 cm x 3.8 cm with 10 % yellow slough and "bloody drainage." The RN wound care nurse's note dated June 9, 2011, documented the resident's Stage II pressure ulcer had yellow slough present with a scant amount of serosanguineous drainage. The note recorded the resident had a gel cushion, and was non-compliant at times with going back to bed in the afternoon. The note did not address alternate interventions for pressure reduction if the resident was non-compliant with returning to bed in the afternoon or experienced increased confusion. There was no documented evidence of a change in the cushion used in the resident's wheelchair, or rationale for not changing it. The Wound Measurement Guidelines form dated June 14, 2011, documented the pressure ulcer measured 4 cm x 4 cm with yellow black slough covering 50% of the wound bed, and "bloody drainage." The RN wound nurse note dated June 16, 2011 documented the resident's pressure ulcer was now a Stage III, with a moderate amount of yellow slough present, and a scant amount of serosanguineous drainage. Continue treatment was noted. This note documented the resident had a gel cushion in her chair and was noncompliant with going back to bed in the afternoon. This note documented the resident was frequently refusing to go back to bed, and stated she did not like to go back to bed, she spent enough time there at night. The note did not address alternate interventions for pressure reduction if the resident was non-compliant with returning to bed in the afternoon or experienced increased confusion. The Wound Measurement Guidelines form dated June 21, 2011, documented the Stage III pressure ulcer measured 4 cm x 4 cm x 0.2 cm with 50% yellow black slough, and bloody drainage. The physician note, dated June 21, 2011, documented the resident had a 4 cm size "deep" ulcer" "not up to the bone" with the base showing slough and "color" on her left buttock The note documented the resident's pressure ulcer was secondary to "persistent seated position. Discouraged her from doing that." Will send her to the wound clinic. The Wound Measurement Guidelines form dated June 28, 2011, documented the pressure ulcer measured 5 cm x 4.2 cm with 50% black slough, and bloody drainage. A nursing note dated June 30, 2011, documented the resident was admitted to the hospital for debridement of the "Stage III" pressure ulcer. A nursing note dated July 1, 2011, documented the resident returned from the hospital. The Readmission History and Physical, dated July 1, 2011, documented the resident was treated at the hospital for the pressure ulcer on her left buttock. This report noted she had sharp debridement of the pressure ulcer while under anesthesia. The Wound Measurement Guidelines form dated July 1, 2011, documented the resident's pressure ulcer on the left lower buttock measured 3 cm x 3 cm x 4 cm (depth) with a red wound bed, and a wound vac (a negative pressure device applied to the wound to promote healing) was in place. The Wound Measurement Guidelines form dated July 6, 2011, documented the pressure ulcer was 2.4 cm x 3.2 cm x 2 cm with tunneling at 2 PM of 5 cm and at 6 PM of 4 cm, there was black eschar (dead tissue) on the side of the wound bed and less then 10% "yellow" in the base of the wound bed. There was a small amount of "bloody drainage" present. The Individualized Daily Resident Care Card dated July 6, 2011, documented the resident was to have a Roho (air flotation cushion) cushion in the wheelchair. The physical therapy note dated July 7, 2011, documented, per recommendation of the skin team, a Roho cushion was issued due to the pressure ulcer on the resident's left buttock. The Physicians Progress Note, dated July 12, 2011 documented the resident was complaining again of some abdominal cramps and the plan was to start [MEDICATION NAME] (anti-spasmodic) to see whether it would help with the abdominal cramps. The physician's orders [REDACTED]. The Physicians Progress Note, dated July 26, 2011 documented that the resident had complained of some abdominal cramps. " I gave her [MEDICATION NAME] and it appeared to have helped, but the patient developed some confusion so it has been discontinued. The nursing note dated August 16,2011, documented the resident was scheduled for surgery on August 22, 2011 for surgical wound closure. The surveyor interviewed the physical therapist (PT) on August 16,2001 at 12:30 PM. She stated her records showed the resident was issued a gel cushion for her wheelchair in December 2010, and a Roho cushion on July 7, 2011. The PT said cushions for chairs and wheelchairs were issued by the physical therapy department. The surveyor interviewed the occupational therapist on August 16, 2011 at 12:30 PM; she stated she goes on wound rounds with the team. She stated the RN wound nurse was the one who told therapy what she wanted for the residents. The OT stated she then relayed that information to the PT, who then issued the cushions. The surveyor observed the resident on August 17, 2011 at 9:40 AM during the pressure ulcer dressing change. The pressure ulcer was measured by the RN treatment nurse and was 3 cm x 4 cm x 4.1 cm (depth). The wound bed was granulation tissue with dark blue areas. The surrounding tissue was dusky blue, and the wound edges were macerated. The surveyor interviewed the RN Unit Manager on August 18, 2011 at 11:50 AM; she stated the nurse who found the open areas on the resident's left buttock should have informed an RN. She said the LPN filled out the Wound Measurement Guidelines form, and the RN does not re-measure the pressure ulcer. The RN stated the LPNs cannot stage a pressure ulcer. The surveyor interviewed the RN wound nurse on August 18, 2011 at 12:40 PM. She stated the skin team looks at pressure ulcers weekly. The team included the RN wound nurse, the unit treatment nurse (may be RN or LPN), PT or OT, and the dietitian. She said the team meets and looks at the pressure ulcers' overall appearance, and assesses related factors such as pressure relief, clothing, toileting, and supplements. The RN wound nurse stated she did not measure pressure ulcers on rounds, that the unit nurse (RN or LPN) did that preferably the day before rounds. She said when a pressure was newly found, there should be an assessment by an RN in the progress notes, in addition to the Wound Measurement Guidelines form (which is filled out by the nurse who initially sees the pressure ulcer, either an LPN or RN). The surveyor interviewed the RN wound nurse on August 18, 2011 at 3:30 PM. She stated if she did not document a specific type of cushion, then it was a 4 inch ultra foam cushion. She said the resident refused changes, staff might have offered a different cushion and the resident refused. The RN was unable to provide documentation to support this. The surveyor interviewed the RN Unit Manager on August 19, 2011 at 11 AM. She stated the resident had recurrent pressure ulcers and non-compliance with pressure relief was the reason. She said the resident was set in her ways and the pressure ulcer deteriorated as a result of the resident's non-compliance. The