Every finding on record at Lewis County General Hospital-Nursing Home Unit

Based on observation, record review, and interviews (iQIES Intake 3001885), the facility failed to ensure a comprehensive person-centered care plan to meet a resident's medical, nursing, mental, and psychosocial needs was developed and implemented for three of three residents (Resident #22, #34, and #64) reviewed. Specifically, Resident #22 did not have a care plan for their diabetes and use of insulin; Resident #64 did not have a care plan for the use of a blood thinner; and Resident #34 had hourly visual checks planned and Certified Nurse Aide #31 documented verification of visual checks when the resident was not present in the facility. Findings include:The facility policy Comprehensive Care Plans, revised 05/2025, documented a comprehensive care plan would be developed for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs.The facility policy Elopement Prevention Measures, revised 06/2026, documented residents would be reviewed by the interdisciplinary team to ensure risk protocols were in place, being followed and the care plan was updated and individualized to meet the resident needs. The facility policy Diabetic Standard, last reviewed 07/2021, documented the care plan would reflect the individualized testing for high blood glucose levels. 1)Resident #22 had diagnoses including diabetes and long-term use of insulin. The 06/10/2026 Minimum Data Set assessment documented the resident had severely impaired cognition and received insulin injections daily. Physician orders documented: -12/17/2025 lispro (a short acting insulin) before each meal and at bedtime; dose determined by glucose level.-01/18/2026 5 units of glargine (a long-acting insulin) once daily.-04/17/2026 check glucose level before every meal and at bedtime.There was no documented evidence Resident #22's Comprehensive Care Plan included diabetes or the use of insulin. During an interview on 07/10/2026 at 9:04 AM, Licensed Practical Nurse #26 stated care plans were completed by the team to include managers, social work, rehab, and families. They were not sure if blood thinners or insulin would be on the care plan and the aides would have to ask nursing if a resident was on insulin or a blood thinner. Resident #22 was on insulin, and their glucose was usually high. They monitored for signs of high and low blood sugars such as diaphoresis, lethargy, and unsteadiness.During an interview on 07/10/2026 at 10:08 AM, Certified Nurse Aide #27 stated if a resident was diabetic, they could tell by looking at their meal ticket and from the nurse reporting they got insulin. They stated Resident #22 was diabetic and they had not had to report any diabetic issues. During an interview on 07/10/2026 at 10:20 AM, Registered Nurse Unit Manager #4 stated care plans were a group effort. They were started on admission and updated with any changes. Blood thinners were added to the care plan by the Unit Manager and if a resident was on a blood thinner, staff should monitor for bleeding risk. Insulin was a high-risk medication and if a resident was receiving insulin there should be monitoring for signs of high and low blood sugar. Medications should be on the care plan so there was an awareness, goals, and directives for care. Resident #22 was on insulin and did not have a related care plan but should. 2)Resident #64 had diagnoses including a history of blood clots. The 07/08/2026 Minimum Data Set documented the resident had severely impaired cognition and received a blood thinner daily.The 10/22/2025 physician order documented Eliquis (a blood thinner) 2.5 milligrams twice a day.There was no documented evidence Resident #64's Comprehensive Care Plan included the use of a blood thinner. During an interview on 07/10/2026 at 9:04 AM, Licensed Practical Nurse #26 stated Resident #64 was taking Eliquis and there should be monitoring for bruising especially after a fall.During an interview on 07/10/2026 at 10:08 AM, Certified Nurse Aide #27 stated there was no way of knowing if a resident was on a blood thinner other than asking the resident or the nurse. They did not know if Resident #64 was on a blood thinner. During an interview on 07/10/2026 at 10:20 AM, Registered Nurse Unit Manager #4 stated Resident #64 was on a blood thinner and did not have a related care plan. 3)Resident #34 had diagnoses including dementia, schizophrenia (a chronic, severe mental illness characterized by an inability to distinguish between reality and imagination), and anxiety disorder. The 03/27/2026 Minimum Data Set assessment documented the resident had severely impaired cognition, was independent with mobility and could walk 150 feet.The Comprehensive Care Plan initiated 03/20/2026, documented Resident #34 had an elopement/wander risk related to cognitive impairment, behavior issues, unsafe wandering, and inappropriate exit seeking behavior. Interventions included hourly visual checks.The 05/02/2026 facility investigation documented the following:-On 05/02/2026 at 1:05 PM Resident #34 eloped because of a care plan violation. The resident was noted as missing at 5:14 PM.-On 05/03/2026 at 10:54 AM, Certified Nurse Aide #31 documented they charted the 2:00 PM and 3:00 PM hourly visual rounds in error.-On 05/07/2026 at 5:35 PM, Registered Nurse Unit Manager #4 documented that on 05/02/2026 walking rounds were not completed, and visual checks of Resident #34 were documented by Certified Nurse Aide #31 for the hours of 11:00 AM through 3:00 PM but they were not completed.During an interview on 07/10/2026 at 12:47 PM, Certified Nurse Aide #9 stated hourly checks would be included in the care plan and it meant the resident had to be seen every hour. They documented hourly rounds in the visual check section of the electronic medical record. They tried to chart hourly checks in real time to ensure all the residents were safe and accounted for, but sometimes they caught up at the end of the shift due to staffing issues. Walking rounds were done at shift change between the oncoming and outgoing staff which included walking room to room, seeing every resident, and the outgoing shift giving a resident report. The purpose of walking rounds was to make sure all the residents were accounted for, in the building, and safe. During an interview on 07/10/2026 at 12:48 PM, Certified Nurse Aide #30 stated hourly checks meant residents were checked on every hour to make sure they were safe and where they were supposed to be. They documented the checks in the electronic medical record under the activities of daily living area. The resident must be seen for the hourly checks. Resident #34 liked to be left alone, but they had to check on the resident every 30 minutes because the resident left the facility before. Walking rounds and shift reports were done at shift change with the purpose of seeing every resident. They did not remember missing any walking rounds.During an interview on 07/10/2026 at 12:48 PM, Registered Nurse Unit Manager #4 stated the process for hourly checks was staff were expected to see the resident and then document it in the electronic medical record on the work list area. They were asked to document in real time, within a couple of hours, and that was not always possible due to the electronic medical record system being difficult to use. The reason for hourly checks was for checking on fall and elopement risk residents and residents who were generally unsafe in some way. The certified nurse aides were responsible for completing the hourly checks. Staff should not sign off on hourly checks that were not completed. There was no time frame defined for how long certified nurse aides had to complete their hourly rounds. The walking rounds were done for many reasons including handing over the care of the residents, performing visual checks, giving report and checking wander alert devices. The nurse was responsible for ensuring the certified nurse aides completed the walking rounds. On 05/02/2026, it was determined that visual checks were not completed for Resident #34. They were not notified of hourly rounds not being completed, due to it being a weekend. During an interview on 07/10/2026 at 1:00 PM, Licensed Practical Nurse #26 stated hourly checks meant visualization of the residents with the purpose of making sure everyone was accounted for. They used that time to check in with the residents to see if they needed anything. Hourly rounds were documented in the electronic medical record on the certified nurse aide worklist. At the end of the shift nurses gave report, and the certified nurse aides did a visual walking report of all the residents. 10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on observation, record review, and interviews (iQIES Intake 3009492) the facility failed to ensure intravenous (through a vein) medications were administered consistent with professional standards of practice and in accordance with physician orders for two of two residents (Residents #122 and #124) reviewed. Specifically, Resident #124's intravenous Zosyn (antibiotic) was not administered timely; their vancomycin (antibiotic) was administered at an incorrect concentration and rate; the provider was not notified of an infiltration (leakage into surrounding tissue) of the resident's intravenous vancomycin; and their intravenous line was not capped when the resident left the facility for an appointment. Resident #122's intravenous antibiotics were administered through their dialysis access site and the resident had conflicting intravenous antibiotic administration orders that were not clarified by staff. Findings include: The facility policy Administration and Documentation of Medications, revised 04/2026, documented medications were to be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice. The accuracy of the Medication Administration Record was to be verified prior to administering medications. A medication review was to be completed by the registered nurse daily. The medication label was to be read and compared to the Medication Record at least three times: when the drug was removed from the storage area, as each drug was prepared, and at the resident's bedside before administration. The administering nurse was to verify the medication was being administered at the proper time, in the prescribed dose, and by the correct route. The staff was to discuss any unresolved, significant concerns with the resident's physician or prescriber. Medication administration errors were to be reported immediately to the attending physician. The Intravenous Therapy Management Quick Reference Guide, created 05/2026, documented all intravenous tubing should be capped with Luer Lock cap when infusion was completed. The line was not supposed to be inserted into the y-site. The facility policy Dialysis-Caring for Residents with Hemodialysis, documented the licensed practical nurse and registered nurse would obtain physician orders including site care. 1) Resident #124 had diagnoses including joint infection and cellulitis (skin infection). The 06/23/2026 Minimum Data Set documented the resident had severely impaired cognition and did not receive intravenous medications. Physician orders documented the following:-07/02/2026 and 07/06/2026 piperacillin sodium/tazobactam (Zosyn 3.375-gram vial) 3.375 gram with 100 milliliters of sodium chloride 0.9% intravenous every six hours at 200 milliliters per hour.-07/02/2026 Vancomycin hydrochloride 1.5 grams with 500 milliliters of sodium chloride 0.9% intravenous every 12 hour at 50 milliliters per hour (a run time of 10 hours).-07/08/2026 Vancomycin hydrochloride 1.5 grams with 500 milliliters of sodium chloride 0.9% intravenous twice a day at 6:00 AM and 6:00 PM at 50 milliliters per hour (a run time of 10 hours). The July 2026 Medication Administration Record documented:-Vancomycin 1.5-gram single dose vial in 500 milliliters sodium chloride 0.9% at a rate of 50 milliliters per hour with a start date of 07/06/2026 and a stop date of 07/11/2026, every 12 hours. The administration times were 8:00 AM and 8:00 PM.-piperacillin/tazobactam/sodium chloride 3.375 gm (Zosyn 3.375) in 100 milliliters sodium chloride 0.9% with a start date 07/06/2026 and a stop date of 07/11/2026, at a rate of 200 milliliters per hour every 6 hours (1/2 hour run time). The administration times were 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. The July 2026 Medication Administration Record Intravenous Flow sheets documented:- on 07/04/2026 the 12:00 PM dose of Zosyn was given at 3:15 PM- on 07/06/2026 the 12:00 AM dose of Zosyn was given at 2:25 AM and the 12:00 PM dose was given at 2:51 PM.- on 07/06/2026 the 8:00 PM dose of Vancomycin was given at 10:06 PM.- on 07/07/2026 the 12:00 PM dose of Zosyn was given at 4:42 PM and completed infusion at 5:12 PM and the 6:00 PM dose was given at 5:54 PM. This was outside every 6 hours as ordered. There was no documented evidence the provider was notified of the late administration of the Zosyn doses or the one late dose of vancomycin. The 07/6/2026 at 12:33 AM Licensed Practical Nurse # 33 progress note documented the resident's intravenous line infiltrated on the evening shift when the 8:00 PM dose of vancomycin was being administered. A new intravenous line was put in by the registered nurse and the same vancomycin dose was restarted. At 12:34 AM, the vancomycin dose still had two hours of running time left and the resident's Zosyn dose was due at 12:00 AM. The supervisor was made aware and stated to wait until the vancomycin was completed and then hang the Zosyn dose. The Zosyn dose would be very off schedule. There was no documented evidence the provider was notified of the intravenous infiltration or of the Zosyn doses being off schedule. During an observation on 07/08/2026 at 9:28 AM, the resident's vancomycin was paused so the resident could go to their morning appointments. The intravenous line that attaches to the peripheral line in the resident's arm was connected to the y-site and set on top of the infusion machine and was not capped off. During a phone interview on 07/08/2026 at 2:55 PM, the contract Pharmacy Manager stated the only recorded communication they had from the facility regarding Resident #124's vancomycin dose was the day it was ordered. They made a phone call to the licensed practical nurse to inform them the dose would be delivered on the morning run from pharmacy. During an observation and interview on 07/08/2026 3:46 PM, Licensed Practical Nurse #26 and Clinical Registered Nurse #34 (floating registered nurse) were in Resident #124's room to reinsert the resident peripheral line (intravenous line). Licensed Practical Nurse #26 stated the resident's vancomycin ran at 50 milliliters per hour from a 300-milliliter bag, so the run time was six hours. The total to be infused during the resident's vancomycin administration was 300 milliliters. They knew what the run rate was by the physician's order. They set the flow rate and the amount to be infused, and the machine (infusion pump) calculated how long the infusion ran. Licensed Practical Nurse #26 reviewed the physician orders and stated the vancomycin total infusion was 500 milliliters and a run time of 10 hours. They stated the bags they received from the pharmacy were 300 milliliter bags. They called pharmacy to clarify the order. They stated the pharmacy informed them they did not make the vancomycin 1.5 grams in 500 milliliters bags, only 300 milliliter bags. The resident was getting the right dose of vancomycin, just not the extra fluid. They stated they should have compared what they received from pharmacy to the physician order to ensure the resident was receiving the ordered dosage of the medication. During a phone interview on 07/09/2026 at 1:17 PM, Registered Nurse #36 stated they were the supervisor on duty for the evening of Sunday 07/05/2026. They stated the only issue they knew about with Resident #124's intravenous infusions were the resident kept getting up and moving their arm so the intravenous pump alarm kept sounding for an occluded (blocked) line so the antibiotics took longer to infuse than they should have. They stated they called the on-call hospitalist (physician) and told them the Zosyn dose was going to be late. The on-call hospitalist could not change orders, so the information needed to be relayed to the next nurse for the facility provider to change the orders. They were unaware the resident's intravenous line infiltrated that night. They stated they had not arrived at the facility until 11:00 PM that evening. During a phone interview on 07/09/2026 at 1:29 PM, Registered Nurse Supervisor #22 stated they were not sure if it was Sunday 07/05/2026 the resident's intravenous line infiltrated. They did not change the resident's intravenous line that day. If a hospital registered nurse changed the peripheral line, it would be their responsibility as the nursing home supervisor to inform the provider. The provider should be immediately informed if a line infiltrated. During a phone interview on 07/09/2026 at 1:37 PM, Licensed Practical Nurse #33 stated Resident #124's vancomycin infiltrated on the shift prior to theirs (the 2:00 PM-10:00 PM shift) on 07/05/2026. They were informed of the infiltration by Registered Nurse Supervisor #22. They did not notify the provider of the Zosyn dose being late, but they discussed it with Registered Nurse Supervisor #22 and thought the registered nurse informed the provider of everything that happened. During an interview on 07/09/2026 at 4:21 PM, Physician Assistant #6 stated if a resident's intravenous line infiltrated the provider should be notified immediately. The on-call hospitalist should have been notified that evening and they should be notified the next day so the resident could be assessed. They were not notified of Resident #124's infiltration on the evening of 07/05/2026. Infiltration of vancomycin could cause necrosis (death of living tissues and cells) in the surrounding area. The nurses should compare the physician's order for intravenous antibiotics to what was received by pharmacy. If an intravenous antibiotic was going to be administered late, the provider should be notified prior to giving the medication. Resident #124's intravenous Zosyn should not have been given at 4:42 PM and then again at 5:54 PM, the doses were too close. Giving two doses close together could hurt the resident's kidneys. They were not aware that this occurred with Resident #124. The provider should have been called for guidance. During an interview on 07/10/2026 at 8:46 AM, Licensed Practical Nurse #37 stated if the schedule for the intravenous medications was delayed, they should notify the provider and document the conversation in the electronic medical record. They did not believe they gave Resident #124's Zosyn doses close together on 07/07/2026 but that was what the record documented. They were unsure why the Zosyn was documented as being given so close together. During an interview on 07/10/2026 at 10:01 AM, Registered Nurse Unit Manager #5 stated the nurses should be comparing the intravenous medication they received from pharmacy to the provider's order to ensure the orders matched. When an intravenous medication needed to be paused and disconnected, the line should be capped with the alcohol caps and not screwed into the other parts of the line. All open ports should have the alcohol caps. If an intravenous medication was going to be delayed, the nurses should reach out to the provider so the order times could be changed, and the conversation should be documented. An intravenous medication that was scheduled for every six hours should not be given at 4:42 PM and then again at 5:54 PM; it was too close. They were not aware of the 07/05/2026 infiltration of Resident #124's intravenous vancomycin until 07/09/2026. The provider should have been made aware especially because vancomycin is a toxic vesicant (may cause tissue damage). 2) Resident #122 had diagnoses including end stage kidney disease, heart failure, and atrial fibrillation (irregular, rapid heart rhythm). The 04/27/2026 Minimum Data Set documented the resident was cognitively intact and received dialysis (process that filters the blood when the kidneys do not function). The unsigned 04/27/2026 admission Assessment documented the resident had a left chest port (implantable device for venous access) in place the resident's adult family member stated the port was for blood transfusions and laboratory work. The dressing was intact. The resident had a right dialysis port with a dressing intact. The resident received dialysis on Monday, Wednesday, and Friday. The 05/01/2026 central venous access device care assessment documented the resident had a right subclavian (below collar bone) implanted central venous catheter port for venous access and intravenous antibiotics (location of catheter not documented). There was no documentation regarding a left chest port. Physician orders documented the following:-05/01/2026 cefepime hydrochloride (antibiotic) 1-gram single dose vial in sodium chloride 0.9% at 50 milliliters at a rate of 100 milliliters per hour for one dose-05/01/2026 cefepime hydrochloride 0.5 grams at 100 milliliters per hour intravenous at bedtime, five doses for 4 days.-05/02/2026 cefepime hydrochloride 0.5 grams with sodium chloride 0.9% at 50 milliliters per hour intravenous at bedtime.-05/02/2026 10 milliliters of sodium chloride 0.9% intravenous every 8 hours. There was no documented care plan for dialysis, intravenous access or intravenous antibiotic use. The May 2026 Medication Administration Record Intravenous Site record documented the resident's right chest wall and/or subclavian port was accessed on:-05/01/2026 at 10:30 PM and 10:57 PM-05/02/2026 at 8:30 AM, 4:00 PM, and 8:56 PM-05/03/2026 at 12:49 AM, 8:57 AM, 2:38 PM, 9:01 PM, and 11:03 PM Nursing progress notes documented:The 05/01/2026 Licensed Practical Nurse #38 progress note documented the resident was ordered intravenous antibiotics. The resident had two ports for dialysis use. Physician Assistant #6 stated not to use the ports for antibiotics. The 05/01/2026 to 05/04/2026 Registered Nurse Supervisor report documented:-during the 05/02/2025 6:00 AM to 2:00 PM shift Resident #122's port was accessed for intravenous cefepime, and the port was flushed, and a dressing was applied; during the 10:00 PM to 6:00 AM shift the permanent catheter was flushed, and intravenous antibiotics were infused.-during the 05/03/2026 6:00 AM to 2:00 PM shift all of Resident #122's ports were flushed easily and during the 10:00 PM to 6:00 AM shift the resident's ports were flushed and intravenous cefepime was given. The 05/04/2026 Physician Assistant #6 progress note documented it was reported the resident's dialysis port was accessed over the weekend with questionable administration of their intravenous antibiotic. The resident had another port that could have been utilized for the administration. The 05/08/2026 Facility Incident Report completed by the Director of Nursing documented:- the resident was identified to need intravenous antibiotics on 05/01/2026. The provider placed an order for central venous access device and flush with unclear instructions.- the registered nurse assessed the left side porta Cath (venous access port) per facility policy but had documented right chest access.- the 05/02/2026 morning registered nurse supervisor (unnamed) accessed the right chest dialysis port located on the right chest wall and utilized it for flushing. The night registered nurse utilized the right chest dialysis permanent catheter for intravenous antibiotics and flushes.- the 05/03/2026 registered nurse supervisor documented the right chest port was flushed and night registered nurse supervisor administered intravenous antibiotics through the dialysis port. During a phone interview on 07/08/2026 at 1:36 PM, Dialysis Registered Nurse #11 (employed at dialysis center) stated nursing home staff was not supposed to access the dialysis port sites; only the dialysis staff should access them. Antibiotics should not be administered through the dialysis access port. Complications of someone other than dialysis staff accessing the port included infection, sepsis, accidental pull, and air bubbles. During a phone interview on 07/08/2026 at 1:54 PM, Dialysis Registered Nurse #12 (employed at dialysis center) stated no one except dialysis staff were supposed to touch the dialysis port. It was strictly for dialysis, and the facility was aware of that. During a phone interview on 07/09/2026 at 8:51 AM, Registered Nurse #10 stated a central line for antibiotics was for registered nurse access and there should be an order to use it. If the order was not clear, the provider should be called to clarify the order. Permacaths were not to be utilized in the nursing home and there would need to be an order to use it. The resident had an implanted port on the left and a dialysis catheter on the right. They were informed the dialysis site was accessed, and the orders were not clear. The site should not have been accessed without an order. The catheter was very specialized and had to be accessed under strict sterile technique by people that were trained specifically to use them. During a phone interview on 07/09/2026 at 9:19 AM, Wound Care Consultant Registered Nurse #13 documented Resident #122 had a dialysis port to the right chest wall that was labeled dialysis. The resident needed antibiotics, and the facility did not have needles (to access the port), so they had to obtain them from the hospital side. Registered Nurse Unit Manager #5 had to access the site, so they assisted. They walked Resident Nurse Unit Manager #5 through the process of accessing the site. They were made aware they had accessed the dialysis catheter site after the fact. The resident returned from dialysis at 5:00 PM and the site was accessed at 6:00 PM so the 8:00 PM dose of intravenous antibiotics could be administered. During a phone interview on 07/09/2026 at 9:47 AM, Registered Nurse Supervisor #14 stated the permanent catheter was like a central line and it had one or two lines outside the body. If giving an antibiotic and the order did not indicate access, they would start a peripheral line or use the port if it was known. They utilized the permanent catheter to administer Resident #122's antibiotics as there was nothing to indicate the resident had a port. They knew it was a dialysis catheter, but they had never administered antibiotics to a resident on dialysis, but it was considered a central line. They knew it was for dialysis but if that was their only access they assumed they could use it. They were informed by Registered Nurse Supervisor #15 they had used the dialysis access site as well. During a phone interview on 07/09/2026 at 10:54 AM, Registered Nurse Supervisor #15 stated. Resident #122 had two orders for a single port catheter and a double catheter. They used the dialysis catheter as the admission nurse had written it was a right chest port, but the port was located on the left. They used the right port as the supervisor report stated the left was only used for laboratory drawings. They did not call the provider to clarify the orders as there was a lot going on. They stated they used to be a dialysis nurse and knew they should not have used it in the nursing home setting, but the documentation was confusing. During an interview on 07/09/2026 at 11:28 AM, Registered Nurse Unit Manager #5 stated they accessed the port when the intravenous antibiotic order came in. The resident had a permanent catheter on the opposite chest wall. The surgeon gave permission to access the port because the resident had poor access. No nurse was supposed to access the dialysis catheter. The dialysis catheter was marked dialysis on tape above the access site. They stated they passed report to Registered Nurse Supervisor #15 they had accessed the port but did not inform them about the dialysis catheter. During an observation on 07/09/2026 at 11:48 AM, the Director of Nursing stated nurses were never to access a dialysis site as they did not have the training to do so. Registered Nurse Unit Manager #5 documented the wrong side accessed and Registered Nurse #15 was aware they should not have used the dialysis catheter site along with Registered Nurse Supervisor #14. Registered Nurse #40 accessed the left port but documented the wrong side as well. The orders did not indicate the intravenous site to use when administering an antibiotic. During an interview on 07/09/2026 at 4:10 PM, Physician Assistant #6 stated they were informed after the fact that the resident had intravenous antibiotics administered through the dialysis catheter. The facility nurses should not have touched it as the dialysis nurses had specialized training to access the catheter. If an order was not clear, the nurse should call the provider to have it clarified. 10 New York Codes, Rules and Regulations 415.12(k)(2)

