Every finding on record at Meadow Park Rehabilitation and Health Center LLC

Based on observation, record review, and interviews during the Recertification and Abbreviated Survey (Complaint #2714675), the facility failed to ensure sufficient nursing staff was consistently provided to meet each residents' needs. Specifically, the facility's staffing levels were repeatedly below facility assessed minimum levels and the Payroll Based Journal Staffing Data Report from 07/2025 through 09/2025 triggered excessively low weekend staffing. The findings include but are not limited to:The Facility assessment dated [DATE] documented the facility had a bed capacity of 143 residents with an average daily census of 134. The facility assessment documented that based on their acuity levels, most residents have reduced physical function and had behavioral health needs. The facility had no independent residents, some residents were dependent, and most residents required the assistance of one (1) to two (2) staff for activities of daily living. The Facility Assessment further documented that based on the resident population and their needs for care and support, the total number of required staff needed to appropriately meet the needs of the residents at any given time were 17 licensed nurses providing direct care and 36 Certified Nursing Assistants. The facility's general staffing plans documented the facility would provide five (5) Certified Nursing Assistants for the 7:00 AM to 3:00 PM shift (day), four (4) Certified Nursing Assistants for the 3:00 PM to 11:00 PM shift (evening) and three (3) Certified Nursing Assistants for the 11:00 PM to 7:00 AM shift (night) for Units 1, 2, and 3.The Payroll Based Journal Staffing Data Report for Quarter 4 (July - September 2025) triggered excessively low weekend staffing.A review of the actual staffing schedules from 07/01/2025 to 02/04/2026 revealed consistently low weekend staffing with documented shortage of licensed nurses and certified nursing aides. The actual staffing schedule documented the following:On 07/06/2025, night shift, there were three (3) Certified Nursing Assistants scheduled for Unit 1, which had a census of 44 residents. The daily staffing documentation revealed only one (1) Certified Nursing Assistant worked.On 07/12/2025, day and evening shifts, there were two (2) Registered Nurses scheduled for Units 1, 2 and 3. The daily staffing documentation revealed no Registered Nurse worked.On 07/19/2025, for all shifts, there were three (3) Registered Nurses scheduled for Units 1, 2, and 3. The daily staffing documentation revealed no Registered Nurse worked.On 08/03/2025, 08/09/2025, 08/10/2025, 08/16/2025 and 08/17/2025, day shift, there were three (3) Registered Nurses scheduled for Units 1, 2 and 3. The daily staffing documentation revealed no Registered Nurse worked.On 09/13/2025, day shift, there were five (5) Certified Nursing Assistants scheduled for each unit (Units 1, 2, and 3) with census ranging from 43 to 44 residents. The daily staffing documentation revealed three (3) Certified Nursing Assistants worked on each unit.On 11/01/2025, 11/02/2025, and 11/16/2025, day shift, there were three (3) Registered Nurses scheduled for Units 1, 2, and 3. The daily staffing documentation revealed no Registered Nurse worked.On 01/25/2026, evening shift, there were four (4) Certified Nursing Assistants scheduled for Units 1 and 2 with census ranging from 43 to 44 residents. The daily staffing documentation revealed only two (2) Certified Nursing Assistants worked on each unit.On 01/29/2026 at 1:50 PM, during the Resident Council meeting, four (4) of nine (9) residents who attended the meeting stated the facility is short staffed on every shift. Resident #82 stated during the meeting that there are totally dependent residents in the unit who are often not changed until the next day. Resident #88 stated during the meeting that there were times when the nurse was busy giving out medications and there was no other staff to answer phone calls or ask questions from. Residents #109 and #135 both stated staffing had been horrible for the past few months that they do not get showered for a few days. On 02/02/26 at 02:00 PM, an interview was conducted with the Staffing Coordinator who stated they are responsible for ensuring all units have sufficient nursing staff. They stated they had been aware of the facility's low nursing staffing since last year. The Staffing Coordinator stated that in December 2025, a family member made a complaint about a delay in receiving care because of insufficient staff in the unit. The Staffing Coordinator stated that nursing staff sometimes call out at the last minute, which makes it difficult to replace. The Staffing Coordinator further stated that the data sent to the Payroll Based Journal is directly linked to the facility's time clock device and is not entered manually; if there is an actual low nursing staffing, it will definitely be triggered in the Payroll Based Journal.On 02/02/2026 at 2:23 PM, an interview was conducted with the Director of Nursing who stated they are also responsible for making sure all units are sufficiently staffed. The Director of Nursing stated the facility currently had low nursing staffing since late last year. They stated that nursing staff calls out late and making them difficult to replace. The Director of Nursing stated they issued disciplinary actions to nursing staff with low attendance records and that they are hiring new staff. On 02/05/2025 at 1:55 PM, an interview was conducted with the Administrator who stated that having sufficient nursing staff is a challenge. The Administrator stated the facility has contracts with several staffing agencies and has been posting nursing vacancies online. They also stated that they started offering bonuses, higher salaries, and provided uniforms as incentive. They also stated they had been offering overtime pay for staff taking extra shifts, and they try to ensure there are additional staff on standby when there are call outs during the weekends. 10 NYCRR 415.13(a)(1) (i-iii)

Based on observation, record review, and interviews, the facility failed to implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences. This was evident for one (1) (Resident #10) of one (1) resident reviewed for Activities out of 38 total sampled residents. Specifically, Resident #10 was observed during multiple observations not engaged in any activity in accordance with their preferences. The findings are:The facility's policy titled Activities with a last revised date of 02/05/2026 documented each resident's interests and needs will be assessed on a routine basis. Activities will be designed with intent to enhance the resident's wellbeing, reflect resident's interests and age, and reflect cultural and religious interests of the residents.Resident #10 had diagnoses of dementia, dysphagia following cerebral infarction, obstructive pulmonary disease, and anemia.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #10 was severely cognitively impaired. The Minimum Data Set assessment also documented that residents' preferences for customary routine and activities were very important.During observation on 01/28/2026 between 11:00 AM and 12:45 AM and 01/29/2026 between 10:00 AM and 3:00 PM, Resident #10 was observed in bed not engaged in any activity. There was a television directly facing the resident's bed, but it was not working. There was no activity calendar observed in Resident #10's room. There was an ongoing recreation activity in the unit day room, however, no recreation staff was observed visiting Resident #10 in their room. On 02/05/2026 at 10:34 AM, Resident #10 was in bed, Recreational Aide #1 and Registered Nurse #1 were also present at the time of this observation. They attempted to turn the television on but could not find the remote control. Registered Nurse #1 then attempted to turn the television by pressing the power button, but it would not turn on. There was no radio and individualized activity calendar found in the resident's room.The Therapeutic Recreation Initial Assessment Form that was completed on 10/09/2024 documented that Resident #10's interest included television, music, and religious services. There was no further recreation assessment completed after 10/09/2024.A comprehensive care plan for activities was initiated for Resident #10 on 10/21/2025. The care plan documented Resident #10's interests included listening to music, keeping up with the news via radio and television. The care plan goal was for Resident 10 to participate in sensory programs such as ensuring television and radio were turned on. The December 2025 and January 2026 Daily Therapeutic Recreational Attendance logs were blank and had no documented evidence that Resident #10 received ongoing activity to meet their interests and needs.02/05/2026 at 11:19 AM, an interview was conducted with the Recreation Aide #1 who stated they are responsible for providing sensory therapy such as music and radios to the residents, and also responsible for conducting one to one visit. They stated they conducted a one-to- one visit for Resident #10 but forgot to complete the daily log since those logs may be completed later during the day. On 02/05/2026 at 11:55 AM, an interview was conducted with Certified Nursing Assistant #1 who stated Resident #10 was in their assignment. They stated it is hard to say if Resident #1 is actually confused because they speak Chinese and that the resident laughs and seems happy when their family members are visiting. They stated that the television in Resident #1's room was always off, and they think it was broken.On 02/05/2026 at 10:44 AM, an interview was conducted with Registered Nurse #1 who stated that Resident 10 had impaired cognition, does not talk but are aware of their environment. Registered Nurse #1 stated that a few months ago, the resident's family member told them that the resident will benefit from a Chinese television channel but could not recall if they inform anyone about it.On 02/05/2026 at 1:45 PM, an interview was conducted with the Director of Recreation. They stated that recreational aides are responsible for completing the recreational assessment every quarter and must update the activities care plan as needed. They stated that Resident #10 was supposed to have a radio and television in their room and that no one informed them that Resident #10's television was not working and that the resident had no radio in their room. 10 NYCRR 415.5(f)(1)