surveyor interviewed with the Director of Nursing on August 19, 2011, at 12:45 PM. The Director of Nursing stated the expectation was that an RN would assess a new pressure ulcer and document the same. She said the Wound Measurement and Guidelines form was supposed to be data collection, and looked at the information as a description of the pressure ulcer. The DON stated if the pressure ulcer had any change, the LPN was to notify the RN. She said they had recently changed the form to include positioning and pressure relief provided. In summary, the resident experienced actual harm as her pressure ulcer deteriorated, resulting in a hospitalization for surgical debridement, and was then scheduled for a second hospitalization for surgical closure of the pressure ulcer when the facility: - did not change or reassess for effectiveness the wheelchair cushion from the time the pressure ulcer was found May 19, 2011, until July 7, 2011 (after surgical debridement and wound vac treatment, with noted deterioration of the pressure ulcer); - did not have a qualified person (registered nurse, physician) assess the pressure ulcer for 5 days after it was found; - did not provide alternate interventions for pressure reduction when the resident was non-compliant with returning to bed in the afternoon; and, - did not address the resident's impaired cognition or increasing confusion as it related to her non-compliance with the plan of care. 2) Resident #12 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated February 15, 2011, documented the resident was at risk for falls and had a wedge cushion in the wheelchair. The CCP dated July 20, 2011, documented the resident was at moderate risk for skin breakdown, due to dementia and incontinence. The CCP documented the resident should have a pressure relieving cushion when sitting in the wheelchair "i.e. Ultrafoam cushion." The licensed practical nurse's (LPN) note dated August 1, 2011, documented the resident had a red blanchable area on the right buttocks, which measured 7 1/2 x 5 (no unit of measurement written), and a red blanchable area on the left buttock that measured 6 x 2 centimeters (cm). The note recorded the registered nurse (RN) was notified, and would inform the wound nurse in the morning that the resident needed to be seen. The RN note, dated August 2, 2011 documented she was called to the room to "check areas" and redness was noted to the left hip, left lateral thigh, left ankle bone, left outer mid foot, and right hip. The areas were blanchable and barrier cream was applied," will continue to monitor areas." There were no entries to apply barrier cream to these areas on the August 2011 TAR (treatment administration record), no changes made to the CCP and no changes to the the Individualized Daily Resident Care Card (nurse aide care card) regarding the use or frequency of barrier cream to these areas. There was no documented evidence the reddened areas on the resident's buttocks were seen by a person who was qualified to assess the areas(registered nurse, physician or nurse practitioner) from August 2, 2011, until August 11, 2011. There was no documented evidence the areas were treated with barrier cream, any other form of treatment or the results of any treatment. The physician note, dated August 9, 2011, documented the resident had been seen and examined for redness of the scrotum. The documentation did not include an examination of the resident's buttocks. The registered nurse note dated August 11, 2011, documented the resident had 3 Stage II pressure ulcers; 1 on the right buttock, 1 on the left buttock, and 1 on the coccyx. There was no documented assessment of the pressure ulcer areas (size, wound bed, drainage). physician's orders [REDACTED]. The LPN documented on the Wound Measurement form, dated August 11, 2011, regarding the Stage II pressure ulcers as follows: - the coccyx measured 2 cm x 1 cm, with a pink wound bed; - the right buttock measured 5 cm x 3 cm with a yellow/green "scab" covering 100% of the wound bed; and - the left buttock measured 2 cm x 1.5 cm with a yellow/green "scab" covering 100% of the wound bed. The treatment documented on this form for the 3 pressure ulcers was RepliCare every 5 days, and as needed. This form documented the resident was on an air mattress, there was no documentation regarding the type of cushion the resident used in his wheelchair. The resident's Minimum Data Set (MDS) assessment, dated August 11, 2011, documented the resident's cognition was severely impaired, he had short term and long term memory impairment. On August 11, 2011, the CCP documented the resident had Stage II pressure ulcers on his coccyx, his right buttock, and his left buttock. The only documented change in planned interventions was the RepliCare dressing. The surveyor observed the resident's pressure ulcers on August 16, 2011 at 10:25 AM during the dressing change. The resident was lying on the bed, with no dressing on the resident's buttocks or coccyx. The resident's buttocks were dusky red and excoriated. There were multiple open areas with 100% yellow slough and the coccyx pressure area was 100% green slough. The LPN measured 1 area on each buttock and the area on the coccyx. She did not measure the dusky red excoriation on both buttocks. The LPN applied RepliCare, using 2 dressings that came together at the coccyx pressure ulcer. The RepliCare did not cover the entire area of excoriation. The surveyor interviewed the LPN immediately after the dressing change observation; she stated that she was going to fill out the Wound Measurement form for the resident. She said she wound rounds would be in 2 days (August 18, 2011), and she always filled out this form 1 or 2 days before the skin team made wound rounds. The LPN documented on the Wound Measurement form, dated August 16, 2011, regarding the Stage II pressure ulcers as follows: - the coccyx measurements were unchanged (from August 11, 2011) and the wound bed was 100% slough (dead tissue); - the right buttock measured 4.0 cm x 2.7 cm with 100% yellow slough in the wound bed; and - the left buttock measured 2.2 cm x 1.7 cm with 100% yellow slough in the wound bed. The assessment was incomplete, as there was no documentation regarding the type of cushion used in the wheelchair in the area titled, "mattress/cushion", or of a change in treatment on the August 16, 2011 Wound Measurement form. The Daily Resident Care Card (used to direct the resident's care), dated August 16, 2011, documented the resident had a wedge cushion in the wheelchair. The surveyor observed the resident in his wheel chair on August 16, 2011 at 11:45 AM; he was seated on a wedge cushion. The surveyor interviewed the physical therapist (PT) on August 16, 2011 at 12:20 PM; she stated she had not been asked to evaluate the resident's cushion. The PT said she knew the resident had new pressure ulcers, and would not be surprised if he needed a different cushion. The PT provided the surveyor with the product information for the wedge cushion used by the resident. This information documented the cushion was a firm foam