Based on observations and interviews, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two of two test trays (lunch tray on 07/07/2026 and lunch tray on 07/08/2026) and seven anonymous residents present at the resident meeting. Specifically, the 07/08/2026 lunch tray included hot foods served below 130 degrees Fahrenheit and cold foods served above 41 degrees Fahrenheit and foods that were not palatable; the 07/07/2026 lunch tray was missing an item listed on the meal ticket and had foods that were not palatable; and seven anonymous residents at the resident meeting stated the hot food was often cold, flavorless, and did not look good. Findings include: The facility policy Meal Delivery, revised 10/2025, documented meals were served in a timely manner to maintain food quality and safe, palatable temperatures. Meal tickets were carefully reviewed when passing trays to ensure the resident was being served the correct diet ordered, all adaptive equipment was present, all listed food and drink items, including condiments were provided.The facility policy Food Temperatures, revised 2024, documented the temperatures of all food items were taken and properly recorded prior to service of each meal to ensure the quality and safety of food/drinks. All hot foods must be cooked to appropriate internal temperatures, held and served at temperatures of at least 140 degrees Fahrenheit and all cold food items must be stored and served at temperatures of 41 degrees Fahrenheit or below to prevent foodborne illness. During a resident group meeting on 07/06/2026 at 2:49 PM, seven anonymous residents reported the food was not good, hot food was cold and did not look or taste good. During an observation and interview on 07/07/2026 at 12:43 PM, Resident #93's lunch meal was used delivered to the resident's room, used as a test tray, and a replacement meal was ordered. Food temperatures were measured and verified by Certified Nurse Aide #8 as follows: pulled pork 149.1 degrees Fahrenheit, sweet corn 134.9 degrees Fahrenheit. The baked beans listed on the meal ticket were not on the tray. The sweet corn tasted bitter and had a rubbery texture. Certified Nurse Aide #8 stated they were not sure why the baked beans were missing and would ensure they were on the replacement tray.During an observation and interview on 07/07/2026 at 1:01 PM, Resident #93 was observed eating their lunch from the replacement tray. They did not have baked beans on the replacement tray as listed and wanted them because they were still hungry. They only ate the pulled pork because the corn was chewy and did not taste good. During an observation and interview on 07/08/2026 at 1:07 PM, Resident #26's lunch meal was tested when delivered to the residents in the dining room, and a replacement meal was ordered. Food temperatures were measured and verified by Certified Nurse Aide #8 as follows: macaroni salad 52.5 degrees Fahrenheit, green beans 143.8 degrees Fahrenheit, hot dog on a bun 129.2 degrees Fahrenheit, coffee 118 degrees Fahrenheit, and strawberries. The hot dog was rubbery, the green beans were mushy, the macaroni salad tasted warm, and one of the strawberries was brown. During an interview on 07/08/2026 at 1:21 PM, Food Service Worker #18 stated food was prepared in the kitchen and brought up on two different carts. When hot food arrived from the kitchen to the kitchenette, the hot foods were placed under heat lamps and in boilers on the steam table to hold temperatures between 160-185 degrees Fahrenheit. The kitchen prepared cold foods like salads, fruits, and drinks, and placed them along with condiments on the resident's tray which arrived on a different cart that kept food cold. Nursing staff removed the trays from the cold cart and Food Service Worker #18 plated the hot foods after reading the meal ticket. It was important to follow the meal ticket to ensure residents received all items they requested. When they ran out of an item, they called the main kitchen for a replacement so the residents would be happy with meal service. They did not recall why Resident #93 did not get baked beans on 07/07/2026. Macaroni salad should not be served at 52.5 degrees Fahrenheit, strawberries should not be brown, and hot dogs should not be served at 129.2 degrees Fahrenheit because it was not appetizing for the residents. During an interview on 07/08/2026 at 1:28 PM, Dietary Supervisor #19 stated the kitchen staff was responsible for putting drinks, salads, condiments, and desserts on individual resident trays using the resident menu and production sheets. Salads should be served below 40 degrees Fahrenheit and macaroni salad served at 52.5 degrees Fahrenheit was too warm and could cause food borne illness. Hot foods should be served above 140 degrees Fahrenheit. Hot dogs served at 129.2 degrees Fahrenheit was not hot enough and could cause food borne illness. It was important for all items listed on a meal ticket to be on the tray for good nutrition and wound healing. During an interview on 07/08/2026 at 1:45 PM, the Director of Nutritional Services stated menus were put in the computer by either the diet technician, dietitian, or dietary staff. It was important for the residents to get all items listed on their meal ticket. If an item was not available, then an appropriate substitution should be made. On 07/07/2026 they served mashed sweet potatoes as a side dish with baked beans as a substitute. If baked beans were not available an appropriate substitution should be made. They expected all residents to get what they ordered for meals. Macaroni salad should be served at 41 degrees Fahrenheit or lower for food safety and to prevent food borne illness. Temperatures of all foods should be taken on the unit prior to serving to ensure proper and safe serving of food. During an interview on 07/08/2026 at 2:14 PM, Certified Nurse Aide #8 stated they delivered both the initial tray and the replacement tray to Resident #93 on 07/07/2026. The test tray did not have the baked beans that were noted on the resident's meal ticket, and the resident wanted the baked beans. They retrieved the replacement tray for the resident and asked Food Service Worker #18 for baked beans and was told they were not available. During an interview on 07/10/2026 at 10:29 AM, Director of Nutritional Services #20 stated they investigated why baked beans were missing off Resident #93 lunch tray on 07/07/2026 and discovered the baked beans did not make it to the production sheet, therefore were not made. 10 New York Codes, Rules, and Regulations 415.14(d)(1)(2)

Based on observations, record review, and interviews, the facility failed to ensure residents were treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of quality of life for one of one resident (Resident #47) reviewed. Specifically, Resident #47's room had a door alarm to deter other residents from entering and there was no documented evidence the use of the device was discussed and agreed upon with Resident #47's representative or alternate measures were attempted before placing the alarm. Findings include: The facility policy Behavior Management, revised 02/2025, documented the facility would ensure that the necessary care and services were person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Resident #47 had diagnoses including Alzheimer's disease and delirium (sudden change in thinking and awareness). The 04/16/2026 Minimum Data Set (assessment tool) documented the resident had mildly impaired cognition, verbal and physical behavioral symptoms for 1-3 of 7 days and required partial to moderate assistance with transfers. The 07/08/2026 Comprehensive Care Plan documented:-the resident had a preventative behavior care plan with interventions including a door alarm to alert if other residents entered their room. -the resident had dementia. Interventions included allowing ample time for the resident to respond, approaching resident in a calm manner, and maintaining a quiet environment. The 07/02/2026 at 11:59 AM Social Worker #23 progress note documented the interdisciplinary care team discussed the possibility of moving Resident #47 to a room at the end of the hall due to another resident entering their room. The resident's family preferred them not to be moved further away from the nursing station due to their history of falls. There was no documented evidence the use of a door alarm to deter other residents from entering Resident #47's room was discussed. The 07/09/2026 at 1:49 PM Registered Nurse #4 progress note documented Resident #47 had a history of being a victim of abuse/aggression due to another resident entering their room, yelling, and pouring syrup on Resident #47's items. Resident #47's room was observed with a door alarm on 07/06/2026 at 11:11 AM, 07/07/2026 at 11:06 AM, 07/08/2026 at 8:49 AM, and 07/09/2026 at 8:36 AM. There was no documented evidence Resident #47's representative was informed about the installation of the door alarm or alternatives were tried prior to installing the door alarm. During an interview on 07/07/2026 at 1:30 PM, Resident #47's family member stated two weeks ago another resident entered Resident #47's room while they were visiting. The resident was redirected out of Resident #47's room. When they visited Resident #47 another time, they found a sticky substance on the resident's bed. The facility installed a door alarm following that incident. They stated they did not want the door alarm installed because they thought it was disruptive to the resident and staff did not respond when it went off. They did not feel it was helpful. During an interview on 07/08/2026 at 9:59 AM, Certified Nurse Aide #27 stated the door alarm was placed about a week and a half ago. It was put in place due to Resident #47's neighbor going into their room and yelling at them. They stated it helped because when the alarm went off, staff went to check on Resident #47. During a telephone interview on 07/09/2026 11:40 AM, Resident #47's Health Care Proxy stated they were aware the facility installed a door alarm, and they were against it. Staff called them to discuss the installation of the door alarm, and they reluctantly agreed to it as they wanted to keep Resident #47 safe from other residents. They asked staff why the door alarm was being installed on Resident #47's doorway and not the other resident's room and staff told them the other resident might become upset or agitated. They stated staff did not discuss any possible alternative interventions at that time. During an interview on 07/09/2026 at 10:16 AM, Registered Nurse Unit Manager #4 stated Resident #47 had a door alarm on their doorway due to another resident entering their room and pouring fluid in the room. The team did not put the door alarm on the other resident's door because that resident would become more aggressive. They did talk to Resident #47's Health Care Proxy who was agreeable to the door alarm to protect Resident #47. They did not discuss alternative interventions with the Health Care Proxy. During an interview on 07/10/2026 at 11:44 AM, Social Worker #23 stated the interdisciplinary team discussed moving Resident #47's room after another resident poured a sticky substance on their bed, but Resident #47's family declined a room change. They stated the family did not want to move Resident #47 away from the nursing station due to frequent falls. No other interventions were attempted prior to installing the door alarm on Resident #47's door. The interdisciplinary team was worried about the safety of Resident #47 due to the other residents being confrontational with them. 10 New York Codes, Rules and Regulations 415.5 (a)

Based on observations, record review, and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one of one resident (Resident #101) reviewed. Specifically, Resident #101's nutritional status was not assessed following a significant weight loss and there was no documented evidence medical was notified of the resident's significant weight loss.Findings include: The facility policy Obtaining Weights, revised 12/2025, documented if there was a weight change of 5 pounds or more from the last documented weight a reweight would be obtained within 24 hours. There was no documented evidence of a facility policy addressing nutritional assessments. Resident #101 had diagnoses including Alzheimer's disease, anorexia (diminished appetite), and diabetes. The 05/11/2026 Minimum Data Set assessment documented the resident had severely impaired cognition, required set-up or clean -up assistance with meals, was 64 inches tall, weighed 123 pounds, and had no significant weight changes at 1 or 6 months. The Comprehensive Care Plan dated 02/03/2026 and revised 07/08/2026 documented tthe resident required setup assistance and encouragement at meals in the dining room. Interventions included providing a regular diet with thin liquids and weighing monthly. The resident was an extremely picky eater and meal preferences were obtained. The resident did not like their foods to touch one another. Physician orders documented: -02/03/2026 regular diet with thin liquids -02/12/2026 push fluids with hydration pass each shift -02/28/2026 push oral fluids every 2 hours while awake -03/05/2026 7.5 milligrams of mirtazapine (antidepressant used as an appetite stimulant) at bedtime daily. The residents' weight record documented: -03/04/2026 142.2 pounds -04/01/2026 139.4 pounds -05/12/2026 131.2 pounds (7.8 pounds/ 5.5% loss at 1 month) -6/11/2026 129 pounds (13.2 pounds/ 9.2% loss at 3 months) The 03/05/2026 Registered Nurse #22 progress note documented the resident's family reported the resident was a picky eater at home. The 03/14/2026 Physician Assistant #6 progress note documented the resident was reported to have poor oral intakes and after a discussion with the family, 7.5 milligrams of mirtazapine was started to aid with increasing appetite. The 04/20/2026 Physician Assistant #6 progress note documented the resident was seen for a 90-day routine visit, the resident had a history of poor oral intakes and would continue mirtazapine due to lack of appetite. The 05/12/2026 Registered Dietitian #28 Nutrition Quarterly Review documented the resident was on a regular diet with thin liquids, was 64 inches, weighed 139.4 pounds, their body mass index was 23.8, within normal limits, and had no significant weight changes. Their meal intakes were fair and there were no changes to the care plan at that time. There were no additional nutrition progress notes addressing the resident's significant weight loss of 7.8 pounds/ 5.5% in 1 month from 04/01/2026 to 06/11/2026. The 06/27/2026 Physician #21 progress note documented the resident was seen for a 60-day routine visit and continued to receive mirtazapine. There was no documented evidence the resident's significant weight changes in May 2026, or June 2026 were addressed. During an observation on 07/08/2026 at 9:04 AM, Resident #101 was eating independently in their room. The resident's meal ticket documented they received a personal pizza, toast, hot cereal, fruit, milk, and soda. The resident consumed 100% of fruit, milk, and soda, 50% of the personal pizza, 25% of the toast, and 25% of the hot cereal. During an interview on 07/10/2026 at 10:01 AM, Registered Nurse Unit Manager #5 stated after licensed practical nurses entered the resident's weights into the computer they reviewed the weights. Significant weight changes were also discussed with the interdisciplinary team. Resident #101 had a significant weight loss from April 2026 to May 2026 and continued to lose weight in June 2026. Personal sized pizzas were added to their meal pattern, and they continued to monitor likes and dislikes. The resident was very particular, and fluids were encouraged. Medical attended the interdisciplinary team meetings and if they were not at the meeting nursing should tell them about any significant weight changes. There was no documented evidence that the resident's significant weight loss was addressed. They stated they were unaware Resident #101 had a significant weight loss. During an interview on 07/10/2026 at 11:38 AM, Diet Technician #29 stated Registered Dietitian #28 ran the weight reports weekly and if a resident had a significant weight change of 5% at 1 month, 7.5% at 3 months, and 10% at 6 months a note should be documented to address the significant weight change. Resident #101 had a significant weight change of 5% in May 2026 and greater than 7.5% in June 2026. They stated they could not find any documented evidence the resident's significant weight changes were addressed. On 07/10/2026 at 12:00 PM, a telephone message was left for Registered Dietitian #28, and they did not call back prior to survey exit. During an interview on 07/10/2026 at 12:04 PM, The Director of Nutrition Services (registered dietitian) stated the resident had a significant weight loss of 5.5% in May 2026 at 1 month and 9.2% loss at 3 months in June 2026. They only addressed significant weight loss of 5% or more at 1month or 10% or more in 6 months and did not address significant weight loss of 7.5% or greater at 3 months. They thought facility's computer system only captured weights that were 30 days apart and if the weights were documented greater than 30 days apart it might not be captured and medical would not be notified of the weight loss either. If a resident had a significant weight loss, they expected the registered dietitian to address the weight loss. They stated the medical provider would not be notified because the resident did not trigger for significant weight loss per the 30 day report. 10 New York Codes, Rules and Regulations 415.12(i)1

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 was in between the Social Service Director's office and the hair salon on the first floor and was not at a resident accessible height. Findings include:The facility Resident Handbook documented residents had the right to examine the results of the most recent federal or state survey of the facility including any statement of deficiencies, any plan of correction in respect to the facility, and any enforcement actions taken by the New York State Department of Health. The results must be made available to the residents in a place that was readily accessible to them. During an anonymous resident meeting on 07/06/2026 at 2:49 PM, 14 of 14 anonymous residents did not know where the state inspection/survey binder was located. During an observation on 07/10/2026 at 10:55 AM the binder containing the New York State Department of Health recertification, complaint, and Life Safety Code surveys was on the wall in a plastic file holder at face height when standing and was not at an accessible height to residents in wheelchairs. During an interview on 07/10/2026 at 11:26 AM, the Social Services Director stated they and Keyboard Specialist #25 were responsible for the survey binder located outside their office. The file holder on the wall was not wheelchair accessible as it was too high. A resident in a wheelchair would need to ask for assistance to access the binder. They were not aware it was a resident right to have the binder in an accessible location without needing to ask for it. During an interview on 07/10/2026 at 11:34 AM, the Administrator stated the Social Services Director was responsible for updating the survey binder with any new complaint or health surveys. The current height the wall holder was at was probably not accessible to residents in wheelchairs and without having to ask for assistance. They were aware it was a resident right for residents to be able to access the survey results. 10 New York Codes, Rules and Regulations 415.3(1)(c)(1)(v)

Based on record review and interviews, the facility failed to provide the appropriate liability and appeal notices to Medicare beneficiaries for one of three residents (Resident #5) reviewed. Specifically, Resident #5 remained in the facility, and the facility did not provide a Notice of Medicare Non-Coverage (NOMNC), Centers for Medicaid and Medicare Services, form 10123 for Medicare Part A, as required.Findings include:The Centers for Medicaid and Medicare Services form instructions for the Notice of Medicare Non-Coverage (NOMNC) Centers for Medicaid and Medicare Services form -10123 (expiration date 11/30/2027) documented a Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The Notice of Medicare Non-Coverage must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not provided daily.The facility policy Notice of Medicare Non-Coverage (NOMNC) Centers for Medicare and Medicaid Services - 10123 (The Generic Notice), last reviewed 11/2024, documented a Medicare provider of health plan (Medicare Advantage plans and cost plans collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing service. The Notice of Medicare Non-Coverage must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care was not provided daily. The provider must ensure that the beneficiary or representative signs and dates the Notice of Medicare Non-Coverage to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Resident #5 had diagnoses including diabetes, colon cancer, and dementia. The 03/16/2026 Minimum Data Set Skilled Nursing Facility Part A Discharge Assessment documented the start of Medicare stay was 03/09/2026 and end of Medicare stay was 03/16/2026. Resident #5 remained in the facility.There was no documented evidence Resident #5 was provided with a Notice of Medicare Non-Coverage, Centers for Medicaid and Medicare Services form 10123, at least two calendar days before Medicare covered services ended.During an interview on 07/09/2026 at 11:52 AM, Registered Nurse Case Manager #32 stated they did not provide Resident #5 their Notice of Medicare Non-Coverage, Centers for Medicaid and Medicare Services 10123 form and this was an oversight and error on their part. They stated it was important to provide the Medicare Notice of Medicare Non-Coverage to residents to ensure they knew their right to appeal timely. During an interview on 07/10/2026 at 10:08 AM the Administrator stated it was an oversight that the Notice of Medicare Non-Coverage was not provided to Resident #5. They stated the Notice of Medicare Non-Coverage, Centers for Medicare and Medicaid Services form 10123, should be delivered to the resident or their representative at least two calendar days prior to the end of their covered day of service. 10 NYCRR 415.3(g)(2)(iii)