Based on record review, and interviews conducted during an abbreviated survey (2616957), the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident for one (1) of three (3) residents (Resident #1) sampled. Specifically, on 09/13/2025, during morning care, Resident #1 sustained a fall when Certified Nursing Aide #1 provided care without another staff as per the plan of care. Resident #1 was transferred to the hospital and diagnosed with a nasal fracture.The finding is:The facility policy and procedure titled 'Accident/Incident' revised 12/04/2023 documented the facility will ensure the resident's environment remains as free of accident hazards as is possible. The policy also documented all accidents will be investigated, documented and reported to the New York State Department of Health as appropriate.Resident #1 was admitted to the facility with diagnoses that included Stroke, Cerebrovascular Accident, and Hemiplegia (weakness on one side of the body) affecting left non dominant side.The Minimum Data Set (an assessment tool) dated 07/04/2025 documented Resident had moderately impaired cognition, and upper extremity impairment on one (1) side and they required supervision or touching assistance for rolling left and right. The Resident Nursing Instructions dated 07/18/2025 documented one-person physical assist was changed to two+ person physical assist.The Resident CNA (Certified Nurse Accountability) Documentation for Bed Mobility dated 09/12/2025 and 09/13/2025 on the 11:00 PM - 7:00 AM shift documented Support Provided: one (1) person physical assist was signed off by Certified Nurse Aide # 1.The Hospital After Visit Summary dated 09/13/2025 documented reason for visit: fall. Diagnosis Closed fracture of nasal bone, closed fracture of left maxillary sinus.The undated, untitled facility's investigation documented Certified Nursing Assistant #1 was providing incontinent care, on 09/13/2025 at approximately 6:10 AM for Resident #1. Resident # 1 required two (2) person physical assist for bed mobility (turning from right side to left side). Interview with Resident # 1 stated they were lying too close to the edge of the bed during care, when they fell off the bed when turned. Resident #1 sustained a nasal fracture. The facility determined Certified Nurse Aide #1 did not follow the plan of care for bed mobility.The Nurse Progress note dated 09/13/2025 at 9:03 AM written by Registered Nurse Supervisor #1 documented Resident #1 was being changed before the fall and rolled out of bed during care. Resident #1 was lying face down on the floor at the bed side. Significant amount of blood coming from their face. Gauze applied; medical doctor notified transferred to hospital.On 11/01/25 at 9:46 AM, Charge Nurse #1 was interviewed and stated on 09/13/2025 at around 6:00 AM, Certified Nurse Aide #1 ran toward them and informed them Resident #1 jumped off the bed. Charge Nurse #1 also stated they saw Resident #1 lying face down, on the floor, on the right side of the bed, between the closet and the bed. Charge Nurse #1 further stated staff are responsible for checking in to the electronic medical record to become familiar with the care needs of their residents, and they just check to see if tasks have been signed off at the end of the shift.On 11/02/2025 at 10:00 AM, an interview was conducted with Certified Nurse Aide #1 who stated they had been assigned to Resident #1 once before and this was their second time being assigned to them. Certified Nurse Aide #1 also stated they are supposed to log into the electronic medical record system to see what care is needed for their assigned residents, but they did not log into the electronic medical record on 09/13/2025 because they did not have time to do so. Certified Nurse Aide #1 further stated they turned Resident #1 to one side, cleaned them, and then turned them over to the other side and they rolled out of bed. Certified Nurse Aide #1 stated they did not log into the electronic medical record at the start of, or at the end of their shift so they did not know Resident #1 needed one (1) or two (2) persons assist for turning and positioning. On 11/03/2025 at 12:52 PM, the Director of Nursing stated the expectation is for the certified nurse aide to log into electronic medical record kiosk before providing hands on care, and after receiving their unit assignments, to ensure the correct and proper level of care is provided. The Director of Nursing also stated no resident care is to be provided care before this step is completed. The Director of Nursing further stated the charge nurse provides reports to staff on newly admitted residents and any change in resident's condition. The Director of Nursing stated during orientation certified nurse aides are taught to log into electronic medical record and check the level of care needed for their residents. The Director of Nursing also stated Resident #1 required two (2) person physical assist for bed mobility, and Resident #1's care level needs were not followed. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00336488), the facility did not ensure the resident's right to be free from abuse and neglect. This was evident for one (1) out of four (4) residents (Resident #1). Specifically, on 03/19/2024 at 9:45 PM Licensed Practical Nurse #1 responded to a loud noise coming from Resident #1 and Resident #2's room. When Licensed Practical Nurse #1 approached the room they observed Resident #2 standing in the doorway holding a wheelchair leg rest in their hand and Resident #1, who was Resident #2's roommate, sitting on the floor in the room. Resident #1 had a laceration to the left side of their forehead and was transferred to the hospital on [DATE]. The hospital Discharge summary dated [DATE] documented left facial and periorbital soft tissue swelling/hematoma. Laceration repaired. Facility staff was not able to state how Resident #2 was able to come into possession of a wheelchair leg rest. The findings are: The facility's policy titled Abuse Prevention and Reporting effective 11/07/2023 documented, each resident had the right to be free from abuse, corporal punishment, and involuntary seclusion. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. Resident #1 was admitted to the facility with diagnoses including Dementia without Behaviors, Depression, and Legal Blindness. The Minimum Data Set Assessment, an assessment tool, dated prior to 02/24/2024 documented Resident #1 had severe cognitive impairment. Resident #1 had a potential for abuse care plan in place dated 02/17/2023. The interventions dated 02/21/2024 documented for ongoing assessment and reporting of any unusual markings on the resident body to nurse charge. Monitoring for any signs or symptoms of distress and sadness. Monitoring body language and facial expression for any signs/symptoms of distress. The care plan was updated to reflect on the abuse incident. Resident #2 was admitted to the facility with diagnoses including vascular Dementia without Behaviors, Anxiety Disorder, and recurrent Major Depressive disorder. The Minimum Data Set assessment dated [DATE] documented Resident #2 had severe cognitive impairment. A Behavior Care Plan (Actual) dated 10/16/2023 that documented as evidenced by verbally abusive, wandering, physically aggressive, aggressive/destructive behavior, screaming/crawling on the floor looking for their children, throwing food, related to new admission, cognitive deficits, and psychiatric history. The interventions documented for staff to identify possible triggers of negative behavior, refer for psychiatry evaluation, administer medications as ordered, and document in the medical record the frequency, intensity, and duration of negative behaviors. A Nursing Progress Note dated 03/19/2024 documented Registered Nurse Supervisor #5 assessed Resident #1, who was alert, but confused. Resident #1 had a small bump on their left lower eye and a small laceration with minimal bleeding. Resident #1's vitals were taken, and Resident #1 was not in any respiratory distress, did not complain of pain and denied dizziness. 