foundation covered by comfort foam, and provided a firm level seat. The surveyor interviewed the occupational therapist (OT) on August 16, 2011 at 12:30 PM; she stated she goes with the skin team on wound rounds. The OT said she had not seen the resident's pressure ulcers, as the dressing was intact so the team did not remove it to assess the pressure ulcers. The OT stated the registered nurse (RN) wound nurse is the one who decides and/or requests an evaluation of resident's cushions or a change in cushion. The surveyor interviewed the LPN on August 18, 2011 at 11:15 AM; she stated when a pressure ulcer is found an RN should be with the LPN, as she (the LPN) records the information on the Wound Measurement form. She said after that she (the LPN) looks at the pressure ulcers and records the information on the form every week. The LPN said the facility liked to have the same person looking at the pressure ulcers each week, so that there was continuity. If the pressure ulcer got better or worse, then the RN would be notified. The surveyor interviewed the RN wound nurse on August 18, 2011, at 12:40 PM; she stated the skin team looks at pressure ulcers weekly. The team included the RN wound nurse, the unit treatment nurse (may be RN or LPN), PT or OT and the dietitian. She said the team meets and looks at the pressure ulcers overall appearance, and assesses related factors, such as pressure relief, clothing, toileting, and supplements. The RN wound nurse stated she did not measure pressure ulcers on the rounds, that the unit nurse (RN or LPN) did that preferably the day before rounds. She said when a pressure is newly found there should be an assessment by an RN in the progress notes, in addition to the Wound Measurement Guidelines form (which was filled out by the nurse who initially saw the pressure ulcer LPN or RN). The surveyor interviewed the RN wound nurse on August 18, 2011 at 2:45 PM; she stated she had not seen the resident's pressure ulcer areas, and had not requested evaluation for a pressure relieving cushion. There was no further explanation offered. The surveyor observed the resident on August 19, 2011 at 11 AM in his wheelchair in the hallway. He was sitting on a wedge cushion. In summary the resident experienced harm, as the reddened areas on the resident's buttocks deteriorated from blanchable redness to unstageable pressure ulcers, and the facility: - did not reassess the resident for pressure relief when in the wheelchair; - did not have a qualified person assess or document an assessment of the resident's buttocks when they were observed to be red, or for 10 days after when the resident was found to have 3 Stage II pressure ulcers; and, - did not notify the RN that the Stage II pressure areas were now unstageable, as they were covered with slough. 3) Resident #15 had the [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated February 11, 2011, and updated August, 2011 documented the following problem, "Resident is at moderate risk for skin breakdown due to: dementia, decreased mobility and incontinence" with a goal of, "Maintain skin integrity, avoid skin traumas." There were no alternate interventions identified for when the resident was non-compliant with going back to be in the afternoon, or repositioning side-to-side. The licensed practical nurse's (LPN) note dated May 2, 2011 documented the resident had a small open area to the right buttock measuring 1.2 centimeters (cm) x 1.0 cm. The physician telephone order dated May 2, 2011 documented an order to apply a RepliCare dressing (used to promote wound healing) to the open area on the right buttock every 5 days and as needed until healed. The unsigned Wound Measurement form dated May 2, 2011, documented the resident had a Stage II pressure ulcer on the right buttock, that measured 1.2 centimeters (cm) x 1 cm and was pink. The form recorded the resident had an Ultrafoam cushion in the wheelchair. There was no documented evidence of an assessment of the new open area by a qualified person from May 2, 2011 until May 5, 2011. The registered nurse (RN) wound nurse's note dated May 6, 2011, documented the resident was seen on skin rounds on May 5, 2011. This note recorded the resident had a Stage II pressure ulcer on the right buttock, which had a pink wound bed of granulation tissue. This note documented the resident would be approached to position side to side when in bed, to go back to bed in the afternoon, and had been non-compliant with this in the past. The note recorded the resident "currently refused this." The RN's note did not address the resident's dementia or any alternate interventions to be implemented when the resident was non-compliant with returning to bed in the afternoon or reposition side to side. The unsigned Wound Measurement form dated May 11, 2011, documented the resident's pressure ulcer was 1 cm x 1 cm, with a closed pink tissue wound base, and was not blanchable. The RN wound nurse's note dated May 12, 2011 documented the resident was not seen on wound rounds as the pressure ulcer dressing was not scheduled to be changed. The unsigned May 16, 2011, Wound Measurement form documented, the pressure ulcer was a Stage II measuring 3 cm x 2 cm, was 60% purple pink in color with an "open base." The RN wound nurse's note dated May 20, 2011 documented the pressure ulcer was Stage II, with pink granulation tissue, a moderate amount of serosanguineous drainage, and deep red [DIAGNOSES REDACTED] (redness) of surrounding tissue. This note documented the resident had a gel cushion in the wheelchair. (Eighteen days after the area was found, during which time it worsened, the resident was provided with alternate pressure relief from the cushion he was using before the pressure ulcer developed). The unsigned Wound Measurement form, dated May 25, 2011, documented the resident had a Stage II pressure ulcer that measured 1.6 x 2 (no unit of measurement recorded), with pink/yellowish wound bed (no percentage recorded) and pink granulation tissue (no percentage recorded). The Wound Measurement form, dated June 1, 2011, documented the pressure ulcer on the resident's right buttock was 2 x 2 (no unit of measurement recorded), the wound bed was 95% white slough (dead tissue) with 5% white edges. The form documented a gel cushion was used in the wheelchair. Physician orders [REDACTED]. The RN wound nurse's note dated, June 3, 2011, documented the resident's pressure ulcer was a Stage II, with pink granulation tissue present, a moderate amount of yellow slough, and a moderate amount of serosanguineous drainage present, "no [DIAGNOSES REDACTED]" (redness) present. The RN note documented the resident had been non-compliant with going to bed in the afternoon and side positioning in the past. This note recorded the resident was now "sometimes" agreeable to it. The RN's note did not address the resident's dementia or include any alternate interventions for when the resident was non-compliant with returning to bed in the afternoon, or repositioning side to side in bed. The unsigned Wound Measurement form, dated June 6, 2011, documented the