Every finding on record at Mary Manning Walsh Nursing Home Co Inc

Based on observations, record review, and interviews conducted during an abbreviated survey (2648284), the facility did not ensure a resident's physician was notified of changes in condition. This was evident for one (1) of four (4) residents (Resident #1) sampled. Specifically, on 10/18/2025 at 9:30 AM, Resident #1, who required supervision with ambulation, spilled hot coffee on their right hand while they were ambulating in the hallway holding onto their rolling walker with their left hand, and holding a cup of hot coffee in their right hand. A physician or nursing supervisor was not immediately notified of the changes in Resident #1's condition. Physician #1 became aware of the burn on 10/20/2025 and assessed Resident #1 to have sustained a third-degree burn to their right hand and thumb. Cold compress and Bacitracin Ointment treatment was applied and burn area was covered with dry gauze. The findings include:A policy titled 'Notification of Resident's Change in Condition'' dated 04/2025 documented that it is the responsibility of the Licensed Nurse/Designee to assess the resident and contact the attending Physician and report pertinent findings, initiate the action indicated by the Physician and document it in the interdisciplinary progress notes. The Licensed Nurse should also notify the nursing supervisor of resident's change in condition, notes on the 24-hour report, interdisciplinary progress notes and communicate changes to the appropriate staff.A review of the Minimum Data Set (a resident assessment tool) dated 08/01/2025 documented Resident #1's cognition was moderately impaired, and they required setup or clean-up assistance during meals. Resident #1 required supervision with ambulation and was able to walk 150 feet.A review of a nursing note by Registered Nurse #1 dated 10/20/2025 at 12:25 PM, documented at approximately 10:30 AM on 10/18/2025 they were informed by Certified Nursing Assistant #1 that Resident #1 burned their right forearm after accidentally dropping hot coffee on it (right forearm). They immediately instructed Resident #1 to dip their right forehand in a basin off water with some ice for 20 minutes. After the allotted time, Registered Nurse #1 dried the right forearm, wrapped it and administered Tylenol for pain. The incident was documented in the huddle book (a book used to endorse report to the next shift). A review of a nursing note by Registered Nurse Manager #1 dated 10/20/2025 at 1:34 PM documented at 8:30 AM, Resident #1 showed Registered Nurse Manager #1 their right hand which presented with three fluid filled blisters, two large blisters on the right index finger and one small blister on the right thumb. As per resident, on 10/18/2025 at 8:30 AM, they were ambulating in the hallway with a cup of coffee in their hand, they lost their grip on the cup spilling the coffee on their right hand.A review of a medical note by Physician #1 dated 10/20/2025 at 4:51 PM documented they were asked to see Resident #1 for third degree burns to their right hand sustained on 10/18/2025. Resident #1 was observed with a large intact blister to the right medial hand and a small vesicle to their right thumb. A review of the Physician's Orders dated 08/27/2025 documented Tylenol 650 milligrams two (2) tablets to be administered by mouth every six (6) hours daily and as needed for pain. An order for Wound Consult dated 10/24/2025 documented evaluate blisters to right hand sustained 10/18/2025. A Wound Care Treatment Daily Order dated 10/25/2025 documented right hand wound to be cleaned with wound cleanser, pat dry, and to apply bacitracin and cover with dry gauze daily. A review of the Medication Administration Record dated 10/2025 showed Resident #1 received Tylenol 650 milligrams as per physician's order.A review of a Surgical Note (Wound Consultation) dated 10/24/2025 documented three (3) bullae (large fluid-fill blisters greater than 10 millimeter) with clear fluid that has started leaking. Bacitracin and dry gauze dressing recommended. A review of the facility's Investigation Summary dated 10/27/2025 documented on 10/18/2025, Resident #1 was ambulating in the hallway on the unit with a cup of coffee in their hand, lost their grip of the cup spilling some of the contents on their right hand. Resident #1 experienced localized erythema to their right hand followed by the formation of a vesicle. On 10/18/2025, Resident #1 was instructed by Registered Nurse #1 to place their right hand in a basin of ice water for twenty minutes and then the hand was wrapped with kerlix. Tylenol was administered to relieve pain, and incident was documented in the huddle book. Incident report further documented on examination, full range of motion present to all extremities, two blisters observed to their hand. The facility investigated and concluded that there was no reasonable cause to believe that abuse, mistreatment, neglect occurred.During an interview on 11/12/2025 at 12:49 PM, Resident #1 stated they walked from their room to the dining room on 10/18/2025 at 8:30 AM to warm up their coffee because their regular certified nursing assistant was off duty. They stated they held the cup of coffee with their right hand as they propelled their walker with their left hand, they burned themself. They stated they did not ask the other staff for assistance. They stated they know the staff are busy, so they did not engage the call bell to ask for help. They stated after they got burned, Certified Nursing Assistant #1 entered their room and placed their hand in cold water. They stated two hours after they were burned Registered Nurse #1 entered their room and wanted to apply ice on their hand, but they refused. They stated on Monday, 10/20/2025, they approached Registered Nurse Manager #1 and showed them their hand.During a telephone interview on 11/14/2025 at 10:05 AM, Certified Nursing Assistant #1 stated on 10/18/2025 at 8:20 AM they were in another resident's room when they saw Resident #1 in the hallway walking towards the dining room. They stated at around 8:30 AM, Certified Nursing Assistant #2 informed them Resident #1 reported burning themself. They stated Resident #1 did not ask them to warm up their coffee and that they observed Resident #1's right hand with redness. They stated they retrieved a basin of cool water and told Resident #1 to submerge their hand in the water while they immediately report the injury to Registered Nurse #1.During a telephone interview on 11/12/2025 at 1:55 PM, Registered Nurse #1 stated on 10/18/2025 at approximately 9:30 AM, Certified Nursing Assistant #1 informed them Resident #1 burned their right hand after spilling coffee on their hand. They stated they assessed Resident #1's hand and did not observe any blisters. They stated Resident #1's hand was red but not swollen, so they retrieved a basin of water with ice and instructed Resident #1 to place their hand in the water for 15 minutes, then wrapped the hand with kerlix and administered Tylenol. They stated they are aware they should have reported Resident #1's changes in condition, however, it did not occur to them to report the burn incident to the supervisor or physician. They stated they documented the incident in the huddle book (an endorsement/report book for nurses). They stated they did not give a verbal report to the oncoming shift because the oncoming nurse was late. They stated they worked on 10/19/2025 (on Resident #1's shift) but did not follow up with the burn incident and they did not receive a report from the off-going shift). During an interview on 11/12/2025 at 2:12 PM, Registered Nurse Manager #1 stated on 10/20/2025 at 8:30 AM Resident #1 approached them and showed them their hand which had two (2) large intact and raised blisters on the right index finger and a small blister on the right thumb. They stated Resident #1 informed them that they warmed up their coffee in the microwave in the dining because their regular Certified Nursing Assistant was not working. They stated Resident #1 reported while they were ambulating back to their room with the coffee and walker, they spilled the coffee on their right hand. They stated Registered Nurse #1 should have immediately reported the burn incident to the nursing supervisor and physician. During a telephone interview on 11/14/2025 at 12:53 PM, Registered Nurse #3 stated they were assigned to Resident #1 on 10/19/2025 on the 3:00 PM - 11:00 PM shift. They stated Resident #1 showed them their right hand, wrapped with a bandage, and reported that they burned themself. They stated they reviewed the chart and there was no documentation or an order for treatment, but the burn was documented in the huddle book, available for all nurses to review. They stated that they do not recall reviewing the huddle book. They stated if they had reviewed the huddle book, they would have informed the supervisor and obtained an order for treatment. During a telephone interview on 11/18/2025 at 11:14 AM, Physician #1 stated on 10/20/2025 they were asked by the nursing staff to evaluate Resident #1 for a burn that occurred on 10/18/2025. They stated neither them nor the weekend physician were notified of the incident on 10/18/2025. They stated they did not receive any messages about the burn. They stated they first became aware of the burn when they were asked to evaluate Resident #1 on 10/20/2025. Physician #1 stated that a physician should have been immediately notified. They stated they evaluated Resident #1 on 10/20/2025 (unsure of time) and the resident had a third-degree burn on their right hand (large blisters on the right hand and thumb). They stated Resident #1 was treated with cold compresses and was seen by the wound team. During a telephone interview on 11/18/2025 at 1:10 PM, the Director of Nursing stated they were informed of the burn by the Administrator on 10/20/2025 via chat at 8:53 AM. They stated they were out of the country when the Administrator reported Resident #1 spilled coffee on themself. They stated the team collaborated and concluded that abuse did not occur. They stated it is hard to say that the incident was avoidable, Resident #1 usually ask staff to warm up their coffee but did not ask on that day when they decided to heat up the coffee themself. They stated the coffee that Resident #1 receives and ask to warm up was brought to them with their breakfast tray, not sure if it was their personal coffee. They stated there were no care plans to reflect resident's preference for warming up coffee. They stated the incident should have been reported the same day to the nursing supervisor and a physician. They stated they reviewed the huddle book and Registered Nurse #1's documentation of the incident was not legible. They stated that a verbal report was not given to the oncoming staff. 10 NYCRR 415.1210 NYCRR 415.12