911 was called and Resident #1's Nurse Practitioner and Power of Attorney, as well as a family member were notified. At approximately 10:00 PM, the police and the Emergency Medical Services arrived. Resident #1 left the facility at 10:33 PM with the police, Emergency Medical Services, and their family. The facility's Investigative Summary dated 03/22/2024 documented, a physical altercation occurred between Resident #1 and Resident #2 on 03/19/2024 at approximately 9:45 PM. Licensed Practical Nurse #1 heard a loud disagreement coming from the joint room of Resident #1 and Resident #2 and immediately responded to the room. Licensed Practical Nurse #1 observed Resident #2 holding a wheelchair leg rest and removed it from Resident #2. Licensed Practical Nurse #1 also observed Resident #1 sitting on the floor of their room with swelling to the left eye and a small laceration under the left eye, at the lateral side of the face. Resident #1 and Resident #2 were transferred to the hospital for evaluation. Resident #1's hospital discharge paperwork dated 03/20/2024 documented that a computer tomograph revealed no acute fracture and the presence of left facial and periorbital soft tissue swelling/hematoma. Resident #2's emergency room discharge paperwork documented no physical injury. The facility's Investigative Summary documented that the incident was unpredictable and unforeseeable as both residents involved in the incident had been roommates since 01/31/2024, and there was no previous history of altercation. The facility's finding was that there was no reason to believe that abuse, neglect, or mistreatment occurred. A Statement of Accident, by Registered Nurse Supervisor #4, dated 03/19/2025, documented that Registered Nurse Supervisor #4 was summoned at approximately 9:45 PM on 03/19/2024 to Resident #1 and Resident #2's room. Resident #1 was observed sitting on the floor of their room with moderate amount of swelling and small laceration to their left lower eye. Resident #2 (roommate) was standing in the doorway holding a wheelchair leg rest in their hand. Resident #2 said can you believe Resident #1 took their spouse away from them and that Resident #1 was not their spouse's type. They are their spouse's type. Resident #1's hospital Discharge summary dated [DATE] documented that Resident #1 was evaluated, and a maxillofacial computer tomograph was done. It revealed no acute fracture and the presence of left facial and periorbital soft tissue swelling/hematoma. During a telephone interview on 05/20/2025 at 1:32 PM, Licensed Practical Nurse #1 stated that they heard a noise in the hallway that was coming from Resident #1 and Resident #2's room. Licensed Practical Nurse #1 stated that they responded to the room and observed Resident #2 standing in the doorway of their room holding a wheelchair leg rest and Resident #1 sitting on the floor in the room. Licensed Practical Nurse #1 stated that Resident #2 was standing less than 6 feet away from Resident #1. Licensed Practical Nurse #1 stated that they screamed for help and removed the leg rest from Resident #2. Licensed Practical Nurse #1 stated that Registered Nurse Supervisor #4 came into the room, and they took Resident #2 out of the room to keep the residents separated. Licensed Practical Nurse #1 stated that they continued with their daily duties while Registered Nurse Supervisor #4 called 911. Licensed Practical Nurse #1 stated that Resident #1 was sent to the hospital. Registered Nurse Supervisor #4 are no longer working at the facility and could not be reached. During a telephone interview on 06/18/2025 at 9:24 AM, Certified Nursing Assistant #4 stated that both Residents #1 and #2 were ambulatory and that they do not know where Resident #2 get the wheelchair leg rest. Certified Nursing Assistant #4 stated after putting the wheelchair bound residents in bed they stationed the wheelchair out of the room, if there are no space in the room to keep the wheelchair. During a telephone interview on 06/23/2025 at 10:08 AM, Certified Nursing Assistant #5 stated they do not know where Resident #2 get the wheelchair leg rest from. Certified Nursing Assistant #5 stated after putting a wheelchair bound resident in bed, the wheelchair would either stay in the room or be taken out of the room and stored in a corner in the hallway. Certified Nursing Assistant #2 stated that a resident would not be able to take off the leg rests from the wheelchair as the wheelchairs are parked with the legs facing the wall. During a telephone interview on 05/29/2025 at 3:09 PM, the Director of Nursing stated prior to current incident, there has never been an altercation between Resident #1 and Resident #2. The Director of Nursing stated that the incident was unpredictable and unforeseeable. The Director of Nursing stated that Resident #2 reported that Resident #1 had taken away their spouse, even though Resident #1 was not the spouse's type. During a follow up telephone interview on 06/23/2025 at 2:00 PM, the Director of Nursing stated there were three residents in a 4-beded room and that one of the residents used a wheelchair. The Director of Nursing stated that they were unsure of how Resident #2 got ahold of the wheelchair leg rest. Further stated that this was the facility's first and only incident involving a wheelchair leg rest. During a follow up telephone interview on 06/26/2025 at 9:25 AM, the Director of Nursing stated that they investigated the incident, but did not think to investigate how Resident #2 was able to get ahold of the wheelchair leg rest. The Director of Nursing stated that they did not implement any interventions to prevent this incident from happening again. The Director of Nursing stated at times they observed that the wheelchair leg rests stayed attached to the wheelchairs but sometimes, the leg rests are placed on the seat of the wheelchair. During a telephone interview on 07/07/2025 at 12:05 PM, Registered Nurse Supervisor #5 stated that when they arrived on the unit, they observed Resident #1 sitting at a dining table in front of the nurse's station for safety, as Resident #2 was holding a wheelchair leg rest. Registered Nurse Supervisor #5 stated that Resident #1 had a small laceration below their left eye and that there were no witnesses to the incident. Registered Nurse Supervisor #5 stated that they do not know where Resident #2 get the leg rest from. Registered Nurse Supervisor #5 stated that they looked at the leg rest but did not see any blood on the leg rest. Registered Nurse Supervisor #5 stated that the wheelchairs are either stored in a small storage room on the unit, in the hallways, or in the residents' rooms. Registered Nurse Supervisor #5 stated that some of the staff members remove the wheelchair leg rests off the wheelchairs when they put the residents in bed, and they store them on the seats of the wheelchair. 10NYCRR 415.4(b)(1)(ii)

Based on record review and interviews conducted during an abbreviated survey (NY00336488), the facility did not ensure that all incidents were thoroughly investigated. This was evident for (1) out of (4) residents (Resident #1). Specifically, on 03/19/2024 at 9:45 PM Licensed Practical Nurse #1 responded to a loud noise that was coming from Resident #1 and Resident #2's room. When Licensed Practical Nurse #1 approached the room, they observed Resident #2 standing in the doorway to their room holding a wheelchair leg rest in their hand and Resident #2's roommate, Resident #1, sitting on the floor in their room. Registered Nurse Supervisor #5 assessed Resident #1 who had a laceration to the left side of their forehead. Resident #1 was transferred to the hospital for an evaluation on 03/19/2024. The Hospital Discharge paperwork dated 03/20/2024 documented that Resident #1 had a soft tissue swelling and hematoma to the left facial and periorbital area. The facility's investigation did not identify where Resident #2 found the wheelchair the leg rest, and there were no interventions implemented to prevent this type of incident from reoccurring. The findings are: The facility's policy titled Abuse Prevention and Reporting effective 11/07/2023 documented, each resident had the right to be free from abuse, corporal punishment, and involuntary seclusion. All reports of alleged abuse, mistreatment, or neglect will be investigated immediately by the Registered Nurse (Assistant Director of Nursing or House Supervisor) and reported to the Director of Nursing/Designee. The Investigation shall include .Registered Nurse Supervisor (Assistant Director of Nursing or House Supervisor) at the time of the occurrence or when reported will: Examine the scene/environment for obstacles, items that may be involved (i.e., tied linens, restraints) equipment in need of repair, wet surfaces, etc. Resident #1 was admitted to the facility with diagnoses included Dementia without Behaviors, Depression, and Legal Blindness. The Minimum Data Set assessment dated [DATE] documented Resident #1 had severe cognitive impairment. Resident #2 was admitted to the facility with diagnoses included Vascular Dementia without Behaviors, Anxiety Disorder, and Recurrent Major Depressive Disorder. The Minimum Data Set assessment dated [DATE] documented Resident #2 had severe cognitive impairment. A Nursing Progress Note dated 03/19/2024 documented Registered Nurse Supervisor #5 assessed Resident #1, who was awake, alert, and confused with a small bump on their left lower eye and a small laceration with minimal bleeding. Resident #1's vitals were taken, the resident was not in any respiratory distress, did not complain of pain and denied dizziness. 911 was called along with the Nurse Practitioner, Resident #1's Power of Attorney, and a family member. At approximately 10:00 PM, the police and emergency medical team arrived, and Resident #1 left the facility at 10:33 PM with the police, the emergency medical team, and Resident #1's family member. Resident #1's hospital discharge paperwork dated 03/19/2024 documented that Resident #1 was evaluated, and a Maxillofacial computer tomograph was done. It revealed no acute fracture and the presence of left facial and periorbital soft tissue swelling/hematoma. The facility's Investigative Summary dated 03/22/2024 documented that a physical altercation occurred between Resident #1 and Resident #2 on 03/19/2024 at approximately 9:45 PM. Licensed Practical Nurse #1 heard a loud disagreement coming from the joint room of Resident #1 and Resident #2 and immediately responded to the room. Licensed Practical Nurse #1 observed Resident #2 holding a wheelchair leg rest and removed it from Resident #2. Licensed Practical Nurse #1 also observed Resident #1 sitting on the floor of their room with swelling to the left eye and a small laceration under the left eye, lateral side of the face. Resident #1 and Resident #2 were transferred to the hospital for evaluation. Resident #1's hospital discharge paperwork dated 03/20/2024 documented that a computer tomograph revealed no acute fracture and the presence of left facial and periorbital soft tissue swelling/hematoma. Resident #2's emergency room discharge paperwork documented no physical injury. The facility's finding was that there was no reason to believe that abuse, neglect, or mistreatment occurred. There was no documented evidence that the facility addressed the wheelchair leg rest