pressure ulcer was a Stage III, measured 2.2 cm x 2 cm, with 95% white slough in the wound bed; the surrounding tissue was "firm red rimmed." The physician note, dated June 6, 2011, documented the resident had an area on his right buttock, which initially started as a blister. The note documented the ulcer was 1.5 cm, open with slough and drainage, surrounded by 4 cm of slightly warm, red induration. The assessment was an infected ulcer. The physician note recorded the resident would be started on [MEDICATION NAME] (an antibiotic) 250 milligrams (mg) by mouth for 10 days. The RN wound nurse's note dated June 6, 2011, documented the resident's pressure ulcer on the right buttock was a Stage III, with: - a moderate amount of yellow slough present; - pink granulation present; - a moderate amount of serosanguineous drainage present; - slight [DIAGNOSES REDACTED] to surrounding tissue present; and - induration present. The RN's note documented the resident had been non-compliant with going to bed in the afternoon and side positioning in the past. This note recorded the resident was now sometimes agreeable to it, and had a gel cushion in the wheel chair. The RN's note did not address the resident's dementia or indicate any alternative pressure relieving strategies for when the resident was non-compliant with returning to bed and side positioning. The unsigned Wound Measurement form, dated June 9, 2011, recorded the resident used a gel cushion in the wheelchair. (There was no documented assessment of the pressure ulcer dated June 9, 2011). The Wound Measurement form dated June 14 - July 18, 2011, documented the resident had: a gel cushion in the wheelchair; a Stage III pressure ulcer on the right buttock, with 85 - 90% yellow or white slough in the wound bed; no pain, and the pressure ulcer measured as follows: - June 14, 2011, 1.8 cm x 1.7 cm; - June 20, 2011, 1.8 cm x 1 cm; - June 27, 2011, 1 cm x 0.6 cm; - July 5, 2011, 0.8 cm x 0.6 cm; - July 12, 2011, 1.4 cm x 0.8 cm; and - July 18, 2011, 1.2 cm x 1 cm. This form documented on July 25, 2011, the pressure ulcer measured, 1 cm x 1 cm with 100% white slough. The wound nurse's notes, dated June 16, 2011 - July 21, 2011, documented the resident had a gel cushion in the wheelchair, was non-compliant at times with going back to bed in the afternoons and side positioning when in bed. The wound nurse's note did not address the resident's dementia or any alternate interventions for when the resident was non-compliant with returning to bed in the afternoon, or side positioning in bed. Physician orders, dated July 28, 2011, documented an order to cleanse the area on the right buttock with normal saline, apply Santyl and cover with Allevyn foam (a type of dressing) every day and as needed. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognitive skills for daily decision making were moderately impaired, his decisions were poor and cues/supervision were required. The assessment documented the resident required extensive assistance of one person to move in bed, turn side to side, or position his body. The Wound Measurement form dated August 2 - 15, 2011, documented the Stage III pressure ulcer on the resident's right buttock had a wound bed that was 100% white slough, was tender and measured 1 cm x 1 cm x 0.8 cm. This form documented the resident had a gel cushion in the wheelchair. The surveyor observed the resident's pressure ulcer on August 17, 2011 at 10:10 AM, during the dressing change. The pressure ulcer measured approximately 1 cm x 0.8 cm, the wound bed was yellow/green with surrounding redness. The physical therapy note dated August 19, 2011, documented the resident was given a Matrix cushion for the wheelchair, "to help reduce pressure on buttocks." The Individualized Daily Resident Care Card dated August 19, 2011 documented the resident's ADL's (activities of daily living) as follows: the resident was non-ambulatory, transferred with the use of a stand-lift and 1 ass

Based on observations, record reviews, staff interviews conducted during the partially extended abbreviated survey (NY 105), it was determined the facility failed to have a system in place to ensure appropriate treatment and services were provided to the 6 residents (Residents #1, 2, 3, 4, 5 and, 6) in the facility fed by a gastrostomy tube ([DEVICE], feeding tube inserted through the abdominal wall). Specifically, Resident #1 required hospitalization for peritonitis (severe infection within the abdomen) due to dislodgement of the [DEVICE] and subsequently expired. For Residents #1, 3 and 5, the interdisciplinary team did not assess and implement interventions to prevent the repeated need for reinsertion of their [DEVICE]s. Resident #2's [DEVICE] was replaced with sizes not ordered by the physician. Additionally, the facility failed to ensure the RNs and LPNs were trained and able to demonstrate competency, regarding the insertion of [DEVICE]s and/or the safe administration of tube feedings for Residents #1, 2, 3, 4, 5, and 6. The facility did not ensure their policies and procedures for feeding tube insertion and the safe administration of tube feeding formula were consistently implemented to ensure they met accepted standards of quality. This resulted in actual harm that was Immediate Jeopardy and Substandard Quality of Care to Resident #1's health and safety; and the potential for serious harm that was Immediate Jeopardy and Substandard Quality of Care for Residents' #2, 3, 4, 5 and 6. Findings include: The facility policy, Replacement/Insertion of Gastrostomy Tube, revised [DATE], documented that after the insertion of a [DEVICE], the licensed nurse was to determine proper placement of the [DEVICE] within the resident's stomach, by instilling 5 cc (cubic centimeters) to 10 cc of air through the tube, while auscultating (listening with a stethoscope) the resident's stomach, listening for a "whooshing" sound. Staff were to "notify (the) physician" if there was any "bleeding or abdominal distention." The policy specified that [DEVICE] replacement should be done every 3 months and PRN (as needed) when the tube became "degraded or faulty in usage." The policy documented "if the [DEVICE] has been in less that one month, DO NOT attempt to re-insert, call MD immediately." The policy did not document to aspirate the resident's stomach contents after the [DEVICE] was replaced/inserted. The facility policy, Gastrostomy Tube Feeding, [MEDICATION NAME] Method (specific amount given at one time), revised [DATE], documented that prior to administering a tube feeding, a licensed nurse was to check the position of the [DEVICE] (for accuracy) by aspirating (withdrawing with a syringe) the [DEVICE] for [MEDICAL CONDITION] (stomach) contents. The policy documented "if tube becomes dislodged, notify MD." 1) Resident #1 had [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment, dated [DATE], documented the resident had severe cognitive impairment; required extensive to total assistance with all activities of daily living; and had a feeding tube. Nursing progress notes, written by LPN #1 on [DATE] at 10:38 