Based on observation, record review, and interviews conducted during an abbreviated survey (2648284), the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) of four (4) residents (Resident #1) sampled. Specifically, Resident #1 spilled hot coffee on their right hand on 10/18/2025 at 9:30 AM. Registered Nurse #1 who was notified by Certified Nursing Assistant #1 on 10/18/2025 at 9:30 AM, did not notify the administrator or designee within 24-hours. Resident #1 was assessed on 10/20/2025 by Physician #1 who diagnosed Resident #1 with third-degree burns to the right hand and right thumb. The administrator was notified on 10/20/2025 before 9:00 AM and they reported the incident to the New York State Department of Health on 10/20/2025 at 11:04 AM. The findings are:A policy titled 'Abuse Prevention Policy and Procedure' dated 03/20/2025 documented all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials in accordance with State law through established procedures.Resident #1 was admitted to the facility with diagnoses including Heart Failure, Seizure Disorder, and Mood Disorder.A review of the Minimum Data Set (a resident assessment tool) dated 08/01/2025 documented Resident #1's cognition was moderately impaired, and they required setup or clean-up assistance during meals. Resident #1 also required supervision with ambulation and was able to walk 150 feet.During a telephone interview on 11/12/2025 at 1:55 PM, Registered Nurse #1 stated on 10/18/2025 at approximately 9:30 AM, Certified Nursing Assistant #1 informed them Resident #1 burned their right hand after spilling coffee on their hand. They stated they assessed Resident #1's hand and did not observe any blisters. They stated Resident #1's hand was red but not swollen, so they retrieved a basin of water with ice and instructed Resident #1 to place their hand in the water for 15 minutes, then wrapped the hand with kerlix and administered Tylenol. They stated they are aware they should have reported Resident #1's changes in condition, however, it did not occur to them to report the burn incident to the supervisor or physician. They stated they documented the incident in the huddle book (an endorsement/report book for nurses). They stated they did not give a verbal report to the oncoming shift because the oncoming nurse was late. They stated they worked on 10/19/2025 (on Resident #1's unit) but did not follow up with the burn incident and they did not receive a report from the off-going shift). A Webform Submission from: Nursing Home Facility Incident Report dated 10/20/2025 showed the facility submitted the report to the New York State Department of Health on 10/20/2025 at 11:04 AM.During an interview on 11/12/2025 at 2:12 PM, Registered Nurse Manager #1 stated on 10/20/2025 at 8:30 AM Resident #1 approached them and showed them their hand which had two (2) large intact and raised blisters on the right index finger and a small blister on the right thumb. They stated Resident #1 informed them that they warmed up their coffee in the microwave in the dining room because their regular Certified Nursing Assistant was not working. They stated Resident #1 reported while they were ambulating back to their room with the coffee and walker, they spilled the coffee on their right hand. They stated Registered Nurse #1 should have immediately reported the burn incident to the nursing supervisor and physician. During a telephone interview on 11/18/2025 at 1:10 PM, the Director of Nursing stated they were informed of the burn by the Administrator on 10/20/2025 via chat at 8:53 AM. They stated they were out of the country when the Administrator reported Resident #1 spilled coffee on themself. They stated the team collaborated and concluded that abuse did not occur. They stated it is hard to say that the incident was avoidable, Resident #1 usually asks staff to warm up their coffee but did not ask staff on that day when Resident #1 decided to heat up the coffee themself. They stated the coffee that Resident #1 receives and asks staff to warm up is brought to them with their breakfast tray. They are not sure on that day if the coffee was from the breakfast tray or if was Resident #1's personal coffee. They stated there were no care plans to reflect resident's preference for warming up coffee. They stated the incident should have been reported the same day to the nursing supervisor and a physician. They stated because the incident was not abuse and the injury was known, the incident did not have to be reported to the Department of Health within two hours.During a telephone interview on 11/18/2025 at 1:53 PM, the Administrator stated they were informed of the 10/18/2025 incident on 10/20/2025 before 9:00 AM by Registered Nurse Manager #1. They stated they notified the Director of Nursing and the other clinical team staff and reported the incident to the Department of Health. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews conducted during an abbreviated survey (2648284), the facility failed to provide an environment that is free from accident hazards and to ensure that a resident received adequate supervision to prevent accidents. This was evident for one (1) of four (4) residents (Resident #1) sampled. Specifically, on 10/18/2025 at 9:30 AM, Resident #1, who required supervision with ambulation, spilled hot coffee on their right hand while they were ambulating in the hallway holding onto their rolling walker with their left hand, and holding a cup of hot coffee in their right hand Resident #1 was assessed on 10/20/2025 by Physician #1 and was diagnosed with a third-degree burn to their right hand and thumb. Cold compress and Bacitracin Ointment treatment was applied and burn area was covered with dry gauze. The findings include:A policy titled 'Microwave Use-Reheating Foods or Liquids in the Microwave' dated 02/2023 documented it is the facility's policy to provide food and hot liquids at comfortable and safe temperatures, ensure that resident's food and/or liquids are reheated safely and ensure microwaves are accessible for use by staff only. The policy further documents residents and visitors will not utilize the microwave but will request from staff to reheat foods and liquids to ensure safety.A policy titled 'Accidents and Supervision' dated 08/2013 documented it is the facility's policy that the resident's environment remains free of accident hazards and that each resident receives adequate supervision and assistive devices to prevent accidents.Resident #1 was admitted to the facility with diagnoses including Heart Failure, Seizure Disorder, and Mood Disorder.A review of the Minimum Data Set (a resident assessment tool) dated 08/01/2025 documented Resident #1's cognition was moderately impaired, and they required setup or clean-up assistance during meals. Resident #1 also required supervision with ambulation and was able to walk 150 feet.A review of Resident #1's care plans revealed no documented instructions for staff to provide supervision during ambulation. A review of the Certified Nursing Assistant Daily Documentation dated 10/2025 revealed no documented instructions for staff to provide supervision during ambulation. A review of the facility's Investigation Summary dated 10/27/2025 documented on 10/18/2025 Resident #1 was ambulating in the hallway on the unit with a cup of coffee in their hand, lost their grip of the cup spilling some of the contents on their right hand. Resident #1 experienced localized erythema to their right hand followed by the formation of a vesicle (small fluid-fill blister). On 10/18/2025, Resident #1 was instructed by Registered Nurse #1 to place their right hand in a basin of ice water for twenty minutes and then the hand was wrapped with kerlix. Tylenol was administered to relieve pain, and incident was documented in the huddle book (an endorsement/report book for nurses). Incident report further documented on examination, full range of motion present to all extremities, two blisters observed to their hand. The facility investigated and concluded that there was no reasonable cause to believe that abuse, mistreatment, or neglect occurred. A review of a nursing note by Registered Nurse #1 dated 10/20/2025 at 12:25 PM documented at approximately 10:30 AM on 10/18/2025 they were informed by Certified Nursing Assistant #1 that Resident #1 burned their right forearm after accidentally dropping hot coffee over it. They immediately instructed Resident #1 to dip their right forehand in a basin off water with some ice for 20 minutes. After the allotted time, Registered Nurse #1 dried the right forearm, wrapped it and administered Tylenol for pain. The incident was documented in the huddle book (an endorsement/report book used by nurses). A review of a nursing note by Registered Nurse Manager #1 dated 10/20/2025 at 1:34 PM documented at 8:30 AM, Resident #1 showed Registered Nurse Manager #1 their right hand which presented with three fluid filled blisters, two large blisters on the right index finger and one small blister on the right thumb. As per resident, on 10/18/2025 at 8:30 AM, they were ambulating in the hallway with a cup of coffee in their hand and lost grip on the cup spilling the content on their right hand. Physician #1 notified and examined Resident #1 with no new orders.A review of a medical note by Physician #1 dated 10/20/2025 at 4:51 PM documented Physician #1 was asked to see Resident #1 for third degree burns to their right hand sustained on 10/18/2025 while carrying a cup of coffee that they reheated in a microwave without asking for assistance. Resident #1 observed with large intact blister to the right medial hand and a small vesicle to their right thumb. Resident #1 was treated with cold compress and Tylenol for pain.A review of the Physician's Orders dated 10/24/2025 documented Wound Care Consult. Evaluate blisters to right hand sustained 10/18/2025. A Wound Care Treatment Daily Order dated 10/25/2025 documented right hand wound to be cleaned with wound cleanser, pat dry, apply bacitracin and cover with dry gauze daily. A review of the Surgical Note (Wound Consultation) dated 10/24/2025 documented wound description -three bullae (large blister on the skin, larger than 10 millimeters) with clear fluid that has started to leak. Bacitracin and dry gauze dressing recommended.During an interview on 11/12/2025 at 12:49 PM, Resident #1 stated they walked from their room to the dining room on 10/18/2025 at 8:30 AM to warm up their coffee because their regular certified nursing assistant was off duty. They stated they burned themself because they were holding the cup of coffee with their right hand as they propelled the walker with their left hand. They stated they did not ask the other staff for assistance because they know that the staff were busy. They stated after they got burned, Certified Nursing Assistant #1 placed their hand in cold water. They stated two hours after they were burned Registered Nurse #1 entered their room and wanted to apply ice on their hand, but they refused. They stated on Monday, 10/20/2025, they approached Registered Nurse Manager #1 and showed them their hand. They stated they did not have any pain and that their hand had healed. During a telephone interview on 11/14/2025 at 10:05 AM, Certified Nursing Assistant #1 stated on 10/18/2025 at 8:20 AM they were in another resident's room when they saw Resident #1 in the hallway walking towards the dining room. They stated at 8:30 AM Certified Nursing Assistant #2 informed them Resident #1 reported burning themself. They stated Resident #1 did not ask them to warm up their coffee and that they observed Resident #1's right hand with redness. They stated they retrieved a basin of cool water and told Resident #1 to submerge their hand in the water while they immediately report the injury to Registered Nurse #1. Certified Nursing Assistant #1 stated they were not aware that Resident #1 needs supervision with ambulation. They stated Resident #1 ambulates independently on the unit with their walker. They stated the Certified Nursing Assistant Accountability Record does not allow them to document Resident #1's ambulation status.During a telephone interview on 11/14/2025 at 10:58 AM, Certified Nursing Assistant #2 stated that Resident #1 reported to them on 10/18/2025 between 8:00 AM and 8:30 AM they heated their coffee in the microwave in the dining room and when they were returning to their room with the coffee in one hand and pushing the walker with the other hand, the coffee spilled and burned them on their right hand. They stated Resident #1's hand was observed to be red, so they stood in the doorway and called out to Registered Nurse #1 to come to Resident #1's room. They stated Resident #1 makes their own coffee and would sometimes ask them to warm the coffee. They stated they have observed Resident #1 attempting to warm their coffee and they would take the coffee and warm it for the resident. They stated they were not aware that Resident #1 required supervision with ambulation. During a telephone interview on 11/12/2025 at 1:55 PM, Registered Nurse #1 stated on 10/18/2025 at approximately 9:30 AM, Certified Nursing Assistant #1 informed them Resident #1 burned their right hand after spilling coffee on their hand. They stated they assessed Resident #1's hand and did not observe any blisters. They stated Resident #1's hand was red but not swollen, so they retrieved a basin of water with ice and instructed Resident #1 to place their hand in the water for 15 minutes, then wrapped the hand with kerlix and administered Tylenol. They stated they are aware they should have reported Resident #1's changes in condition, however, it did not occur to them to report the burn incident to the supervisor or physician. They stated they documented the incident in the huddle book They stated they did not give a verbal report to the oncoming shift because the oncoming nurse was late. They stated they worked on 10/19/2025 (on Resident #1's unit) but did not follow up with the burn incident and they did not receive a report from the off-going shift). During an interview on 11/12/2025 at 2:12 PM, Registered Nurse Manager #1 stated on 10/20/2025 at 8:30 AM Resident #1 approached them and showed them their hand which had two (2) large intact and raised blisters on the right index finger and a small blister on the right thumb. They stated Resident #1 informed them that they warmed up their coffee in the microwave in the dining room because their regular Certified Nursing Assistant was not working. They stated Resident #1 reported while they were ambulating back to their room with the coffee and walker, they spilled the coffee on their right hand. They stated Registered Nurse #1 should have immediately reported the burn incident to the nursing supervisor and physician. During a telephone interview on 11/14/2025 at 12:53 PM, Registered Nurse #3 stated they were assigned to Resident #1 on 10/19/2025 on the 3:00 PM - 11:00 PM shift. They stated Resident #1 showed them their right hand, wrapped in a bandage, and reported that they burned themself. They stated that they reviewed the chart and there was no documentation or an order for treatment. They stated that the burn was documented in the huddle book, available for all nurses to review, but they do not recall reviewing the huddle book. They stated if they had read the huddle book, they would have informed the supervisor and obtained an order for treatment. During a telephone interview on 11/18/2025 at 11:14 AM, Physician #1 stated on 10/20/2025 they were asked by the nursing staff to evaluate Resident #1 for a burn that occurred on 10/18/2025. They stated neither them nor the weekend physician were notified of the incident on 10/18/2025. They stated they first became aware of the burn when they were asked to evaluate Resident #1 on 10/20/2025. Physician #1 stated that a physician should have been immediately notified. They stated they evaluated Resident #1 on 10/20/2025 (unsure of time) and the resident had a third-degree burn on their right hand (large blisters on the right hand and thumb). They stated Resident #1 was treated with cold compresses and was seen by the wound team. During a telephone interview on 11/18/2025 at 1:10 PM, the Director of Nursing stated they were informed of the burn by the Administrator on 10/20/2025 via chat at 8:53 AM. They stated they were out of the country when the Administrator reported Resident #1 spilled coffee on themself. They stated the team collaborated and concluded that abuse did not occur. They stated it is hard to say that the incident was avoidable, Resident #1 usually asks staff to warm up their coffee but did not ask staff on that day when Resident #1 decided to heat up the coffee themself. They stated the coffee that Resident #1 receives and asks staff to warm up is brought to them with their breakfast tray. They are not sure on that day if the coffee was from the breakfast tray or if was Resident #1's personal coffee. They stated there were no care plans to reflect resident's preference for warming up coffee. They stated the incident should have been reported the same day to the nursing supervisor and a physician. They stated they reviewed the huddle book and Registered Nurse #1's documentation of the incident was not legible. They stated that a verbal report was not given to the oncoming staff. They stated that the nurses are responsible for ensuring Resident #1 receives supervision during ambulation. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews, the facility failed to ensure each resident received food that accommodated their preferences. This was evident for one (1) (Resident #404) of three (3) residents reviewed for Choices out of 35 total sampled residents. Specifically, Resident #404, who's meal preferences include salad for lunch and dinner, are often not being met. The findings include:The facility policy titled Meal/Tray Assembly Procedures with a last revised date of 01/2025 documented that meal service is prompt and accurate to ensure temperatures and nutrient content of food is preserved. The procedure included to check meals for accuracy.Resident #404 had diagnoses of Diabetes Mellitus and Hypertensive Heart Disease.A dietary progress notes dated 08/06/2025 at 1:46 PM documented that Resident #404 preferred vegetables.The dietary order dated 08/31/2025 documented that Resident #404 requested additional salad for lunch and supper. A comprehensive care plan for nutrition concerns was initiated for Resident #404 on 08/08/2025. The care plan interventions included to provide food preferences such as side salad for lunch and dinner. A Care plan meeting note dated 08/22/2025 documented that Resident #404 follows a diabetic and thin liquids diet. It also documented that the resident requested bananas and a salad. During observation on 09/03/2025 at 12:30 PM, Resident #404's lunch tray was observed with fish, carrots, potatoes, soup, tea, and gelatin. There was no salad on the lunch tray. The meal ticket for Resident #404 documented: Lunch: Consistent Carbohydrate Diet, no added Salt, Milk 4 ounces, Salad Tossed 1/2 cup, 4 ounces cup of strawberry gelation, 6 ounces of minestrone soup, 4 ounces of baked fish, 4 ounces of lyonnaise potatoes, 4 ounces of baby carrots and 6 ounces of hot tea. On 09/03/2025 at 12:30 PM, Resident #404 was interviewed and stated they were supposed to get a salad for lunch today but did not receive it. Resident #404 stated that there are items missing from their tray often, while at other times they receive the wrong items. Resident #404 stated they informed the staff who called the kitchen and was told there was no more salad. Resident #404 further stated that this is the third time within the last 2 weeks that they have missed salad for lunch.On 09/05/2025 at 11:38 AM, Registered Nurse #2 was interviewed and stated that at times residents complain of missing items on their meal tray; when alerted, staff contacts the kitchen to deliver the missing food items. Registered Nurse #2 stated that Resident #404 was missing a salad in their lunch tray. They stated they called the kitchen and was told there was no salad left. They stated they offered Resident #404 fruit salad which the resident declined. Registered Nurse #2 further stated that it is important for residents to receive what they requested because it is necessary for their nourishment. Registered Nurse #2 further stated that when residents do not receive what they requested, they can get depressed, dehydrated and not eat altogether.On 09/05/2025 at 11:22 AM, Dietician #1 was interviewed and stated they evaluated Resident #404 on 08/22/2025, and the resident stated they wanted a banana and a salad for lunch and dinner. On 09/04/2025 at 2:08 PM, the Operations Manager was interviewed and stated they are responsible for assigning employees for breakfast and lunch. They stated there is a checker responsible for ensuring that meals are accurately assembled by comparing meal tickets against the lunch tray. The Operation Manager further stated that while there are occasional concerns of missing salt or sugar on the lunch tray, there have not been any complaints of other food items missing from the residents' trays.On 09/04/2025 at 2:13 PM, the Director of Food Service was interviewed and stated that they oversee residents' lunch along with the Assistant Director of Food Service. They stated that salad is not on the menu but is offered by the dietitian to the residents. They stated that salad is delivered later than the residents' meal trays because it is not yet ready by the time the residents' meal tray goes up to the units, but the goal is to have all food items listed on the ticket delivered together. The Director stated that residents' food preferences must be accommodated since the facility is their home.10 NYCRR 415.14(d)(4)