and implemented preventive measures. During a telephone interview on 05/20/2025 at 1:32 PM, Licensed Practical Nurse #1 stated that they heard a noise in the hallway coming from Resident #1 and Resident #2's room. Licensed Practical Nurse #1 stated that they responded to the room and observed Resident #1 sitting on the floor in the room and Resident #2 standing less than 6 feet away from Resident #1 holding a wheelchair leg rest. Licensed Practical Nurse #1 stated that they screamed for help and removed the leg rest from Resident #2. Licensed Practical Nurse #1 stated that Registered Nurse Supervisor #4 came into the room, and they took Resident #2 out of the room to keep the residents separated. Licensed Practical Nurse #1 stated that they continued with their daily duties while Registered Nurse #4 called 911. Licensed Practical Nurse #1 stated that Resident #1 was sent to the hospital. Registered Nurse Supervisor #4 are no longer working at the facility. During a follow up telephone interview on 06/23/2025 at 2:00 PM, the Director of Nursing stated there were three residents in a 4-beded room and that they were unsure if one of the residents used a wheelchair. The Director of Nursing stated that they were unsure of how Resident #2 got ahold of the wheelchair leg rest. Further stated that this was the facility's first and only incident involving a wheelchair leg rest. During a follow up telephone interview on 06/26/2025 at 9:25 AM, the Director of Nursing stated that they investigated the incident, but did not think to investigate how Resident #2 was able to get ahold of the wheelchair leg rest. The Director of Nursing stated that they did not implement any interventions to prevent this incident from happening again. The Director of Nursing stated at times they observed that the wheelchair leg rests stayed attached to the wheelchairs but sometimes, the leg rests are placed on the seat of the wheelchair. During a telephone interview on 07/07/2025 at 12:05 PM, Registered Nurse Supervisor #5 stated that when they arrived on the unit, they observed Resident #1 sitting at a dining table in front of the nurse's station for safety, as Resident #2 was holding a wheelchair leg rest. Registered Nurse Supervisor #5 stated that Resident #1 had a small laceration below their left eye and that there were no witnesses to the incident. Registered Nurse Supervisor #5 stated that they do not know where Resident #2 get the leg rest from. Registered Nurse Supervisor #5 stated that they looked at the leg rest but did not see any blood on the leg rest. Registered Nurse Supervisor #5 stated that the wheelchairs are either stored in a small storage room on the unit, in the hallways, or in the residents' rooms. Registered Nurse Supervisor #5 stated that some of the staff members remove the wheelchair leg rests off the wheelchairs when they put the residents in bed, and they store them on the seats of the wheelchair. 10NYCRR 415.4(b)(1)(ii)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00355163), the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and their needs, and that each resident and resident representative, if applicable, is involved in the developing the care plan and making decisions about their care. This was evident for one (1) out of four (4) residents (Resident #4). Specifically, on 08/06/2024 at 10:25 PM Resident #4 was observed on the floor next to their bed. The Physical Therapist evaluated the resident on 08/07/2024, as ordered by the physician, and recommended a floor bed. There was no documented evidence that the care plan was reviewed and revised to reflect the fall of 08/06/2024. The findings are: The facility policy titled Comprehensive Care Planning, revised 03/2019, documented that assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. The facility policy titled Fall Prevention Program, revised 04/01/2024, documented that each resident's risk factors, and environmental hazards will be evaluated when developing the residents comprehensive plan of care. Interventions will be monitored for effectiveness and the plan of care will be revised as needed. When any resident experiences a fall, the facility will, among other actions, review the resident's care plan and update as indicated, Resident #4 was admitted to the facility with diagnoses including Acute Respiratory Failure with Hypoxia, Dementia, and Hypertension. The Minimum Data Set, an assessment tool, dated 07/03/2024 documented Resident #4 had a short-term memory problem. The Fall Risk assessment dated [DATE] documented under History of falls (past three months) that Resident #4 had one-two falls and a total fall risk assessment score of eight (8) denoting low to moderate fall risk. A review of Resident #4's Comprehensive Care Plan dated 06/14/2024 documented Resident #4 was at Risk for Falls/Injury. The interventions documented reducing environmental hazards, i.e., keep floors dry and clear; instruct/reinforce safety measures with resident/family, i.e., transfer techniques, proper footwear, locking wheelchair; providing resident/family with information on safety risk factors; advising staff/resident/family to keep personal items within reach; call bell within reach. Encouraging resident to ask for assistance as needed, monitoring for changes in Activities of Daily Living. Resident #4's Certified Nursing Assistant Accountability and Nursing Instructions for July 2024 documented no bed rails; precautions for fall and keep at nursing station. Licensed Practical Nurse #2's nursing progress note dated 08/06/2024 documented that Resident #4 was observed sitting on the floor mat next to their bed. Resident #4 could not explain what had happened. Resident #4 was assisted back to their bed with the assistance of two staff members. Resident #4 was assessed by Registered Nurse #3 with no visible injuries observed. Resident #4 did not complain of pain or discomfort. The emergency contact and primary medical doctor were notified. Primary Medical Doctor #1 ordered on 08/07/2024 a Physical Therapy Screen to evaluate and treat for fall. A Fall Risk Assessment completed by Registered Nurse #3 on 08/06/2024 following Resident #4's fall documented under the section History of Falls (past three months): No falls and a total fall risk assessment score of 8 (low to moderate fall risk). Physical Therapist #1's Progress Note dated 08/07/2024 documented that Resident #4 was seen following their fall and denied any pain. Range of motion to bilateral lower extremities was within functional limits. Resident #4 required constant assist of one (1) person for all transfers and a floor mat was noted. Physical Therapist #1 recommended a floor bed and made Registered Nurse #2 aware. There was no documented evidence that the care plan was updated to reflect on the fall of 08/06/2024. There was no documented evidence Resident #4 received or did not receive a floor bed. Registered Nurse #3 stated during a telephone interview on 05/21/2024 at 12:32 PM that it might have been a mistake that they did not click 1-2 falls on the fall assessment following the resident's first fall on 08/06/2024. Registered Nurse #3 further stated that they might have just clicked through the assessment and missed that 08/06/2024 accident. During an interview on 05/21/2025 at 3:43 PM, the Director of Nursing stated, if the Physical Therapist evaluated Resident #4 and recommended a floor bed, then it should have been listed as an intervention on the resident's fall risk care plan. The Director of Nursing stated during a follow up telephone interview on 06/10/2025 at 1:21 PM that any Registered Nurse can update a resident's care plan and the nursing instruction on the Certified Nursing Assistant Accountability, but that the person ultimately responsible for supervision is the Minimum Data Set coordinator. The Director of Nursing stated that the Physical Therapist discussed during morning meeting that they have recommended a floor bed. The Director of Nursing stated that the Director of Building Services, who was at the morning meeting stated that they would take care of it. The Director of Nursing stated that the nurse did not document in Resident #4's progress notes that a floor bed was delivered. The Director of Nursing stated that they were now aware that it was an omission that the floor bed was not added to Resident #4's care plan and that it should have been updated as an intervention on 08/06/2024 after the resident's first fall. 10 NYCRR 415.11(c)(1)

Based on record review, and interviews conducted during an Abbreviated Survey (NY00336488), the facility did not ensure that the results of all investigations pertaining to alleged violations involving abuse, neglect, exploitation or mistreatment, were reported to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident for one out of four residents (Resident #1) sampled for abuse. Specifically, on 03/19/2024 at approximately 9:45 PM Licensed Practical Nurse #1 responded to a loud verbal disagreement into Resident #1 and Resident #2's room. Licensed Practical Nurse #1 observed Resident #2 standing at their room door holding the leg rest of a wheelchair in their hand and Resident #1 was sitting on the floor in their room with swelling and a laceration to their left eye. The facility submitted their five-day investigation results to the New York State Department of Health on 03/27/2024 at 4:08 PM. The findings are: The facility's Policy and Procedure titled Abuse Prevention and Reporting with an effective date of 11/07/2023 documented under the heading Investigation: The Director of Nursing/Designee will complete the investigation summary and attach it to the occurrence report and collected statements, oversee the investigation process, determine need for further information, collect all facts and ensure all alleged abuse is reported to the Department of Health, and report all occurrences immediately to the Administrator. Resident #1 was admitted to the facility with diagnoses including