AM, [DATE] at 4:12 AM, and on [DATE] at 2:45 AM, documented that prior to administering the resident's tube feedings, she checked the [DEVICE] for correct placement by hearing "air in the stomach." There was no documentation that LPN #1 aspirated [MEDICAL CONDITION] contents to check for accurate placement of the [DEVICE], as specified in the facility's policy. The comprehensive care plan (CCP), dated [DATE], documented the resident relied on tube feedings to meet her nutrition/hydration needs. Approaches included monitoring the resident for tolerance to the tube feeding; monitoring for signs/symptoms of infection/aspiration (inhalation of stomach contents); and placement of an abdominal binder over the [DEVICE] site, to prevent the resident from pulling it out; "If out- replace." The current CCP, "reviewed (by the interdisciplinary team) [DATE]" did not address interventions to prevent the resident's repeated removal of the [DEVICE]. physician's orders [REDACTED]. The physician's most recent progress note was dated [DATE] and documented "episodically she (the resident) pulls the PEG out and then staff is able to put it back with no major trouble." Nursing progress notes documented nursing staff reinserted the resident's [DEVICE] 14 times between [DATE] and [DATE], including: - on [DATE], RN #2, Coordinator of Staff Development, checked the [DEVICE] placement by "injection of 60 ml (milliliters) air". (The facility policy documented instilling 5 cc to 10 cc of air through the tube). - on [DATE] at 8:16 PM, the nursing note documented the resident's [DEVICE] became dislodged; the "nursing supervisor and MD were notified"; and the nursing supervisor replaced it with an "18 french 20 ml PEG tube. PEG site presented with a small amount of herniated tissue; a scant amount of frank blood. Resident complained of moderate pain during the replacement procedure, otherwise tolerated well." The documentation was unclear whether the physician was notified of the resident's herniated tissue, abdominal pain and frank blood present. On [DATE], the physician ordered the resident's tube feeding formula changed from [MEDICATION NAME] 1.2 Cal (tube feeding formula) to [MEDICATION NAME] 1.5 Cal for 5 cans a day, [MEDICATION NAME] feeding; with water flushes before and after feedings and medications; and specified "If tube becomes dislodged, notify the physician." On [DATE], RN Supervisor #1's progress note at 10:48 PM, documented a certified nurse aide (CNA) noticed the resident's [DEVICE] lying in the resident's bed with the balloon (filled with water to prevent the tube from coming out) intact. "New PEG tube inserted without difficulty." The note did not specify how, or if, the nurse verified placement of the [DEVICE] within the resident's stomach. - On [DATE] at 10:48 PM, RN Supervisor #1 documented a "late entry" that specified "placement of resident's PEG tube replacement checked with this writer and charge nurse after insertion on [DATE] evening." The next nursing progress note was dated [DATE] at 1:27 PM by the LPN. The LPN documented the resident had "abdominal distention with pain when touched. Vomited a moderate amount". The note specified the physician was called, and the resident was sent to the hospital at 11:00 AM that day. The facility Patient Transfer Form, dated [DATE], documented the resident was transferred to the hospital due to "distention of abdomen on right side, complaints of pain when touched. Last tube feeding done at 6 AM. Vomited mod(erate) amount of yellow emesis. Tube replaced on ,[DATE] (shift) on [DATE]." The hospital physician's Emergency Provider Record, dated [DATE], documented: - the resident was evaluated at 11:59 AM for complaints of constant, dull, abdominal pain; - the resident's abdomen was distended; - an abdominal CT scan was abnormal; - the physician's clinical impression was abdominal pain related to intestinal perforation after [DEVICE] placement; - the resident was admitted to the hospital at 3:21 PM on [DATE]; and - the resident's [DEVICE] was removed at 6:30 PM on [DATE]. The CT (radiological test) of the resident's abdomen and pelvis, dated [DATE] at 2:18 PM, documented free air in the abdomen, and a [DEVICE] projecting over the left abdomen. "It is not entirely clear that this tube is in the stomach. It may be next to the stomach in the abdominal fat." A nursing note, written by a hospital emergency department RN on [DATE] at 4:14 PM, documented she called the facility about an issue with the resident's [DEVICE], and was told that after the resident pulled out the [DEVICE], it was replaced by the nursing supervisor during the evening shift on [DATE]. Verbal physician's hospital admission orders dislodgement (of) [DEVICE]." The hospital admission and physical examination, dated [DATE], documented the resident's [DEVICE] came out on [DATE], and was reinserted. "Today her abdomen was distended. She has been admitted with peritonitis." The hospital attending physician's discharge summary, dated [DATE], documented the resident continued to deteriorate, and expired that date from septic shock, secondary to peritonitis. The hospital final principal [DIAGNOSES REDACTED]." Secondary diagnoses, also present on admission, included peritonitis, [MEDICAL CONDITION], and septic shock. The facility Investigation Report of Accident with Injury, signed (not dated) by the Assistant Administrator, and provided to the surveyor on [DATE], documented the resident's [DEVICE] was found out on [DATE]; was reinserted; and its placement was checked. The resident was sent to the hospital due to abdominal distention, pain upon palpation, and vomiting. The resident developed peritonitis and expired [DATE] at 2 AM. Three employee statements included in the facility's investigation report included: - a personal statement, dated [DATE], by RN Supervisor #1 (who reinserted the resident's [DEVICE] on [DATE]), documented "placement was checked after insertion. There were 4 other people in the room. This was all done about 10:30 PM." There was no documentation how the [DEVICE]'s placement was "checked". - a personal statement, by LPN #2 on [DATE], documented she was in the room when the resident's [DEVICE] was replaced, placement verified, and air instilled in the tube. "The sound was so loud everyone in the room could hear it. I said I can hear correct placement without the stethoscope!" - a personal statement, dated [DATE] by LPN #1 (who administered the resident's 6:00 AM tube feeding on [DATE]), documented she checked the [DEVICE] for placement, "which was confirmed." There was no documentation how the [DEVICE]'s placement was "confirmed". The "Summary of Investigation Outcome" was blank; the report did not include signatures of the Director of Nurses (DON) or the Administrator. At 3:15 PM on [DATE], a surveyor interviewed RN #2, the Coordinator of Staff development, regarding staff training and demonstration of competency to insert [DEVICE]s and administer tube feedings. RN #2 stated the facility did not provide nurses with specific training to replace [DEVICE]s, and they were not required to demonstrate