Based on record review and interviews during the abbreviated surveys (NY00341596, NY00353814, NY00354138, and NY00354190) the facility failed to ensure residents were free from verbal, physical, and mental abuse for 4 of 16 residents reviewed (Resident #1, #3, #4, and #5). Specifically: - Resident #4 was forced to ambulate against their will by several staff members; - Resident #5 was physically restrained by Registered Nurse #9 and Certified Nurse Aide #8 when the registered nurse attempted to obtain a nasal swab for COVID-19 testing from the resident. - Resident #1 was physically and verbally abused by Certified Nurse Aide #6 who was not immediately removed from resident access; - Resident #3 was verbally abused by Certified Nurse Aide #6 who spoke inappropriately to the resident and shared the resident's personal health information with others which resulted in mental anguish for the resident; The facility's failure to protect residents from abuse resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Residents #1, #3, #4, and #5 and placed all 123 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death. Findings include: The facility policy, Abuse and Neglect / Complaint Investigation, revised 8/2023, documented the facility did not use or permit verbal, mental, sexual, or physical abuse, including corporal punishment or involuntary seclusion of residents or misappropriation of property or exploitation. Abuse was defined by the willful infliction of injury, unreasonable confinement, intimidation, or punishment that resulted in physical harm, pain, or mental anguish. Willful was defined in the definition of abuse meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. All staff would attend annually training on abuse where examples were provided and how to report allegations of abuse. Any allegation of abuse would be investigated immediately. The potential for harm would be determined and the accused person or persons would be removed from the situation until the investigation was completed. 1) Resident #4 had diagnoses including dementia with behavioral disturbance, anxiety disorder, and unspecified disorder of bone density and structure. The 6/24/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, had physical and verbal behavioral symptoms directed toward others 1-3 of 7 days, behavioral symptoms not directed toward others 1-3 of 7 days, did not reject care, and was independent with transfers and ambulation. The Resident Preference and Function (care instructions) initiated 1/8/2021 documented the resident was independent with ambulation and encourage use of four wheeled walker. Resident was walk to dine, must eat in the dining room with supervision. Resident ate in a regular chair with a low table when in their room, preferred to eat in their room, and encourage to eat in the dining room. The comprehensive care plan initiated 7/25/2023 documented the resident had inappropriate behaviors related to cognitive decline, history of wandering, resistance, and agitation. Interventions included the resident did not like to be touched and was very territorial. Do not try to redirect and reapproach. The facility Nursing Home Incident Report submitted on 9/9/2024 at 4:11 PM documented the Nurse Manager (unidentified) was investigating another incident and came across video footage of Resident #4 on 9/6/2024. The facility incident report initiated by Registered Nurse Unit Manager/Supervisor #20 on 9/9/2024 at 1:53 PM, documented on 9/6/2024 at 5:52 PM Resident #4 was observed on video ambulating out of their bedroom with resistance. The resident had 2 certified nurse aides (unidentified) on both sides of their arms, sliding the feet of the resident down the hallway. The resident sat on a loveseat in the mid-hallway and the staff stood across the hall waiting for the resident. Within 1 minute the 2 staff got the resident up and the resident resisted and slid their feet to tell staff not to ambulate at that time . The resident stopped and other staff (unidentified) came to assist the 2 certified nurse aides. The licensed practical nurse, another certified nurse aide, and the supervisor came to assist (unidentified). The 2 certified nurse aides were sliding the resident down the hallway. Witness statements included: - On 9/9/2024 by Registered Nurse Supervisor #13. On 9/6/2024 they were at the nursing station and heard a yell for help. They went down the hallway and saw two certified nurse aides holding a resident up as it looked like the resident was going to fall. The certified nurse aides and the licensed practical nurse assisted the resident from falling and began to ambulate the resident down the hall, with one certified nurse aide on each side and the licensed practical nurse to follow. The resident began to resist and scratched the certified nurse aide. The licensed practical nurse was bitten when the resident was assisted into a chair. - on 9/10/2024 by Certified Nurse Aide #14 . On 9/6/2024 they were in the dining room serving dinner trays and they went to help 2 other staff members when they yelled for help. They helped walk the resident down the hall. - On 9/11/2024 by Certified Nurse Aide #12. On 9/6/2024 they were asked by the nurse to get Resident #4 for dinner. The Nurse Manager told them all residents had to come out for mealtime. They and Certified Nurse Aide #8 went to get the resident and the resident was pushing them back and forth, so they sat the resident on the couch. They told Certified Nurse Aide #8 they would take the resident to the nursing station so someone could watch them eat. They tried to get the resident up and the resident started sliding and they called for extra help. Certified Nurse Aide #14, Licensed Practical Nurse #15, and the supervisor (not named) came to assist. Licensed Practical Nurse #15 and Certified Nurse Aide #14 had the resident's arms and Certified Nurse Aide #12, and Certified Nurse Aide #8 were behind the resident. - on 9/13/2024 by Certified Nurse Aide #8. On the evening of 9/6/2024 they were asked to bring the resident out for dinner by the nurse. They and Certified Nurse Aide #12 went to get the resident from their room, the resident did not want to come out and fought them down the hall. They sat the resident on the couch, gave the resident a minute to breath, and got them back up. The resident almost fell on the floor and other staff was called to assist. - on 9/14/2024 by Licensed practical Nurse #15. On 9/6/2024 they heard aides yell for assistance. They say two certified nurse aides with the resident who was very agitated and was being walked toward the dining room. The resident started to resist and tried to put them self on the floor. They assisted with the registered nurse and another certified nurse aide to get the resident safely to the chair. - On 9/13/2024 the Director of Quality Assurance documented Certified Nurse Aides #8 and #12 were suspended pending investigation. The way the resident was taken to the dining room was considered abuse. Both certified nurse aides watched the surveillance footage and were educated on a resident's right to refuse, documentation of refusals, communication with change of command regarding refusals, and alternative approaches. All nursing staff would be educated on resident's right to refuse, documentation of refusals, communication with change of command regarding refusals, and alternative approaches which would be headed up by social work. There was no documented evidence of education or corrective action for Licensed Practical Nurse #15, Certified Nurse Aide #14, or Registered Nurse Supervisor #13. There was no documented evidence of education with all nursing staff regarding a resident's right to refuse, documentation of refusals, communication with change of command regarding refusals, and alternative approaches. The facility's surveillance video from the resident's nursing unit on 9/6/2024 from 5:49 PM through 6:15 PM was reviewed: - At 5:51 PM, Certified Nurse Aide #12 entered Resident #4's room, followed by Certified Nurse Aide #8. - From 5:51 PM to 5:52 PM, Certified Nurse Aides #8 and #12 each had one arm holding above the resident's elbow and one arm holding the resident's wrists, while the resident struggled and resisted. The resident was placed on a couch in the hallway by both certified nurse aides. - At 5:53 PM, Certified Nurse Aides #8 and #12 using both arms, attempted to pull the resident off the couch by their arms while the resident swatted out at them and resisted until they forcibly pulled the resident off the couch into a standing position. - From 5:53 PM to 5:54 PM, Certified Nurse Aides #8 and #12 pulled the resident down the hallway by their arms as the resident struggled and fought and planted their feet, causing their feet to slide against the floor as they were pulled. Certified Nurse Aide #8 attempted to move the resident forward and the resident grabbed onto the railing to stop their movement. Certified Nurse Aide #14 and Licensed Practical Nurse #15 came to assist and got on either side of the resident and held the resident's arms while Certified Nurse Aide #8 and #12 held the resident from behind. Registered Nurse Supervisor #13 came down the hall and stood off to the side, then behind the group, as the other staff members slid the resident down the hallway as the resident remained rigid and struggled with staff. They placed the resident in a chair across from the nurses' station outside the dining room and all four staff members (Certified Nurse Aides #8, #12, and #14, and Licensed Practical Nurse #15) struggled with the resident to get them to sit in the chair while Registered Nurse Supervisor #13 observed. The certified nurse aides went to the dining room, the licensed practical nurse went to the nursing cart, and the registered nurse supervisor went to the nurses' station. - At 5:55 PM Certified Nurse Aide #8 brought an overbed table to the resident, the resident pushed the table away and got up and walked down the hallway into another resident's room and shut the door. During an interview on 9/25/2024 at 1:49 PM, the Director of Nursing stated Certified Nurse Aides #8 and #12 were bringing the resident out to eat dinner as the dementia unit had a lot of residents the Unit Manager preferred to come out of their rooms to eat. The Director of Nursing stated after watching the video they saw the certified nurse aides were rough with the resident and had pulled the resident out of their room. Certified Nurse Aides #8 and #12 received written education on what happened if a resident refused assistance. The resident could not be forced, and if the resident still said no, they should inform the charge nurse and document on the refusal. The Supervisor stated they went to assist with the resident to avoid the resident from falling. The supervisor did not realize the resident had been dragged out their room by Certified Nurse Aides #8 and #12. There was no education provided to the staff members who came to assist because they thought the resident was falling. If a resident was combative and looked like they were going to fall, they should be lowered to the floor. The incident was discovered because Licensed Practical Nurse #15 submitted a report that they had been bitten by the resident, so the Director of Nursing watched the surveillance footage and saw the incident with Certified Nurse Aides #8 and #12 During an interview on 9/25/2024 at 2:23 PM, Certified Nurse Aide #8 stated on 9/6/2024 the resident had not had any medications and had not eaten so they brought the resident out for dinner and to get their medication. The Nurse Manager told the certified nurse aides they had to bring residents out for meals. Resident #4 was care planned to be supervised for meals so they could not eat in their room. They stated they stood the resident in their room and the resident started to push them back and forth in the hallway, so they sat the resident down on a couch. They were trying to figure out if they should sit the resident there or bring the resident to the nurses' station. They did not want to get in trouble, so they brought the resident to sit near the nurses' station to eat so the resident would be supervised with their meal. They stated the resident likely did not want to get off the couch, but they got the resident up, and had to call for assistance because the resident was trying to sit on the floor in the hallway. As a group they helped the resident walk down the hallway and sit down in a chair near the nurses' station. During an interview on 9/26/24 at 1:29 PM, Licensed Practical Nurse #15 stated they were behind the nurses' station with the registered nurse when they heard a yell for help. The resident was between two aides and was very aggressive, rocking back and forth. They and another aide went down the hallway and the registered nurse followed. They stated Resident #4 was very upset, so they decided to sit the resident down in a chair; there were four staff members walking the resident at one point. The chair was across from the nurses' station down the hallway . When they got the resident to the chair , the resident bit them on the hand and scratched Certified Nurse Aide #14. They were going to get the resident a snack or a drink, but the resident got right back up and left. They stated they did not know why the certified nurse aides were assisting the resident down the hallway as they did not work on the dementia unit a lot. Registered Nurse Supervisor #13 oversaw the situation but did not say much. They stated they normally would have walked away from a resident that agitated but at that point the resident was attempting to throw themselves down, so it was decided to get the resident to a safe place. During an interview on 9/26/2024 at 3:15 PM, Registered Nurse Supervisor #13 stated they were an agency nurse. They stated they were sitting at the nurses' station and there was a certified nurse aide and a licensed practical nurse nearby. They heard a yell for help and thought they saw the resident falling and the two certified nurse aides holding the resident up. The resident took a few steps then resisted walking. There were five staff members with the resident, four of them were assisting the resident (Certified Nurse Aides #8, #12, and #14, and Licensed Practical Nurse #15). The resident walked to the chair next to the nurses' station but was resistive. They got the resident to a chair across from the nurses' station. They completed an incident report as the resident had bitten Licensed Practical Nurse #15 and scratched Certified Nurse Aide #8. They were unaware that Certified Nurse Aides #8 and #12 had pulled the resident out of their room when the resident did not want to go to dinner. 2) Resident #5 had diagnoses including dementia with behaviors, Lewy body dementia (a specific type of dementia), and agitation. The 7/22/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, delusions, and hallucinations, rejected care, had physical, verbal, and other behavioral symptoms, and required setup or was independent for all activities of daily living except dressing and personal hygiene. The Comprehensive Care Plan initiated 1/30/2024 documented the resident had altered mood and behaviors related to history of past behaviors and history of becoming aggressive and being a victim of aggression. The resident did not like loud, crowded situations. Outcomes included staff would try to minimize things that triggered behaviors. Interventions included do not argue with the resident, as it increased agitation; do not touch without permission; approach in a calm, positive manner; redirect when demonstrating inappropriate behaviors; and do not overreact or confront, respond calmly and firmly. The Resident Preference and Function (care instructions) dated 9/18/2024 documented the resident was independent with ambulation, was able to communicate clearly but forgot and became frustrated, required 30- minute checks for safety and behaviors, the resident did not like being touched without their permission, had a history of being aggressive and being a victim of aggression. 9/9/2024 physician's order documented COVID-19, influenza, and respiratory syncytial virus nasopharyngeal (nose) swab. The facility incident report documented on 9/9/2024 at 10:00 AM Resident #5 had an incident with another resident when they threw a can of soda. The soda hit the other resident on the side of the head. - Resident #5 sustained a skin tear on their left hand between the first and second finger. They were triangle shaped and sized about 1.5 by 1.5 centimeters, 1 by 1 centimeters, and 0.5 by 0.5 centimeters. - During an interdisciplinary review of the event on 9/10/2024 by Registered Nurse Unit Manager/Supervisor #20, the resident-to-resident event was triggered by Registered Nurse #9 who had swabbed the resident for COVID-19 at 9:45 AM with arm support around the resident's neck and head. Certified Nurse Aide #8 held the resident while the resident was swabbed twice. - A statement by Social Work Assistant #10 on 9/10/2024 at 12:23 PM documented Resident #5 threw a can of soda in the direction of another resident in reaction to agitation by Registered Nurse #9 who tried to intervene. Resident #5 remained upset with Registered Nurse #9 for the remainder of the day as evidenced by observation from staff. - A statement by Registered Nurse #9 entered by the Quality Assurance Director on 9/11/2024 documented they were swabbing residents for COVID-19. Resident #5 was agitated, yelling, and attempting to grab the unopened swabs on their cart. They redirected the resident not to do that and removed the cart from the resident's reach. They thought the resident would be uncooperative and combative for the nasal swab, so they had Certified Nurse Aide #8 hold the resident's hands and they put their arms around the resident, not in front of their neck, to swab the resident quickly. - A statement by Certified Nurse Aide #8 entered by Registered Nurse Unit Manager/Supervisor #20 on 9/12/2024 at 2:20 PM documented Resident #5 had come over to hold Certified Nurse Aide #8's hands. Registered Nurse #9 told them to hold on and swabbed Resident #5 which upset the resident. Registered Nurse #9 ended up taking the resident back to their room. - A statement by the Director of Quality Assurance on 9/13/2024 at 10:51 AM documented Registered Nurse #9 was removed from the schedule pending investigation. Registered Nurse #9 watched the surveillance video and was educated prior to returning to work on a resident's right to refuse, documentation of refusals, communication with the chain of command when a resident refused, and alternative approaches. All nursing staff would be educated on a resident's right to refuse, documentation of refusals, communication with the chain of command when a resident refused, and alternative approaches. The incident was not reported to the New York State Department of Health until 9/11/2024 at 4:15 PM. There was no documented evidence of education or disciplinary action for Certified Nurse Aide #8. The facility's surveillance video from the nursing unit was reviewed for 9/9/2024 from 9:49 AM through 10:30 AM: - From 9:56 AM to 9:57 AM, Resident #5 was ambulating independently in the hall, approached Registered Nurse #9's treatment cart, and attempted to take an object off the top of the cart. Registered Nurse #9 attempted to push the resident's hands from the cart and took the container when the resident attempted to grab it. Registered Nurse #5 pushed the cart away from the resident and around to the other side of the nurses' station. - At 9:57 AM, Resident #5 took Certified Nurse Aide #8's arm while the certified nurse aide was walking with another resident and began talking to them. - From 9:57 AM to 9:58 AM, Registered Nurse #9 walked from the opposite side of the nurse's station, approached the resident and Certified Nurse Aide #8, and opened a swab. They opened one swab while Certified Nurse Aide #8 held the resident's hands. Registered Nurse #9 put their left arm around the resident's left side of their neck with their hand along the side of the resident's jaw as the resident attempted to resist and obtained a swab with their right hand. Certified Nurse Aide #8 held both resident's hands and wrists while the resident attempted to struggle away from Registered Nurse #9. The resident attempted to release themself from Certified Nurse Aide #8. Certified Nurse Aide #8 let go of the resident's hands and the resident attempted to swing at Registered Nurse #9 and Certified Nurse Aide #8 took the resident's left elbow to hold them back and proceeded to lead the resident down the hall for a short distance. - From 9:58 AM to 10:01 AM, Resident #5 approached the nurse's station desk, picked up a can of soda, and walked around to the other side. They started to interact with another resident in a wheelchair. Registered Nurse #9 came out from behind the nurses' station to intervene and reached their hand out toward Resident #5 who smacked it away. Resident #5 threw a can of soda in the nurses' direction which appeared to glance off the side of the other's resident's head who was wearing a helmet. Registered Nurse #9 attempted to take Resident #5, who began to struggle, away from the nurse's station. Registered Nurse #9 had one hand on the resident's arm/elbow and the other arm behind the resident and began to pull the resident away. Resident #5 was struggling against Registered Nurse #9 as they were led away. Registered Nurse #9 had one hand under the resident's armpit and one on their elbow area. Resident #5 grabbed onto the mobility bar on the wall with their right hand. Registered Nurse #9 attempted to pull the resident off the bar by their other arm, and the resident would not move. Registered Nurse #9 released the resident's fingers from the bar and the resident grabbed the bar again with their other hand. Registered Nurse #9 continued to struggle with Resident #5 and attempted to release the resident's hand as they grabbed the bar. Certified Nurse Aide #8 came and assisted with removing the resident from the rail. Registered Nurse #9 and Certified Nurse Aide #8 walked the resident down the rest of the hallway holding onto the resident's arms. During an interview on 9/25/24 at 1:49 PM, the Director of Nursing stated Resident #5 was angry all day, and they attempted to figure out why, so they pulled the surveillance footage to see what had happened that day. They had noticed in the video that Registered Nurse #9 had obtained a swab from the resident by grabbing the resident and swabbing their nose with the assistance of Certified Nurse Aide #8. Certified Nurse Aide #8 held the resident's hand so the resident would feel safe during the swab. Registered Nurse #9 did not hold the resident tightly but did hold them in place during the swab. The resident was upset after this incident. Certified Nurse Aide #8 did not receive any education as the certified nurse aide did not do any restraining, when the resident moved her hand, the certified nurse aide let go; the certified nurse aide did not try to hold the resident's hand. They did not talk to Certified Nurse Aide #8 about reporting a resident being restrained by a staff member. Registered Nurse #9 told them they did not realize they had been restraining the resident ; they thought they were just obtaining a swab on a resident that would be difficult to swab. They were unsure of why the incident was not reported to the Department of Health until 9/11/2024. They were unsure of how Resident #5 obtained the skin tear in their hand. During an interview on 9/25/24 at 2:23 PM, Certified Nurse Aide #8 stated Resident #5 had been yelling at everyone that day. They didn't know what set the resident off that day, but they were not themselves. Resident #5 had approached them and grabbed their hands. Registered Nurse #9 came over and stated they were going to swab the resident. They stated Registered Nurse #9 went to the side of the resident, completed the swab, and the resident got mad at the nurse. They did not remember if Registered Nurse #9 held the resident. They stated the nurse did not inform the resident before the swab was completed. They remembered Registered Nurse #9 brought the resident to their room and they went to go complete care for another resident. During an interview on 9/26/24 at 2:39 PM, Registered Nurse #9 stated they were moved from the Dementia Unit after they held a resident while doing a COVID-19 swab. Due to them holding a resident, it was considered abuse. They stated on 9/9/2024 before they swabbed Resident #5, the resident was angry and was yelling and had tried to grab their unopened kits from the cart. They moved their cart to the other side of the nurses' station. Resident #5 had an order to be swabbed as they were exposed to COVID-19. The resident was standing with Certified Nurse Aide #8, so they asked Certified Nurse Aide #8 to hold the resident's arm, so they did not swing out or hurt themselves. They wanted to get the swab done quickly because they knew the resident was not cooperative and had a history of yelling and combative behavior. They put their arm behind the resident, grabbed the resident's chin, and did the COVID-19 swab with the other hand. The resident said stop and they did not want it done. Registered Nurse #9 stated they felt the swab needed to be done so they did it. After they swabbed the resident, the resident yelled at another resident, so they attempted to intervene. They stated Resident #5 threw a soda can at another resident, so they stood in front of Resident #5 and pulled the two residents apart. They stated they brought the resident to their room by holding their hand and arms. They wanted to get the resident to a safe place. The resident had a lot of behaviors the rest of the day. They stated they held other residents to get COVID-19 swabs that morning. They stated they were educated about the incident the next day and were informed they would be removed from the floor. They worked Thursday 9/12/2024 and Friday 9/13/2024 but were suspended for one day on Monday 9/16/2024 for their involvement in the incident. 3) Resident #1 had diagnoses including Alzheimer's dementia, schizoaffective disorder, and Parkinson's disease (a progressive neurological disease). The 8/16/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had fluctuating disorganized thinking, had verbal, physical, and other behavioral symptoms, and was dependent for care except eating and oral hygiene. The 8/26/2024 Resident Preference and Function care plan documented the resident was dependent for toileting and transfers and required substantial/maximum assistance for bed mobility and dressing. The resident always required two caregivers and was to be given something to hold during transfers and care. The resident had a history of verbal aggression, physical aggression, and sexually inappropriate comments. The 9/11/2024 facility incident report documented staff were made aware of an incident that occurred at 6:15 PM. Registered Nurse Supervisor #2 was notified by Certified Nurse Aide #5 (no documentation of the time of notification) that Certified Nurse Aide #6 was rough with handling and caring for Resident #1 while putting them to bed. Certified Nurse Aide #6 made derogatory comments, intimidating remarks, belittled the resident about their genitalia, and called the resident an [expletive] and a [expletive]. Certified Nurse Aide #6 did not deny the event and was educated about abuse and the consequences. Registered Nurse Supervisor #2 attempted to interview Resident #1, but the resident did not remember the incident. The Administrator and Director of Nursing were notified at 7:38 PM and Registered Nurse Supervisor #2 was instructed to send Certified Nurse Aide #6 home. Certified Nurse Aide #6 was escorted by Registered Nurse Supervisor #2 to the lobby and Certified Nurse Aide #6 exited the building (no time documented). - A statement from Certified Nurse Aide #5 documented on 9/11/2024 at 6:15 PM they witnessed Certified Nurse Aide #6 being rough with Resident #1 during care which included pulling on the resident, slapping the resident's chest, calling the resident names, screaming in the resident's face, and making fun of the resident's genitalia. The statement did not include who Certified Nurse Aide #5 reported the incident to, or the time. - Certified Nurse Aide #6 was interviewed by Registered Nurse Supervisor #2 and stated they were sorry and did not deny the accusation. - Certified Nurse Aide #6 was sent home on 9/11/2024 pending investigation per the direction of the Director of Nursing. The incident report did not include a statement from Licensed Practical Nurse #7. The facility's surveillance video from Resident #1's nursing unit on 9/11/2024 from 6:23 PM through 8:35 PM was reviewed: - At 6:32 PM Certified Nurse Aide #5 and Certified Nurse Aide #6 exited Resident #1's room. - At 6:33 PM Certified Nurse Aide #6 went back into Resident #1's room, exited the room with the mechanical lift and entered another resident room with Certified Nurse Aide #5. - At 7:03 PM, Certified Nurse #5 was speaking with Licensed Practical Nurse #7 at the medication cart at the end of the hallway near the elevators. - At 7:05 PM, Licensed Practical Nurse #7 went towards the elevators and made a phone call and went back to their medication cart. - At 7:15 PM, Certified Nurse Aide #6 left the floor. - At 7:26 PM, Certified Nurse Aide #5 left the floor. - At 7:42 PM, Certified Nurse Aide #6 was at the nursing station then walked into a resident room. - At 8:10 PM, Certified Nurse Aide #6 left the floor with their jacket on. - At 8:20 PM, Certified Nurse Aide # 6 returned to the floor and walked down the hallway. - At 8:21 PM, Certified Nurse Aide #6 carried a slipper to a resident's room. - At 8:22 PM, Certified Nurse Aide #6 assisted an unidentified resident near the nursing station to sit in a chair. - At 8:24 PM, Certified Nurse Aide #6 walked down the hallway with an unidentified certified nurse aide to a resident's room. The two certified nurse aides were in the alcove between two resident rooms out of view of the camera, then they walked back to the nursing station. - At 8:24 PM Certified Nurse Aide #6 remained at the nursing station until Registered Nurse Supervisor #2 came to the floor at 8:33 PM and took Certified Nurse Aide #6 into the breakroom behind the nursing station. Certified Nurse Aide #6's timecard documented they clocked out at 8:35 PM on 9/11/2024 and they did not work any other shifts past 9/11/2024. There was no documented evidence Certified Nurse Aide #6 was immediately removed from resident access after the allegation of abuse. The 9/12/2024 Employee Performance Appraisal form documented Certified Nurse Aide #6 was suspended pending investigation on 9/12/24. The investigation was completed, Certified Nurse Aide #6's actions were confirmed abuse, therefore, their employment was terminated. The 9/12/2024 at 3:00 PM Registered Nurse #9 Skin Risk Assessment Scale documented the resident had two points of purple bruising observed on their right arm and one bruise on their left arm. During an interview on 9/24/24 at 12:11 PM, Registered Nurse Supervisor #2 stated at approximately 6:15 PM on 9/11/2024, Licensed Practical Nurse #7 messaged them and stated that there was a complaint made. They had Licensed Practical Nurse #7 send Certified Nurse Aide #5 to the Supervisor's office on the first floor. Certified Nurse Aide #5 informed them they were in Resident #1's room with Certified Nurse Aide #6, providing care and Certified Nurse Aide #6 was behaving inappropriately. They asked Certified Nurse Aide #5 to write a statement and then sent the certified nurse aide back upstairs and asked Licensed Practical Nurse #7 to send down Certifie [TRUNCATED]