Dementia, Depression, and Legal Blindness. The Minimum Data Set, an assessment tool, dated 11/24/2024 documented Resident #1 had severe cognitive impairment. Resident #2 was admitted to the facility with diagnoses including Vascular Dementia, Stroke and Hypertension. The Minimum Data Set, dated [DATE] documented Resident #3 had severe cognitive impairment. The facility's Investigative Summary dated 03/22/2024 documented that Licensed Practical Nurse #1 heard a loud verbal disagreement coming from Resident #1 and Resident #2's joint room. As Licensed Practical Nurse #1 entered the residents' room, they observed that Resident #2 was holding a wheelchair leg rest in their hand and Resident #1 was sitting on the floor with swelling and a laceration to the left eye. The facility's Investigative Summary dated 03/22/2024 documented that the incident was unpredictable and unforeseeable as both residents involved in the incident had been roommates since 01/31/2024, and there was no previous history of altercation. The facility's finding was that there was no reason to believe that abuse, neglect, or mistreatment occurred. The facility reported the incident to the Department on 03/19/2024 at 11:06 PM and received an email from the Department of Health that the report was received on 03/20/2024 at 12:51 PM. The facility however, submitted their final facility investigation results on 03/27/2024 at 4:08 PM. During an interview on 05/21/2025 at 3:43 PM, the Director of Nursing stated that the facility had five business days from the date the facility received the Department's email that the incident was received, to submit the final facility investigation to the Department. The Director of Nursing stated after they reviewed the March 2024 calendar, the facility's final investigation should have been submitted on 03/26/2027. 10 NYCRR 415.4(b)(2)

Based on observations, record review, and interviews conducted during the Recertification survey from 3/26/2024 to 4/02/2024, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident for 1 of 3 dining rooms (2nd Floor). Specifically, Certified Nursing Assistant #6 was observed assisting multiple residents with hand hygiene with bare hands without performing hand hygiene in between residents and was also observed touching the inside of paper and plastic cups while preparing beverages for residents at the lunch meal on the 2nd floor. This was evident for 1 of 3 dining rooms during the Dining Task. The findings are: The facility policy titled Infection Surveillance revised 10/16/2023 documented employee, volunteer and contract employee infections will be tracked as appropriate, such as influenza and gastrointestinal outbreaks. The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying. Data to be collected, including how often and the type of data to be documented including observations of staff including the identification of ineffective practices, if any. On 03/26/2024 from 11:54 AM to 11:57AM, Certified Nursing Assistant # 1 was observed handing out hand wipes to residents on the 2nd floor to clean their hands before lunch. Certified Nursing Assistant #1 adjusted a resident's clothing, gave wipes to 3 other residents to clean their hands, assisted Resident # 14 to clean their hands, picked up the used hand wipe and proceeded to get a hand wipe for Resident #29 and wiped the hands of Resident #55 without performing hand hygiene between residents. On 03/26/2024 from 11:57 AM to 12:16 PM, Certified Nursing Assistant #1 was observed washing their hands at the sink. Certified Nursing Assistant #1 then handed out clothing protectors to residents and picking up used hand wipes in paper cloth protector and disposed of them. Certified Nursing Assistant #1 was then observed pouring beverages into paper and plastic cups for residents. Certified Nursing Assistant #1 was observed placing their fingers inside the cups while handling before placing lids on the cup. During an interview on 03/26/2024 at 12:59 PM, Certified Nursing Assistant #1 stated that they did wash their hands in-between residents and the resident's hands must be cleaned to protect the residents and the staff. During an interview on 4/01/2024 at 12:03 PM, Registered Nurse #2 was interviewed and stated when staff come into room, they utilize hand sanitizer to clean their hands. If helping residents with wiping their hands they should sanitize their hands in between residents. Registered Nurse #2 also stated that the aides should place the cups on the tray and serve to the residents and hands should not touch the inside of the cup, top of the cup or anywhere resident's mouth will make contact. During a subsequent interview on 04/01/2024 at 3:03 PM, Certified Nursing Assistant #1 stated that it is important that the beverage cups are handled correctly so residents do not get sick and there is not bacteria in anything they are going to drink. During an interview on 04/02/2024 at 11:52 AM, the Infection Preventionist stated that they do rounds once a day in the morning. Hand hygiene in-service was done in December 2023 by the Assistant Director of Nursing. They stated that they observe dining once a week to look for resident use of hand wipes, staff hand hygiene, handling of cups with bare hands and sanitizer before anything. 10 NYCRR 415.14(h)

Based on observations and interviews conducted during the Recertification survey from 3/26/2024 to 4/02/2024, the facility did not ensure that drugs and biologicals were safe and secure to protect from unauthorized access. Specifically, 1) antibiotic solutions and intravenous fluids were located in unlocked cabinets in the nurse's station on the 3rd floor where authorized licensed staff and unauthorized staff were noted entering the nurses station area, and 2) medications were noted to be left out on the medication cart unsecured. This was evident for the Medication Storage Task on Unit 2 and Unit 3. The findings are: 1.The facility policy titled Storage of Drugs revised 12/14/2023 documented all drug s in the nursing station are to comply with the following conditions: Drugs are stored in an orderly manner in cabinets, drawers, or care of sufficient size to prevent crowding. All medications and other drugs including treatment items, are stored in locked cabinet or room, inaccessible to residents and visitors. Drugs are accessible only to personnel designated in writing by facility resident care policies. On 03/28/2024 at 11:57 AM, Registered Nurse #3 was observed taking 0.95 % Sodium chloride intravenous solution and Ampicillin 2-gram placed in a dark brown light protection bag from an unlocked drawer in the nurse's station on Unit 3 and walking down the hallway. Registered Nurse #3 stated that they were going to hang the intravenous antibiotic for Resident #62 after lunch. On 03/28/2024 at 12:56 PM, Registered Nurse #3 was observed administering the intravenous antibiotics to Resident #62. On 03/28/2024 at 03:42 PM, Registered Nurse #3 stated that intravenous medications are stored in the nurse's station and there is not any place else. They are in the process of reconstructing the building and they are doing this floor and unsure of the date maybe after the survey. The Director of Nursing and Administrator are aware of the lack of storage for the intravenous and intravenous antibiotics, and this issues has been brought up at morning meeting. Registered Nurse # 3 stated that the medications need to be secured. On 03/29/2024 at 10:20 AM, multiple medications were observed in the drawer in the nurse's station bellow the binders on the shelf that included 0.9% sodium chloride flush -1 flush, 11 bags of 1000 milliliters of intravenous fluids of 0.45% sodium chloride, 2 bags of 1000 milliliters bags of 5% dextrose intravenous fluids. Bags of intravenous fluids also were also observed labeled with resident's personal information stored in an unlocked drawer at the back of the nurse's station. On 03/29/2024 at 10:33 AM, Maintenance Worker #1 was observed on the unit putting locks on the nurse's station drawers. There was on lock on the top right side drawer. On 03/29/2024 at 12:50 PM, Registered Nurse #5 was interviewed and stated they check the medication cart every shift with the medication nurses. We had supplies of intravenous fluids medication supplies and all antibiotics and items should be locked up because we have wandering residents. On 04/01/2024 at 11:56 AM, Maintenance Worker #1 was interviewed and stated that one side to the locks were done and the staff kept losing the keys. There were antibiotics and intravenous fluids which needed to be locked up so we repaired the broken lock and added locks to the other side on all 3 floors. On 04/01/2024 at 1:01 PM, Maintenance Worker #2 stated that the locks were not working properly, they were loose and they were replaced a month ago. Maintenance Worker #2 also stated that they were told that the locks were not working properly so they are in the process of repairing them. 40565 2. During multiple observations of the Unit 2 medication cart conducted from 3/26/24, the medication cart had been observed placed in hallway, sometimes unattended. On 03/29/24 at 09:57 AM, the facility Medication Storage task was performed on Unit 2 with Licensed Practical Nurse #1 and 2 bottles of Liquid Protein Supplement 960ml, one 510g bottle of Polyethylene Glycol 3350 powder, and one 473ml bottle of Docusate sodium liquid were placed unsecured, on top of the left side of the medication cart. Licensed Practical Nurse #2 was interviewed immediately and stated that there was not enough space in the medication cart to store the medications inside the cart. On 03/29/24 at 10:13 AM, Registered Nurse #2 was interviewed and stated that the medications on top of the cart should not have been there but there is no space to lock them up in the cart. Registered Nurse #2 also stated that they do not stock medication in their medication room on the unit, and all the stocked medications are collected from the storage downstairs as they are needed. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review and staff interviews conducted during the Recertification/Complaint Survey from 3/26/24 to 4/2/24, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, there was no comprehensive care plan developed and implemented for resident's use of anticoagulant therapy. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of 30 sampled residents (Resident #59). The findings are: The facility policy and procedure titled Comprehensive Care Planning dated 01/2008, last revised 03/2019, documented that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident. The policy also documented that each resident's comprehensive care plan is designed to incorporate identified problem areas. Resident #59 was admitted to the facility with diagnoses that included Atrial Fibrillation, Coronary Artery Disease, Cerebrovascular Accident, and Non-Alzheimer's Dementia. The Admission Minimum Data Set assessment dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The Minimum Data Set assessment also documented that resident received antidepressant, anticoagulant, and hypoglycemic medication. The Comprehensive Care Plan (CCP) titled Cardiovascular dated 01/30/2024 last updated 2/14/2024, documented that the resident is at risk for Cardiovascular dysfunction and resident will be free from signs/symptoms of cardiovascular dysfunction for 90 days. Interventions included monitor for signs/symptoms of cardiovascular dysfunction, mental status changes, headache, fatigue, weakness, palpitations, rapid weight gain cyanosis, shortness of breath, blurred vision, congestion, bradycardia, tachycardia. The Physician's order dated 3/27/2024 documented: Eliquis 2.5 mg tablet by g-tube route every 12 hours for unspecified Atrial Fibrillation which first became standing on 1/30/2024. There was no documented evidence a comprehensive care plan had been developed to address the resident anticoagulant therapy. On 03/28/24 at 02:30 PM, an interview was conducted with Registered Nurse Supervisor- Registered Nurse #1 who stated that Resident #59 is prescribed Aspirin 81mg daily and Eliquis 2.5 every 12 hours for Atrial Fibrillation. Registered Nurse #1 also stated that Resident #59 was prescribed Eliquis upon admission from the hospital. Registered Nurse #1 further stated that there is care plan for cardiovascular and psychotropic medication use but there was none for anticoagulant therapy. Registered Nurse #1 further stated that the Admission Nurse was supposed to initiate the care plan on admission as Resident #59 was prescribed anticoagulant medication when they first came to the facility. Registered Nurse #1 stated they are not sure why the care plan was not initiated since admission. On 03/28/24 at 02:38 PM, the Director of Nursing was interviewed and stated the Registered Nurse should be initiating the care plan upon admission, and the next day, the Registered Nurse Supervisor should review it for completion. The Director of Nursing also stated that the care plan for anticoagulant therapy could have been on the resident's cardiovascular care plan. 10 NYCRR 415.11(c)(1)

Based on interviews and record review conducted during Recertification and Complaint investigations (NY00332356), the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property were reported to the State Survey Agency. Specifically, the facility did not report suspected abuse that resulted in a resident sustained a 4-centimeter hematoma to right side of their forehead. This was evident for 2 of 2 residents reviewed for Abuse out of a sample of 30 residents. (Resident # 12 and Resident #68). The findings are: The facility policy and procedure titled Abuse Prevention and Reporting effective 11/7/2023 documented facility will investigate all incidents and complaints and report all occurrences promptly to the Department of Health when there is reasonable cause to believe abuse, neglect, or mistreatment (hereinafter abuse) has occurred. All employees and licensed health care professionals are required by the regulation to report any instance of physical abuse, neglect, or mistreatment to the New York State Department of Health Office. Professionals who care for Nursing Home residents and those employed by this facility as well as those who provide services to the residents are mandated reporters. All facility staff must notify the supervisor who will notify the registered Nurse Supervisor immediately of any observation or communication that abuse, neglect, or mistreatment has/may have occurred. All reports of alleged abuse, mistreatment or neglect will be investigated immediately by the Registered Nurse Supervisor and reported to the Director of Nursing/Designee. The facility will ensure that the Department of Health is notified of all reportable events. The Nursing Progress Note dated 1/28/2024 at 2:30 AM written by Licensed Practical Nurse #1 documented they were called to Resident #12's room and observed them with a bruise on their forehead and crying and when asked that stated their roommate Resident #68 [NAME] a plastic bottle that hit them on their forehead. The nurse supervisor was called to the floor, resident assessed, ice applied pack applied and pain medication given. Resident #68 was moved and family notified. The Nursing Progress Note dated 1/28/2024 at 3:39 AM was written by the Registered Nurse Supervisor #1 stated that they were called to see the resident at 12:45 AM on arrival observed Resident #12 crying in bed saying their roommate hurt them. Resident #12 pointed to resident #68. Resident #12 was noted with a hematoma measure 4 centimeters to their right forehead with small, bruised area in the center measuring 0.3 cm. Resident #68 admitted they were angry and because they were agitated, they threw a perfume bottle but they did not hit resident #12. A plastic perfume bottle was found on the floor near their doorway. Cold compress applied immediately, and pain medication given for pain. The medical provider called and pain medication cold compress and neuro checks ordered. An Accident Report dated 1/28/2024 at 12:48AM documented that Resident #12 was noted with a hematoma 4 centimeters on their forehead. Resident #12's roommate threw a plastic bottle and it hit Resident #12 on the forehead. Resident #12 was moved away from roommate and Resident #68 was moved out of the room to another unit. The Department of Health in the Health Electronic Response Data System (HERDS) confirmation email from the Department of Health dated 1/30/2024 at 3:06 PM documented the incident report has been received. The resident-to-resident incident was reported to the New York State Department of Health 1/30/2024 at 3:06 PM more than 48 hours after the incident occurred. During an interview on 4/01/2024 at 3:47 PM, Registered Nurse Supervisor #1 was interviewed and stated that they were called to the unit and the investigation revealed a bruise of the right forehead and assumed resident #68 threw a bottle at resident #12. The Director of Nursing was not notified right away but a few hours later. The incident occurred at approximately 1 AM or at the beginning of the shift 12AM-2AM. Registered Nurse Supervisor #1 also stated that there is a protocol in place and abuse should be reported immediately. During an interview on 04/02/2024 at 12:11 PM, the former Director of Nursing stated that they were called to the unit and informed of the incident but they could not recall the time of day that the incident was reported to them. The former Director of Nursing stated that they called the administrator to report the incident and that they have to report a major injury or abuse within 2 hours and all other incidents report within 24 hours. During an interview on 04/02/2024 at 11:43 AM, the Administrator was interviewed and stated that they are informed of the incidents and the Director of Nursing was in charge of reporting the incident to the Department of Health. The Administrator also stated that they have access to the reporting system. The Administrator further stated that the time frame for reporting for a resident-to-resident incident is 24 hours. During an interview on 4/2/2024 at 1:48 PM, the current Director of Nursing was interviewed and stated that if there is a resident-to-resident altercation with injury it needs to be reported within 2 hours and a resident-to-resident altercation with no injury needs to be reported within 24 hours. If there is an injury of unknown origin it needs to be reported within 2 hours. 10 NYCRR 415.4(b)(1)(2)