competency to perform the procedure. RN #2 stated that if a nurse was uncomfortable with replacing a [DEVICE], he or she would be observed by a nurse manager, supervisor, or Coordinator of Staff Development. He stated, "This is within the scope of practice for RNs and LPNs." Regarding verification of placement of the [DEVICE] within the stomach, RN #2 stated the procedure was to inject air into the [DEVICE] with a syringe, and listen for a gurgle in the stomach. He stated aspiration of stomach contents was not required, as this is not in the facility policy. A surveyor interviewed RN Supervisor #1 at 3:35 PM on [DATE] who stated she replaced the resident's [DEVICE] on [DATE]. RN Supervisor #1 stated [DEVICE]s were discussed during general orientation when she began employment at the facility 7 years ago. She stated she was not required to demonstrate competency for [DEVICE] insertion. When asked how she checked for placement of the [DEVICE] within the resident's stomach at the time of insertion on [DATE], RN Supervisor #1 stated she injected 60 cc of air and listened over the resident's stomach with a stethoscope. She stated she needed to push the plunger of the syringe with enough force to hear the "swish" of air in the resident's stomach. She stated had replaced Resident #1's tube 2 to 3 times before and had "to move" it "to the left when inserting." When asked if she the resident for stomach contents, RN Supervisor #1 stated she did not aspirate, as it was not the facility policy. At 3:50 PM on [DATE], a surveyor interviewed LPN #2, who was present on the evening of [DATE] when RN Supervisor #1 replaced the resident's [DEVICE]. LPN #2 stated she was standing next to the resident's bed, and could hear the air when it was injected into the [DEVICE]. LPN #2 stated she had no formal training to insert a [DEVICE], and had never inserted one. She stated she watched RN Supervisor #1 insert several [DEVICE]s, and RN Supervisor #1 told her she would know how to insert one, if needed, since she observed this procedure. At 3:55 PM on [DATE], a surveyor interviewed a CNA who stated she was standing at the foot of the resident's bed when RN Supervisor #1 inserted her [DEVICE] on the evening of [DATE]. The CNA stated that when the RN Supervisor #1 inserted air into the resident's [DEVICE], she heard a sound like air coming out of a balloon. A surveyor interviewed LPN #1 via telephone at 9:30 PM on [DATE], regarding her administration of a tube feeding to the resident at 6:00 AM on [DATE]. She stated she inserted air into the [DEVICE] to check for placement within the resident's stomach. LPN #1 stated she did not aspirate the resident's stomach contents prior to administration of the tube feeding, and "never" did so. LPN #1 stated she had been employed by the facility for [AGE] years, and did not recall if she was trained to insert [DEVICE]s and administer tube feedings; and was unsure if she was required to demonstrate competency to perform these procedures. On [DATE], review of nursing staff's personnel and training records revealed: - RN Supervisor #1 was hired as a Nursing Supervisor on [DATE]. The "Nurse Skills Verification Checklist," dated [DATE], documented initials of a "mentor", dated [DATE], for tube feeding-related skills including "continuous/pump, [MEDICATION NAME] feed, and gravity feed." The skill of "Replacement/Insertion of Gastrostomy Tube" was marked, N/A (not applicable). - RN #2 (Coordinator of Staff Development) was hired on [DATE]; the personnel file contained no documented evidence of training/demonstration of competency to insert a [DEVICE] and administer tube feedings. - LPN #1's personnel file contained no documented evidence of training/demonstration of competency to insert a [DEVICE] and administer tube feedings. During an interview with RN #2 at 9:30 AM on [DATE], he stated the facility had no records of staff training for staff hired prior to 2004. He stated a search of computer records showed no documented evidence of staff training and/or demonstration of competency to insert [DEVICE]s and safely administer tube feedings. The hospital radiologist was interviewed via telephone on [DATE] at 8:30 AM. He stated he remembered the resident well, and was worried that her [DEVICE] was not in the proper position when she was hospitalized on [DATE]. The radiologist stated that feeding tubes fell out or were pulled out in nursing home residents frequently. He stated that when a resident resided in a nursing home, and radiologic images were not available, stomach contents must be aspirated to verify proper placement. The radiologist stated that injecting 60 cc of air into a feeding tube that was not in proper position would be a problem. He stated that administration of a feeding without verifying placement could be worse than the damage caused by injecting 60 cc of air. In summary, the facility failed to protect Resident #1's health and safety, as she developed peritonitis, [MEDICAL CONDITION], and septic shock related to the re-insertion of the [DEVICE] and the subsequent administration of a tube feeding, without determining the proper location of the resident's [DEVICE], as stated in the facility policy. The facility: - failed to ensure RNs and LPNs were trained and demonstrated competency to insert [DEVICE]s and administer tube feedings safely; - failed to ensure the interdisciplinary team assessed the resident and developed effective interventions related to her repeated removal of the [DEVICE]; and - the facility failed to ensure policies and procedures were consistently implemented for feeding tube insertion and the safe administration of the tube feeding formula. 2) Resident #5 had [DIAGNOSES REDACTED]. Nursing progress notes documented, between [DATE] and February 18, 2011, nursing staff (including LPN #4, RN #4 and #5) reinserted the resident's [DEVICE] 11 times. The annual Minimum Data Set (MDS) assessment, dated [DATE], documented the resident had severe cognitive impairment; required extensive to total assistance for all activities of daily living; and received her calories and fluids via feeding tube daily. The comprehensive care plan (CCP), dated [DATE], documented the resident had excessive spastic movements, and received all nourishment and fluids via [DEVICE]. There was no documentation on the CCP that effective interventions were developed regarding her repeated removal of the [DEVICE]. The CCP did not address the resident's potential for injury related to removal of the [DEVICE] with the balloon inflated. A nursing progress note, dated [DATE] at 7:36 PM, documented that after the resident pulled out the [DEVICE], an RN (name not documented) replaced the [DEVICE]. A nursing progress note, dated [DATE] at 11:45 AM, documented a small amount of bleeding at the site of insertion when the resident pulled out her [DEVICE]. RN #3 replaced the tube and identified correct placement by auscultation (listening over the abdomen while injecting air into the [DEVICE]). A nurse practitioner (NP) monthly note, dated [DATE], documented the resident exhibited "thrashing and constant