Based on record review and interviews during the abbreviated survey (NY00341596, NY00353814, NY00354138, and NY00354190) the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the administration failed to ensure policies and procedures were properly identified, communicated, and consistently implemented for abuse and dementia care. The administration was not aware of the extent of the deficient practices and Immediate Jeopardy was identified on 9/25/2024 in the area of abuse (refer to F 600). Findings include: The facility policy, Quality Assessment and Performance Improvement Plan, revised 9/2023, documented the program was intended to identify and prioritize problems and opportunities based on performance indicator data and resident and staff input that reflected organizational processes, functions, and services provided to residents. The program would identify corrective actions necessary to address gaps in systems, and then these actions were evaluated for effectiveness. The program was established around the premise of safety, quality, rights, choice, and respect. The facility policy, Administrator Policy [Residential Healthcare Facility], reviewed 3/2022, documented the purpose of the Administrator was to be a focal point for information while developing a hierarchy within the Residential Health Care Facility and establishing a responsible party for management of the facility. An Administrator, licensed by the State of New York, would be appointed by the Chief Executive Officer and would be responsible for the management and oversight of the facility. The Administrator would report to the Chief Executive Officer. The facility department heads, contractors, and consultants reported directly to the Administrator. The Administrator ensured that all policies, procedures, mandated regulations, and quality of resident care were followed to the highest possible standards. The 3/20/2014 facility Director of Nursing Service job description documented the position involved responsibility for planning, directing, and supervising activities as they applied to nursing services. Their supervision and direction were to be exercised over all nursing home facility nursing services personnel. They conferred with facility administrator and other administrative and professional personnel to assist in establishing and reviewing policies, programs and procedures effecting patient care. They were also responsible for evaluating the quality and quantity of the nursing services rendered in the facility and for making changes as necessary to meet State and Federal requirements. Freedom from Abuse, Neglect, and Exploitation Refer to citation text under F600. Residents #1, #2, #4, and #5 were not free from verbal, physical, and mental abuse. The facility's failure to ensure residents were free from abuse placed all 123 residents at risk for serious injury, serious harm, serious impairment, or death. This resulted in Immediate Jeopardy to resident health and safety. During an interview on 9/24/2024 at 1:23 PM, the Director of Nursing stated for incidents of abuse they educated the involved staff immediately. They planned to have a long-term care day where they educated the staff. The facility had an abuse course which was very good, and they requested the education to be done for all staff. During a follow up phone interview on 10/10/2024 at 11:24 AM, the Director of Nursing stated they had not identified any patterns with the abuse incidents, and they all involved different staff members. They stated they believed part of the issue was a lack of education. They stated they had not been educated with the Teepa Snow (a specialized dementia care program) program since they started in August 2024, but had asked to be educated on the next course date. During an interview on 9/24/2024 at 3:00 PM, the Director of Quality Assurance stated they put together an education due to the facility having four incidents that were related. They stated they combined their efforts for education on physical, verbal, emotional abuse, and residents' rights. During an interview on 9/24/2024 at 4:42 PM, the Administrator stated they identified a trend of reportable incidents in the facility, so they had tasked their three Teepa Snow trained staff (including the Activities Director and the Director of Social Services), to research and put together a training for all staff. The training had not been approved and implemented yet. They stated they had focused on implementing the plan of correction and education from their last recertification survey first. During a follow-up telephone interview on 10/07/2024 at 4:05 PM, the Administrator stated they became aware of an issue at the facility with abuse related issues around 9/15/2024 or 9/16/2024. They had five incidents in two weeks with different issues which included some residents refusing care. A resident had the right to refuse care but there was a fine line between care, abuse, and neglect. These incidents had different issues and encompassed several nuances including abuse and neglect. The interdisciplinary team, which included department heads and Unit Managers, reviewed incidents regularly. While reviewing these incidents, questions were raised, and it was decided they would come up with staff education and training for the abuse follow up. The staff education was designed but had not been implemented yet because it took longer than planned to complete. The process for identifying trends was determined by the interdisciplinary team that met monthly, and by the Quality Assurance Committee which met monthly. Each case was reviewed for repeating issues. Even though the facility had a dementia unit, there were residents with dementia on all four units. When a resident with dementia needed more care, they were moved from the dementia unit to one of the other floors, often the fourth floor. The education that was planned was geared toward dementia communication. Staff working on the dementia floor had been given special training in Teepa Snow 1 which addressed that. The dementia care unit staff would be receiving Teepa Snow 2 instruction which was more in depth and helped them communicate and understand dementia better. The plan was for the entire facility to get Teepa Snow 1 education, but this had not yet been implemented. During an interview on 10/9/2024 at 1:20 PM, the Medical Director stated they had not been consulted by the Chief Executive Officer regarding the issues with abuse the facility had recently had but they had initiated a conversation briefly with the Administrator and Director of Nursing to propose their own solution of being more present on the floors of the facility. They did not believe there was enough administrative presence on the nursing home unit floors, or these issues would not have occurred. They stated the previous Chief Operating Officer had a philosophy where the staff are presumed innocent until proven guilty, so they were not allowed to remove staff from the floor until the investigation had been concluded and the staff found to have been guilty of the allegation. They also believed the issue was lack of education as the traveling nurse staff were not as educated the same as those directly employed by the facility. They stated they were educated when they started, but not well enough or these issues would not have happened. 10 NYCRR 483.70(i)

Based on observation, record review, and interviews during the abbreviated (NY00348034, NY00353814, NY00354138) surveys, the facility did not ensure a resident who displays or is diagnosed with dementia receives the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for 3 of 16 residents (Residents #4, #5, and #16) reviewed. Specifically, Residents #4, #5, and #16 had diagnoses of dementia and resided on the dementia unit in the facility and were not cared for in a dementia-informed manner. Resident #4 was forced to ambulate against their will by several staff members after refusing to go to the dining room; Resident #5 was physically restrained by a registered nurse and a certified nurse aide while a nasal swab was obtained; and Resident #16's care plan was not followed which resulted in a fall with a skin tear. Refer to F 600. Findings include: The facility policy, GEMS Stages of Dementia Classification, created 11/2023, documented the GEMS Model was a framework for understanding and caring for individuals with the diagnosis of dementia. The model used gemstones as a reference for each stage of dementia, such as sapphire, diamond, emerald, amber, ruby, and pearl. The purpose was to diminish negative stereotypes associated with dementia and to create a more positive dementia care culture. The GEMS State Model was the standardized method of identifying an individual's stage in the dementia process at the facility. The GEMS State Model provided a means of quickly identifying interventions and approaches best suited to the resident, allow the staff who did not have easy access to the resident charts to identify the stage of dementia for the resident, and to continue to educate staff on all stages of dementia. The GEM care plan would appear on the resident's function and preference which was placed in a binder at the nurses' station on the first floor. 1) Resident #4 had diagnoses including dementia with behavioral disturbance, anxiety disorder, and disorder of bone density and structure. The 6/24/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, physical and verbal behavioral symptoms directed toward others 1-3 of 7 days, behavioral symptoms not directed toward others 1-3 of 7 days, did not reject care, and was independent with transfers and ambulation. The 9/16/2024 Resident Preference and Function care plan documented the resident was independent with ambulation and was to be encouraged to use their four wheeled walker. The resident must eat in the dining room with supervision. The resident ate in a regular chair with a low table when in their room where the resident preferred to eat. Encourage to the resident to eat in the dining room as the resident threw food in the toilet. The facility incident report initiated by Registered Nurse Unit Manager/Supervisor #20 on 9/9/2024 at 1:53 PM, documented on 9/6/2024 at 5:52 PM Resident #4 was observed on video ambulating out of their bedroom with resistance. The resident had 2 certified nurse aides on both sides of their arms, sliding the feet of the resident down the hallway. The resident sat on a loveseat in the mid-hallway and the staff stood across the hall waiting for the resident. Within 1 minute the 2 staff went to get the resident up and the resident resisted and slid their feet to tell staff not to ambulate at that time. The resident stopped and other staff came to assist the 2 certified nurse aides. The licensed practical nurse, another certified nurse aide, and the supervisor came to assist. The 2 certified nurse aides (unidentified) were sliding the resident down the hallway. The facility's surveillance video from the nursing unit on 9/6/2024 from 5:49 PM through 6:15 PM was reviewed: - From 5:51 PM to 5:52 PM, Certified Nurse Aides #8 and #12 each had one arm holding above the resident's elbow and one arm holding the resident's wrists, while the resident struggled and resisted. The resident was firmly placed on a couch in the hallway. - At 5:53 PM, Certified Nurse Aides #8 and #12 using both arms, attempted to pull the resident off the couch by their arms while the resident swatted out at them and resisted until they forcibly pulled the resident off the couch into a standing position. - From 5:53 PM to 5:54 PM, Certified Nurse Aides #8 and #12 pulled the resident down the hallway by their arms as the resident struggled and fought and planted their feet, causing their feet to slide against the floor as they were pulled. Certified Nurse Aide #8 attempted to move the resident forward and the resident grabbed onto the railing to stop their movement. Certified Nurse Aide #14 and Licensed Practical Nurse #15 came to assist and got on either side of the resident and held the resident's arms while Certified Nurse Aide #8 and #12 held the resident from behind. Registered Nurse Supervisor #13 came down the hall and stood off to the side, then behind the group, as the other staff members slid the resident down the hallway as the resident remained rigid and struggling with staff. They placed the resident in a chair across from the nurses' station outside the dining room and all four staff members (Certified Nurse Aides #8, #12, and #14 and Licensed Practical Nurse #15) struggled with the resident to get them to sit in the chair while Registered Nurse Supervisor #13 observed. The certified nurse aides headed toward the dining room, the licensed practical nurse to the nursing cart, and the registered nurse supervisor to the nurses' station. During an interview on 9/25/2024 at 2:23 PM, Certified Nurse Aide #8 stated the Nurse Manager told the certified nurse aides they had to bring residents out for meals. Certified Nurse Aide #8 stated they were told the residents on the unit did not know how to refuse. Resident #4 was care planned to be supervised for meals so they could not eat in their room. They stated they stood the resident in their room and the resident started to push them back and forth in the hallway, so they sat the resident down on a couch. They were trying to figure out if they should sit the resident there or bring the resident to the nurses' station, so they brought the resident to sit near the nurses' station to eat so they were supervised. They stated the resident likely did not want to get off the couch, but they got the resident up, and had to call for assistance because the resident was trying to sit on the floor in the hallway. As a group they helped the resident walk down the hallway and sit down in a chair near the nurses' station. Certified Nurse Aide #8 stated they had been previously educated on the Teepa Snow (a specialized dementia care program) program for the dementia unit. 2) Resident #5 had diagnoses including dementia with behaviors and agitation. The 7/22/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, delusions, and hallucinations, rejected care, had physical, verbal, and other behavioral symptoms, and was independent after setup for most activities of daily living. The 9/18/2024 Resident Preference and Function care card documented the resident was independent with ambulation, was able to communicate clearly but would forget and become frustrated, required 30-minute checks for safety and behaviors, did not like being touched without their permission, and had a history of being aggressive and being a victim of aggression. 9/9/2024 physician's order documented a COVID-19, influenza, and respiratory syncytial virus nasopharyngeal (nose) swab was to be collected. The facility's surveillance video from the nursing unit was reviewed for 9/9/2024 from 9:49 AM through 10:30 AM: - At 9:51 AM, Registered Nurse #9 swabbed an unidentified resident sitting in a chair in front of the nurses' station with the assistance of another unidentified staff member while the resident fought against the swab. - At 9:54 AM, Registered Nurse #9 swabbed an unidentified resident sitting in a chair in front of the nurses' station with their arm braced on the resident's chest while the resident attempted to move their head away from the swab. - At 9:56 AM, Registered Nurse #9 went to the side of a resident from behind, put their arm around the back of the resident's neck and shoulders and swabbed the resident as they tried to move their head away. - From 9:57 AM to 9:58 AM, Registered Nurse #9 put their arm around Resident #5's left side of their neck with their hand along the side of the resident's jaw. They secured the resident's head/neck between their forearm and shoulder to hold the resident and went around the right side of the resident to swab their nose. Certified Nurse Aide #8 had a visible hold of the resident's hands and wrist area while the resident struggled away from Registered Nurse #9. The resident attempted to get their arms released as well from the certified nurse aides' grip. When the swab was done, the certified nurse aide let go of the resident's hands as they struggled, and the resident attempted to swing out at the registered nurse but was halted by Certified Nurse Aide #8 who took the resident's arm at the elbow and held them back. The resident was visibly agitated and shaking their first at Registered Nurse #9. Certified Nurse Aide #8 attempted to get the resident to follow them down the hallway, but the resident refused. During an interview on 9/26/24 at 2:39 PM, Registered Nurse #9 stated before they swabbed Resident #5 on 9/9/2024, the resident looked angry and was yelling. The resident looked dangerous and had tried to grab the unopened kits off the treatment cart. Registered Nurse #9 stated they had moved the cart to the other side of the nurses' station out of the resident's reach. The resident was standing with Certified Nurse Aide #8, so they asked Certified Nurse Aide #8 to hold the resident's arm because they did not want the resident to swing out or hurt themself. Registered Nurse #9 stated they wanted to get the swab done quickly because they knew the resident was not cooperative and had a history of yelling and combative behavior. They put their arm behind the resident, grabbed the resident's chin, and did the COVID-19 swab with the other hand. The resident had stated stop and that that they did not want to do it, but Registered Nurse #9 felt it needed to be done so they did it. The resident was yelling at another resident, so they attempted to intervene. Resident #5 threw a soda can, so they stood in front of Resident #5 and pulled the residents apart. They brought Resident #5 to their room by holding the resident's hand and arms. They stated they wanted to get the resident to safe place, like their room. The resident had a lot of behaviors the rest of the day. 3) Resident #16 had diagnoses including Alzheimer's disease, osteoporosis, and cardiac arrhythmia. The 8/19/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, continuous inattention and disorganized thinking, physical and verbal behaviors for 1 to 3 of 7 days that significantly interfered with the resident's care and activity participation, required substantial to maximum assistance for dressing, partial to moderate assistance for transfers, and supervision to touching assistance for ambulating 150 feet with a walker. The 7/8/2024 Resident Preference and Function documented the resident required supervision to touching assistance with a two wheeled walker, was substantial to maximum assist of one person into the bathroom with red toilet seat, and attempt to toilet the resident when they were initiating movement/ready to get up and walk. Fall precautions included frequent visual checks of 30 minutes, to keep their walker or assistive device with the resident, to wear hipsters, and to wear shoes when out of bed. Behavior interventions included to allow the resident to feel in charge and have active part of their care, walk with the resident on the unit as resident will rest when they're tired, and ensure they have a chair before allowing the resident to sit as the resident had poor safety awareness. Resident's GEMS color was amber (mid-stage to late-stage dementia). Interventions included to be careful of over of under stimulation, to limit noise and touch, and to make the environment safe for exploring. The 7/11/2024 incident report documented: - Resident #16 had an unwitnessed fall with 0.5-centimeter skin tear to their right elbow and a red mark on their right shoulder. - The 7/12/2024 statement by Registered Nurse/Nurse Manager #20 documented the resident was supervision to touching with their walker. Resident #16 was given their medications by Licensed Practical Nurse #25 at 7:03 PM and then the resident was using the handrails in the hallway. At 7:07 PM, Certified Nurse Aide #26 brought Resident #16 into the bathroom for toileting and gave the resident their walker to ambulate. Certified Nurse Aide #26 left the bathroom and brought a scoot chair to the other side of the hallway. The resident ambulated out of the bathroom at 7:20 PM and ambulated to resident room [ROOM NUMBER]. The resident left the walker outside room [ROOM NUMBER] and ambulated into resident room [ROOM NUMBER]. Another resident noticed Resident #16 immediately and notified staff the resident was on the floor. Certified Nurse Aide #26 was educated by Registered Nurse Supervisor #19 at 6:22 PM regarding the resident's transfer status prior to the fall. The 7/22/2024 Employee Performance Appraisal documented education was provided to Certified Nurse Aide #26 for failure to follow policy. On 7/11/2024, Certified Nurse Aide #26 took Resident #15 to the bathroom and left the resident. The resident left the bathroom, wandered to another resident room, and fell . The resident was not safe to be left alone. Certified Nurse Aide #26 did not follow the resident's plan of care of the resident being substantial to maximal assist in the bathroom. Certified Nurse Aide #26 was re-educated on the resident's plan of care and documentation in the resident's record. During a telephone interview on 10/07/2024 at 4:05 PM, the Administrator stated they became aware of an issue at the facility with abuse related issues around 9/15/2024 or 9/16/2024. They had five incidents in two weeks with different issues which included some residents refusing care. A resident had the right to refuse care but there was a fine line between care, abuse, and neglect. These incidents had different issues and encompassed several nuances including abuse and neglect. The interdisciplinary team, which included department heads and Unit Managers, reviewed incidents regularly. While reviewing these incidents, questions were raised, and it was decided they would come up with staff education and training for the abuse follow up. The staff education was designed but had not been implemented yet because it took longer than planned to complete. The process for identifying trends was determined by the interdisciplinary team that met monthly, and by the Quality Assurance Committee which met monthly. Each case was reviewed for repeating issues. Even though the facility had a dementia unit, there were residents with dementia on all four units. When a resident with dementia needed more care, they were moved from the dementia unit to one of the other floors, often the fourth floor. The education that was planned was geared toward dementia communication. Staff working on the dementia floor had been given special training in Teepa Snow 1 which addressed that. The dementia care unit staff would be receiving Teepa Snow 2 instruction which was more in depth and helped them communicate and understand dementia better. The plan was for the entire facility to get Teepa Snow 1 education, but this had not yet been implemented. During a phone interview on 10/9/2024 at 9:57 AM, Certified Nurse Aide #26 stated they were an agency certified nurse aide and they no longer worked at the facility. They stated they were informed that if Resident #16 had to use the bathroom, they had to use the hallway one and if they wanted to have a nap, they had to use the couch as they could not be in their room alone due to falls. They stated the resident required supervision for walking with their walker. They stated when they started at the facility, they were told supervision for Resident #15 meant they had to check on the resident every 15 minutes, they had to know where the resident was and if they had their walker with them. They stated they received education over the phone in which they were informed the resident was supervision and that supervision meant the staff had to be right next to the resident. They stated they did not receive specialized training for the dementia unit or how to address the dementia specific behaviors. During a phone interview on 10/9/2024 at 12:55 PM, Registered Nurse/Nurse Manager #20 stated the staff on the dementia unit goes through the Teepa Snow training and they should know how to communicate and communicate in different ways and motions as well as get residents with dementia to engage. They stated all the staff should be trained to work on the dementia unit and the facility was working to make sure travelers had training as well. The training was yearly. Each resident had a specific care plan but on the dementia unit, the care plans were kept in a binder at the nurses' station on the dementia unit as opposed to in the residents' closet on other units. During a phone interview on 10/10/2024 at 11:24 AM, the Director of Nursing stated they had not identified any patterns with their incidents; they all involved different staff members. They stated they believed part of the issue was that a lack of education. They stated they had not been educated with the Teepa Snow program but had asked to be educated during the next training course. They stated they used something different for dementia training in the state they were from. They stated they did not know if the Teepa Snow program provided any specific education to the staff on the dementia unit on how to handle refusals, behaviors, or dementia specific issues but the staff on the regular floors are taught to reapproach. 10NYCRR 415.12