Based on interviews and record reviews conducted during an abbreviated survey (NY 813) on 7/30/2020, the facility did not ensure that a resident was free from abuse and that care was provided in a safe environment. Specifically, on 4/29/2020 during the morning shift, a Certified Nursing Assistant (CNA#1) self- reported to the Charge Nurse that she hit a resident on her shoulder after the resident hit her during an altercation. This was evident for one of 3 residents (Resident #1) reviewed for Abuse. The finding is: The Abuse/Neglect/Mistreatment Policy dated 4/2019 states the resident has the right to be free from any form of abuse including physical abuse. Resident #1 was admitted to the facility for medical management and long-term care with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was cognitively intact and required extensive assistance with most areas of Activities of Daily Living (ADL), except eating. The Comprehensive Care Plan (CCP) for Potential for Abuse/Neglect Care Plan, initiated on 12/17/18, and last updated on 4/23/2020, documented interventions that include, monitoring and observing for signs of abuse and encouraging the resident to verbalize any concerns. On 4/29/2020 after the incident, which occurred on 4/28/2020, the CCP was updated with the new interventions of removal of accused staff member, refer the resident to psychologist/ psychiatrist, and staff re-in-services on Abuse/Neglect/Mistreatment. The Communication CCP initiated 12/24/18 documented interventions that include, use of devices and computer- based programs for communication with the resident and introducing the resident to other Creole speaking staff and residents. There are no changes to these interventions post incidence. Nurse's Progress Notes dated 4/28/2020-4/30/2020 revealed that on 4/29/2020 CNA #1 informed the Charge Nurse (LPN#1)that she struck Resident #1 on the shoulder. The resident was assessed by LPN #1 and initially documented that there was no visible injury she noted however, that Resident #1 was crying, speaking in Creole and using a striking motion toward her face. The Physician's Assistant (PA) note dated 4/29/2020 documented that the resident had a small darkened area on her right cheek which later disappeared. The Facility Investigation Summary dated 4/29/2020 revealed a thorough investigation was done. CNA #1 was suspended immediately and terminated post investigation. A definitive conclusion of abuse was not made, and when interviewed the Registered Nurse Supervisor, the Director of Nurisng and Administrator stated the events were confusing, however, CNA #1 admitted she hit Resident #1 and abuse will not be tolerated. CNA #1's initial s statement is that she hit Resident #1 on her should in retaliation after she was first hit by Resident #1. The police report dated 4/29/2020 deemed the incident as harassment. In-service records dated January-April 2020 revealed that facility staff received in-service on Abuse/Neglect/Mistreatment pre and post incident. Resident #1 was interviewed on 7/30/2020 at 11:25AM with a Creole speaking CNA (#2) as translator. The resident stated that they informed CNA#1 that it was their shower day. Resident #1 waited from 7:30AM to 10:30AM, and the CNA never said anything about when the resident would be showered. The resident decided to clean herself at the sink when CNA #1 arrived with another resident (Resident #2). CNA #1 asked Resident #1 if they were ready for the shower. She responded that it was too late. The accused CNA attempted to place Resident # 2's basin on Resident #1's basin, and Resident #1 told CNA #1 not to do so. CNA #1 pushed off her basin and she bent down to pick it up. As she was coming up from bending over, the CNA hit her on the right brow with her hand and she called for the nurse. The nurse responded to the call. Resident #1 denied having any other similar issues with anyone. On 7/30/2020 at 11:45AM the Licensed Practical Nurse (LPN#1,charge nurse) was interviewed. She stated CNA #1 informed her that she hit the resident on the shoulder after the resident hit her. She went to the room and saw Resident #1 crying. There was no visible injury, however later a small discolored area was noted on her right brow. LPN #1 stated there was a verbal altercation between CNA #1 and the resident over a basin. On inquiry about ensuring the residents are not abused, LPN #1 stated that she does spot checks on staff providing care and observes for any bruising or unexplained injuries. She also stated that they always try to have someone on the unit who speaks Creole, but if needed, there is a translator service which is utilized. The Registered Nurse Supervisor (RNS#1) was interviewed on 8/26/2020 at 3:08PM. He stated the resident was interviewed via a language service translator and it was unclear exactly where on her body Resident #1 was hit. He also stated that the situation seemed to have occurred quickly and was very confusing. On further inquiry, he stated that CNAs are screened before hire, educated on abuse, given reminders and monitored. The Administrator was interviewed via telephone on 8/27/20 at 9:47AM. He stated that the facility does backgrounds checks on staff, they are in-serviced and reminded about what could be seen as abusive. The Police were called, and they did not see the incident as abuse, more a form of harassment. He stated CNA #1 may have been stressed and did not seek assistance. She was a good CNA, and there was no issues with her. He stated he feels it was a misunderstanding, however the facility has zero tolerance for anything that may appear as abusive. CNA #1 was interviewed via telephone on 9/1/2020 at 9:25AM. She stated she had a good relationship and knew Resident #1 was scheduled to be showered on the day of the incident. She informed Resident #1 that she would provide the showere after breakfast. However, there was another resident (Resident #2) who was very soiled with feces. She decided to care for him first, and she informed Resident #1 of her decision. After caring for Resident #2, she returned to Resident #1 who was in the bathroom splashing water on herself. She asked Resident #1 if they were ready for the shower. Resident #1 was very annoyed and stated they were not ready, so she went to get another resident (Resident #3) for care. When she returned, Resident #1 had their basin in the sink. CNA #1 stated she asked Resident #1 to excuse her, so she could get some water to use on for providing care to Resident#3. Resident #1 responded in Creole which she did not understand. She placed Resident #3's basin on top of Resident #1's basin to get the water she needed. Resident #1 pulled the basin from her hand and turned it over. CNA #1 said she ignored what occurred and started to obtain some water a 2nd time and Resident #1 hit her on her face shield which surprised her. CNA #1 stated she then turned around and gave Resident #1 a pat on the shoulder. Resident #1 called the nurse and she (CNA #1) stepped out of the bathroom, called the nurse and informed her what occurred. The Social Worker was called and Resident #1 told her she was hit in the eyes, which she denied. The police were called and she was sent home. Later, she was informed that she was terminated. 451.4(a)(1) (i)

Based on interviews and record reviews conducted during an abbreviated survey (NY 813) on 7/30/2020, the facility did not ensure that a resident's right to self-determination was upheld. This was evident in one of 3 residents sampled. Specifically, on 4/29/2020 when Resident #1 informed her assigned CNA (#1) it was her day to be showered and the resident was not showered or assisted with her personal hygiene by CNA #1. Findings are: The Policy/ Procedure on Residents' Rights revised 6/2020 states that the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. Resident #1 was admitted to the facility 3/15/2015 for medical management and long-term care. The Minimum Data Set (MDS) dated [DATE] documented that the resident is cognitively intact, and she requires extensive assistance with most areas of Activities of Daily Living (ADL) except eating. The Activities for Daily Living (ADL) Comprehensive Care Plan (CCP) initiated on 12/17/18 and updated on 4/23/2020 documents, the resident requires extensive assistance with bathing and personal hygiene. The Communication CCP initiated 12/24/18 documents interventions that include, use of devices and computer- based programs for communication with the resident and introducing the resident to other Creole speaking staff and residents. There are no changes to these interventions post incidence. Nurse's Progress Notes dated 4/28/2020-4/30/2020 were reviewed and revealed CNA#1 informed the Charge Nurse that she struck Resident #1 on the shoulder. The resident was assessed and initially there was no visible injury. however, Resident #1 was crying, speaking in Creole and using a striking motion toward her face. The Physician's Assistant (PA) evaluated the resident post incident on 4/29/2020 and a small darkened area was noted on her right cheek. The Psychiatrist evaluated the resident on 5/10/2020 and stated that Resident #1 had no complaints and she denied any symptoms of depression or anxiety. Support and educational counselling were provided, and It was determined that no medication was needed. Follow-up was as needed (PRN) The CNA Unit Assignment dated 4/29/2020 was reviewed and there was no indication that the resident was to be showered. The Facility Investigation Summary dated 4/28/2020 revealed a thorough investigation was done. CNA #1 was suspended immediately and terminated post investigation. On 7/30/2020 Resident #1 was interviewed at 11:25AM via a Creole speaking CNA #2 as translator. She stated that she informed CNA #1 that it was her shower day. She waited from 7:30AM-10:30AM and the CNA never said anything about when she would be showering her. She (Resident #1) decided to clean herself at the sink when CNA #1 arrived with another resident (Resident #2) and asked whether she (Resident #1) was ready for her shower. She t responded that it was too late. An altercation ensued and CNA #1 hit the resident on the right brow with her hand. On 7/30/2020 at 11:45AM the Licensed Practical Nurse (LPN #1, charge nurse) was interviewed. She stated CNA #1 informed her that she hit the resident on her shoulder after the resident hit her. She went to the room and saw the resident crying. LPN #1 stated there was an altercation between CNA #1 and Resident #1 over a basin and she informed nursing administration. On 7/30/2020 at 11:30AM the currently assigned CNA #2 (translator) was also interviewed. She stated, she is the regularly assigned CNA but was off that day. She stated she is assigned to all the residents in the room because they are all Creole speaking. She was knowledgeable about types of abuse and stated they are in-serviced. On 7/30/2020, the Director of Nursing (DON) was interviewed at 3:30PM, she stated that staff receive annual in-services on Abuse/Neglect/Mistreatment, and they are instructed to inform and report all forms of abuse. The charge nurses are also required to spot check staff on their rounds and the Registered Nurse Supervisors (RNS) are required to make at least three rounds to the units per shift. Residents are encouraged to report any issues observed. A follow-up interview with the DON on 8/26/2020 at 3PM. She stated that Resident #1 when interviewed