Based on observation, record review, and interviews, the facility failed to provide necessary services to maintain good grooming and personal hygiene to a resident who is unable to carry out activities of daily living. This was evident for one (1) (Resident #280) of three (3) residents reviewed for Choices out of 33 total sampled residents. Specifically, Resident #280 was not provided showers as stated in the care plan. The findings include:The facility's policy titled Activities of Daily Living Support with a last reviewed date of 03/2025 documented that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy's interpretation and implementation documented that appropriate care, and services will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene. Resident #280 had diagnoses that included Arthritis and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set (a resident assessment tool) dated 07/09/2025 documented Resident #280's cognition as severely impaired, no behaviors, had impairment on both sides of lower extremities, and required maximal assistance with feeding and showers, and was dependent on staff for transfers and toilet use.On 09/03/2025 at 11:00 AM, Resident #280 was observed in their room, in a recliner, with their family representative at the bedside. The resident's representative stated they visit every day, and the last time Resident #280 received a shower was on 06/29/2025. They stated they asked for Resident #280 to get a least one shower a week, but this has not been happening. The representative stated Resident#280 had been scratching their hair and have fungus on their toes because they were not getting showers.09/05/2025 at 11:30 AM, Resident #280 was observed in their room, in a recliner, with their representative at the bedside. The representative stated that Resident #280's assigned Certified Nursing Assistant stated that Resident #280 will receive a shower next Friday. The representative stated they were happy that shower was offered for the resident. A comprehensive care plan for activities of daily living was initiated on 11/25/2022. The care plan documented Resident #280 required assistance with activities of daily living function related to dementia. The facility interventions included providing showers weekly or as scheduled. A review of the 3rd Floor shower schedule revealed that showers were scheduled based on each resident's room assignment. Resident #280's shower days were Mondays on day shift and Wednesdays on the evening shift. The Certified Nursing Assistant Daily Documentation from 06/01/2025 through 09/04/2025 showed that Resident #280 received shower once during this time period (06/08/2025). On other occasions, the resident received a full or partial bed bath. There was no documentation that Resident #280 had been offered and/or refused showers.A review of Resident #280's progress notes from 06/01/2025 through 09/05/2025 contained no documented evidence that Resident #280 had been offered and/or refused showers. There was no documentation of any medical condition or clinical justification for not giving showers and limiting Resident #280 to bed baths. A nurse's progress notes dated 09/05/2025 at 2:00 PM documented that the assigned certified nursing assistant reported that Resident #280's representative requested for the resident to receive shower tomorrow as they forgot to bring shampoo and body wash. On 09/05/2025 at 12:33 PM, Certified Nursing Assistant #3 was interviewed. They stated that they have been assigned to Resident #280 for the past week. According to the Certified Nursing Assistant, Resident #280 is totally dependent on staff for activities of daily living, including showering. They stated that Resident #280's shower schedule is every Friday during the 7:00 AM - 3:00 PM shift. However, Certified Nursing Assistant #3 stated they did not provide a shower to the resident today, which was a Friday, stating they were unsure if the Certified Nursing Assistant from the previous day had already done so. Certified Nursing Assistant #3 stated they told the resident's representative they would shower Resident #280 next time. On 09/05/2025 at 1:00 PM, Certified Nursing Assistant #1 was interviewed and stated they have been assigned to Resident #280 on different occasions. They stated that Resident #280 required total care. The Certified Nursing Assistant stated they gave Resident #280 a bed bath on the days that they do not receive shower. On 09/05/2025 at 3:44 PM, Certified Nursing Assistant #2 was interviewed and stated they were previously assigned to Resident #280. According to Certified Nursing Assistant #2, Resident #280 is totally dependent on staff for showers and requires a Hoyer lift with the assistance of 2 staff for transfers. Certified Nursing Assistant #2 stated that Resident #280 was once showered in a regular shower chair and that the resident would slide down. They stated the resident needs a reclining shower chair so resident would not slide during shower but there was none available in the unit. The Certified Nursing Assistant stated the lack of reclining chair is the reason showers could not be provided for Resident #280, and they added that the nursing supervisor was aware of the issue. On 09/05/2025 at 3:53 PM, Registered Nurse #1 was interviewed and stated they have been the unit nurse manager since 08/04/2025 and was not aware if Resident #280 refused showers, and do not recall if Resident #280's representative requested a shower. They stated that staff would notify the supervisor of any missing equipment, but they were not aware that there was no shower chair. On 09/09/2025 at 12:01 PM, Social Worker #1 was interviewed and stated they recall once during a care plan meeting that the representative requested a shower for Resident #280, but they do not know if shower was given. On 09/09/2025 at 3:22 PM, the Chief Clinical Officer was interviewed and stated they were not aware that showers were not being given to residents, and that this issue was not raised during staff town hall meetings. The Chief Clinical Officer stated there were no grievances related to lack of showers for residents or the unavailability of reclining shower chairs. On 09/09/2025 at 3:31 PM, the Administrator was interviewed and stated that there were no grievances related to Resident #280 not receiving showers. The Administrator stated the staff had not stated there was a need for a reclining shower chair. 10 NYCRR 415.12(a)(3)

Based on record review and interviews conducted during the Recertification and Abbreviated survey (NY00321684), the facility did not ensure that a resident received adequate supervision to prevent elopement. This was evident for 1 of 5 residents reviewed for Accidents (Resident #375) out of a sample of 38 residents. Specifically, on 8/8/23, Resident #375, identified as a high risk for elopement and wearing a wander guard, took the elevator from the 9th floor and exited the building through the front door. The findings include: The facility's policy and procedure titled Elopement, with the last revised date of June 2021 documented that the facility's purpose is to ensure that all residents identified as at risk for elopement/unsafe wandering do not elope from the facility. The policy further states that elopement occurs when a resident leaves the premises or safe area without authorization and any necessary supervision. Resident #375 was admitted with diagnoses that include Malignant Neoplasm of the Brain and Hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 375 cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of 10 out of 15. The resident had a wandering behavior and required extensive assistance from one person for bed mobility, transfer, and locomotion on and off the unit. Elopement Risk assessment dated [DATE] documented that Resident #375 is at risk for elopement, as evidenced by wandering on the unit and verbalizing wanting to go home. A Nurse's Progress Note dated 7/27/23 at 8:43 PM documented that Resident # 375 verbalized they wanted to go home and refused admission assessment. The resident was noted to be confused and able to ambulate-high risk for elopement. The resident partner was informed about the wander guard application for elopement/wandering precautions and agreed. Security was informed. A Comprehensive Care Plan (CCP) related to Risk for Elopement initiated on 7/27/23 documented that Resident #375 has behavior symptoms and requires ongoing redirection, monitoring, and structured activities to alter behavior problems related to confusion, pacing on the unit verbalizing the desire to go home and leave the building as evidence by wandering. The interventions include identifying behavior patterns, ensuring proper placement and function of the ankle alert, and checking placement and monitoring wander guard on the right ankle every shift. The CCP has no documented evidence of supervision of the resident and monitoring of the elevators. A Psychiatry Consult Note dated 8/1/23 at 6:39 PM documented that Resident #375 was seen attempting to get up and pack their belongings. Resident #375 stated they were getting ready to go home and no longer wish to be in rehab. The nurse's notes dated 7/28/23 to 8/8/23 have no documented evidence of active exit-seeking behavior. A Nurse's Progress Note dated 8/8/23 at 2:59 PM documented the right lower extremity wandering guard. Constant redirection is needed. A Nurse Manager's note dated 8/8/23 at 4:56 PM documented that at 3:50 PM, the Certified Nursing Assistant #2 (CNA #2) noticed Resident #375 was not in their room during CNA's rounds. The Registered Nurse (RN) in charge of the unit was notified, and all the staff on the 9th floor searched. The resident was not seen anywhere. At 4:00 PM, security was notified, and code MP (Missing Person) 10 was called. At 4:45 PM, Close Circuit Television (CCTV) footage was reviewed, and Resident #375 walked past security at the front entrance, going outside the building at 3:18 PM. The spouse was notified, and 911 was called for a missing person. The facility occurrence Report dated 8/8/23 documented that the initial investigation summary concluded that Resident #375 intentionally left the building to go home and could not be found in the unit. CCTV footage was reviewed, and the resident left the building unescorted at 3:18 PM. The investigation concluded there is no cause to believe an alleged abuse, mistreatment, or neglect regarding Resident #375 has occurred. On 11/14/23 at 11:33 AM, Certified Nursing Assistant #1 was interviewed and stated they were assigned to resident #375 on 8/8/23 during the day shift. CNA #1 last saw Resident #375 lying on their bed around 2:30 PM. Resident #375 had a wander guard on, and when they got on the elevator, it would not move and alarm. CNA #1 left the unit at 3:00 PM on 8/8/23. There was no documentation of resident's wandering or exit seeking behavior in the resident's medical record. On 11/15/23 at 3:21 PM, CNA #2 was interviewed and stated that they were assigned to Resident #375 during the evening shift. CNA #2 was doing rounds at the beginning of their shift, (does not remember the time) and Resident #375 was not in their room or the hallway. They informed the nurse immediately. On 11/14/23 at 11:10 AM, Registered Nurse #1 was interviewed and stated that around 3:25 PM, one of the CNAs told them that Resident #375 was not in their room and not on the unit. Security was informed, and they paged MP10. Resident #375 was identified as high risk for elopement and was wearing a wander guard. On 11/14/23 at 12:47 PM, Security Guard #1 (SG #1), who was on duty on 8/8/23, was interviewed and stated that they do not recall much of the incident. The resident was going out and thought it was a visitor. They did not see the resident had an ankle bracelet. The alarm went off. SG #1 looked around and did not see anyone, so they reset the alarm. SG #1 said they did not know the alarm went off because the resident had left the building. On 11/15/23 at 9:49 AM, the Switch Board staff was interviewed and stated they were responsible for deactivating the entrance and exit door alarms. The main entrance alarm went off; they looked but did not notice the resident, so they asked SG #1 to turn it off. Located at the front desk were pictures and names of residents who were identified as at risk for elopement. On 11/16/23 at 9:02 AM, the Director of Nursing (DNS) was interviewed and stated that. Resident # 375 was identified as high risk for elopement on admission because the resident verbalized that they wanted to go home. They placed a wander guard on the resident, and the resident's picture was on every floor, department, and security at the front entrance. The staff knew that the resident was at high risk for elopement and had a wander guard. Resident # 375 was on visual monitoring, and they were not documenting it. When a resident with a wander guard gets on the elevator, the elevator would open but not move and would alarm until someone disarms it. The resident got on the elevator during shift change with staff members going home, and one of the staff deactivated the alarm. The staff on the unit did not notice the resident was going to the elevator. They changed the system so only security, rehab, and the supervisors can deactivate the alarm in the elevator. The front entrance double door has been locked; only the side entrance opens, so the security can watch who enters and comes out of the building. Resident #375 went to their apartment and was picked up by security at 8:00 PM. The resident was placed on one-to-one monitoring until discharged . On 11/15/23 at 4:06 PM, the Administrator was interviewed and stated that Resident # 375 had a plan and waited till the shift ended. The staff in the elevator did not think it was a resident, and they deactivated the alarm. The staff at the front desk did not do their job to prevent the resident from exiting the building and deactivated the front door alarm. They changed the entire system and limited the number of people who could deactivate the alarm in the elevator. The security, department heads, and supervisors are the only people who can deactivate the alarms in the elevators and the exit doors. 415.12(h)(2)

Based on record review and interviews conducted during the Recertification and Complaint (NY00324925) survey from 11/09/2023 to 11/16/2023, the facility did not ensure all alleged violations involving abuse were reported within 2 hours to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #14) of 40 total sampled residents. Specifically, Resident #14 reported an allegation of abuse that was not reported to the NYSDOH within 2 hours of occurrence. The findings are: The facility's policy titled Abuse Prevention Policy and Procedure dated 10/3/2022 documented all alleged violations must be reported immediately but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. Resident #14 had diagnoses of major depressive disorder and anxiety disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #14 was moderately cognitively impaired and required the assistance of 1-2 people to complete activities of daily living. The facility's investigation report initiated 9/26/2023 at 5:30 PM documented Resident #14 reported to Registered Nurse (RN) #3 that the male volunteer distributing books touched them inappropriately on the 7-3 shift. The Aspen Complaint Tracking System documented the facility reported the incident involving Resident #14 to NYSDOH on 9/27/2023 at 10:46 AM, more than 2 hours after the occurrence. On 11/16/2023 at 12:30 PM, the Director of Nursing Services (DNS) was interviewed and stated the investigation of this incident involving Resident #14 was initiated immediately on 9/26/2023 when the allegation was reported to RN #3. The DNS stated they did not report the incident to NYSDOH within 2 hours because they wanted to speak to police and assess the resident first. The DNS acknowledged that the alleged incident was not reported to the NYSDOH within 2 hours and was submitted the next morning instead. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews during an abbreviated survey (Case # NY00313388), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, with a comprehensive person-centered care plan for 1 resident (Residents #1) of 3 residents reviewed. Specifically, on 02/11/2023, Resident #1 was admitted to the facility from the hospital and was at risk for constipation, due to no bowel function (BF) while in the hospital. The hospital discharge summary dated 02/07/2023, documented that Resident #1 consumed 75 percent of two meals each day and had no bowel movement (BM) yet in-house, no nausea or no vomiting. There was no documented evidence of Resident #1's BF on the Facility's Bowel Movement Listing (BML) from 02/11/2023 to 02/19/2023, 02/22/2023 to 02/28/2023 and from 03/08/2023 to 03/16/2023. The findings are: The Facility's Policy entitled Bowel Management / Preventing Constipation, last revised on 08/2021, documented that the nursing staff will document bowel functioning every shift. Nursing staff will establish resident bowel history, determine bowel habits and the need for interventions. Resident #1 was admitted to the facility with diagnosis which included Cerebral Infraction, Aphasia, Dementia, Pulmonary edema. The Minimum Data Set (MDS, an assessment tool) dated 02/17/2023, documented that Resident #1 had severe cognitive impairment, and required one person to assist with eating and toileting. Resident #1 was incontinent (unable to control) of bladder and bowel. The Bowel Movement Listing (BML) record dated from 02/11/2023 to 02/19/2023, there were no documented evidence of BM. Medical interventions were implemented on 02/20/2023 for Senokot 17.2 milligrams (mg) give 17.2 mg by mouth daily. Magnesium Hydroxide (Milk of Magnesia 2400 grams (gm/10, give 7200 gm (30 ml) by mouth at bedtime with 8 ounces of liquid, and Bisacodyl 10 mg, give 10 mg 1 suppository rectally at bedtime as need if no BF. The BML record and nursing notes from 02/22/2023 to 02/28/2023, revealed no documentation for BM. The BML record and nursing notes from 03/08/2023 to 03/16/2023, revealed no documentation of BM. The Elimination Bowel/Bladder Care Plan dated 02/22/2023, documented interventions to encourage fluid intake, observe for changes in behavior, and to administered incontinent care as needed. There were no interventions for staff to monitor and document Resident #1's bowel function. A Physician order dated 02/20/2023, documented Senokot 17.2 mg, give 17.2 mg by mouth daily, Magnesium Hydroxide (milk of Magnesia 2400 gm/10, give 7200 gm (30 ml) by mouth at bedtime with 8 ounces of liquid, and Bisacodyl 10 mg, give 10 mg 1 suppository rectally at bedtime as need please give if there isn't any bowel movement (BM). A Nursing note dated 03/15/2023 at 12:23 AM, by RN #1, documented that Resident #1 vomited once with greenish vomitus. The Medical Doctor (MD) was informed. Will continue to monitor. A Physician's order dated 03/15/2023 at 12.40 PM, for Zofran 4 mg by mouth every 8 hours for Nausea and vomiting. A Nursing progress note dated 03/16/2023 at 2:39 PM, written by License Practical Nurse (LPN) #1, documented that at approximately 1:00 PM, The Resident's friend came in to visit. During the shift, Resident #1 had multiple episodes of vomiting. Zofran was given and was not effective. The Primary Medical Doctor (MD) was informed and ordered Zofran 4 mg intramuscular (IM). On 3/16/2023, There was no documented evidence of Resident #1's bowel function or bowel movements. On 03/16/2023, Medical interventions were implemented for Zofran 4mg (antiemetic drugs), Labs and an abdominal x-ray of the Kidney, Ureter, and bladder (KUB) were ordered. A Radiology Report dated 03/17/2023 at 12:03 PM, the abdominal x-ray result documented that Gas pattern was nonspecific with no abnormal masses or calcifications noted. No acute intra-abdominal pathology noted. If the resident was clinically suspect for intra-abdominal pathology. Computerized Tomography (CT) Scan may be advised. A Nursing Progress Note dated 03/18/2023 at 07:55 PM, completed by Registered Nurse (RN) #2, documented that Resident #1 's family member informed RN #2 that Resident #1 was very agitated and had a small amount of green emesis. A physical assessment was done, and Resident #1 was noted with pain to the upper right quadrant of the abdomen. The MD and Nursing Supervisor (RNS) were informed. Orders were given to administer Bisacodyl 10 mg suppository and IVF (intravenous fluid) for hydration and Sodium Chloride 0.45 % intravenously at 50 ml/hr. for 3 Days. A Physician's Progress note dated 03/19/2023 at 7:34 AM, documented status post severe Cerebral Vascular Accident (CVA) and partial aphasia with nausea and vomiting for a few days. IV fluids, labs, and abdominal ultrasound were ordered. Resident pulled out intravenous (IV) line, KUB was done. Resident was a poor historian. No fever, labs with mild leukocytosis, Creatine 1.8, Bicarbonate (HCO3) 32, anion gap 18 abdomen-mild tenderness, no rebound, extremities, no edema, neuro partial aphasia. Abdominal (Abd) pain, nausea, and vomiting- IV fluids 1/2 Normal Saline at 50 cc per hour, intravenous (IV) Zosyn 2.25 g, IV every 8 hours for 5 days. Abdominal ultrasound, hold Lasix, repeat labs tomorrow. The family was called. An Activities of daily living (ADL) care record dated 03/13/2023 to 03/17/2023, documented that Resident #1 was consuming fifty percent of meals. On 03/18/2023, Resident #1 did not consume any intake, IV Fluids were administered. Resident #1 pulled out the heplock on 03/19/2023 and was transferred to the hospital on 03/19/2023. During an interview on 03/29/2023 at 11:29 AM, RNS #1, stated that on 03/16/2023, Resident #1 had a lot of vomitus after breakfast. RNS #1 stated the MD was notified and order immediate Abdominal X-ray, and blood work. RNS #1 stated that Resident #1 did not have any more episodes of vomiting during the day shift. RNS #1 stated that Resident #1 was eating and drinking juice and water and a friend visited and was notified. During interviews on 03/31/2023 on 10:00 AM, five other CNAs stated that Resident #1 had bowel functions and was toileted, but they forgot to document the bowel movements. During interview on 03/31/2023 at 11:15 AM, the Medical Doctor stated that on 03/16/2023, orders were given for Resident #1 to have blood work and x-ray done. The results showed that their mild elevation with the blood count, Resident #1 was started on treatment. The Medical Doctor meet with the family and explained Resident #1's condition and treatment. The family request that Resident #1 be transferred to the hospital. Resident #1 was transferred to the hospital. During interview on 04/17/2023 at 9:56 AM, the Director of Nursing (DON) stated that there is a process for checking bowel movement (BM) alert on the electronic medication administration record (eMAR). The DON stated that the CNAs, Nurses, and Managers can see the alert on the eMAR. The DON stated that during morning report the nurses reminded the CNAs to check and document residents BM. The DON stated that if there was no documentation of BM in 72 hours, the nurses are required to out if residents have a BM or if CNAs forgot to document. The Nurses will counsel the CNAs if the documentation was not done. The DON stated that the nurses must follow up and call the medical doctor (MD) for interventions. The DON stated that she cannot answer what occurred, the CNAs knows that when there is no BM for 3 days, they are to tell the nurses. The DON stated that the BM alerts will stay on the Electric medical record for 72 hours then recalculated again. The DON stated that each unit has a manager and two Assistant Directors of Nursing (ADON) to oversee the CNAs work. The DON stated that the system works but it was the staff who did not follow through on their tasks. 10 NYCRR: 415.12