Based on observation, record review, and interview during the recertification survey conducted 7/24/2024 - 7/30/2024, 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. Specifically, 7 individual serving size portions of moist and minced fish were stored in cardboard containers dated 2/21 with ice buildup inside the containers; 1 cardboard box of cooked chicken was stored on top of 2 packages of flatbreads; the ice cream cooler contained an employee's personal 20-fluid ounce frozen bottle of water; and the tray line preparation cooler contained 10 sheet pans of uncovered coleslaw, and uncovered 4-ounce servings of strawberries with whipped topping. Findings include: The following observations in the main kitchen were made on 7/24/2024 between 10:30 AM and 11:01 AM: - In the walk-in freezer there were 7 individual serving size portions of minced and moist fish dated 2/21 with ice buildup on the inside of the containers, and there was 1 cardboard box of cooked chicken breast stored on top of 2 plastic sleeves of flatbread. The Food Service Director discarded the 7 portions of minced and moist fish and stated the cooked chicken should not be stored on top of the flatbread. - In the ice cream cooler there was an employee's personal 20-fluid ounce bottle of frozen water. The Food Service Director stated staff should not store personal food items with resident food items and discarded the frozen water bottle. - In the cold food prep cooler there were 10 sheet pans of uncovered coleslaw and uncovered 4-ounce servings of strawberries with whipped topping. During an interview on 7/30/2024 at 10:52 AM, the Food Service Director stated the moist and minced fish containers were discarded immediately. The chicken breast that was stored on top of the flatbread was cooked, but still could cross-contaminate the flatbread and pose a food safety issue. The frozen bottle of water was discarded immediately, and employees should not store personal food or drink items with resident food. It was important to maintain food safety in the main kitchen for the safety of the residents and staff. NYCRR10 415.14(h)

Based on observation and interview during the recertification survey conducted 7/24/2024-7/30/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meal test tray reviewed (the 7/26/2024 lunch meal on Unit 3 and the 7/29/2024 lunch meal on Unit 2). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 7/26/2024 and 7/29/2024. Additionally, Resident #26 stated the food did not taste good. Findings include: The facility policy Food Temperatures effective date 12/2019 documented: - Temperatures of all food items would be taken and properly recorded prior to service of each meal and ensure quality and safety of food/drinks. - All hot food items must be held and served at a temperature of at least 140 degrees Fahrenheit. - All cold items must be stored and served at a temperature of 41 degrees Fahrenheit or below. During an interview on 7/24/2024 at 12:37 PM, Resident #26 stated they were served cold food, and it did not taste good. During a lunch meal observation on 7/26/2024 at 1:01 PM on Unit 3, Resident #26 was served their lunch meal tray. A replacement tray was ordered, and Resident #26's original meal tray was tested . The roast beef was measured at 128 degrees Fahrenheit, the green beans were 118 degrees Fahrenheit, the orange juice was 54.3 degrees Fahrenheit, the butterscotch pudding was 51.8 degrees Fahrenheit, and the vanilla pudding was 46.6 degrees Fahrenheit. During an interview on 7/26/2024 at 1:02 PM, Licensed Practical Nurse #20 stated cold items were sent to the unit on a cart from the kitchen, and hot items were served from the steam tables on the unit. They were unsure what temperatures hot and cold food items should be when served. During a lunch meal observation on 7/29/2024 at 12:51 PM on Unit 2, a sample lunch meal tray was requested. At 12:54 PM, the lunch meal tray was served and tested . The lasagna was measured at 123 degrees Fahrenheit, the broccoli was 105 degrees Fahrenheit, the mashed potatoes were 135 degrees Fahrenheit, the gravy was 120 degrees Fahrenheit, and the soup was 123 degrees Fahrenheit. During an interview on 7/29/2024 at 1:05 PM, the Food Service Director stated all hot food items should be served at 140 degrees Fahrenheit or higher and cold food items should be served between 35 degrees Fahrenheit and 40 degrees Fahrenheit. The lasagna, broccoli, gravy, and soup were not acceptable temperatures. Hot food was served directly from the steam table and the food should hold temperatures. It was important for residents' food to be served at palatable and safe temperatures. During an interview on 7/30/2024 at 10:40 AM, the Food Service Director stated they were responsible for completing test trays, they did not have a set schedule, and they were completed randomly. They looked at a meal's appearance, taste, and temperature, and ensured the food on the tray matched the ticket. The staff were not made aware prior to the completion of a test tray, and they would complete them more often if they noticed any negative trends. The orange juice, roast beef, and green beans were not acceptable temperatures, and the pudding should have been served cold. Hot food items should be served at a minimum of 140 degrees Fahrenheit and cold food items should be served below 40 degrees Fahrenheit. 10NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interview during the recertification and abbreviated (NY00308041 and NY00343021) surveys conducted 7/24/2024-7/31/2024 the facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for 2 of 4 resident units (Units 1 and 3) observed and for 1 of 4 residents (Resident #77) reviewed. Specifically: - Unit 1 (dementia unit, also known as the Rainbow Community) had environmental accident hazards readily accessible to residents. - Resident #77, who resided on Unit 1, had a history of wandering throughout the unit and ingesting inedible items, including bar soap. Resident room [ROOM NUMBER] was observed with multiple bars of soap on the sink counter. - the door to the clean utility room on Unit 1 was unsecured and contained oxygen equipment, wound care supplies, and other nursing care items. - Unit 1 common area had metal wheelchair leg rests on a table. - An unsecured, open cart with needle-nose pliers and other electrical test items was left unattended in the hallway. - Unit 2 had environmental accident hazards in resident rooms including a four-slice toaster and a microwave on a long dresser at the foot of a bed, and a microwave on the dresser behind the head of a bed. Findings include: The facility philosophy for the Rainbow Community (Unit 1) dated 3/2006, documented every resident at the facility had the right to thrive, to flourish, and to be treated with dignity and function at the highest practicable level. The environment and creative caring concern for residents resulted in special approaches to individuals with the diagnosis of dementia. The facility policy, Behavior Management, revised 6/2024, documented the facility promoted and supported a resident-centered approach to care. Behavioral health encompassed a resident's whole emotional and mental well-being. Training would be completed for all frontline staff on the care and services of residents with behavioral health needs and dementia which included caring for the residents' environment and care of the cognitively impaired residents. The facility policy, Food preparation on all Units and in Facility Departments, reviewed by the facility 3/2024, documented staff were to follow manufacturer's instructions for items being prepared in a microwave or toaster and were not to leave the microwave or toaster unattended until the cycle was complete. The policy did not include use of toasters or microwaves in resident rooms. The facility policy, Electrical Equipment, effective 7/2023, documented any new electrical equipment brought in by a resident's family had to be inspected and tagged by the Plant Operations Department before it could be used. It was the responsibility of the residential health care facility staff to enter a Plant Operations work order requesting the inspection of the equipment. Resident #77: Resident #77 had diagnoses including dementia with behavioral disturbance, major depressive disorder, and insomnia. The 6/3/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had inattention and disorganized thinking that was continuously present, did not wander, did not exhibit behavioral symptoms, and was independent for bed transfers and ambulation. A facility incident dated 12/1/2023 at 6:30 PM and entered by documented Resident #77 wandered into other resident rooms and throughout the unit while awake as the resident was independent. The resident had been witnessed with a soapy smell coming from their mouth and white residue around their mouth. The resident was observed on video coming out of resident room [ROOM NUMBER] with the soap bar. To prevent reoccurrence, the staff would ensure residents' personal hygiene products were locked up if residents did not independently use them. For residents who preferred to have their soap in the bathroom, travel containers that closed would be ordered and they would ensure residents could use them. An addendum to the report was made on 1/19/2024 that documented the residents and staff had been using the travel soap containers. A facility incident report dated 3/19/2024 at 7:57 PM documented Resident #77 was found with a bar of soap in their mouth; there were no chunks of soap gone but the soap bar had bite marks in it. The resident had a reaction to the soap indicated by a swollen lip. An addendum added on 3/21/2024 by the Registered Nurse Unit Manager #17 documented residents had taken soap out of the soap containers and Resident #77 found them in the rooms. The soap used on the unit was changed to a different soap Resident #77 was not sensitive to. The 7/23/2024 Comprehensive Care Plan documented the resident was independent with ambulation, was not allowed condiment packages on their meal tray after setting up to prevent accidental consumption of non-food items, required frequent visual checks for behaviors, and had a history of wandering and invading the privacy of others. The care plan documented the resident did not have a soap preference. The resident stayed up late at night. Make environment safe for exploring. Eliminate items that could cause harm but offer substitutions. The following observations were made: - On 7/24/2024 at 11:52 AM Resident #77 was walking up to the activities cart and reached their hand into the basket that contained the nail polish. Activities Aide #30 told the resident they could paint their nails. Resident #77 walked away from the cart and went into resident room [ROOM NUMBER]'s bathroom. - On 7/25/2024 at 9:43 AM Resident #77 was wandering to the unit entrance door pushing on the door. An unidentified certified nurse aide called the resident's name and the resident turned away from the door. They wandered back down the hallway with an Alzheimer's association pamphlet in their hand. At 2:21 PM Unit Helper #19 took the resident out of room [ROOM NUMBER] for a walk down the hallway to their own room. - On 7/26/2024 at 9:40 AM Resident #77 was walking into room [ROOM NUMBER]. At 10:05 AM, Resident #77 was lying asleep in the window side bed in resident room [ROOM NUMBER]. At 12:51 PM, they took a baby doll from the nursing station and walked down the hallway. - On 7/29/2024 at 12:40 PM, Resident #77 was lying on a bed in resident room [ROOM NUMBER]. - On 7/29/24 at 4:36 PM the bathroom sink in resident room [ROOM NUMBER] had 3 pieces of disintegrating white soap: one in the sink, one in between the cold water handle and faucet, and one in between the hot water handle and faucet. - On 7/30/24 at 10:17 AM the bathroom sink in resident room [ROOM NUMBER] had 2 pieces of disintegrating white soap: one in between the cold faucet handle and faucet, and one between the hot water handle and faucet. - On 7/30/2024 at 10:27 AM, Resident #77 was wandering into room [ROOM NUMBER]'s bathroom. During an interview on 7/25/24 at 10:03 AM, Resident #77's family representative stated they had been informed over the last few months the resident had attempted to ingest two bars of soap and a foam Easter egg. The staff could not tell them where the resident had obtained the soap bars or the foam Easter egg. They had informed the social worker that the interventions that were put into place after the first incident with the soap were not working and they needed to take away the resident's access to soap. They felt lack of supervision was an issue on the unit. Accident Hazards on Units 1 and 3: Unit 1 (dementia unit) observations: - On 7/24/2024 at 10:48 AM a gray handled, open bag full of wound care supplies which included dressings in wrappings, adhesive bandages, saline syringes, and scissors were on the lower counter of the nursing station within reach of a resident. - On 7/24/24 at 11:40 AM the bathroom of resident room [ROOM NUMBER] had therapeutic shampoo with ingredients consisting of coal tar 0.5%, sitting on the sink with a prescription label for a resident. - On 7/24/24 at 11:43 AM the bathroom of resident room [ROOM NUMBER] had two full bags of shampoo and body wash on the floor for a dispenser under the sink and a bar of soap on the floor of the shower. - On 7/24/24 at 11:49 AM the window side of resident room [ROOM NUMBER] had a 250 milliliter bottle of wound solution on the nightstand. The pharmacy label on the bottle had a dispense date documented as 7/12/2024. - On 7/25/2024 at 2:38 PM a contract employee was in a closed clean linen room and left their open cart unattended in the hallway. The cart contained tools, electrical testers, needle-nose pliers, electrical tape, a laptop, stickers, and small packets of wipes. At 2:41 PM, the contract employee returned to the cart, walked away, and left the cart unattended in the hallway. - On 7/25/24 at 2:02 PM the bathroom of resident room [ROOM NUMBER] had two dispenser bags of shampoo and body wash hanging over the edge of the sink, a bar of soap was on floor of the shower, and the therapeutic shampoo with coal tar 0.5% was on top of the paper towel dispenser. - On 7/25/24 at 2:03 PM the window side of resident room [ROOM NUMBER] had a medicine cup with ointment on the bedside table and a bottle of wound wash on the nightstand. - On 7/26/24 at 9:58 AM in resident room [ROOM NUMBER] there was a bag of shampoo and soap on the bedside table next to the bathroom door. The therapeutic shampoo with coal tar 0.5% was on the towel dispenser in the bathroom. - On 7/29/24 at 10:06 AM there were metal wheelchair legs on a table in the back corner of the unit outside resident room [ROOM NUMBER]. - On 7/29/24 at 11:00 AM the door to the clean linen room across from resident room [ROOM NUMBER] was partially open. The room contained oxygen cylinders and medical supplies such as bandages, tape, and disposable bed pans. There were no staff in the clean linen room at that time. - On 7/29/24 at 4:36 PM the bathroom sink in resident room [ROOM NUMBER] had 3 pieces of disintegrating white soap: one in the sink, one in between the cold water handle and faucet, and one in between the hot water handle and faucet. - On 7/30/24 at 10:17 AM the bathroom sink in resident room [ROOM NUMBER] had 2 pieces of disintegrating white soap: one in between the cold faucet handle and faucet, and one between the hot water handle and faucet. - On 7/30/24 at 10:14 AM resident room [ROOM NUMBER] had a bag of soap and shampoo for the dispenser on the sink in the bathroom. Unit 3 observations: - On 7/24/24 at 12:15 PM resident room [ROOM NUMBER] had a toaster and a microwave. - On 7/24/24 at 12:37 PM resident room [ROOM NUMBER] had a microwave with a 2024 black sticker on the appliance. - On 7/26/24 at 12:14 PM resident room [ROOM NUMBER] had a microwave on their dresser behind the bed. The microwave had a 2024 black circular sticker on it, - On 7/26/24 at 12:16 PM resident room [ROOM NUMBER] had a long dresser at the foot of the bed that had a four-slice toaster and a small microwave; both items had a circle sticker with 2024 on it. During an interview on 7/29/2024 at 4:58 PM, the Director of Nursing stated the procedure for residents who brought in their own items was the unit clerk would put in a work order for the maintenance department, and a maintenance employee would go to the floor and inspect the equipment before use. Staff would document what the maintenance staff was to inspect in the work orders and Maintenance would document what was inspected. They did have some residents who were allowed to have a microwave, but they did not have a toaster policy. They were not aware the resident in room [ROOM NUMBER] had a toaster. During an interview on 7/29/2024 at 5:02 PM, Registered Nurse Manager #28 stated the risk of having a toaster and microwave in a resident room could be the potential for something catching on fire and burning. There were some wandering residents on the unit, but they were unsure if they would wander into room [ROOM NUMBER]. They followed the directions on a package of food when heating up an item but did not take the temperature of the food, so there was always a risk of burns. Residents were not care planned to use a toaster or a microwave in their room, but they did have care plans for residents who preferred their coffee hotter. There should be a care plan to say if they could use the equipment properly. During an interview on 7/29/2024 at 5:07 PM, the Director of Plant Operations stated they did not have a master list of equipment/appliances residents could have in their rooms. A work order would document what the equipment/appliance was. They were unaware the resident in room [ROOM NUMBER] had a toaster. A toaster could pose a safety risk for fires, burns, and electrocution. During an interview on 7/30/24 at 10:19 AM, Unit Helper #21 stated residents were showered in the bathroom in their rooms. They did not believe medicated shampoos or soap bars were supposed to be left in the bathrooms, but it depended on what a resident's plan of care stated. Wheelchair leg rests were not supposed to be left out on the unit. There was a designated area to put wheelchair leg rests away as it was a safety hazard to leave them out. The clean utility room door should be pulled shut as that was where they stored their supplies and the clean laundry. They had several residents who wandered around the unit and in and out of other resident rooms. Resident #77 was one of those residents. During an interview on 7/30/24 at 10:30 AM, Licensed Practical Nurse #22 stated most of the residents on the unit wandered in and out of other resident rooms. The showers in resident rooms usually had a bin with soap in it that was locked up after the shower was completed. Soap bars were okay to be left in a resident's bathroom, but all liquid soaps should be locked up. They did not have travel containers for bar soaps on the unit and the bars of soap were just left out. The bags of shampoo and body wash for the dispensers should not be left on the floor. Medicated shampoo should not be left in a resident's room, it should be given back to the nurse or brought into the clean utility room. Wheelchair leg rests should not be left out on a table on the unit and were supposed to be put in a resident's closet, on the wheelchair, or a pocket on the back of the wheelchair when not in use. The clean utility room door should not be accessible to residents. They could get stuck in the room and panic if the door was to shut completely behind them. During an interview on 7/30/24 at 10:48 AM, Certified Nurse Aide #23 stated they had several residents who wandered in and out of other resident rooms and removed items. If a resident was showered in their room, medicated shampoos should go back to the nurse to be locked up in the medication room. Non-medicated shampoos should be locked up in a resident's closet or in the cabinet in the resident's bathroom. Bars of soap were not to be left out and could be stored in the mirrored cabinet. Soap that was left out could be a hazard as a resident could eat it. The soap bags that went into the dispensers should be thrown out when empty and placed in the dispensers when full. Wheelchair leg rests should not be left out as a resident could pick them up or trip over them. The clean utility room door should be pulled shut and locked. During an interview on 7/30/24 at 11:32 AM, the Director of Nursing stated they were aware that Resident #77 had two incidents where they attempted to ingest a bar of soap. The soap was now non-toxic because of the incidents. Some residents had soap bars accessible in their rooms if they were able to use them independently; otherwise, they were locked in their closets in shower caddies. The bagged shampoo and soap for the dispensers should not be left on the sinks or the floors of resident bathrooms. Medicated shampoos and wound washes should not be left in resident rooms, as they could be a potential hazard on the dementia unit. Wheelchair leg rests should not be left out on the dementia unit. Residents could pick up the leg rests and they could be a potential hazard. A maintenance or bio-med employee leaving their cart on the dementia unit unattended was not appropriate, and leaving their cart on outside of a closed door was considered unattended. During an interview on 7/30/2024 at 11:54 AM, the Director of Plant Operations stated when maintenance went to the dementia unit, they were supposed to keep all their tools secured and not out on the unit. They should also take as little equipment as possible onto the unit. The bio-med staff member who was on the unit with the open cart was contracted with the hospital. Contracted employees went through the same trainings as the facility staff. During an interview on 7/30/2024 at 12:03 PM, Bio-Med Technician #25 stated they were on the dementia unit recently. They had not received any training regarding dementia residents or the dementia unit specifically, only safe patient handling. Their open cart should not had been left unattended while on the dementia unit. Going behind a closed clean utility door with their cart outside the room in the hallway was considered unattended. An unattended cart could have been taken by a resident and items including needle nose pliers and other equipment, could be considered a safety hazard if left unattended on the dementia unit. 10 NYCRR 483.25(d)