movement," and "This past month she has pulled out her Foley (urinary catheter) and feeding tube numerous times." The resident's most recent physician's orders [REDACTED]. The resident's [DEVICE] was to be changed every 3 months. A nursing progress note, dated [DATE] at 7:00 PM, documented the nursing supervisor, (RN #7) was called after the resident pulled out her [DEVICE]. When replacing the tube, the "procedure resulted with immediate [MEDICAL CONDITION] return, position verified with injection of 20 ml (milliliters) of air via syringe down PEG tube." On [DATE] at 3:30 PM, a surveyor interviewed RN #7 regarding her training to insert [DEVICE]s. She stated she was not trained to insert [DEVICE]s prior to her employment at the facility in [DATE]. RN #7 stated that RN #2 showed her how to replace the [DEVICE]s of Residents #1 and 3. She stated she verified placement of the [DEVICE] within the stomach by injecting 20 ml of air and listening for a "swoosh." RN #7 stated she did not verify placement by aspirating stomach contents. During an interview with RN #3 at 2:00 PM on [DATE], she stated she "was shown a policy at general orientation" on [DEVICE] replacements, when she was hired 2 ,[DATE] years ago. She stated she did not receive "hands-on training" before she began inserting [DEVICE]s herself; and was not required to demonstrate competency to perform the procedure. RN #3 stated she was told to determine proper [DEVICE] placement by auscultating over the stomach while injecting 10 cc of air. She said she was not told to aspirate the resident's stomach contents prior to feeding, as specified in the [DEVICE] Feeding [MEDICATION NAME] Method policy. At 3:00 PM on [DATE], a surveyor interviewed RN #6 regarding insertion of [DEVICE]s. She stated she could not remember if she was ever trained or required to demonstrate competency to insert [DEVICE]s. She stated she determined proper placement of the [DEVICE] within the stomach by injecting 10 cc of air through the tube and auscultating over the stomach. RN #6 stated she "occasionally aspirated" stomach contents to check placement. At 3:20 PM on [DATE], a surveyor interviewed LPN #4 regarding [DEVICE] insertion. He stated he was employed by the facility as an LPN since [DATE]. He stated he did not receive training to insert [DEVICE]s, and did not demonstrate competency to perform the procedure. LPN #4 stated he "went over the procedure" with RN #5, a former charge nurse. He stated he verified placement of the [DEVICE] by injecting 10 cc of air through the tube and auscultating over the stomach. LPN #4 stated he used no other method to check placement. Review of LPN #4's Nurse Skills Verification Checklist revealed his skill to administer a gravity (without pump or syringe) tube feeding was verified on [DATE]. His skill to administer continuous/pump feedings was not verified, and the skill for Replacement/Insertion of Gastrostomy tube was blank. At 9:10 AM on [DATE], a surveyor interviewed RN #4 regarding [DEVICE] insertion. She stated she did not remember receiving training to insert [DEVICE]s, and was not asked to demonstrate competency to perform the procedure. She stated she could call another nurse if she needed help. RN #4 stated she verified placement of a [DEVICE] by auscultating while injecting the tube with 30 cc of air. She stated that she did not check placement by aspirating stomach contents. In summary, the facility failed to protect the health and safety of Resident #5, as: - RNs and LPNs did not receive training and were not required to demonstrate competency to insert [DEVICE]s and administer tube feedings safely; - policies and procedures for feeding tube insertion and maintenance were not consistently implemented and evaluated to ensure they met accepted standards of quality; and - the interdisciplinary team did not assess the resident and implement interventions for the potential for injury related to her ability to repeatedly remove the [DEVICE]. 3) Resident #2 had [DIAGNOSES REDACTED]. The resident's physician's orders [REDACTED].#10 [DEVICE], to be changed every 3 months (due [DATE]). A nursing progress note, written by LPN #3 at 1:41 PM on [DATE], documented the resident's [DEVICE] was found on his lap, and LPN #3 inserted a size #20 Foley (catheter) for a replacement [DEVICE]. A nursing progress note, written by LPN #3 at 12:20 PM on [DATE], documented a "new PEG tube place" with a size "#14 placed; uneventful." A nursing progress note, written by LPN #6 at 4:14 AM on [DATE], documented the resident's "new PEG (percutaneous endoscopic [DEVICE]) looks smaller in diameter and appears to be working its way back out." There was no documented progress note that an RN assessed the resident's [DEVICE] placement and no documentation the physician was notified. physician's orders [REDACTED].#10 [DEVICE] was to be changed every 3 months (due [DATE]); the resident was to receive a [MEDICATION NAME] feeding of 2 Cal HN daily at 10:00 PM; and staff were to administer 100 cc of water before and after the feeding, and 200 cc of water at 10:00 AM and 4:00 PM. The [DATE] treatment administration record (TAR) documented the resident's [DEVICE] was size #10, and was changed on [DATE]. The [DATE] TAR documented the size #10 [DEVICE] was due to be changed on [DATE]. The resident's most recent Minimum Data Set (MDS) assessment, dated [DATE], documented the resident had severe cognitive impairment and received 25% or fewer calories, and 501 cc or more fluids, via feeding tube daily. The comprehensive care plan (CCP), dated [DATE], documented the resident received [DEVICE] feeding to provide additional calories and fluids. The CCP did not specify the size of the resident's ordered [DEVICE]. On [DATE], the physician wrote an order to discontinue the resident's 10:00 PM tube [MEDICATION NAME] feeding, and continue to flush his [DEVICE] with 200 cc of water BID (twice daily). The resident's [DATE] TAR documented the resident's size #10 PEG tube was due to be changed on [DATE]. At 1:00 PM on [DATE], a surveyor interviewed LPN #3, who stated she was employed by the facility for [AGE] years. She stated the protocol was to change [DEVICE]s every 3 months, and "could be done by any nurse on any shift". LPN #3 stated that after inserting a [DEVICE], she determined correct placement by listening with a stethoscope over the [DEVICE] insertion site while injecting 5 to 10 cc of air into the [DEVICE]. She stated she did not aspirate stomach contents to verify correct placement of the [DEVICE]. LPN #3 said she could not remember when she demonstrated competency to insert a resident's [DEVICE]. Review of LPN #3's personnel file at 4:00 PM on [DATE], revealed no documented evidence of training and demonstration of competency to insert [DEVICE]s. The training records documented the LPN was assessed for providing a [MEDICATION NAME] tube feeding in [DATE]. At 2:00 PM on [DATE], a surveyor interviewed RN #3, the charge nurse on the resident's unit, about the size of the resident's [DEVICE]. She stated she did not know why the resident had a size #14 [DEVICE], when a size #10 was