Based upon observation and interview, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food safety. Specifically, staff were observed not performing hand hygiene in between tasks and food handling. This was evident for the Kitchen Observation facility task. The findings are: Specifically, Policy and Procedure titled Sanitation and Infection Prevention/Control Subject Hand Hygiene, date issued: 5/95, revised 1/22, documented in the Food & Nutrition Services Department, all associates associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times: before handling food or clean utensils/dishes/equipment, before putting on gloves, and after any other activity that may contaminate the hands. On 01/11/22 at 11:46 AM, the Second Cook was observed coming out of the walk-in refrigerator with gloves on. The Second Cook left the kitchen, walked across the hall to the dry storage area, and exited the storage area still wearing the same gloves. The Second Cook returned to the cooking area with a container of fresh garlic, stirred a pot, opened the garlic container and put some in a blender, and added water to the blender. Afterwards, the Second Cook removed the gloves. Hand washing was not observed. The Second Cook was interviewed on 01/11/22 at 11:55 AM with regard to the policy on hand washing/infection control. The Second Cook stated hands should be washed for 30 seconds prior to donning gloves. He/She further stated hands should be washed when coming in to work and after removing gloves. Hands should be washed between glove changes when doing different activities. On 01/11/2022 at 12:05 PM, an interview with the Food Service Director (FSD) was conducted. The FSD stated that staff have been in-serviced on proper hand washing. The Executive Chef will do another hand washing in-service with the Cooking staff immediately. 415.14(h)

Based on observation, record review, and staff interview conducted during the Recertification survey, the facility did not ensure that medication and biologicals were labeled in accordance with currently accepted professional principles, and include the appropriate expiration date when applicable. Specifically, eye drops, insulin vials, and insulin pens did not have labels that included the medication name, prescribed dose, strength, expiration date, the resident's name, route of administration, and appropriate instructions and precautions directly affixed to the medication. The medication labels were affixed to plastic bags. This was evident 1 on 11 units reviewed for Medication Storage (Unit 9). The findings are: The Medication Storage Policy was requested. On [DATE] at 11:13 AM, an observation of the medication cart on the 9th floor was conducted during Medication Storage Observation with the Registered Nurse (RN# 6). One unlabeled open bottle of [MEDICATION(S)] ophthalmic solution 2% was in a plastic bag with a label affixed to it. The bag was labeled with date of open date of [DATE]. One unlabeled open bottle of [MEDICATION(S)] eye drops was in a plastic bag with a label affixed to it. The bag was labeled with an open date of [DATE]. One vial of [MEDICATION(S)] insulin ( open [DATE], exp [DATE]), one vial of [MEDICATION(S)] insulin (open [DATE]), and one [MEDICATION(S)] ,d+[DATE] pen (open [DATE]), and one Ademalog pen (open [DATE]) were each stored in a separate plastic bag with a label affixed to the bag. The bags were labeled with resident name, medication name and dosage, instructions, and open dates, but there were no medication labels on the insulin vials or pens itself. An interview was conducted on [DATE] at 11:37AM with RN #6 who stated that staff should label the medications directly on the vial, bottle, or pen with the date of opening and expiration. RN #6 stated staff did not date the medication itself, only the plastic bag. The nurse on duty is in charge of making sure medications are labeled, and the labels are checked before using the medications. On [DATE] at 11:51 AM, an interview was conducted with the Registered Nurse Supervisor (RN #4) who stated that the insulin pens, insulin vials, and eye drops should be labeled with open and expiration date. The staff should use the green and white labels when labeling the medication with the open and expiration dates. The labels should be used because the hand sanitizer can rub the ink off of the dates written on the medications. The labels should be affixed to the medication itself. Staff should be aware of the medication expiration date so that it can be removed from the cart and re-ordered when needed. RN #4 stated they do audits of the medication carts daily. On [DATE] at 12:33 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when staff give medications, they should check the expiration date. The DON stated we don't want to give any expired medication. The reason the medication is put inside a bag is because sanitizing solution rubs off the ink on the labels. The DON stated both the bag and actual medication should be labeled. The DON stated eye drops should be labeled with the open date and receive date directly on the bottle. 415.18 (e) (,d+[DATE])

Based on record reviews and interviews conducted during the Recertification survey, the facility failed to notify a resident's medical provider when there was a need to alter treatment significantly. Specifically, a resident's medical provider was not informed when the resident's blood sugar increased to 350 on one occasion. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 35 (Resident #245). The finding is: The Facility's policy titled Clinical, Acute change in condition, System -Wide last revised 8/27/18 documented it is the policy of the facility that acute changes in resident's condition are immediately shared with the resident/representative and reported to the attending physician. The nurse should immediately notify the resident's physician and the resident/ resident representative of acute changes due to abnormal vital signs, blood glucose levels that are beyond MD parameters, abnormal lab results and abnormal X-ray results. Resident # 245 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The resident received insulin. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a standing order for [MEDICATION(S)] at 12 units via subcutaneous tissue before daily but she did not have a sliding scale order that required additional insulin. Blood sugar monitoring sheet documented that the resident blood sugar for 01/06/22 at 07:30 AM was 350. The Nursing notes from 01/06/21 to 01/13/22 were reviewed. There was no documented evidence that the resident's Primary Care Physician was notified on 01/06/22 about the blood sugar of 350. During an interview on 01/12/22 at 03:08 PM, the Licensed Practical Nurse (LPN #2) stated that she checked the resident blood sugar on 1/6/22, and it was 350. LPN #2 stated that we are supposed to call the Doctor if the blood sugar is over 300. LPN #2 stated that he/she was the only nurse on the unit and extremely busy that day which is the reason why the Doctor was not called. LPN # 2 stated that the doctor should have been called about blood sugar over 300. During an interview on 01/12/22 at 03:47 PM, the Registered Nurse (RN #4) stated the Primary Care Physician must be contacted for blood sugar over 300 and under 70. RN #4 stated that we are supposed to follow the Doctor's order. if the order directs us to call the Doctor, we must ensure that the physician is notified. During an interview on 01/13/22 at 10:36 AM, the Medical Director stated that the nurses are expected to contact the Doctor if the resident's blood sugar is over 300 and under 70. The nurse must call the Doctor even if the resident has a standing order for insulin. If the sugar is extremely high, the Doctor may need to provide coverage to bring the blood sugar down to normal limits. There is no documented evidence that the primary Care Physician was called about the resident's blood sugar of 350 on 01/06/22. During an interview on 01/13/22 at 11:13 AM, the Director of Nursing (DNS) stated that the nurse is supposed to call the Doctor if the resident's blood sugar is over 300. The nurses must follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . We cannot ignore the doctor's orders. The DNS further stated that it does not matter how busy it gets, it is our policy to notify the Doctors immediately when there is a change in the resident's condition. Blood sugar over 300 should be reported to MD right away. 415.3(e)(2)(ii)(b)