Based on observation, record review, and interview during the recertification survey conducted 7/24/2024-7/30/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 1 of 1 resident (Resident #85) reviewed. Specifically, Resident #85 had 6 medications left in a medication cup in their room and there was no documented evidence the resident was assessed to determine their ability to safely self-administer medications or had a physician order for self-administration of medications. Findings include: The undated facility policy, Self-Administration of Medications, documented if a resident wished to self-administer medications the interdisciplinary team would assess the resident's cognitive, physical, and visual abilities to administer his/her own medications. Resident #85 had diagnoses including dementia. The 4/30/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required set-up or clean-up assistance for eating and oral hygiene, and was dependent to substantial/maximal assistance for all other activities of daily living. The 5/21/2024 quarterly comprehensive care plan meeting note by Social Worker #6 did not document if the resident was able to self-administer medications. Physician orders for routine medications as of 7/25/2024 documented: - amlodipine besylate (treats high blood pressure) 10 milligrams by mouth daily (order date 11/29/2022). - aspirin enteric coated 81 milligrams by mouth daily (order date 11/29/2022). - losartan potassium (treats high blood pressure) 50 milligrams by mouth twice daily (order date 11/28/2022). - budesonide/formoterol fumarate (treats lung disease) 2 puffs twice daily (order date 11/28/2022). - furosemide (diuretic) 40 milligrams daily (order date 12/6/2022). - umeclidinium bromide (treats lung disease) 62.5 micrograms inhale daily (order date 7/20/2023). - atorvastatin calcium (treats high cholesterol) 40 milligrams by mouth every 48 hours (order date 2/13/2024). - famotidine (treats excess stomach acid) 20 milligrams by mouth daily (order date 3/20/2024). - glipizide (treats diabetes) 5 milligrams by mouth daily (order date 7/13/2024). - insulin human lispro (rapid acting insulin) subcutaneous injection before meals and at bedtime/sliding scale (order date 7/1/22024). - insulin glargine (long-acting insulin) 5 units subcutaneous injection twice daily (order date 7/12/2024). - alendronate sodium (treats osteoporosis) 70 micrograms by mouth every 7 days (order date 7/25/2024). There was no physician's order for the resident to self-administer medications. The July 2024 Medication Administration Record documented the following medications were administered to the resident on 7/25/2024 during the morning (day shift) medication pass by Licensed Practical Nurse #9: - amlodipine besylate 10 milligrams at 9:12 AM. - aspirin enteric coated 81 milligrams at 9:18 AM. - losartan potassium 50 milligrams at 9:17 AM. - furosemide 40 milligrams at 9:18 AM. - famotidine 20 milligrams at 9:18 AM. - glipizide 5 milligrams at 9:18 AM. There was no self-administration of medications assessment in the resident's medical record. During an observation on 7/25/2024 at 9:22 AM, the resident had a medication cup on their overbed tray table in their room. The cup contained 6 various sized white pills. The medication nurse, Licensed Practical Nurse #9, was in another resident room. At 9:49 AM Resident #85 stated they had taken their pills. The empty medication cup was observed in the trash can. During the continuous observation from 9:22 AM to 9:49 AM, Licensed Practical Nurse #9 never re-entered the resident's room to verify they had taken their medications. During an interview on 7/26/2024 at 9:35 AM, Resident #85 stated the nurses sometimes left pills on their overbed table without watching them take the pills. During an interview on 7/29/2024 at 11:46 AM, Certified Nurse Aide #7 stated they had never seen any medications left in a residents' room on Unit 2 and was not aware of any residents who could self-administer medications. During an interview on 7/29/2024 at 10:51 AM, Resident #85 stated they did not recall nurses ever coming to their room to conduct a medication self-administration assessment. During an interview on 7/29/2024 at 11:52 AM, Licensed Practical Nurse #8 stated there were a few residents on Unit 2 who could self-administer medications. They had the names of residents who could self-administer medications on a piece of paper they could refer to during the medication pass. Resident #85 was not on the list. They thought either a registered nurse or the physician assistant made the determination for a resident to be able to self-administer their medications. During an interview on 7/29/2024 at 1:13 PM, Licensed Practical Nurse #9 stated they knew which residents could self-administer medications because their names were highlighted on a sheet of paper they kept on top of the medication cart. They would never leave pills in a resident's room, and they would always make sure a resident took their pills before they left their room. They thought they had worked on Unit 2 7/25/2024 but could not recall Resident #85. During an interview on 7/30/2024 at 10:37 AM, Registered Nurse Unit Manger #10 stated there was a medication self-administration assessment tool and registered nurses completed them quarterly. A resident had to have a Brief Interview for Mental Status score higher than an 8 (moderate to intact cognition) for them to complete the self-administration of medications assessment with a resident. Resident #85 could not self-administer medications and they could not have medications kept at their bedside because their Brief Interview for Mental Status score was 6 (a score of 0 - 7 indicates severely impaired cognition). For residents who could not self-administer their medications, they expected the medication nurses watch them take their medications and not leave the medications at the bedside. This could cause the potential for another resident coming into the room and taking the medications. If medications were left in a room for a resident to take without follow-up from the nurse, the resident might not take their medications appropriately. 10NYCRR 415.3(e)(1)(vi)

Based on observation, interview, and record review during the recertification survey conducted 7/24/2024-7/30/2024, the facility did not ensure residents were provided appropriate assistive devices and appropriate assistance to maintain or improve their ability to eat and or drink independently for 1 of 1 resident (Resident #29) reviewed. Specifically, Resident #29 was not served food or drinks at meals as planned. Findings include: The facility policy, Meal Delivery, revised 1/2024, documented dietary staff would load meal trays in the kitchen with the appropriate meal service items according to the meal ticket before each meal. This would include adaptive equipment. Meal tickets would be carefully reviewed when passing meal trays to ensure the correct resident was served, all adaptive equipment was present, and tray notes were reviewed. If staff believed something on the meal ticket or the meal itself was incorrect, the meal should not be served, and the Dietary Department contacted for a replacement meal. Resident #29 was admitted to the facility with diagnoses including dementia with behaviors, history of a stroke, and catatonic disorder (neuropsychiatric disorder that can cause abnormal movements). The 5/13/2024 Minimum Data Set assessment documented the resident had moderate cognitive impairment, required supervision or touching assistance with eating, and had a mechanically altered diet. The 10/13/2023 Occupational Therapist #31 evaluation documented Resident #29 had increased tremors with feeding and required maximal assistance. The prior level of functioning was supervision to touch assistance with eating, cups half-full, food in bowls, unbreakable meal service items, one item at a time with no tray, soup spoons, and remove empty items as finished with them. Staff needed reeducation regarding the resident's care plan for one item at a time and cups half full. No changes to care plan were needed. The 5/15/2024 quarterly dietary assessment documented the resident had an easy to chew regular diet with thin liquids. Their weights were stable, and the resident had adequate meal intakes. The resident was to receive supervision, touching assistance with partial or moderate assistance for meals. The assessment did not document adaptive equipment. The 5/30/2024 updated comprehensive care plan documented the resident needed assistance with eating. Interventions included supervision or touch assistance, fill cups only half-full, food in bowls, soup in mugs, plastic dishes due to resident having a history of throwing them, one item at a time, do not give a tray, remove each dish immediately after the resident finished one, and provide a soup spoon instead of regular spoon. The resident should sit in a regular chair with their feet on the floor in the dining room. Encourage the resident to eat in the dining room but may eat at desk if overstimulated. The 7/25/2024-7/30/2024 Resident #29's meal tickets documented supervision at meals, fill cup half-full, no knife, use unbreakable dishes, one item at a time, food served in bowls, soup in a mug, use a soup spoon instead of regular spoon, and do not use glass dishes. The 7/2024 meal consumption records documented the resident required set-up to maximal assistance for eating and the resident ate 50-100% most meals. Resident #29 was observed at the following times: - on 7/24/2024 at 12:46 PM, the resident was brought into the dining room for lunch. Their meal ticket documented food in bowls (was circled), soup in mug, soup spoon, no glass dishes, regular easy to chew food texture, thin liquids, fill cup half-full, no knife, unbreakable dishes, items one at a time, and supervise. The resident received a ground hot dog on a bun and a peeled banana served on a regular plate. Three cups were placed on the table within the resident's reach. One cup was 3/4 full of iced tea and one cup was filled almost to the brim with chocolate milk. - on 7/24/2024 at 1:05 PM, Registered Nurse #29 came to the table where the resident was seated, stood next to them, and moved the drinks, bowl of beans, and macaroni salad closer to the resident. The nurse gave the resident a spoon, the resident took a bite of food, and the nurse left the dining room. The nurse returned to the dining room a minute later and wiped up a mess the resident made on the table. The nurse put the beans and macaroni salad on the resident's plate and stood next to the resident while the resident was eating. The nurse redirected the resident at times. - on 7/26/2024 at 12:53 PM, Activities Director #30 brought the resident into the dining room where their lunch was sitting at the table. The resident was served a cup of chocolate milk that was filled almost to the brim. At 1::08 PM, Licensed Practical Nurse #22 served the resident a sandwich and cheese doodles on a regular plate. - on 7/29/2024 at 12:46 PM the resident was served a cup of chocolate milk filled to the brim with chocolate milk. The resident's meal was served in separate bowls and provided to the resident all at the same time. During an interview on 7/30/2024 at 10:30 AM, Licensed Practical Nurse #22 stated Resident #29 should not have been given all their bowls at once on the table. If Resident #29 received all their bowls at once on the table, they would become overwhelmed and play with their food instead of eating it. They stated Resident #29 should not be given full glasses when their meal ticket listed half-full because when they picked up the glass their hands shook, and the liquid spilled out of the cup. During an interview on 7/30/24 at 10:40 AM, Food Service Director #1 stated meal ticket directions were generated by the dietitians and therapy. Residents were evaluated and the dietitians updated residents' tickets based on the evaluation. The Director expected staff to prepare the meal per each resident's meal ticket instructions. Meal tickets were printed daily. During an interview on 7/30/2024 at 10:48 AM, Certified Nurse Aide #23 stated they were responsible to ensure the special instructions on meal tickets were followed. Resident #29's food should be served in bowls, glasses of liquids should be served half-full, and food should be given one item at a time in a bowl for every meal. These instructions were important because the resident threw their food and cups at times. They stated staff that floated to the unit did not always follow meal ticket instructions. During an interview on 7/30/2024 at 12:17 PM, Registered Dietitian #29 stated the special instructions on residents' meal tickets were provided by input from Nutrition, Occupational Therapy, and Speech-Language Pathology. It was the responsibility of the Dietary Department and Dietary Supervisors in the kitchen to update resident tickets as appropriate. They expected staff to follow the instructions that were on the ticket so the resident would have the best possible nutritional outcome, and to prevent any illnesses that might result from not eating well. 10NYCRR 415.14(g)