ordered by the physician. She stated, "Maybe the correct size was unavailable." At 5:10 PM on [DATE], a surveyor observed the resident when LPN #7 checked the size of the resident's [DEVICE]. The LPN stated it was size #14. When interviewed about the size of the [DEVICE], LPN #3 stated it should be the size ordered by the physician. At 12:05 PM on [DATE], a surveyor interviewed the Director of Nursing (DON) about the resident's [DEVICE], ordered to be size #10. She stated she did not know why the resident's [DEVICE] was replaced with sizes #20 and 14 in [DATE], and why the resident currently had a size #14 [DEVICE]. The DON stated the resident should have the [DEVICE] size that was ordered by the physician. In summary, the facility failed to protect the health and safety of Resident #2, as: - the resident's [DEVICE] was replaced with sizes that were not ordered by the physician; - RNs and LPNs did not receive training and were not required to demonstrate competency to insert [DEVICE]s and administer tube feedings safely; and - policies and procedures for feeding tube insertion and safe tube feeding administration were not consistently implemented and evaluated to ensure they met accepted standards of quality. ADDITIONAL PERTINENT STAFF INTERVIEWS: - At 9:25 AM on [DATE], a surveyor interviewed LPN #5, the charge nurse on the unit where Residents #3, 4, and 5 resided. She stated she had not inserted a [DEVICE] prior to her employment at the facility, and inserted her first [DEVICE] alone after observing another nurse insert one. LPN #5 stated that when inserting a [DEVICE], she checked for proper placement by inserting 30 cc of air into the [DEVICE] with a syringe, then removing the piston and listening for a "burp" of air to come from the stomach. She stated she used the same method to check for correct [DEVICE] placement prior to administering a tube feeding. - At 3:30 PM on [DATE], a surveyor interviewed the Medical Director via telephone regarding facility policies and procedures for [DEVICE] insertion and tube feeding. He stated he would expect the facility to train nurses and have them demonstrate competency to perform these procedures. 10NYCRR 415.12(g)(2)

Based on observations, record reviews, and staff interviews conducted during the partially extended abbreviated survey (NY 105), it was determined the facility's administration (including Administrators and the Director of Nurses) failed to administer the facility in a manner that protected the health and safety of its 6 tube fed residents (Residents #1, 2, 3, 4, 5, and 6). Specifically, the facility's administration failed to have a system in place to ensure Residents #,[DATE] who were fed via gastrostomy tube ([DEVICE], inserted through the abdominal wall), received appropriate treatment and services in accordance with accepted professional standards. This resulted in actual harm for Resident #1 and the potential for serious harm for Residents #2, 3, 4, 5 and 6 that is Immediate Jeopardy. Findings include: F322 - Gastrostomy tube feeding - the facility's administration, including the Administrator and the Director of Nurses (DON): - failed to have a system in place to ensure nursing staff received formalized training and were required to demonstrate competency to safely insert [DEVICE]s and administer tube feedings, flushes, and medications. - failed to have a system in place to ensure consistent implementation of policies and procedures that met accepted professional standards of quality related to services provided to residents with [DEVICE]s. - failed to have a system in place to ensure assessment and implementation of interventions for the potential for injury related to repeated removal and reinsertion of [DEVICE]s (Residents #1, 3 and 5). - failed to have a system in place to ensure the physician ordered [DEVICE] size was inserted into Resident #2. At 11:00 AM on [DATE], a surveyor interviewed the Assistant Administrator/Director of Quality Assurance (QA). She stated: - within the past year, the facility did not conduct QA monitoring or topic reviews related to [DEVICE] insertion by nurses and tube feeding administration procedures. - staff should be trained and required to demonstrate competency to insert [DEVICE]s and administer tube feedings. She stated there was "no training going on for the last couple of years because the inservice person was running the CNA (certified nurse aide) training classes." - she was unaware nurses utilized multiple methods of verifying [DEVICE] placement when inserting [DEVICE]s and administering tube feedings, and did not aspirate stomach contents prior to administering tube feedings per policy. - there were no audits/monitoring of staff compliance regarding the consistent implementation of facility policies. - Resident #1 expired following the [DEVICE] insertion by a facility RN Supervisor on [DATE]. There was no additional investigation, other than nurse interviews, and no revisions were made to the facility's policies or procedures. At 12:00 PM on [DATE], a surveyor interviewed the Director of Nurses (DON) regarding facility policies and procedures for staff training and demonstration of competency to insert [DEVICE]s and administer tube feedings. She stated that for newly hired nurses, there was no policy to train them to insert [DEVICE]s, or to demonstrate competency to perform these procedures. During orientation, a nurse would verbally describe to a mentor the steps to perform these procedures. Competency would later be demonstrated with a resident with a [DEVICE]. The DON stated the facility had no formal documentation of staff training/demonstration of competency to insert [DEVICE]s, or to administer tube feedings. She stated this would be documented in the nursing progress notes of specific residents. When re-interviewed at 9:40 AM on [DATE], the DON stated nurses could aspirate stomach contents to check for proper placement of a [DEVICE], "but the facility does not expect them to do that. Nurses are to follow the facility policy to inject air only." When asked how nurses were to check for proper [DEVICE] placement prior to administering a tube feeding, the DON stated they were to insert air only, and were not required to aspirate stomach contents. At 11:20 AM on [DATE], a surveyor interviewed the Administrator. He stated: - RN #1 and LPN #1 were interviewed, and said they followed facility procedures correctly for [DEVICE] insertion and tube feeding administration, respectively. He stated the nurses were not questioned to determine if they followed the specific components of the procedures. - his role in QA is to attend quarterly meetings and present issues identified in the Plan of Correction from the most recent standard facility survey. The most recent quarterly QA meeting was in [DATE]. There has been no data tracking/monitoring of problems with [DEVICE] insertion and administration of tube feedings. - after [DATE], the facility did not evaluate other facility residents with [DEVICE]s for the potential for problems related to [DEVICE] insertion and tube feeding administration. 10NYCRR 415.26