Based on interview and record review conducted during a recertification (6RBP11), complaint survey (NY 552) completed on 01/13/2022, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made, to the State Survey Agency. Specifically, the facility did not report an allegation of resident-to-resident abuse to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for one allegation for 1 of 5 residents reviewed for Abuse (Resident #196). The findings are: The policy and procedure titled Clinical, Resident Abuse Reporting and Investigational Protocol, Policy and Procedure revised 06/27/2019 documented that Archcare takes seriously any and all witnessed and/or suspicion of resident/patient abuse, mistreatment, neglect, misappropriation of funds and/or exploitation by anyone including facility staff, other residents, consultants, volunteers, staff of other agencies, family members, legal guardian's, friends or individuals. Archcare will adhere to the Federal and State requirements (42 CFR 483.12; 42 CFR 482.12 and 10 NY CRR 415.4 respectfully) that mandate the reporting of alleged violations of abuse, mistreatment and neglect, including injuries of unknown origin as well as misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion immediately to the facility Executive Director/Administrator/designee in accordance with state law, to the department of Health. Documented definition of immediately as Centers for Medicare services (CMS) has defined immediately as soon as possible but not to exceed 24 hours after the discovery of the incident. However, reports should be made only if and when the reasonable cause threshold has been achieved. This may occur before the facility investigation into the incident has begun or at any time during the investigation. If the reasonable cause threshold has not been achieved, notification to the Department of Health (DOH) is not required under the aforementioned Federal and State law. The results of an investigation of abuse, mistreatment, neglect, injuries of unknown origin, misappropriation of resident property and exploitation must be reported to the Executive Director/Administrator/Designee/DON and the Department of Health within 5 working days of the incident. Reporting Witnessed or Suspected Abuse the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later then 2 hours after the allegation is made, if events that cause the allegation do not involve abuse or result in serious bodily injury, or not later than 24 hours If events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. 1) Resident #329 the aggressor, was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident had intact cognition and no documented behaviors. Resident #196, the Victim, was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #196 had intact cognition. Resident #196 exhibited no behavioral symptoms that include physical, verbal and other behaviors. The Care Plan for victimization dated 10/30/2020 documented resident at risk due to behavior related to psychiatric illness: depression as evidenced by (AEB) verbally abusive to staff, hard to redirect and interventions include: calm approach/talk is soothing manner, recognize that resident cognitive status may inhibit understanding of behaviors exhibited and or demonstrated towards him/her, identify triggers for behaviors & develop interventions to address, include resident representative in discussion relate to victimization concerns to identify triggers and develop strategies to address, provide emotion support and reassurance at all times, psych meds as order monitor effectiveness, psychology and psychiatry eval and treat as ordered, separate from others as needed and engage in task/activity of interest, visual checks as indicated per protocol and plan of care. Resident #196 care plan for Behavior symptoms: accusatory, threatening etc dated 7/15/2020 included interventions: wandering ensure proper placement and function of ankle alert, check electronic unit health record (eUHR) placement, encourage family involvement in care and visits, encourage/ monitor participation in ADLs. Praise all efforts, identify pattern of behavior, identify reason for behavior, provide [CONDITION(S)] meds if ordered, monitor adverse reaction to medication. psychiatric consult as needed, Social Services intervention and evaluation needed. Resident #196 care plan for [CONDITION(S)] meds dated 7/14/2020 included interventions to administer meds ordered by Medical Doctor (MD)/Nurse Practitioner (NP), assess behavior pattern daily, assess coping mechanisms and provide emotional support, assess effectiveness of medication, assess need for psychotherapeutic meds, encourage verbalization of feelings psychiatry or psychology consult and F/U as necessary, monitor for changes in behavior and mood. The incident report dated 10/30/2020 documented Resident #196 reported that a week ago, their roommate (Resident #329) threw something and hit them on the head. The incident occurred in the room, and Resident #196 reported the object hit them in the back of the head towards the left side. The Registered Nurse assessment documented there was no visible injury and Resident #196 complained of pain to the back of the head. The supervisor was notified on 10/30/20 at 4:45 PM, designated representative was notified at 5:19 PM and Nurse Practitioner notified at 5:30 PM on 10/30/2020. Statements were obtained from the resident, assigned certified nursing assistant. Summary of investigation form documented DOH notified on 10/31/2020 at 3:30 PM and case number documented. Law enforcement was notified documented, and Resident #196 refused to file a case. The DON and Administrator reviewed the documentation on 10/31/2020. The summary of event investigation completed 10/30/2020 documented and Resident #196 was reinterviewed by Social work and Nursing about the allegation and resident #196 reported that resident #329 threw an empty milk carton that hit them in the back of their head that still hurt and recently called them names could not recall the exact date of the incident occurred and stated some time last week and did not report it to anyone else except the Social worker on 10/30/2020. Resident #196 stated that they do not think it was intentional and believed their roommate was just displacing their anger towards their inability to talk to their nephew. Staff reported no knowledge of the incident occurring between the two residents. Other residents were interviewed in relation to the incident. Interventions included RN assessment conducted to check for latent injury, no injury noted, Tylenol as needed administered, neuro check for 3 days, encourage resident to report immediately when any similar incident occur. Conclusion, it is possible that the reported unintentional incident of object throwing did occur although Resident #329 denied doing it or calling Resident #196 names. The investigation revealed there is cause to believe alleged abuse has occurred and signed on 10/31/2020 by the DON. Social Services Progress note on 10/30/2020 at 5:19 PM documented that Resident #169 reported the alleged incident between them and their roommate took place last week, Social work (SW) notified nursing, administration and left message for resident family member, the resident #169's roommate was being transferred to another unit today. Resident #169 expressed their appreciation for SW support assistance. Assistant Director of Nursing Services (ADNS) note on 10/30/2020 at 6:33 PM documented they had a lengthy conversation with Resident #169 incident reported to the social worker that occurred last week but can't remember the exact date, denied emotional or psychological effect on them and did not want to file any charges. Resident #169 narrated what happened. Resident #169 believed it was not intentional and Resident #329 was just displacing their anger because a family member did not call them back. Resident #169 stated they had pity for Resident #329. Resident #169 mentioned that they did not report to anyone when the incident occurred. Resident was rest assured that the writer is available anytime they need to talk to anyone and will continue to follow up. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/ Incident Investigation Report for compliant NY 552 documented the facility reported the altercation between Resident #196 and Resident #329 occurred on 10/30/2020 at 4 PM and reported to NYSDOH on 10/31/2020 at 3:03 PM. The nursing progress note written at 5:10 PM on 10/30/2020 documented report of the incident. This allegation of resident-to-resident abuse was reported 23 hours and 03 minutes after the reported incident. The HERDS report was submitted by the Director of Nursing on 10/31/2020 at 03:03:46 PM to the NYS Department of Health. During an interview on 1/10/2022 at 03:41 PM, the Licensed Practical Nurse (LPN #3) was interviewed and stated if there is any abuse/neglect/ mistreatment they notify the nurse manager and medical provider. During an interview on 1/11/2022 at 05:03PM, LPN #4 was interviewed and stated Resident #196 had an altercation with their roommate (Resident #329) and alleged Resident #329 was going to harm them. Any allegation of abuse is reported to the supervisor. During an interview on 1/13/2022 at 01:45PM, RN Supervisor (RN # 4) stated if they received any abuse allegation, they would inform the nurse manager and would report to the DOH complaint hotline. They could not recall the incident with the resident. During an interview on 1/12/2022 at 12:24 PM, the Director of Nursing (DON) stated that the Resident #196 reported to the social worker that Resident #329 threw a milk carton that hit them on the back of the head and that it still hurt. Resident #196 and Resident #329 were interviewed by Social Services and Nursing in relation to the incident and could not remember when incident occurred. Resident #196 stated that the incident occurred last week when interviewed. Resident #329 was displacing their anger about not being able to speak with a family member. Resident #329 was moved to another unit. The DON stated allegations of abuse should be reported within 24 hours. The facility has up to 5 days to investigate and make a determination. DON stated the facility had to interview staff and reported the incident to DOH on 10/31/2020 at 3:03 PM which is less than 24 hours. The Administrator and Executive Director are also reporters. 415.4(b)(1)(i)

Based on record reviews and interviews conducted during recertification and complaint (NY 048) survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to address resident's concerns. Specifically, there was no documented evidence that a comprehensive care plan was developed and implemented with appropriate interventions to address resident #326 actual fall and resident # 574 use of oxygen therapy. This was evident for 2 of 38 sampled residents (Resident #326 & Resident #574). The finding is: 1) Resident #326 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE] documented the that the resident cognitive level is intact. The resident requires extensive assistance and two persons assist for bed mobility, transfer and toileting. The MDS documented no falls. Nursing note dated 2/20/21 documented the resident was found on the floor. Occurrence report dated 2/20/21 documented the resident was found on the floor. The resident tried to stand up to go to the bathroom and the resident fell . The Doctor was notified. X-ray and labs were ordered. The X-ray was negative for fractures. There was no documented evidence that the fall prevention CCP (Comprehensive Care Plan) had been reviewed and revised after the fall with the appropriate interventions to prevent future falls. On 01/12/22 at 02:26 PM, RN # 5 stated that when a resident fall, an actual fall care plan must be created to include date of recent fall and new interventions on the same day. RN # 5 stated there is a care plan for potential fall. There is no care plan for actual fall in place after the fall. RN # 5 further stated there should have been a care plan in place for actual fall with additional interventions. There should have been re-education to the resident about pressing call bell when she needs assistance. On 01/13/22 at 11:08 AM, the DNS stated that when a resident fall, there should be an actual fall care plan put in place with new interventions after the fall. An actual fall care plan should have been created right way. The incident was investigated. It was determined that the resident attempted to get up without assistance. There was no injury sustained. The X-ray was negative for fracture. 2) The facility policy and procedure titled Comprehensive Care Plan dated 9/07 and last revised 11/2021 documented the Comprehensive Care Plan (CCP) is developed by the Interdisciplinary Team within 7 days after completion of the comprehensive assessment. It also documented the Interdisciplinary Team shall include Licensed Nurse with responsibility for the Resident, Dietician, Social Worker, CNA, Activity Worker, Therapist if applicable. The facility policy and procedure titled Oxygen Therapy with effective date 07/17 documented under section Responsibility that physician/licensed nurse 1. Assesses resident for oxygen therapy and 2. Writes order. Resident #574 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital H&O (history and orders) note dated 11/2/2021 documented Resident #574 had active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident #574 had a Brief Interview of Mental Status (BIMS) score 12 out of 15, indicating moderately impaired cognition. Resident #574 did not reject care, was able to make self understood and to understand others. It also documented Resident # 574 was on oxygen therapy. On 01/06/22 at 10:14 AM, 01/07/22 at 09:08 AM, 01/10/22 at 09:37 AM, 01/11/22 at 10:14 AM, 01/12/22 at 09:23 AM, 01/13/22 at 10:16 AM and other occasions during the survey, Resident # 574 was observed sleeping in bed and receiving oxygen at 2 LPM (liter per minute) via nasal cannula in their room. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued 12/9/2021 The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that a physician ordered oxygen therapy between 12/10/2021 and 1/9/2022. The Baseline Comprehensive Care Plan (CCP) dated 11/9/2021 had no documented evidence that oxygen therapy was on the plan or any interventions were developed for oxygen therapy. The CCP related to Respiratory: Ineffective airway clearance / Oxygen related to Aspiration Precaution status, History of [CONDITION(S)] / distress, Upper Respiratory Infection initiated 1/10/2022 documented the interventions included providing oxygen therapy as ordered by MD/NP and checking proper placement of oxygen tubing every shift and PRN. There was no documented evidence that a CCP related to oxygen therapy was developed by the Interdisciplinary Team from 11/9/2021 to 1/9/2022. The nursing notes for Form: Medicare - Daily Skilled Note dated from 11/10/2021 to 12/12/2021, 12/15/2021, 12/17/2021, 12/20/2021, 12/22/2021, 12/26/2021, 12/27/2021 documented Resident #574 was on oxygen with 2 L/Min via NC (nasal cannula). The nursing notes dated 12/30/2021, 1/1/2022, 1/2/2022, 1/4/2022, 1/7/2022, 1/11/2022, and 1/12/2022 documented Resident #574 received oxygen at flow rate 2 L/Min. On 01/11/22 at 11:30 AM, Registered Nurse (RN) #3 was interviewed. RN #3 stated Resident #574 was confused but responsive and required extensive assistance with 1 person for ADLs. RN # 3 stated they provided oxygen to a resident upon admission if the hospital discharge summary indicated the resident required oxygen therapy. RN #3 also stated the Admission RN entered the medication orders including oxygen therapy for the new admission. RN #3 further stated a resident on oxygen therapy should have a care plan related to oxygen therapy and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN # 3 stated they had training for oxygen therapy including to enter order and develop care plan in orientation and in-service as needed. On 01/11/22 at 12:27 PM, the Assistant Director of Nursing (ADN) was interviewed. The ADN stated the Admission RN reviewed the hospital discharge summary and notified the attending physician to obtain verbal orders for medications and enter orders into medical record. The ADN also stated they must have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADN stated that during unit rounds on 1/10/2022, they found Resident #574 was on oxygen without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADN further stated all nurses received training for oxygen treatment, which includes entering orders and care planning, during orientation and as needed. The ADN stated they were unable to explain why the order and care plan were not entered for oxygen therapy. On 01/11/22 at 03:02 PM, the Medical Director was interviewed. The Medical Director stated there had to be a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical Director also stated the new EMR set the default duration of orders to 30 days for medication entry and this was the reason the oxygen order with a start date on 11/9/2021 was automatically discontinued on 12/9/2021. Medical Director stated the nurse should have entered a new order for the oxygen when the old one was discontinued, or the admission nurse should change the default setting of oxygen order duration to 999 days. Medical Director also stated the nurse was responsible to enter the oxygen order and notify the attending physician to review and sign it. Medical Director further stated it was lucky this time that Resident #574 was not injured from receiving the oxygen without order. On 01/12/22 at 11:34 AM, Chief Nursing Officer (CNO) was interviewed. CNO stated there had to be a care plan for oxygen therapy and the nurse or the admission nurse had to enter it within 14 days of admission. CNO also stated a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . CNO stated they switched the EMR software in the summer 2021 and the staff were not familiar with entering the order properly in the new system. CNO also stated the nurses did not change the default setting of order duration from 30 days to 999 days when entering the oxygen order for Resident #574, causing the order to be automatically discontinued after 30 days. CNO stated they were not able to explain why the care plan related to oxygen was not entered until 1/10/2022 when Resident #574 started oxygen therapy on 11/9/2021 and the staff did not find out the oxygen order was discontinued on 12/9/2021 until 1/10/2022. CNO also stated the nurses had training for oxygen therapy and would provide in-service to reinforce them again. 415.11(c)(1)