Based on observation, record review, and interview during the abbreviated surveys (NY 341 and NY 724) the facility failed to ensure residents were free from abuse for 1 of 4 residents (Resident #2) reviewed. Specifically: - On [DATE] licensed practical nurse (LPN) #7 was scratched by Resident #2 during care. LPN #7 returned to Resident #2's room and proceeded to the cut the resident's fingernails causing multiple superficial lacerations with profuse bleeding. - On [DATE] certified nurse aide (CNA) #10 was observed via video surveillance grabbing Resident #2 after the resident struck them with their walker; the resident lost their balance and fell to their knees; the CNA attempted to grab the resident's wrists and dragged the resident away from their chair; and slapped the resident's wrist. Findings include: The facility policy Abuse and Neglect/Complaint Investigation reviewed ,d+[DATE] documented the facility did not permit verbal, mental, sexual, or physical abuse. The facility provided initial and ongoing education for all employees which addressed abuse prevention. 1) Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, exhibited behavioral symptoms ,d+[DATE] of 7 days, behaviors significantly interfered with resident care, rejected care ,d+[DATE] of 7 days, and required extensive assistance with most activities of daily living (ADLs). The comprehensive care plan (CCP) initiated [DATE] documented the resident had cognitive loss and dementia. Interventions included allow ample time for resident to respond, approach in a calm manner, maintain quiet environment, discuss past happenings, give simple directions, increase distance if they cue to do so, the resident did not like being touched, allow to calm in room when agitated and/or avoid common areas. The CCP included multiple specific interventions for behaviors. The Investigation Summary Form dated [DATE] at 4:00 PM and completed by registered nurse (RN) #5 documented at 3:00 PM the event was discovered by the RN on the floor with CNA conversation at 3:00 PM. The resident had been agitated all day from 7 AM. LPN #7 and CNA #6 assisted the resident to bed at 3 PM. LPN #7 held down the hands and wrists of the resident. The resident pinched and attempted to bite LPN #7. LPN #7 went back in the room to cut the resident's fingernails and cut the resident's fingers. The physician was notified. CNA #6's statement documented when they were assisting the resident to bed LPN #7 was aggressive towards the resident, grabbing their wrist quite hard and the resident was upset. The CNA tried to get the LPN to stop. LPN left the room and the resident calmed. LPN #7 returned with nail clippers. CNA #6 told RN #5 the resident had calmed down when LPN #7 was trimming their nails, but CNA #6 needed to use the restroom so they left the room quickly. The investigation conclusion documented there was intimidation/abuse by LPN #7. The LPN returned to the resident's room after the altercation with intent to cut the resident's nails so they would not get dug again. LPN #7 was in the resident's room trimming nails from 3:09 PM-3:28 PM per video. CNA #6 went back to the room to find the room a mess and the resident in the hallway with LPN #7 and CNA #8. They were attempting to cover wounds that were bleeding profusely. The resident's wounds were covered, and CNA #6 brought the resident away from LPN #7 to the front of the nursing station. An immediate assessment of the resident and investigation was initiated. LPN #7 was removed from the building at 5:45 PM until the investigation was completed. Medical assessment by the physician assistant (PA) was completed. The X-ray of the left forearm was negative for fractures. The resident's family and Administrator were contacted. A staff statement dated [DATE] by LPN #7 documented the resident was having behaviors all shift since 7 AM. At about 3:00 PM LPN #7 and CNA #6 went to lay the resident down for a nap, during the transfer the resident began to dig, slap, punch, pinch, and kick at both. The resident also attempted to bite them. The LPN stated their arms were covered in pinch and dig marks. They went and got nail clippers and clipped the resident's nails. They were in the room about 15 minutes. They did not notice any bleeding until they were done with the second hand and then noticed blood on the resident's pants. They got up and got a wet towel and the resident started to slap them, causing what looked like a lot of blood go all over them, the bed, and the floor. The LPN would almost get the bleeding stopped when the resident would start slapping them. The LPN went back to the bathroom to wash their hands and arms and the resident walked out the door. The Supervisor walked onto the floor and was informed what was going on. A staff statement by CNA #6 dated [DATE] documented they helped LPN #7 put the resident in their room. The LPN said they were going to clip the resident's nails, so they waited in the resident's room. LPN #7 clipped the resident's thumb nail, and it was not bleeding. They left the room and then heard someone screaming and they thought it was another resident. When they were down the hallway CNA #8 yelled, they needed help. When CNA #6 got to CNA #8 there was blood everywhere, all over the resident's hands, on the bed sheets, and on the floor. They ran to get the Nurse Manager. When CNA #6 was with the resident they also found a bump on their arm and notified the Nurse Manager. Prior to the nails being clipped, the resident was very agitated towards LPN #7 and LPN #7 was very aggressive towards the resident and grabbing their wrist quite hard. They tried to get the LPN to stop but they did not listen. The resident was in the bed with LPN #7 holding them down. When LPN #7 left the room the resident calmed down. When the LPN came back to clip the nails, the resident became agitated again. A staff statement dated [DATE] by registered nurse Supervisor (RNS) #5 documented they were on the floor at the nursing station when the resident was wheeled to the nursing station by CNA #6. The resident's hands had small bandages on a few fingertips and sanguineous drainage was coming through the bandages. CNA #6 stated LPN #7 clipped the resident's fingernails, and they were bleeding badly. RNS #5 went to the resident's room and found sheets, towels, floors, room separator curtain, and the floor outside of the room had large amounts of blood on them. The resident received [MEDICATION(S)] and [MEDICATION(S)] (blood thinners). The Director of Nursing (DON) was called. LPN #7 told RNS #5 flatly, with no emotion, they clipped the resident's nails and did not know they were bleeding until later. The LPN showed no remorse or emotion. The physician assistant (PA) was called immediately. RNS #5 attempted to assess the hands, but the resident was nervous and agitated. The PA assessed the resident and noted the left forearm was bruised with [CONDITION(S)] and new purple in color. Another bruise had started on the left hand. An X-ray was ordered to rule out a fracture. The left hand had lacerations at the fingertips of the 1st, 2nd, and 3rd digits. Another LPN was called to take over for LPN #7. The LPN was removed from the facility and informed not to return until investigation was completed. A nursing note dated [DATE] at 4:17 PM by LPN #7 documented they clipped the tip of 2 fingers on each of the resident's hands and did not notice bleeding right away, but once bleeding occurred it would not stop. The Supervisor was notified. A progress note by PA #9 dated [DATE] documented the resident was seen for bleeding on multiple fingertips following fingernail trimming by staff earlier that day. Nursing staff reported they were trimming the resident's nails as was routinely done and did not notice the bleeding until trimming was complete. Nursing staff also noticed some swelling on the dorsal left forearm that they were not previously aware of. The resident reported moderate pain associated with the wounds on the fingertips and swelling to forearm. There were ,d+[DATE] fingertip wounds on each hand, each approximately 1 centimeter (cm) long, superficial, and linear in nature. The resident continued to bleed from these wounds minimally. The resident was on [MEDICATION(S)] and [MEDICATION(S)] (blood thinners) which complicated hemostasis (stopping blood flow). An X-ray would be ordered to rule out fracture of the forearm. Nursing staff were to dress the wounds with gauze and adherent dressing with mild to moderate compression to achieve hemostasis. An X-ray of the resident's left forearm dated [DATE] at 4:25 PM documented the resident had dorsal swelling of the mid forearm. There was no acute fracture A [DATE] at 12:45 PM progress note by the Assistant Director of Nursing (ADON) #11 documented the resident had a bruise, light blue/purple in color along the right jaw close to the mouth area extending under the chin. An Administrator progress note dated [DATE] at 12:42 PM documented the incident was reviewed by the Interdisciplinary Team, care plan violations noted regarding how to approach the resident while behavioral. Harm was caused to the resident when their fingernails were cut to a short length, nicking the skin around and under the nails. 4 fingertips were bandaged due to bleeding after the incident, and the resident was on blood thinners. The resident was seen by medical, bandages were discontinued, and wounds were left open to air. The incident was reported to the NYSDOH. LPN #7 and CNAs #6 and 8 were unable to be reached for interviews after multiple attempts. [DATE] 1:50 PM ADON #11 stated they were no longer employed at facility but remembered the incident. All the information they had was 3rd hand. When they saw the resident, their hands were dressed and all information about the incident came from RNS #5. During a telephone interview with RNS #5 on [DATE] at 8:50 AM they stated they remembered the fingernail trimming incident well. They had worked later that day for some reason and was still at the facility. LPN #7 had gone in to trim the resident's nails and closed the door. CNA #6 came and got them and said they were worried about the resident. RNS #5 went in the room and the resident's fingers were bleeding. The resident was on blood thinners and there was a lot of blood. The resident at that time was much more cognitively aware, and they expressed fear of LPN #7. LPN #7 told the RNS they had to hold the resident down to clip their nails. The LPN said they had not seen any blood when they were trimming. The nails had been cut far shorter than they should have been. LPN #7 had cut the skin underneath the nails and along the sides of nails. The resident usually wore their nails long, that was their preference. The resident would dig their nails into people if they became agitated. The RNS said they had never seen anything like the condition of the fingers after the trimming. When they interviewed LPN #7, the LPN showed no emotion at all and had no remorse. The LPN said the resident needed their nails trimmed. The resident was often scared of the nurses and this event made it worse and the resident suffered a lot of trauma from this. This was LPN #7's regular unit they worked on. All staff were educated during orientation on abuse and on dealing with residents with dementia. They did not believe the LPN had previous issues with resident care while working on the unit. After they assessed the resident, they had the LPN come to their office and had them hand over the keys to another LPN and had them leave the facility. The LPN should not have attempted to trim the resident's nails when they were agitated. They needed to step back and have someone else reapproach the resident later if the nails required trimming, usually a supervisor. They should have let it be. The LPN was not wearing the arm protectors which they should have been. Sometimes the arm protectors were difficult to get to and put on quickly if the care was immediate. If the LPN went in knowing they were going to cut nails, they should have put them on ahead of time. When the RN went in to assess the resident, they had bandages on their hands. The PA assessed the resident and there were bruises on the arm and on the face, like a C-cup hold when you hold someone's head during CPR. It looked like the resident was held down causing bruises. The RNS stated they could not be sure they were caused by the LPN but there were no other reported incidents after the nail trimming. The RN stated they had never seen actual abuse until this and was very upset that it could happen. During an interview with PA #9 on [DATE] at 10:26 AM they stated they no longer worked at the facility and did not remember the incident. During a telephone interview on [DATE] at 1:14 PM with the current DON they stated they were a Nurse Manager at the time of the incident. They remembered and was involved with the incident. LPN #7 and CNA #6 had taken the resident to their room to put in bed and the resident became behavioral. The CNA left and the LPN was alone in the room with the resident and clipped their nails. There was bruising and it appeared the resident's hands had been held down to clip the nails. They were too short and were bleeding. The resident was on a blood thinner as well which made the bleeding worse. The LPN left the room and did not report it to anyone. The resident had wheeled out into the hallway when the CNA saw the blood and called RNS #5 who was also the Nurse Manager on the resident's unit. RNS #5 obtained a statement from LPN #7 and sent them home right away. The LPN never returned to the facility and was terminated. The incident appeared suspicious. The LPN had received abuse training at the facility at least once. 2) Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Minimum Data Set (MDS) documented the resident had moderate cognitive impairment, required extensive assistance of 2 for walking in room and corridor, used a wheelchair and walker for mobility, had verbal and physical behavioral symptoms directed toward others, behaviors put the resident and others at significant risk for injury, the behaviors significantly interfered with care, and had 2 falls without injury and 2 falls with injury. The resident preference and function initiated [DATE] documented behavior interventions included hand massage, one to one time when agitated, frequent visual checks, offer a different person when agitated, take to a back common area for a change of view, reapproach and redirect, during times of extreme agitation may make resident 1:1, may allow to calm in room, don Derma Sleeves if resident is combative to protect arms. Resident to wear Geri sleeves to both arms to protect from bruising. Resident does not like being touched The CCP dated [DATE] documented the resident had potential for inappropriate behaviors. Interventions included remind resident, q 1 hour visual checks, answer call light promptly, offer toileting, food, and drink, redirect as needed, allow to calm in room when agitated and/or avoid common areas. The Investigation Summary Form dated [DATE] by RN Unit Manager #2 (current Director of Nursing) documented at 7:52 PM CNA #10 was ambulating with the resident, the resident became behavioral per the CNA, and fell . A video review showed CNA #10 pulling at the resident, causing a fall, and a physical altercation followed the fall. The CNA stated the resident was behavioral causing themselves to fall. A full body check was completed by the nurse practitioner (NP) on [DATE]. The video was reviewed after the fall was reported by CNA #10. The video showed CNA ambulating towards another resident, who they were waving to. A conversation was had, and the resident lifted their walker and struck CNA #10 with it. The CNA immediately grabbed the resident as to hold them down causing the resident to lose their balance. CNA appeared to try to get resident into the chair, which was approximately 5 feet ahead of them, Resident #2 was resistive and went to their knees as CNA #10 was holding the resident. CNA #10 then attempted multiple times to grab the resident's wrists. Resident again resisted; CNA then dragged the resident away from the chair. Resident #2 slapped at the CNA, and the CNA slapped the resident's left wrist. The CNA let go of the resident and called for help. Resident #2 crawled to the chair, got up and into the chair independently. The plan of correction was CNA #10 was suspended pending investigation and was terminated on [DATE]. The resident was assessed by nursing, medical, and social services. Resident #2 was found to have a [CONDITION(S)] and began antibiotic treatment for 7 days. Mandatory abuse training for all nursing home employees beginning [DATE]. A [DATE] statement written by CNA #10 documented the resident had been agitated because they did not want their shoes on. After the resident put their shoes on, they started heading to the main double doors. CNA #10 stood in front of the doors to prevent the resident from trying to push open the door. Resident #2 saw another resident and began heading toward them. CNA #10 tried to get the resident to sit down before they fell . IN the process the resident started hitting the CNA with their walker. The resident tried to bite the CNA while they were trying to stop the resident from hitting them with the walker. The resident scratched the CNA's right upper arm. The CNA noticed the resident started to fall and they grabbed the resident and slowly lowered them to the ground. The CNA was calling for help from other staff the whole time. A NP #15 progress note dated [DATE] documented the resident was seen for examination related to an abuse allegation. The resident stated they were afraid of people, did not appear traumatized and had not slept in nearly 48 hours. The NP was uncertain if the resident could remember incident with clarity. There was a fearful component and they appeared very hypervigilant. There was significant bruising to the right wrist and fingers in various stages of healing. An X-ray was obtained, and no fracture was seen. There appeared to be no further signs of physical abuse, the psychological signs of abuse would need to be continuously followed. Multiple attempts to contact CNA #10 were made with no result. A certified letter was sent on [DATE] with no response. During an interview on [DATE] at 8:50 AM with RN Unit Manager #5 they stated they were the UM on the dementia Unit. They did not remember CNA #10 very well and the CNA no longer worked there. The resident had behavioral issues and could be resistive. If the resident became aggressive staff should tag out which meant to keep the resident safe but back off to deescalate the situation. Staff would have to take a step back and let it be and not push the resident. When staff started directing the resident, the resident would become more agitated. This would include letting the resident stand if they were trying and if they thought the resident was going to fall, they should ask for help. If the resident hit staff, they should not have gone back and made the situation worse. Let the resident be and walk away. The resident got frustrated with younger staff and liked to have conversations and ask about families. They liked to be doted on and talk about life. The resident had said I feel trapped. I never thought I would be here. In 2021 the resident could have conversations but lately medically had declined and was not really the same. Physical changes had lessened the aggression. The incident with the resident was on video and it was apparent CNA #10 did not act in an appropriate manner and should not have caused the resident to become more agitated. There were no witnesses, and the CNA was terminated. During an interview on [DATE] at 1:14 PM with the DON they stated after reviewing the video of the events they concluded abuse did occur when the CNA forcefully grabbed the resident and the resident fell . There were no witnesses. The CNA was terminated. The CNA did not work at the facility very long and had not had any previous concerns. They had abuse training and the behavior was not acceptable. The resident had interventions in place when they became behavioral, and the CNA did not attempt any of the interventions. 10NYCRR 415.4(b)

Based on observation, record review and interview during the recertification and abbreviated surveys (NY 492) conducted 6/28/22-7/6/22, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #37) reviewed. Specifically, Resident #37 was at risk for falls, was not using their wheeled walker and was not assisted when ambulating as planned and sustained a fall with a pelvic fracture. Additionally, the resident was observed using a bassinet as an assistive device for ambulating and did not have non-skid floor strips in place in their room as planned. This resulted in actual harm to Resident #37 that was not Immediate Jeopardy. Findings include: The facility policy Fall Team reviewed 1/2020 documented the fall team consisted of the Director of Nursing (DON), Nurse Managers, social work, occupational/physical therapy (OT/PT), and activities. The fall team would meet each weekday to review those residents who had a fall. All falls that had occurred since the last review would be reviewed to determine the root cause of the fall. The team would collaborate to determine new and appropriate interventions and document in the progress note and care plan the date and implementation of all safety measures. Residents whose interventions were not working would be evaluated. A therapy evaluation would be requested after two falls in 30 days. Falling star (yellow sign) would be placed outside the resident's bedroom door or on a personal mobility device to indicate high fall risk. The facility policy Fall Protocol revised 1/2020, documented fall prevention measures included frequent reorientation and repetitively reinforcing the use of the call bell and making sure it was within reach, reassessing for a clutter-free, well-lit environment, adjusting the bed to its lowest position, and reinforcement of the use of assistive devices. Resident #37 had diagnoses including Alzheimer's Disease with behavioral disturbances. The 1/13/22 Minimum Data Set (MDS) assessment documented the resident had 1 fall without major injury since the last assessment. The 2/5/22 MDS assessment documented the resident had moderate cognitive impairment, did not wander, required extensive assistance of 2 for bed mobility, transfers and walking in room, limited assistance of 2 for walking in the corridor, extensive assistance of 1 for locomotion on unit, was not steady walking and was only able to stabilize with human assistance, used a walker and wheelchair, and had no falls since admission or prior assessment. The 6/15/22 MDS assessment documented the resident required limited assistance of 1 with walking in their room and corridor, and supervision with assistance of 1 for locomotion on the unit. A 1/1/22 maintenance work order documented to place non-skid strips in front of Resident #37's bed and recliner. The order was completed on 1/1/22 at 2:48 PM by maintenance worker #32. A 1/12/22 fall risk assessment by registered nurse (RN) #20 documented the resident was impaired with gait/transferring, had a history of falls, used a walker, and was assessed as a high fall risk. The care assessment (comprehensive care plan, CCP) dated 2/28/22 documented to encourage the resident to ambulate to the toilet and dining room with the use of 2 wheeled walker or hand held assistance, and limited assistance of 1. The resident needed cues for use of the wheeled walker. Fall precautions included toileting schedule, and non-skid strips by the bed and chair. Behavior interventions included to keep one bassinet in room to reduce stress. A maintenance work order dated 3/7/22 documented a request to patch and paint a hole in the resident's room, environmental services was asked that floor waxing was to be done and was needed ASAP. The work order documented that on 3/8/22 plant operations worker #49 completed their portion. There was no documentation the non-skid floor strips were removed for waxing or replaced if they had been removed. An incident and accident report dated 4/11/22 at 8:25 PM documented Resident #37 had a witnessed fall in the hallway. The resident was ambulating, lost their balance and was incontinent. The resident did not use their assistance device properly. Injury site documented none, left leg, and injury type documented none, fracture. The post fall assessment documented the resident fell while ambulating and was lying on their left side in the hallway in front of their room. The resident was unable to describe the fall. No evidence of any injury was noted on physical assessment, no complaints of pain or injury by the resident, and no change in the resident's behavior was noted. The resident had assistive devices including a standard walker. The resident was screened a future fall risk. Fall interventions included instruct resident and reinforce safety precautions, physical therapy (PT)/occupational therapy (OT) consult as needed, assess for environmental factors that contributed to fall, educate resident if needed, offer frequent repositioning and toileting. The 4/11/22 incident report included the following addendums: - by registered nurse (RN) #47 on 4/11/22 at 11:52 PM, was notified at approximately 8:25 PM the resident fell in the hallway while walking into their room. The fall was witnessed by maintenance worker #25 who stated the resident did not hit their head. The resident was wearing proper shoes and was not utilizing their walker. - by RN #21 on 4/12/22 at 9:31 AM, video was reviewed, the resident was seen trying to move a Geri chair (positioning chair), a maintenance person was seen coming down the hallway and the resident lost their balance. The plan included to keep the walker with the resident, hourly checks, and follow up with staff. - by the Director of Nursing (DON) on 4/13/22 at 9:30 AM, the resident complained of pain to left side/pelvic region, assessment completed, and X-ray ordered. The X-ray results included a left superior and inferior pubic ramus fracture, diffuse osteopenia (loss of bone mineral density), no hip fracture seen. - by RN Nurse Manager #20 on 4/13/22 at 10:04 AM there were no care plan violations. The resident had increased pain, X-ray done, see impression. Obtain PT/OT evaluation. Witness statements included: - on 4/12/22 at 4:29 PM, maintenance worker #25 stated they were exiting the elevator and saw the resident standing at a chair outside their room. The resident was holding onto a movable chair walking toward their room and fell to the ground. The resident's walker was in their room. - on 4/12/22 at 5:01 PM certified nurse aide (CNA) #48 stated the resident had behaviors during their shift and was hyper focused on their baby dolls, would not use their walker after multiple attempts from the CNA and other staff members. The resident had multiple emotional and angry outbursts when staff attempted to provide care. The resident was walking around the unit throughout the shift with their bassinet and would not stay seated for very long. They did not witness the fall but had seen the resident sitting in a regular chair with their babies next to them. There was no documentation how the facility determined there were no CCP violations related to the fall with fracture when the resident was not using their walker or assisted by staff with ambulation as planned. The 4/13/22 PT #33's evaluation documented the resident had 4 falls over the past year and during the last fall was not using their walker. The resident had previously been encouraged to use the wheeled walker but at times was too distracted and hand held assistance worked best. They documented the resident also used their bassinet full of baby dolls and other furniture to walk around the unit. The Physical Therapy recommendations documented to use a stand lift if resident was unable to walk with their 2 wheeled walker and use a commode if unable to walk to the bathroom. The 4/13/22 OT #34's evaluation documented the resident was encouraged to use the 2 wheeled walker and that staff would find the resident using furniture to steady themselves. Recommendations included 1-2 assistance with a 2 wheeled walker and to use a stand lift if the resident was unable to walk due to impaired safety awareness. The care assessment dated [DATE] at 7:17 PM documented encourage to ambulate to toilet and dining room using a two wheeled walker or hand held assistance and limited assistance of 1, needed cues for wheeled walker use. On 4/13/22 at 1:16 PM and updated, documented therapy only at this time for ambulation and at 2:43 PM assist of 1 with ambulation with 2 wheeled walker if the resident chose to walk. Do not force unless they chose to walk. Toileting schedule, keep walker with the resident, non-skid strips by bed and by chair. A 4/14/22 progress note by nurse practitioner (NP) #12 documented that they had consulted with orthopedic physician assistant (PA) #26 and the order for Resident #37 was weight bearing as tolerated and pain management and to work with PT. A 5/1/22 post fall assessment documented by RN #10 documented the resident had a history of falls, used a walker and was a high fall risk. The Resident Preference and Function effective on 6/7/22, documented the resident required supervision to limited assistance if they chose to walk. Do not force unless the resident chose to walk, and make sure they used their walker. Keep walker with resident, auto lock brakes on wheelchair, non-skid strips by bed and chair. The 6/7/22 CNA care instructions documented Resident #37 required supervision to limited assistance of 1-2 for bed mobility, transfers, and walking, and required a 2 wheeled walker and strips were to be in front of the bed and recliner as fall precautions. Resident #37 was observed: - On 6/28/22 at 10:14AM, sitting in the hallway with a bassinet containing several baby dolls and stuffed animals in front of them. No walker was observed next to the resident. - On 6/29/22 at 1:28 PM, pushing a bassinet containing baby dolls and stuffed animals down the hall with no staff assistance. CNA #28 was on a computer and was observed watching the resident walk towards them and they did not get up to assist the resident. - On 6/30/22 at 10:53 AM, ambulating in their room with no walker and no supervision from staff. Non-skid strips were not in place on the floor next to the bed and chair as care planned. - On 6/30/22 at 12:55 PM, pushing the bassinet containing baby dolls and stuffed animals toward the unit elevators without their walker. - On 7/05/22 at 4:34 PM, walking in the hall outside of their room without their walker and staff were not present. During an interview on 6/30/22 at 1:05 PM with CNA #28, they stated that they knew Resident #37 and they had had a fall in 4/2022, and they were care planned to use a walker. CNA #28 stated that anyone could give the resident their walker but that ultimately if it is listed on the CNA care instructions for the resident to use a walker, then the CNAs should be following the plan. During an interview on 7/01/22 at 12:29 PM, with PT #30 and OT #29, OT #29 stated they looked for function, mobility, environmental issues, strength, range of motion (ROM) and balance when they did a post fall evaluation on a resident. The OT stated they had completed a fall evaluation on Resident #37 in 4/2022 and determined they were a fall risk and therapy would implement any assistive devices. OT #29 stated that they send a care plan change of status to the nurses and CNAs for communication. OT #29 stated they did not think the use of furniture or other non-assistive devices were safe Resident #37 to use for walking. OT #29 stated they had not evaluated the resident's bassinet as an assistive device to be used when walking, and stated they trialed a different kind of bassinet from the maternity ward in the hospital for the resident to use but it was not safe. OT #29 stated there were no written evaluations for the items. PT #30 stated Resident #37 was care planned to always use a 2 wheeled walker. During an interview on 7/1/22 at 2:56 PM, RN #20 stated that they considered the resident to be a fall risk. They stated the resident was care planned to always use a 2 wheeled walker and that anyone could ensure they had it in front of them. RN Nurse Manager #20 stated that they and LPN #8 and the CNAs were ultimately responsible to make sure the resident used the walker. RN Nurse Manager #20 stated they did not know if the bassinet wheels locked, and it was not safe for them to be walking with it. The resident had been pushing their bassinet around most of the day on 4/13/22, then later was observed by maintenance worker #25 walking towards their room without a walker and falling. During an interview with LPN #8 on 7/5/22 at 4:36 PM, they stated that they thought therapy was responsible for placing a work order request for non-skid strips, but RN Nurse Manager #20 could also place them. During an interview with RN Nurse Manager #20 on 7/05/22 at 4:37 PM, they stated the non-skid strips on the floor in the resident's rooms were for fall precautions. The strips were not on the floor and the RN stated the reason was either the resident was not evaluated for them or that they may have been removed for floor cleaning. RN Nurse Manager #20 stated that the Nurse Managers were responsible for putting in work orders for the strip placements. Resident #37 had been care planned for floor strips to be placed in front of their bed and in front of their recliner in their room since 12/2021 for safety. They stated if the strips were not in place it could result in an additional fall with possible injury. During an interview on 7/6/22 at 9:55 AM with Plant Operations Supervisor #2, they stated when the Nurse Managers placed a work order into the computer, the plant operations staff received them in real time, and they would assign them to be completed. Usually, the therapy department would do a fall assessment to determine if non-skid strips were needed and the Nurse Manager would put the work orders into the computer. When interviewed on 7/7/22 at 3:50 PM, physician #19 stated they were uncertain if Resident #37 would have known to use their walker due to dementia and that the resident's fracture was a result of their fall. When interviewed on 7/6/22 at 3:22 PM, the Administrator stated they did not report Resident #37's incident because the Interdisciplinary Team (IDT) felt the resident did not have a care plan violation. 10NYCRR 415.12(h)(2)