Based on record review and interviews conducted during the Re-certification Survey from 1/6/2022 to 1/13/2022, the facility did not ensure, to the extent practicable, that residents were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents and resident representatives were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. This was evident for 1 of 4 residents reviewed for Participation in Care Planning out of a sample of 38 residents (Resident # 82). The findings are: The facility policy and procedure titled Comprehensive Care Plan (CCP) Meeting dated 12/1/2001 and last reviewed 9/20/2017 documented the Social Workers invite the resident and/or family to attend the Care Planning Meeting for initial, annual or significant change if appropriate (not necessary for quarterly) and document in the medical record. It also documented that for quarterly reviews each discipline provides an update and discusses any episodic events. Resident # 82 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Date Set (MDS) dated [DATE] documented Resident # 82 had a Brief Interview of Mental Status (BIMS) score 10 out of 15, indicating moderately impaired cognition. Resident #82 did not reject care, was able to understand others and make self understood. It also documented Resident #82 participated and family was not involved in the assessment. On 01/06/22 at 02:46 PM, the family representative was interviewed. Family representative stated the facility only invited them to care plan meeting like 2 to 3 times since Resident # 82 was admitted to facility on 8/20/2020. Social Service note dated 2/17/2021 documented the IDT team called family representative during the quarterly care plan meeting and family representative attended the care plan meetings via phone. Social Service note dated 7/28/2021 it was a special care plan meeting requested by family representative on the day. Social Service notes dated 5/3/2021 and 8/11/2021 documented social worker invited family representative to quarterly and annual care plan meeting scheduled on 5/12/2021 and 8/18/2021 respectively. Social Service note dated 11/17/2021 related to Care Plan Meeting - Long Term documented no family members in attendance and Resident # 82 was not present during the care plan meeting. Care Plan Attendees dated 2/17/2021, 5/12/2021, 7/28/2021, and 8/18/2021 documented family representatives attended the care plan meetings. There was no documented evidence that Resident # 82 and/or family representative were invited to the care plan meeting on 11/17/2021. On 01/10/22 at 03:39 PM, Nurse Manager (RN # 2) was interviewed. RN # 2 stated Resident # 82 was alert and very forgetful. RN # 2 stated social worker was responsible to invite resident and/or family representative to Initial, Significant Change, and Annual care plan meetings and documented the invitation in the social services notes. RN # 2 stated the resident and/or family representative were not invited to Quarterly care plan meetings, and the social worker or other IDT (interdisciplinary team) member would update the resident and/or family representative during or after the meeting if there was any special/significant change in the care plan. RN # 2 further stated the IDT members included nursing, social worker, dietitian and MDS Assessor. On 01/10/22 at 04:01 PM, Director of Social Services (DSS) was interviewed. DSS stated care plan meeting was held according to MDS schedule and it was for Admission, Quarterly, Significant Change, and Annual. DSS also stated they notified residents and called family representatives 1 week in advance for the scheduled Admission, Significant Change, and Annual care plan meetings. DSS further stated it was the policy of the facility not to invite resident and/or family representative to Quarterly care plan meeting unless they requested to attend and only the IDT including the nurse manager, social worker, and dietitian met to review the care plan. DSS stated the care plan meeting on 11/17/2021 was quarterly one and Resident # 82 and/or family representative were not invited to attend. DSS also stated resident and/or family representative were able to request a care plan meeting at any time if they wanted. 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews conducted during Re-certification Survey from 1/6/2022 to 1/13/2022, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, a resident received oxygen therapy without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was evident for 1 out of 4 residents reviewed for Quality of Care out of a sample of 38 residents (Resident # 574). The findings are: The facility policy and procedure titled Comprehensive Care Plan dated 9/07 and last revised 11/2021 documented the Comprehensive Care Plan (CCP) is developed by the Interdisciplinary Team within 7 days after completion of the comprehensive assessment. It also documented the Interdisciplinary Team shall include Licensed Nurse with responsibility for the Resident, Dietician, Social Worker, CNA, Activity Worker, Therapist if applicable. The facility policy and procedure titled Oxygen Therapy with effective date 07/17 documented under section Responsibility that physician/licensed nurse 1. Assesses resident for oxygen therapy and 2. Writes order. Resident #574 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital H&O (history and orders) note dated 11/2/2021 documented Resident #574 had active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident #574 had a Brief Interview of Mental Status (BIMS) score 12 out of 15, indicating moderately impaired cognition. Resident #574 did not reject care, was able to make self understood and to understand others. It also documented Resident # 574 was on oxygen therapy. On 01/06/22 at 10:14 AM, 01/07/22 at 09:08 AM, 01/10/22 at 09:37 AM, 01/11/22 at 10:14 AM, 01/12/22 at 09:23 AM, 01/13/22 at 10:16 AM and other occasions during the survey, Resident # 574 was observed sleeping in bed and receiving oxygen at 2 LPM (liter per minute) via nasal cannula in their room. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued 12/9/2021 The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that a physician ordered oxygen therapy between 12/10/2021 and 1/9/2022. The Baseline Comprehensive Care Plan (CCP) dated 11/9/2021 had no documented evidence that oxygen therapy was on the plan or any interventions were developed for oxygen therapy. The CCP related to Respiratory: Ineffective airway clearance / Oxygen related to Aspiration Precaution status, History of [CONDITION(S)] / distress, Upper Respiratory Infection initiated 1/10/2022 documented the interventions included providing oxygen therapy as ordered by MD/NP and checking proper placement of oxygen tubing every shift and PRN. There was no documented evidence that a CCP related to oxygen therapy was developed by the Interdisciplinary Team from 11/9/2021 to 1/9/2022. The nursing notes for Form: Medicare - Daily Skilled Note dated from 11/10/2021 to 12/12/2021, 12/15/2021, 12/17/2021, 12/20/2021, 12/22/2021, 12/26/2021, 12/27/2021 documented Resident #574 was on oxygen with 2 L/Min via NC (nasal cannula). The nursing notes dated 12/30/2021, 1/1/2022, 1/2/2022, 1/4/2022, 1/7/2022, 1/11/2022, and 1/12/2022 documented Resident #574 received oxygen at flow rate 2 L/Min. On 01/11/22 at 11:30 AM, Registered Nurse (RN) #3 was interviewed. RN #3 stated Resident #574 was confused but responsive and required extensive assistance with 1 person for ADLs. RN # 3 stated they provided oxygen to a resident upon admission if the hospital discharge summary indicated the resident required oxygen therapy. RN #3 also stated the Admission RN entered the medication orders including oxygen therapy for the new admission. RN #3 further stated a resident on oxygen therapy should have a care plan related to oxygen therapy and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN # 3 stated they had training for oxygen therapy including to enter order and develop care plan in orientation and in-service as needed. On 01/11/22 at 12:27 PM, the Assistant Director of Nursing (ADN) was interviewed. The ADN stated the Admission RN reviewed the hospital discharge summary and notified the attending physician to obtain verbal orders for medications and enter orders into medical record. The ADN also stated they must have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADN stated that during unit rounds on 1/10/2022, they found Resident #574 was on oxygen without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADN further stated all nurses received training for oxygen treatment, which includes entering orders and care planning, during orientation and as needed. The ADN stated they were unable to explain why the order and care plan were not entered for oxygen therapy. On 01/11/22 at 03:02 PM, the Medical Director was interviewed. The Medical Director stated there had to be a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical Director also stated the new EMR set the default duration of orders to 30 days for medication entry and this was the reason the oxygen order with a start date on 11/9/2021 was automatically discontinued on 12/9/2021. Medical Director stated the nurse should have entered a new order for the oxygen when the old one was discontinued, or the admission nurse should change the default setting of oxygen order duration to 999 days. Medical Director also stated the nurse was responsible to enter the oxygen order and notify the attending physician to review and sign it. Medical Director further stated it was lucky this time that Resident #574 was not injured from receiving the oxygen without order. On 01/12/22 at 11:34 AM, Chief Nursing Officer (CNO) was interviewed. CNO stated there had to be a care plan for oxygen therapy and the nurse or the admission nurse had to enter it within 14 days of admission. CNO also stated a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . CNO stated they switched the EMR software in the summer 2021 and the staff were not familiar with entering the order properly in the new system. CNO also stated the nurses did not change the default setting of order duration from 30 days to 999 days when entering the oxygen order for Resident #574, causing the order to be automatically discontinued after 30 days. CNO stated they were not able to explain why the care plan related to oxygen was not entered until 1/10/2022 when Resident #574 started oxygen therapy on 11/9/2021 and the staff did not find out the oxygen order was discontinued on 12/9/2021 until 1/10/2022. CNO also stated the nurses had training for oxygen therapy and would provide in-service to reinforce them again. 415.12

Based on observation, interviews and record review conducted during the Recertification and Abbreviated survey (NY 258), the facility did not ensure that a resident received adequate supervision to prevent elopement. This was evident for 1 of 3 residents reviewed for Accident (Resident #1). Specifically, on 6/22/21 at around 7:10 PM to 7:49 PM the resident was observed via camera surveillance exiting stairwell B (S/W) on the 3rd floor and going to all areas of the indoor stairwell space and pushed the door exit bar several times to try to leave. At 7:50 PM, Resident #1 successfully exited the facility exit door via 72nd street exit. The door alarm was activated, and Security #1 responded but did not check the exterior of the building the moment he/she reset the alarm. Security #2 did not check the security camera when the alarm turned on. Resident #1 was dropped at the police station and the facility was notified by the police department that resident was at 19th Precinct at 11:50 PM. The findings are: A Facility policy entitled Elopement revised on 6/2021 documented that the facility has a comprehensive process to assess, care plan, monitor, and evaluate residents to determine those who have a potential for wandering/ elopement. The facility has an established process for ensuring resident safety from unsafe wandering and elopement. The residents identified to be at risk will have an individualized plan of care established to ensure that all residents who are identified as at risk for elopement / unsafe wandering do not elope from the facility. A facility policy entitled MP10 /Missing Resident revised 10/5/13 documented that the facility provides a safe and secure environment for all residents. In the event of a resident elopement or a resident missing, or unaccounted for, it is the policy of facility to immediately implement the MP10/ Missing Resident Policy and Procedure to locate the resident in a timely manner. It is the responsibility of the nursing staff to know where residents are at all times, especially at change of shift, mealtimes, medication times and bedtime. Security guard job code documented that security essential functions are to monitor security signal system in security office or on doors. Take Appropriate action if warning signal is received. Notifies appropriate authorities within facility when an incident of significant has occurred. In addition to chief of security it is imperative that the nursing supervisor on duty, or if so directed, the administrator on call be provided with full particulars of the incidents and to observed video monitors for intruders, trespassers and situation out of the ordinary. Resident #1 was admitted at the facility on 10/9/2017 with diagnoses including Dementia, Alzheimer's disease, restlessness and agitation, delusional disorder, [CONDITION(S)] disorder, and intracerebral hemorrhage. The Minimum Data Set (MDS, a resident assessment tool), dated 5/17/21 documented that Resident #1 had a Brief Interview for Mental Status (BIMS), a scale used to determine attention, orientation, and ability to recall information, score of 02/15, indicating severe cognitive impairment. The resident required limited assistance of one person for locomotion on and off the unit and was bowel and bladder continent. Section E0900 of the MDS documented that wandering behavior occurred 1 to 3 days during the look back period. A Facility Accident/Incident Report and Internal Investigation dated 6/21/2021 documented: Resident #1 exited the facility at 7:50 PM from the 72nd Street exit. The alarm was activated but Security #1 who responded did not check the exterior of the building at the time he/ she reset the alarm. The resident apparently accessed the stairwell (B) and walked down to the first floor where Resident #1 lingered in the egress area for 30 minutes. The exit door is equipped with a 15 second delay which unlocks after 15 seconds when someone pushes the door to exit and unlocks after 15 seconds when someone pushes the door to exit. Security #2 in the Security office did not monitor the closed-circuit television (CCTV) system as required and did not see Resident #1 in the egress area for 30 minutes. Occurrence Report dated 6/22/21 at 9:30 PM documented that Resident #1, who was confused with a BIMS score of 2 out of 15 was noted to be missing at 9:30 PM by the CNA#1. A full sweep was done on the floor and Resident #1 was not found on the entire building. 911 and family was called. Law enforcement was notified on 6/21/21 at 10 PM and Department of Health was notified on 6/22/21 at 5 PM. A wandering/ elopement risk assessment dated [DATE] documented that Resident #1 was at high risk for elopement with a score of 09 as evidenced by wandering behavior, cognitive impairment, and independence with mobility. Interventions included providing identification bracelet, making staff aware that resident is wander risk, and having a photograph of the resident on wander list. Elopement score code 2-4=no risk, at risk =5-7 points and high risk =8-28 or more points. Wanderer, Risk for Elopement Care Plan dated 8/23/19 and reviewed on 11/11/21 documented that Resident #1 was at risk related to wandering, assessed as high risk for elopement, and dementia. The interventions included having a right wrist wander guard, providing redirection from staff when behavior occurs, identify patterns of behavior, and encourage family involvement. The CCP did not include any specific supervision needs for the resident. The Treatment Administration Record (TAR) dated 6/21/21 documented that Resident #1 right wrist wander guard placement was checked prior to elopement incident. The wander guard system daily testing log dated 6/21/21 at 5:30 PM documented that Resident #1's wander guard was checked prior to elopement. The Security Testing Log dated 6/21/21 documented that the 72nd Street exit door was checked on the Day shift, Evening Shift and night shift. There was no system error during elopement. During the incident, the 72nd exit door alarmed, and Security #1 turned the alarm off. Resident CNA documentation History Detail for Safety documented that on 6/21/21, the 7-3 shift CNA checked Resident #1 wander guard placement and documented that the wanderguard is fully functional. Episodic Weekly behavior Nursing Progress note dated 6/16/21 document that Resident #1 showed behaviors such as pacing, biting, temper outburst, wandering and physical aggression. A non-pharmacological intervention was provided such as a staff redirecting Resident#1 and was noted effective at the time. The 24-hour nursing report dated 6/21/21 documented that Resident #1 continuously ambulated on the floor and was noted missing at 9:30 PM. LPN#1 informed RN #1 and security of the missing resident, and a search of the floor and building was done. The 24-hour Nursing report dated 6/22/21 documented that RN #1 was notified by LPN #1 that Resident #1 was unable to be located on the floor. Code MP10 was called, full sweep done on all floors. At 10:43 PM, Resident #1's family member was notified that Resident #1 was missing. The facility called 911 at 10:30 PM and at 12:05 AM Officers from the facility were made aware by the police that Resident #1 was at the Police Precinct. Resident #1 was brought back to the facility at 12:20 AM. Nursing note dated 6/22/21 at 12:36 AM documented that RN #1 was informed that on 9:30 PM, Resident #1 was unable to be located on the floor and full sweep were performed. 911 was called at 10:30 PM, Police Department was notified at 10:40 PM. At 12:04 AM officers at the facility were made aware by the police that resident was at 67th precinct and Resident #1 was brought back to the facility at 12:20 AM. The security note dated 6/21/21 at 9:30 documented that Security #2 received a call from the 3rd floor, requesting to announce Missing resident code MP10 and staff started to search for Resident #1. At 10:50 PM the police officers arrived. There was no documentation noted about the alarm being set off by Security #1 or any incident that the resident eloped prior to 9:30 documentation. Prior to elopement incident, Resident #1 was provided with a wander guard and was not placed on 15-minute, hourly, or one on-one monitoring. Observation conducted of the 3rd floor and stairwell (S/W) B, and Stairwell leading to 72nd street exit door was conducted on 1/12/22 at 2:30 PM with the CNO and security director. Resident #1's room was on the 3rd floor, 15 rooms from the (S/W) B stairwell exit door. The exit door had a key fob coded exit door that a staff member must use an issued key fob to be able to open the door before exiting the stairway otherwise the door would not open. There is no delay egress on the stairwell exit door as the door would not open without an issued key fob. Resident #1 went down from the 3rd floor stairwell to the 72nd exit door. The 72nd exit door is equipped with a 15 second delay which unlocks after 15 seconds when someone pushes the door to exit, and the alarm turns on that needed a staff to physically go to the 72nd exit door to disarmed the alarm. The 72nd exit door leads out to the 72nd street. On 01/12/2022 at 12:43 PM, an interview with the LPN #1 was conducted. LPN#1 stated that he/she gave the medication earlier prior to the time ordered as resident constantly is wandering and Resident #1 likes to walk around. LPN #1 added that he/she did not notice the resident leaving the unit as she was busy giving medications to other residents and only noticed the incident when CNA #1 notified her of the missing resident. On 01/13/2022 at 11:11 AM, an interview with RN #1 was conducted. RN#1 stated that Resident #1 prior to incident was not on every 15 minutes, hourly or one to one monitoring as all elevators alarms does not close and moved when a resident with a wander guard goes near the elevator and the stairwell doors does not open if the staff does not use any key fob. RN#1 stated that around 9 PM, he/she was notified by LPN#1 that Resident #1 was missing, and the entire unit staff searched for Resident #1. Once the staff realized that Resident #1 was missing, Missing Code MP10 was called. RN #1 stated that a total facility search was initiated, police department, and hospitals were being notified. At around 11:50 PM the police officer contacted the facility and stated that the resident was in the police station and on its way to the facility. On 1/11/22 at 3:10 PM, an interview with the Chief Nursing Officer (CNO) was conducted. CNO stated that prior to elopement there was no every 15 minute, no hourly nor one on one monitoring done for the resident as resident's wander guard was in place and all elevators will not work once any resident with wander guard goes near the elevator. After the elopement on 6/22/21, upon facility readmission the resident was placed on one-on-one monitoring for elopement and behavioral issues. On 1/12/22 at 12:04 PM, an interview with the Physical therapist (PT#1) was conducted. PT#1 stated that staff were instructed when moving from one unit to the other using the facility stairwell, an issued key fob will be used, and all staff must ensure that no resident followed any staff when exiting the unit door. PT#1 added that when he/she left the exit door, he/she did not notice any resident Infront or behind him/her and did not realize that Resident #1 eloped that day until being notified. On 01/12/22 at 11:20 AM, an interview with Security #1 was conducted. Security #1 stated that it was a very busy day, and he/she was assigned at the front desk where people are coming in and out at the facility entrance door. Later that day, the 72nd door alarm and as per security #1 he went to the 72nd exit door and disarmed the alarm and immediately went back to his post and continued his assigned task. Security #1 stated that when he/she disarmed the alarm he/she did not noticed anyone and admitted that he/she did not check 72nd street and later found out that Resident #1 has eloped exiting 72nd exit door. Security #1 was remorseful and admitted that he/she was overwhelmed with his task and failed to check outside when the alarm was on. On 01/12/22 at 11:42 AM, an interview with Security #2 was conducted. Security #2 stated that he/she saw the resident standing by the elevator and asked Security # 1 to check if the resident was still in the unit. As per Security #2, Security #1 did not do anything and did not check the resident. Security #2 added that he was so busy that day and the 72nd exit door alarm turned on and requested Security #1 to check the alarm. Security #1 turned off the alarm and told security #2 that all was good, and no one was at the door. Security #2 admitted that he/she was so busy when the alarm tuned on and only checked the CCTV once and failed to thoroughly check the CCTV again and continued to attend someone at the front desk. On 01/12/2022 at 12:18 PM, an interview with Security Director (SD) was conducted. SD stated that he got a phone call from the security saying that there was an elopement. After the phone call, SD immediately notified the administrative staff of the incident. SD added that as soon as they arrived at the facility, they reviewed the CCTV surveillance and discovered that Resident #1 successfully exited the facility at 7:50 PM. Both security guards were terminated due to failure to follow the facility procedures by turning the 72nd alarm door off without checking and failed to check the surveillance camera when the alarm turned on causing the resident to elope successfully. On 1/11/22 at 3:10 PM, an interview with the Chief Nursing Officer (CNO) was conducted. CNO stated that PT#1 was exiting the stairwell (S/W) B and Resident #1 followed PT#1 and goes to the stairwell then exited the 3rd floor building going down to stairwell then to 72nd exit door. The security guards have disarmed the alarm and failed to check the video. The facility staff are well aware that when exiting using the stairwell it is their responsibility to make sure the door is closed and that no resident is following them. As for the security guards, both has failed to follow the facility policy and protocol causing the resident to successfully elope. Both security guards are already terminated, and additional interventions were in place with re-in services to prevent reoccurrence. CNO stated that prior to elopement there was no every 15 minute, no hourly nor one on one monitoring done for the resident as resident's wander guard was in place and all elevators will not work once any resident with wander guard goes near the elevator. After the elopement on 6/22/21, upon facility readmission the resident was placed on one-on-one monitoring for elopement and behavioral issues. 415.12(h)(2)

Based on observations, record review, and interview during the recertification survey, the facility did not ensure that an effective pest control program was in place. Specifically, small insects (Gnats) were observed in hallways and food storage areas. This was evident for 2 of floors observed for Environment (Floors 1 and 7). The Finding includes: The Small Fly Service Guidelines (Dated May 2019) documented that small fly integrated pest management stresses eliminating the conditions which may lead to infestations and preventing them from either becoming worse or happening in the first place. The buildup of garbage, decaying organic matter, and grease, in combination with moisture that leads to a small fly infestation. On 03/02/2020 at 9:00 AM, an initial observation was done going to the kitchen and observed small insects flying around in the 7th-floor hallway. On 03/03/2020 at 08:15 AM, an observation was conducted with the food service director. Small insects were flying around the 1st-floor hallway leading to the emergency food storage room, 7th-floor hallway towards the kitchen, and inside the dry storage room. On 03/03/2020 at 08:18 AM, an observation was conducted with the food service director at the dry storage room and observed small insects flying upon entrance, and right beside the entrance door was the ice maker machine. Observed 5 small flying insects resting on the sides of the upper unit of the ice maker machine, and 4 small flying insects on resting on the sides of the lower unit of the ice maker machine. Two small flying insects were observed flying around the ice maker machine drainpipe. The Ice maker machine was observed with two drainpipes touching the floor drainage without any air gap. On 03/04/2020 at 03:45 PM, while exiting from the 9th floor to 7th-floor staircase and exited in front of the kitchen hallway, both the surveyor and the food service director observed small insects flying around. The food service director pointed at more small flying insects flying around the ceiling and stated it is because of the construction all these little insects are here. Invoices from the Pest Management company dated 2/6/2020 thru 3/5/2020 documented an ongoing problem with flies and fruit flies in the dry storage room and the 7th floor with treatments of liquid residual pesticide, fogging, dusted drains and glue boards for German roaches and fruit flies done weekly. On 2/13/20, the invoice notes documented moderate fruit fly activity was observed. The 2/13/20 invoice was the only invoice that described the level or severity of the fruit fly issue. On 03/04/2020 at 02:51 PM, an interview with the food service director was conducted. The FSD stated that there is ongoing construction causing small insects to come out on the hallways. He does not know why there are gnats inside the dry storage room where there is no food around. He has all the insect extermination files to show they have been trying to get rid of these insects for weeks. On 3/4/2020 at 3:48 PM, an interview with the housekeeping and maintenance director was conducted. He stated he has noticed all the little insects flying in the hallway and dry storage room. That is why he called the exterminator to get rid of them. Unfortunately, these insects have been a current issue despite doing a lot of insect exterminator techniques hoping they will be eradecated. On 3/5/2020 at 12:01 PM, an interview with the facility administrator was conducted. He stated that recently we had some insect issues and tried to have the areas treated weekly to twice per week. Despite the heavy insect treatments, the insects are coming back. 415.29(j)(5)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure that a resident and the resident's representative was notified of a hospital transfer in writing. Specifically, a resident that was hospitalized was not provided with a notice of transfer/discharge as soon as practicable once the transfer occurred. This was evident for 1 of 2 residents reviewed for hospitalization (Resident #207). The findings are: A facility policy and procedure related to Involuntary Transfer/Discharge, dated 10/16/18, documented that when a resident is temporarily transferred on an emergency basis to an acute care setting, a Notice of Transfer may be provided as soon as practicable to the resident or resident's representative. Resident #207 was diagnosed with [REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented that the resident is cognitively intact. An Admission, Discharge, Transfer (ADT) Activity Detail Report for Resident #207 documented that the resident was hosptalized on [DATE] and readmitted to the facility on [DATE]. The resident was also hosptalized on [DATE] and readmitted to the facility on [DATE]. Nursing Notes dated 1/2/20 documented that the resident was transferred to the hospital due to respiratory distress. The resident's daughter was present during the resident's transfer. Nursing notes dated 1/28/20 documented that the resident was readmitted to the facility. A SBAR Communication Form dated 2/25/20 documented that the resident's condition has worsened and that she was being transferred to an acute care hospital. There was no documentation reflecting that the resident or resident's representative was provided with a notice of transfer and discharge. The Director of Social Work (DSW) was interviewed on 03/05/20 at 02:24 PM. She stated that she is not responsible for sending the notice of transfer/discharge to the resident or family member when a resident is transferred to the hospital. She believes that it is the Administrator's responsibility. She is responsible for providing these notices to residents who have planned discharges to the community. An interview was conducted with the Administrator on 03/05/20 at 03:21 PM. He stated that he does send monthly lists to the Ombudsman's office containing the names of residents that have been hospitalized or discharged home. He is aware that notices of transfer/discharge need to be provided to residents or their representatives when they are hospitalized , but the facility has not been providing these notices in these instances. The DSW provides the notices of transfer/discharge to the residents when they have a planned discharge to the community, but there is not anyone assigned to do so when they are hospitalized . This notice makes the resident and their representative aware of their rights upon discharge. 415.3(h)(1)(iii)(a-c)

F625 Resident #207 hospitalization Based on record review and interviews conducted during the recertification survey, the facility did not ensure that a resident was provided with a notice of bed hold policy within 24 hours of emergency transport to the hospital. Specifically, a resident that was hosptalized on [DATE] and 2/25/20 did not receive a bed hold letter. This was evident for 1 of 2 residents reviewed in the area of hospitalization . (Resident #207) The findings are: A facility policy and procedure related to Bed hold and Return to Facility was revised on 7/15/19 and documented that a resident and representative will be provided with bed hold information before a hospital transfer. Resident #207 was diagnosed with [REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented that the resident is cognitively intact. An Admission, Discharge, Transfer (ADT) Activity Detail Report for Resident #207 documented that the resident was hosptalized on [DATE] and readmitted to the facility on [DATE]. The resident was also hosptalized on [DATE] and readmitted to the facility on [DATE]. Nursing Notes dated 1/2/20 documented that the resident was transferred to the hospital due to respiratory distress. The resident's daughter was present during the resident's transfer. Nursing notes dated 1/28/20 documented that the resident was readmitted to the facility. A SBAR Communication Form dated 2/25/20 documented that the resident's condition has worsened and that she was being transferred to an acute care hospital. There was no documentation that the resident was provided with a notice of bed hold when tranferred to the hospital. An interview was conducted with the Director of Admissions (DOA) on 03/05/20 at 02:33 PM. The DOA stated that she did not provide Resident #207 or her family member with a bed hold letter, and she did not call them to inform them of the bed hold policy after the resident had been hospitalized . If the DOA discusses this with a resident's family member by phone, she usually makes a note of it in her billing system; however, she does not have any notes regarding any conversations that took place with the family of this resident. The bed hold letter is supposed to go with the resident when they are transferred to the hospital and is included with the medical records that are sent to the hospital. The nursing staff on the resident's unit are responsible for sending them. An interview was conducted with Registered Nurse (RN) #4 on 03/05/20 at 12:21 PM. RN #4 is the Nurse Manager of the resident's unit and stated that it is the responsibility of the nurse on duty at the time of transfer to send a bed hold notice with the resident when they are transferred to the hospital. There is a binder on the unit with the bed hold policy and blank letters for the nurses to use. This was not done on the last two hosptializations for Resident #207 on 1/2/20 and 2/25/20. It was most likely not provided because due to the urgency of the transfer to the hospital, the nurse responsible must have forgotten. On 03/05/20 at 12:39 PM, an interview was conducted with RN #5, the RN that was responsible for coordinating the resident's discharge to the hospital on [DATE]. RN #5 stated that there is a bed hold letter that is supposed to be sent with the resident while they are being transferred to the hospital. RN #5 was previously unaware of this policy. The facility administration just recently informed her that she is responsible for sending the bed hold letter with the resident. 415.3(h)(4)(i)(a)

Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that all drugs and biologicals were kept in locked compartments. Specifically, there was no staff present when an unopened vial of [MEDICATION NAME] was observed to be on an overbed table in a resident's room. This was evident for 1 of 10 units reviewed for Medication Storage. (Unit #10)) The findings are: A facility policy and procedure related to Storage of Medication was revised on 3/5/20 and documented that drugs shall be stored in cabinets, drawers, and arts or automatic dispensing systems. On 03/02/20 at 07:17 AM, the resident's room [ROOM NUMBER] was entered, and an unopened vial of [MEDICATION NAME] 500 was observed on the overbed table next to the resident's bed. The pink top had not been removed and there was a small amount of clear liquid in the vial. The resident was lying in bed, in and out of sleep, and it was a private room. Identifying markings on the [MEDICATION NAME] vial: Batch - CHN 6/EXP - SEP 2021, N 16. Resident #502 had a [DIAGNOSES REDACTED]. physician's orders [REDACTED]. This order was discontinued and changed on 3/3/20 to [MEDICATION NAME] ([MEDICATION NAME]) unit/mL injection every 12 hours. A Comprehensive Care Plan (CCP) related anticoagulation therapy was initiated on 2/16/20 and documented that the resident uses [MEDICATION NAME]. Medications are to be administered as ordered. A Minimum Data Set ((MDS) dated [DATE] documented that the resident is cognitively intact and received 6 days of an anticoagulant. The Medication Administration Record [REDACTED]. A Medical Doctor (MD) progress note dated 3/3/20 documented that the resident was refusing the [MEDICATION NAME] mini dose every 8 hours and that it will be changed to every 12 hours with patient in agreement. An interview was conducted with the Registered Nurse (RN) #1/Medication Nurse for the 7 AM to 3 PM shift on 03/02/20 at 07:19 AM. After the RN #1 observed the [MEDICATION NAME] vial in the room of Resident #502, the RN stated that it must have been left by the nurse from the previous shift. The resident is due to receive [MEDICATION NAME] at 6 AM but had refused that morning. The medication is not supposed to be left in the resident's room. RN #1 did not have a chance to do her rounds as of yet and did not see it. On 03/05/20 at 10:46 AM, an interview was conducted with the medication nurse that worked at 6 AM on 3/2/20, RN #3. She stated that she is an agency nurse and does not usually work on the resident's unit. She became nervous when she heard that the New York State Department of Health had entered the building and made an oversight by leaving the [MEDICATION NAME] vial in the resident's room. Medication, including those in vials, should never be left unattended in a resident's room. If the resident refuses the medication, it should be brought back to the medication cart. An interview was conducted with the nurse manager for the resident's unit, RN #2, on 03/06/20 at 09:08 AM. The medication should not have been left in the resident's room at all. The nurse was inserviced on not ever leaving medications at the bedside. If the resident refuses the medication, then the medication nurse is to take it back, put it back in the original packaging, and lock it in the medication cart. The MD is then notified, and the nursing supervisor is made aware so that the resident can receive further counseling. The nursing staff are then responsible for documenting the refusal in a nursing note and on the MAR. 415.18(e)(1-4)