Based on interview, and record review during the recertification survey conducted 6/28/22-7/5/22, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, Specifically, there was no documented evidence of a carbon monoxide (CO) policy and procedure including staff education on responding to a CO activation. Findings include: The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection (adopted by New York State), documented the requirement of facilities to have a policy for carbon monoxide detection and activation and for all staff to be trained on how to respond. The facility Emergency Preparedness and Disaster Plan with a revised date of 9/2021, did not include a policy and procedure for a CO activation incident in the facility. The annual staff training records for Emergency Preparedness had no documented evidence of training specific to CO and the response to the activation of a CO detector. When interviewed on 6/29/22 at 4:00 PM, the Director of Emergency Preparedness stated they were not aware of a policy and procedure on carbon monoxide emergencies. They did not think staff were trained specifically on the topic of carbon monoxide emergencies. 2012 NFPA 101: 2.2 2012 NFPA 720 2015 International Fire Code, Section 915 483.70 (b) 10NYCRR 400.2

Based on record review and interview during the recertification and abbreviated (NY 162) surveys conducted 6/28/22 to 7/6/22, the facility failed to ensure all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated for 1 of 9 residents reviewed (Resident #4). Specifically, Resident #4 sustained a burn from coffee, a timely assessment was not completed by the registered nurse (RN) which lead to confusion as to which arm sustained the burn. Findings include: The facility policy Incident Report Completion reviewed 1/2019 documented incident reports would be completed prior to the end of the shift when a resident had an injury of unknown origin or accident. If determined to be abuse, neglect, or failure to follow the plan of care, the Director of Nursing (DON) or Administrator must be notified immediately. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/28/21 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive to total assistance with most activities of daily living (ADL), and required supervision after set-up for eating. The resident had functional limitation in range of motion in one arm. The 5/31/21 care instructions documented to set-up the resident's cups with lids and straws; hot beverages were to be in mugs with lids; regular diet; position out of bed for meals, and to eat in a scoot chair (positioning chair) with right foot on the floor or in a recliner with both feet on the floor per preference. The facility incident report dated 8/26/21, documented: - the resident had a burn on the arm (did not specify which arm or location on the arm). - Registered nurse (RN) #35 documented on 8/26/21 at 2:48 PM, they were notified by an unidentified licensed practical nurse (LPN) the resident had a burn to the left arm and the LPN reported coffee was spilled on 8/25/21 on the resident's right arm. There was no redness to the right arm. Upon RN assessment, the resident had a 11.5 centimeter (cm) x 5.5 cm burn to the left arm that was bright red with closed yellow blisters. The resident denied pain, the left arm was immobile, and the resident stated they could not feel anything in that arm. The resident did not remember spilling anything today on their arm. The resident required set-up for meals and fed themselves. The nurse practitioner (NP) was notified, and ordered to wrap the area, so the area did not rub against anything to open the blisters. - LPN #41's statement dated 8/27/21 at 4:00 PM, documented the certified nurse aide (CNA) reported to them that they spilled coffee on the resident's good arm on (Wednesday) 8/25/21. When the CNA removed the lid from the coffiee cup, they spilled the coffee. LPN #41 observed the resident's arm (did not indicate which arm) and did not see any issues. On 8/26/21, a CNA reported a burn on the resident's left arm when they got the resident up for lunch. They notified the RN. CNA #37 told the LPN the resident's Hoyer pad (lift pad) had coffee spilled on it. - CNA #38's statement dated 8/27/21 at 4:33 PM, documented on (Wednesday) 8/25/21, the CNA brought the resident their tray at about 1:00 PM. The resident was sitting in their chair. When the CNA was giving the resident the tray the tray moved a little and coffee tipped over rand got on the resident. The CNA notified the LPN. On (Thursday) 8/26/21, the CNA was washing the resident and noticed a red mark on the resident's other arm, on the part close to the body, so the arm had to be moved out to see it. The 8/26/21 at 4:35 PM, Skin and Wound Observation flowsheet documented the resident had a burn to the left arm measuring 11.5 cm x 5.5 cm. The area was reddened and the resident could not tell whether it was painful or not due to not having feeling in that arm. Yellow closed blisters throughout, area wrapped with Kerlix (dry dressing), and the NP was notified. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Report to RN if blisters open. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover with non-adhesive dressing daily. When interviewed on 6/30/22 at 4:54 PM, CNA #39, stated the CNAs were to report any skin issues immediately to the unit nurse or Supervisor if the nurse was unavailable. When interviewed on 7/1/22 at 10:09 AM, RN #35 stated they recalled going to the unit as the resident had a burn. The RN thought it was on the resident's left side. Resident #4 had been in a recliner in their room with a bedside table in front of them. There was a reddened area that was measured when the resident was assessed. The resident did not appear to be in pain and medical was notified. Unit staff were expected to notify the Supervisor for a skin assessment even if they spilled cold coffee on themselves as it would be unknown if the coffee was hot or not. When interviewed on 7/1/22 at 11:54 AM, LPN #41 stated the resident ate in their room and used their right hand. The resident always had lids on the coffee mugs and staff did not think the lid was on completely when the coffee spilled. The resident frequently drank coffee. They were encouraged to go to the dining room but often refused. They were made aware of the burn mark, looked at it and notified the Supervisor. LPN #41 was not aware when the coffee was first spilled. When interviewed on 7/5/22 at 11:57 AM, RN Manager #20 stated all unit staff who were on duty when the burn was noted were interviewed. The incident report was started by the RN on duty and completed by the Unit Manager. Originally, there were no injuries noted when the spill first occurred. On 8/25/21, the LPN should have notified the on-duty RN about the CNA spilling coffee on the resident. There were no progress notes about the coffee spill until 8/26/21. RN #20 stated they did not know which arm the coffee was spilled on as an RN was not notified to perform an assessment. RN #20 stated they looked at the resident's arm on 8/26/21, the area looked like a drip line, did not realize it was the right arm, and did not document the observation. Unit staff were re-interviewed with no additions. The CNA stated they told LPN #41 and LPN #41 did not state which arm was injured. Monitoring of the area should have been done as the resident had no sensation in the effected arm. They did not know if the resident was sitting in their chair when the spill occurred. When interviewed on 7/5/22 at 12:54 PM, RN Manager #42 stated the investigation was started on 8/26/21 as the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #35 was covering as Supervisor and completed the assessment. RN #35 was notified by the LPN the resident had a left arm burn on 8/26/21. The CNA reported to the LPN coffee spilled on the resident's left arm on 8/25/21 and the LPN did not see any abnormality on the right arm. RN #42 stated the LPN should have made a progress note verifying they looked at the arm so there was documentation as to which arm was looked at and to tell the RN so they could assess the resident. Usually with [CONDITION(S)], abnormalities in skin condition show after time had passed and not initially. The process for incident reports was the RN Manager signed off for completion, it went to the Director of Nursing (DON) and Administrator reviewed it. When interviewed on 7/6/22 at 12:39 PM, the DON stated they expected LPN #41 to observe the area and document findings. At the time, LPN #41 did not document the observation or tell the RN about the incident, which was not good follow through. Left arm blisters were reported the next day (8/26/21) and assessed. During the investigation, it was determined CNA #38 reported the wrong arm being burned. The DON stated LPN # 41 should have reported the spill earlier so that they could have determined which arm had coffee spilled on it. 10NYCRR 415.4(b)(2,3)

Based on observation, record review, and interview during the recertification survey conducted 6/28/22-7/6/22, the facility failed to ensure that all alleged violations involving abuse and neglect were reported to The New York State Department of Health (NYS DOH) as required for 1 of 4 residents (Resident #37) reviewed. Specifically, Resident #37 required limited assistance of one for ambulation, sustained a fall with a fracture while ambulating independently and the incident was not reported to the NYS DOH as required. Findings include: The facility policy Incident Report Completion reviewed 1/2019 documented incident reports would be competed prior to the end of the shift. Upon completion of the report, it was reviewed by registered nurse (RN) Nurse Manager/Supervisor and then immediately forwarded to the Director of Nursing (DON). After review by the DON it was then forwarded to the Administrator and Risk Manager. If the report is determined to be resident abuse, neglect, misappropriation of property, sexual abuse, seclusion, significant injury resulting from staff negligence, mental abuse, or failure to follow the plan of care, notification must be made immediately to Administrator, DON, and/or Assistant Director of Nursing (ADON) in the absence of the DON. A determination must be made at that time of notification to the Department of Health reporting. The facility policy Abuse and Neglect/Complaint Investigation reviewed 5/2018 documented failure to follow the plan of care must be reported if one or both of the following occur: -there were repeated failures by staff to follow a resident's care plan. -resident harm had occurred that is related to a care plan violation. The DOH holds the facility accountable for monitoring staff to assure the care plan was followed. If, in addition to not following the plan of care, harm occurred, it must be reported. Resident #37 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/5/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, did not wander, required extensive assistance of 2 for bed mobility, transfers and walking in room, limited assistance of 2 for walking in the corridor, extensive assistance of 1 for locomotion on unit, was not steady walking and was only able to stabilize with human assistance, used a walker and wheelchair, and had no falls since admission or prior assessment. The care assessment (comprehensive care plan, CCP) dated 2/28/22 documented to encourage the resident to ambulate to the toilet and dining room with the use of 2 wheeled walker or hand held assistance, and limited assistance of 1. The resident needed cues for use of the wheeled walker. Fall precautions included toileting schedule, and non-skid strips by the bed and chair. An incident and accident report dated 4/11/22 at 8:25 PM, documented Resident #37 had a witnessed fall in the hallway. The resident was ambulating, lost their balance, and was incontinent. The resident did not use their assistance device properly. The post fall assessment documented the resident fell while ambulating and was lying on their left side in the hallway in front of their room. No evidence of any injury was noted on physical assessment, no complaints of pain or injury by the resident, and no change in the resident's behavior was noted. The resident had assistive devices including a standard walker. The resident was screened a future fall risk. Fall interventions included instruct resident and reinforce safety precautions, physical therapy (PT)/occupational therapy (OT) consult as needed, assess for environmental factors that contributed to fall, educate resident if needed, offer frequent repositioning and toileting. The 4/11/22 incident report included the following addendums: - by registered nurse (RN) #47 on 4/11/22 at 11:52 PM, who was notified at approximately 8:25 PM the resident fell in the hallway while walking into their room. The fall was witnessed by maintenance worker #25 who stated the resident did not hit their head. The resident was wearing proper shoes and was not utilizing their walker. - by RN #21 on 4/12/22 at 9:31 AM, video was reviewed, the resident was seen trying to move a Geri chair (positioning chair), a maintenance person was seen coming down the hallway and the resident lost their balance. The plan included to keep the walker with the resident, hourly checks, and follow up with staff. - by the DON on 4/13/22 at 9:30 AM, the resident complained of pain to left side/pelvic region, assessment completed, and X-ray ordered. The X-ray results included a left superior and inferior pubic ramus fracture, diffuse osteopenia (loss of bone mineral density), no hip fracture seen. - by RN #20 on 4/13/22 at 10:04 AM there were no care plan violations. The resident had increased pain, X-ray done, see impression. Obtain PT/OT evaluation. Witness statements included: - on 4/12/22 at 4:29 PM, maintenance worker #25 stated they were exiting the elevator and saw the resident standing at a chair outside their room. The resident was holding onto a movable chair walking toward their room and fell to the ground. The resident's walker was in their room. - on 4/12/22 at 5:01 PM certified nurse aide (CNA) #48 stated the resident had behaviors during their shift and was hyper focused on their baby dolls, would not use their walker after multiple attempts from the CNA and other staff members. The resident had multiple emotional and angry outbursts when staff attempted to provide care. The resident was walking around the unit throughout the shift with their bassinet and would not stay seated for very long. They did not witness the fall but had seen the resident sitting in a regular chair with their babies next to them. There was no documentation how the facility determined there were no CCP violations related to the fall with fracture when the resident was not using their walker or assisted by staff with ambulation as planned. When interviewed on 7/6/22 at 3:22 PM, Administrator #9 stated that they use the NYS DOH Reporting Manual to determine if an incident was reportable. The Administrator stated they did not report Resident #37's incident because the Interdisciplinary Team (IDT) felt the resident did not have a CCP violation. 10NYCRR 415.12 (b)(4)

Based on observation, record review, and interview during the abbreviated survey (NY 829) the facility did not ensure adequate supervision was provided to prevent accidents for 2 of 8 residents reviewed (Residents #1 and 4). Specifically, Resident #4 was planned to be on 1:1 supervision, the assigned certified nurse aide (CNA) was not educated on how to provide 1:1 supervision and Resident #4 had an altercation with Resident #1 where Resident #1 sustained pelvic fractures in 3 places. This resulted in actual harm to Resident #1 that was not immediate jeopardy. Findings include: At the time of the incident, the facility did not have a policy or a process on providing 1:1 supervision. Resident #1 had [DIAGNOSES REDACTED]. The 8/1/2019 Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired with short and long-term memory deficits. The resident exhibited verbal, physical, and other behaviors and wandered daily. Resident #4 had [DIAGNOSES REDACTED]. The 8/2/2019 MDS assessment documented the resident's cognition was moderately impaired with memory problems and the resident exhibited verbal and physical behaviors. Resident #4's 7/26/2019 comprehensive care plan (CCP) documented the resident displayed verbal and physical aggression. Interventions included to assess risk factors associated with problematic behaviors, daily and weekly behavior progress notes, allow the resident more time to respond, assist to identify inappropriate behaviors, approach in a calm manner, listen, provide positive reinforcement, exercise, activities, monitor patterns of behavior, provide 1:1 as indicated, provide a safe and quiet environment, redirect, and reinforce appropriate behaviors. Resident #4's Resident Function and Preferences (care instructions) included an undated list that documented the resident could make needs known, walked around the unit looking for their spouse and became tearful and upset at not finding their spouse. Behavior interventions included prayer and talking about Ireland. The resident became more aggressive towards residents and staff, especially when refusing care. The resident required more supervision during those times. Staff should greet the resident with an upbeat voice. Resident #4's behavior charting notes from 9/2-9/12/19 documented the resident refused/resisted care, yelled at and hit staff, threw things, had exit seeking behaviors, yelled at and hit other residents and intrusively wandered into other residents' rooms. Incident reports documented Resident #4 had two resident to resident incidents on 9/28/2019: - At 4:55 PM, Resident #4 punched another resident in the left arm and 10 minutes later, punched the same resident in the back. Resident #4 was placed on 1:1 after the incidents to prevent further incidents. The plan included [MEDICATION NAME] IM (antipsychotic medication, intramuscularly) if the 1:1 was ineffective. - At 6:45 PM, Residents #4 blatantly pushed Resident #1, causing Resident #1 to fall and hit their head on a door jam. Resident #1 had multiple bruises, a skin tear, and complained of sharp pains to the left hip and groin areas. Resident #1 was sent to the emergency room and was diagnosed with [REDACTED]. Resident #4 was given [MEDICATION NAME] IM for continued aggression, and 1:1 was to continue for Resident #4 until the resident went to bed or was calmer. Certified nurse aide (CNA) #2's statement, dated 9/29/2019, documented on 9/28/2019, Resident #1 was walking down the hall behind Resident #4 and Resident #4 turned and pushed Resident #1 causing Resident #1 to hit their head. The Director of Nursing's (DON) statement, dated 10/06/2019, documented the DON reviewed the video of the incident and observed CNA #2 halfway down the hall when the incident occurred. Per the DON's statement, the registered nurse Supervisor (RNS) directed CNA #2 to do 1:1 with Resident #4 due to the previous incident at 4:55 PM, with another resident on the same date. On 1/2/2020 at 3:45 PM, the video of the incident on 9/28/19 involving Residents #4 and #1, was viewed with the DON. The upper bodies and backs of the two resident's heads were visible as the two residents were walking in the hall. Resident #1's body and head disappeared to the left of the screen and Resident #4's head also moved in that direction. CNA #2 was seen coming around a corner, going towards the residents as the incident occurred. CNA #2 was not close to Resident #4 prior to the incident or when it occurred. Registered nurse Supervisor (RNS) #1 was interviewed on 1/2/2020 at 11:30 AM, and stated when Resident #4 was placed on 1:1 observation, she educated CNA #2 on providing 1:1. She told CNA #2 that someone needed to be close to the resident but may need to back away a little bit if the resident was agitated. She stated this was not written down and was communicated verbally with the CNA. She stated it was the nursing Supervisor who initiated and discontinued 1:1. She stated when a resident was on 1:1, the CNAs should call someone when they go on break or to the bathroom so that someone else could provide the 1:1. RNS #1 stated the 1:1 done by CNA #2 for Resident #4 was not effective and the CNA was not close enough. At the time of the incident, the resident's CCP was updated regarding the resident's high risk for violence. At 12:05 PM on 12/12/2019, the DON stated in an interview, instructions regarding 1:1 would be listed on the resident's Preferences sheet and on the CCP. The DON stated the facility had no policy for 1:1 and staff would need to be close to the resident and stand in between the residents, instead of the opposite side of the resident. On 1/2/2020 at 3:00 PM, CNA #5 stated in an interview, she was regularly assigned to care for Resident #4. The resident became upset between the hours of 4:00 PM through 10:00 PM. Resident #4 was known to hit, bite, and pinch, and wandered often. Approaches used for Resident #4 included redirection and to ask the resident to sweep the floors. CNA #5 stated 1:1 meant that staff should stand right next to the resident to watch them closely. When someone was on 1:1, the nurse told the staff during report and it was also listed on the Preference List. On 01/02/2020 at 4:35 PM, the Administrator and DON were interviewed together. Both stated there was no written policy on 1:1 observation, only a policy addressing visual observation and hourly checks, which was updated in 1/2020. On 01/07/2020 at 04:15 PM, CNA #2 was interviewed via the telephone. The CNA worked on 9/28/2019 and recalled the two incidents involving Resident #4. On that evening, CNA #2 was asked by the RNS to do 1:1 with Resident #4. He stated he was asked soon after Resident #4 struck another resident in the back. CNA #2 did not know if he was supposed to do 1:1 when he was on orientation and when his preceptor was not present at the facility, but he agreed when he was asked by the RNS. He stated the RNS did not give him any direction on providing 1:1. During supper that evening, there was only one CNA in the dining room so he left Resident #4 to ambulate alone in the hallway and he went into the dining room to help the other CNA with the meal. When CNA #2 and the other CNA were done passing trays, he was coming out of the dining room as Resident #4 was pushing Resident #1. Resident #1 fell after being pushed. CNA #2 stated it was his understanding that when the resident on 1:1 became calmer and less aggressive that the staff could decide they no longer needed 1:1 observation and they could stop it. He stated he used his judgement that evening and decided that Resident #4 was calmer and did not need the continued 1:1 observation while he passed meal trays. On 1/9/2020 at 2:15 PM, the DON stated in a follow-up interview, at the time of the incident, the facility did not have a policy on 1:1 supervision but they did cover close observation of residents and completing behavioral charting during new hire orientation. She stated the resident's plan of care should have been updated after each incident to prevent further incidents. On 1/30/2020 at 11:30 AM, the attending physician stated in an interview, nursing decided when someone was placed on or taken off of 1:1 and they notified him. He stated when he thought of 1:1 he thought of the person being closely observed by someone and also that they might have a sitter assigned to them. 10 NYCRR 483.25(d)