Based on observations, record reviews and staff interviews, the facility failed to have a Quality Assessment and Assurance (QAA) program that identified, developed and implemented appropriate plans of action to correct the identified and on-going issues related to the fluctuating water temperatures throughout the facility. Specifically, the committee did not identify the immediate and potential risk to resident health and safety [MEDICAL CONDITION] scalding injuries related to excessively hot water. This was evident for all of the twelve beverage dispensers located in each unit dining room, in multiple resident room sinks and community shower rooms. This deficient practice had the potential to affect all of the facility's 378 residents. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to resident health and safety. The findings are: The facility identified that the water temperatures were a problem in April of 2012 and had brought in an outside company to check the mixing valves as well as a steam consultant to assess the fluctuating water temperatures. The QA Committee identified that there was an issue with fluctuating water temperatures. The QA Committee failed to follow-up on the effectiveness of the interventions initially put into place to remedy the fluctuating water temperatures. The QA Committee failed to identify that the hot beverage dispensers and the hot surface of a fan-coil heating unit were a potential safety hazard to all residents. The following members of the Quality Assurance Team were interviewed: The Director of Nursing, The Administrator, and The Director of Support Services. The Director of Nursing Services (DNS) was interviewed on 01/18/13 at 2:30 PM. The DNS stated that she was aware (since last year) that there were temperature fluctuations with the water in the resident room sinks and common shower rooms. The water was fluctuating "too cold, not too hot." The DNS further stated that she had not been informed by the maintenance staff or the Administrator that the hot water temperatures were measured above 120 degrees Fahrenheit and had the potential to cause scalding [MEDICAL CONDITION] the residents. On 1/18/2013 at 2:40 PM, the Administrator was interviewed by the survey team. He stated that initial concern with the hot water was brought to his attention by Resident Council. He stated that the water temperatures were being monitored during the night shift by a maintenance worker who was responsible for checking the temperatures at random resident room sinks and documenting the temperatures on the monitoring log. The monitoring was done weekly. Although the monitoring logs indicated that the temperatures were within acceptable ranges, he said that the maintenance staff had made him aware that there were temperature fluctuations ranging from too hot to too cold. In April, he was made aware that a sink in a resident's room, (room [ROOM NUMBER]) the temperature reading was 132 degrees Fahrenheit. He was also made aware that there were problems with temperature readings at sinks on the upper units. A review of the temperature logs revealed temperatures exceeded 120 degrees at various times and mostly technicians responded by adjusting the valve located at the bottom of each sink. The Administrator stated that these valves have an access panel and only maintenance staff are able to adjust the water temperature. However, there were times when the job was beyond the repair of maintenance staff and a plumbing contracting company was called. The Administrator further stated that in April of 2012 he contacted a company specializing in engineering and steam, and the company identified that there were problems with the two hot water tanks located in the basement. They informed him that the tanks needed rebuilding, the work was started in April and completed in July and August of 2012. One tank was shut down and one was rebuilt. Regarding the beverage dispensers the Administrator said that the facility did not have a system in place for monitoring the temperatures of the fluids that were dispensed. The Administrator was interviewed and stated that the facility identified the water temperature fluctuation back in April of 2012. He further stated that this issue was brought to the QA Committee and they were working on the problem. On 01/25/13 between 1:00 and 2:00 PM an interview was conducted with the Director of Support Services. He stated that usually the water is too cold and that he was aware of the problem for approximately 5 to 6 weeks. He further stated that the maintenance department takes water temperatures at certain locations in the building and that they take a certain amount of temperatures, but that he is not really sure of the whole thing but that he has been more involved the last few weeks because the Maintenance Director is on vacation and he is overseeing the Maintenance Department. The Immediate Jeopardy was removed on 1/24/2013. The team exited the facility on 1/25/2013. Prior to the team's exit the following concerns were addressed to remove the immediacy: 1) All beverage dispensers were turned off, unplugged and a sign was placed on each dispenser stating that they were out of order. 2) The maintenance staff tested the water temperatures in all resident rooms and common areas with freshly calibrated thermometers and documented in a log that indicated that the thermometer had been calibrated before the testing. Any sink with a water temperature over 120 degrees was immediately fixed by the plumber. 3) The maintenance staff implemented a system that included shutting off the water in any room where the temperature could not be adjusted to less than 120 degrees and notifying the floor nurse that the water had been shut off. 415.27(a-c)

Based on observations, record reviews, staff and resident interviews, the Administrator failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently. Specifically, the Administrator failed to ensure that water temperatures in resident accessible areas were within acceptable and safe ranges. This had the potential to affect the 358 residents in the facility. This resulted in no actual harm with the potential for serious harm to all residents that is Immediate Jeopardy to resident health and safety. (See also - F 323 ) The findings are: 1) During an initial unit tour of the 10th floor, on 1/18/13 at 11:30 - 12:00 PM, the sinks in the following resident rooms: #1005, #1006 and #1019 were observed with extremely hot water. The surveyor tested the hot water by running the water over her hand. After approximately 25-30 seconds, the hot water became so hot that the surveyor had to remove her hand. The Sanitarian then measured the water temperature using the facility's digital stem- type thermometer. The hot water readings were noted to range from 125 to 136 degrees Fahrenheit (F) at the sinks in the common residents' bathing rooms, resident rooms and other areas accessible to the residents. A review of the temperature monitoring logs revealed temperatures exceeded 120 degrees at various times and the maintenance staff responded by adjusting the mixing valves located beneath each sink. The Director of Nursing (DNS) was interviewed on 1/18/13 at 2:30 PM. The DNS stated that she was aware (since last year) that there were temperature fluctuations with the water in the resident room sinks and common shower rooms. The water was fluctuating "too cold, not too hot." The DNS further stated that she had not been informed by the maintenance staff or the Administrator that the hot water temperatures that were measured above 120 degrees Fahrenheit had the potential to cause scalding [MEDICAL CONDITION] the residents. On 1/18/2013 at 2:40 PM, the Administrator was interviewed by the survey team. He stated that initial concern with the hot water was brought to his attention by Resident Council. He stated that the water temperatures were being monitored during the night shift by a maintenance worker who was responsible for checking the temperatures at random resident room sinks and documenting the temperatures on the monitoring log. The monitoring was done weekly. Although the monitoring logs indicated that the temperatures were within acceptable ranges, he said that the maintenance staff had made him aware that there were temperature fluctuations ranging from too hot to too cold. In April, he was made aware that a sink in a resident's room, (room [ROOM NUMBER]) the temperature reading was 132 degrees Fahrenheit. He was also made aware that there were problems with temperature readings at sinks on the upper units. A review of the temperature logs revealed temperatures exceeded 120 degrees at various times and mostly technicians responded by adjusting the valve located at the bottom of each sink. The Administrator stated that these valves have an access panel and only maintenance staff are able to adjust the water temperature. However, there were times when the job was beyond the repair of maintenance staff and a plumbing contracting company was called. The Administrator further stated that in April of 2012 he contacted a company specializing in engineering and steam, and the company identified that there were problems with the two hot water tanks located in the basement. They informed him that the tanks needed rebuilding, the work was started in April and completed in July and August of 2012. One tank was shut down and one was rebuilt. Regarding the beverage dispensers the Administrator said that the facility did not have a system in place for monitoring the temperatures of the fluids that were dispensed. The Immediate Jeopardy was removed on 1/24/2013. The team exited the facility on 1/25/2013. Prior to the team's exit the following concerns were addressed to remove the immediacy: 1) All beverage dispensers were turned off, unplugged and a sign was placed on each dispenser stating that they were out of order. 2) The maintenance staff tested the water temperatures in all resident rooms and common areas with freshly calibrated thermometers and documented in a log that indicated that the thermometer had been calibrated before the testing. Any sink with a water temperature over 120 degrees was immediately fixed by the plumber. 3) The maintenance staff implemented a system that included shutting off the water in any room where the temperature could not be adjusted to less than 120 degrees and notifying the floor nurse that the water had been shut off. 415.26

Based on observation, record review, and staff interviews during the recertification survey, the facility failed to ensure that the residents' environment remained free of accident hazards. Specifically, the facility failed to protect all of the (358) residents from the potential for burns and scalding related to excessive hot water temperatures from the facility's domestic hot water system, hot beverage dispensers, and from the hot surface of a fan-coil heating unit in a common resident use area. This deficient practice was evident at the resident sinks and common, hallway bathrooms on the 8th to 13th floors, the beverage dispensers on all of the twelve resident dining rooms and one heating unit in a resident sitting area on the 9th floor. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care to all residents' health and safety. The findings are: During the environmental and unit tours conducted on 01/18/13 between 9:45AM and 12:00 PM, the following was noted: 1) During an initial unit tour conducted on 1/18/13 at 11:30- 12:00 PM, on the 10th floor, the sinks in the following resident rooms: #1005, #1006 and #1019 were observed with extremely hot water. The surveyor tested the hot water by running the water over her hand, after approximately 25-30 seconds the hot water became so hot that the surveyor had to remove her hand. The Sanitarian measured the water temperature using the facility's digital stem- type thermometer. Hot water readings were noted to range from 125 to 136 degrees Fahrenheit (F) at sinks in the common residents' bathing rooms, resident rooms and other areas accessible to the residents. Examples of hot water temperatures taken at the hand washing sinks at various locations included but were not limited to the following: 13th floor: Common restroom 129F Resident room # 1319 - 129F 12th floor: Common restroom 132F Resident room # 1219 - 132F 11th floor: Common restroom 125F Resident room # 1108 - 125F 10th floor: Common restroom 136F Resident room # 1006 - 136F 9th floor: Common restroom 130F Resident room # 914 - 130F 8th floor: Common restroom 128 F Resident room # 815 - 126F 6th floor: Resident room # 608 - 121 F 2) Beverage dispensers were located in dining rooms in each of the twelve resident units, including a unit housing residents diagnosed with [REDACTED]. The dispensers were operated with a one-touch push button device. The temperatures of the dispensed fluids were found to be between 160 and 193 degrees. The 10th floor dining room sink was observed with hot water temperature of 183 degrees F and the temperature of the coffee that was dispensed was 178 degrees F. 3) On 1/18/2013 at approximately 11:45 AM, it was noted that the surface of a fan-coil heating unit in the 9th floor "Sitting Room" was hot to the touch with an air flow temperature reading of 138 degrees F. The temperature was measured by the facility's Housekeeping Supervisor using a digital stem type thermometer. He immediately alerted a maintenance employee about the issue with the fan coil unit. On 1/18/2013 at approximately 11:30 AM, the Supervisor of Housekeeping was interviewed. He stated that he was in charge of overseeing the day to day maintenance activities since the Director of Maintenance went on vacation. He further stated that the maintenance department is responsible for checking the domestic hot water temperatures on a daily basis to ensure safe hot water temperatures at the resident hand washing sinks. He immediately alerted a maintenance employee about the issue with the domestic hot water. On 01/18/13 from 1:30 PM - 2:30 PM staff members from the 3rd and 2nd floors were interviewed. Certified Nurse Aides # 1-4 each stated that the water temperatures during the residents' showers fluctuated considerably. The CNAs reported that they turn on the water, regulate it by mixing the hot and cold water, and check the temperature by testing the water on their wrist, hand, arm or elbow. The CNAs reported that if the water "felt too hot," they would then remove the resident and postpone the shower until later in the day. The CNAs further stated that the frequent water temperature fluctuations was common knowledge and that they would "sometimes" notify the nurses. Each of the CNAs denied being inserviced or informed that they were responsible for taking the temperatures with thermometers and that to their knowledge, the acceptable range for hot water temperatures was 80 -95 degrees. The CNAs further stated that the doors to the dining rooms were not kept locked. On 01/18/13 from 1:30 PM - 2:30 PM, the 2nd and 3rd floor RN Managers were interviewed. The Licensed Practical Nurses #1-7 (LPN) were interviewed, and Registered Nurses (RN) #1-4 were also interviewed. All nursing staff stated that they were aware of the water temperature fluctuations, but did not consistently report this to maintenance staff. On 1/18/2013 at 12:10 PM, the Dietary Director was interviewed. She was unaware that the temperatures of the dispensed beverages was over 180 degrees, and added that the temperatures were not being monitored by her department. She further stated that all the hot beverage dispensers were set up to operate the same way with the same temperatures for coffee and hot water. She stated that she was not aware if any other department was monitoring the temperatures from the beverage dispensers. On 1/18/2013 at 2:40 PM, the Administrator was interviewed by the survey team. He stated that initial concern with the hot water was brought to his attention by Resident Council. He stated that the water temperatures were being monitored during the night shift by a maintenance worker who was responsible for checking the temperatures at random resident room sinks and documenting the temperatures on the monitoring log. The monitoring was done weekly. Although the monitoring logs indicated that the temperatures were within acceptable ranges, he said that the maintenance staff had made him aware that there were temperature fluctuations ranging from too hot to too cold. In April, he was made aware that a sink in a resident's room, (room 507) the temperature reading was 132 degrees Fahrenheit. He was also made aware that there were problems with temperature readings at sinks on the upper units. A review of the temperature logs revealed temperatures exceeded 120 degrees at various times and mostly technicians responded by adjusting the valve located at the bottom of each sink. The Administrator stated that these valves have an access panel and only maintenance staff are able to adjust the water temperature. However, there were times when the job was beyond the repair of maintenance staff and a plumbing contracting company was called. The Administrator further stated that in April of 2012, he contacted a company specializing in engineering and steam, and the company identified that there were problems with the two hot water tanks located in the basement. They informed him that the tanks needed rebuilding, the work was started in April and completed in July and August of 2012. One tank was shut down and one was rebuilt. Regarding the beverage dispensers the Administrator said that the facility did not have a system in place for monitoring the temperatures of the fluids that were dispensed. The Immediate Jeopardy was removed on 1/24/2013. The team exited the facility on 1/25/2013. Prior to the team's exit the following concerns were addressed to remove the immediacy: 1) All beverage dispensers were turned off, unplugged and a sign was placed on each dispenser stating that they were out of order. 2) The maintenance staff tested the water temperatures in all resident rooms and common areas with freshly calibrated thermometers and documented in a log that indicated that the thermometer had been calibrated before the testing. Any sink with a water temperature over 120 degrees was immediately fixed by the plumber. 3) The maintenance staff implemented a system that included shutting off the water in any room where the temperature could not be adjusted to less than 120 degrees and notifying the floor nurse that the water had been shut off. 415.12(h)(l)