kept changing where and how she was hit. The DON also stated that CNA #1 was a good worker and had recently returned from Family Leave. She believes it was a miscommunication between CNA #1 and the resident due to a language barrier. She also stated that the staff is instructed to walk away and call the nurse before a situation escalates. The Registered Nurse Supervisor (RNS) was interviewed and stated that Resident #1 was interviewed via a language service translator and it was unclear exactly where on her body she was hit. He also stated that the situation seemed to have occurred quickly and was very confusing. On inquiry, he stated that CNAs are screened before hire, educated on abuse and monitored. CNA #1was interviewed via telephone on 9/1/2020 at 9:25AM. She stated she had a good relationship. and knew Resident #1 was scheduled to be showered on the day of the incident. She informed Resident #1 that she would shower her after breakfast. However, there was another resident (Resident #2) who was very soiled with feces. She decided to care for him first, and she and she informed Resident #1 of her decision. After caring for Resident #2 she returned to Resident #1 was in the bathroom (located in her room) and she was observed splashing water on herself. She asked resident #1 whether she was ready for her shower. Resident #1 was very annoyed and stated she was not ready, so she went to get another resident (Resident #3) for her care. When she returned, Resident #1 had her basin in the sink. CNA #1 stated she asked Resident #1 to excuse her, so she could get some water for use on Resident#3. Resident #1 responded in Creole which she did not understand. She placed Resident (#3) basin on Resident #1 to get the water she needed. Resident #1 pulled the basin from her hand and turned it over. CNA #1 said she ignored what occurred and started to obtain some water a 2nd time and Resident #1 hit her on her face shield which surprised her. CNA #1 stated she then turned around and gave Resident #1 a pat on the shoulder. Resident #1 called the nurse and she (CNA #1) stepped out of the bathroom room, called the nurse and informed her what occurred. The Social Worker was called and Resident #1 told her she was hit in the eyes which she denied. The police were called and she (CNA #1) was sent home and later informed she was terminated. 415.5(b)(3)

Based on observation, record review and interview conducted during the COVID-19 Focused Infection Control Survey (#NY 313), completed on 7/30/20 the facility did not ensure that infection control protocols were followed on 1 of 3 units (3rd Floor) reviewed. Specifically, staff did not complete proper hand hygiene and wear proper Personal Protective Equipment (PPE), gown and gloves, when in a room with a resident on contact precautions for [MEDICAL CONDITION] ([MEDICAL CONDITION] infection). The findings are: The facility policy on Infection Control [MEDICAL CONDITIONS] infection dated 02/2020 documented: Encourage hand washing with soap and water over alcohol-based hand sanitizers after contact with a resident with [MEDICAL CONDITION] or contact with his/her immediate environment. The policy further documented staff will be monitored for compliance/competency in hand washing. The facility policy on PPE revised 06/2020 documented the facility promotes appropriate use of personal protective equipment (PPE) to prevent the transmission of pathogens to residents, visitors and other staff. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. PPE will be utilized as part of standard precautions regardless of a resident suspected or confirmed infection status. The red dot indicates that the staff should wear all PPE. The facility policy on Handwashing revised 05/2018 documented: All staff will receive education on proper hand washing technique and will be monitored for competency in hand washing techniques as the most effective method for preventing and spreading of infection. Hand sanitizers cannot be used when hands are visibly soiled, before attending to food, or after caring for residents with spore forming infections ([MEDICAL CONDITION]). Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 7/29/20, documented the resident and total dependence for toilet use and extensive assistance with personal hygiene. Resident laboratory results on 07/27/2020 documented [MEDICAL CONDITION] DNA, Molecular-Positive result. On 07/30/2020 at 11:25 AM, an observation of room [ROOM NUMBER] was conducted, and the following was observed: The room door was labeled with a sign depicting a red dot, and a metal PPE bin containing gowns, gloves, and surgical masks was hanging on the room door of Resident #1. A Physical Therapy Assistant (PTA) was providing range of motion (ROM) exercises to Resident #1. The PTA was wearing only a surgical mask. The PTA exited the room without performing hand hygiene. A Recreation Leader (RL), wearing only a surgical mask, was also in the room taking menu choices from all four residents in the room. The RL exited the room without performing hand hygiene and proceeded to use the phone at the nurse's station. On 07/30/2020 at 11:41 AM, the PTA was interviewed, and she stated she did not notice the red dot sign or the PPE container on the room door upon entering the residents' room. She stated that she is aware that the red dot indicates the resident is on precautions and PPE should be worn when providing care. PTA also stated that she would do handwashing before seeing her next resident. On 07/30/2020 at 11:47AM, the RL was interviewed, and he stated that he did not notice the PPE container on the door before entering the room. He stated that he gets a daily update on resident status. He stated that the red dot on door means 100% caution and to use all PPE. He stated hand hygiene should be done before and after touching food and visiting rooms. On 07/30/2020 at 12:24PM, Registered Nurse (RN) # 1 was interviewed and stated residents on precautions are on the 24-hour report. The room is labeled with a red dot on the door, and the sign with the red dot indicates staff should wear all PPE. She stated that the resident in 317B is on contact precautions for [MEDICAL CONDITION]. On 07/30/2020 at 12:36PM, Infection Preventionist was interviewed and stated that the red dot sign on the room door informs staff there is someone on contact precautions in the room. She stated that there is a PPE bin at the door that was put in place when a resident was diagnosed with [REDACTED]. The resident tested positive for [MEDICAL CONDITION] on 07/27/2020 and was placed on contact precautions right away. She stated the resident was placed on the 24-hour report, and the nursing supervisor, interdisciplinary treatment team (IDTT) team, and department heads are informed of residents on contact precaution. She stated she audits all rooms of residents on precautions to ensure PPE is in place, staff are following PPE protocols, and proper cleaning is done. On 07/30/2020 at 1:03PM, Director of Nursing Services (DNS) was interviewed, and she stated staff providing care to Resident #1 should perform hand hygiene before providing care, after completion of care, and before moving on to the next resident. On 07/30/2020 at 2:25PM, the Physical Therapy Director was interviewed and stated that Resident #1 is provided physical therapy services 5 times per week. He stated that if there is a red dot on the door, staff should wear PPE, at all times, and practice handwashing. They should remove PPE before leaving room and practice hand hygiene with sanitizer or soap and water after providing care. He stated that there is a clear policy that signage with a yellow dot or red dot indicates staff should practice universal precautions and strict precautions. 415.19 (a) (1-3) (b)1

Based on observations and staff interviews during the recertification survey, the facility did not ensure pertinent state agency information had been posted as required. Specifically, the New York Department of Health Complaint Hotline number and information was not posted on any resident units or lobby area. The finding is. During the initial tour on 06/03/19 of units one, two, and three, and the lobby, there were no postings informing residents of the telephone number to New York State Department of Health Complaint Hotline. The Director of Nursing (DON) was interviewed on 06/03/19 at 11:00AM and she stated she is the responsible person for ensuring residents rights are respected and that they are informed. She further stated it is very important for residents, families, and staff to have independent and outside resources to enhance the confidence and freedom in reporting complaints without facility constraints. 415.3(d)(3)

Based on record review and resident and staff interviews during the re-certification survey, the facility did not provide reasonable accommodation of resident's needs and preferences to ensure residents preferences were essential in creating an individualized, home-like environment. Specifically, residents were instructed to eat in their rooms when ordering out non-Kosher food. This was evident in 12 of 12 residents (#21, 89, 106, 28, 114, 108, 65, 4, 117, 57, 67, 72) all of whom participated in the resident council meeting. The finding is. The facility food committee meeting minutes were reviewed from 12/2018 to 04/2019. The food committee staff which consists of the Food Service Director (FSD) and residents had a meeting on 04/18/19. Residents were reminded about the non-Kosher food restriction stating, As always, residents are permitted to eat non-Kosher food in their room. As of 06/06/19 to 06/07/19, the facility provided a list of 21 residents out of a census of 141 residents who are currently following kosher diet practices. On 06/05/19 at 11:00 AM, 12 residents participated in the resident council meeting. All 12 residents stated they were not allowed to eat in the dining room facility when they order out non-Kosher food. On 06/06/19 at 04:03 PM, resident #28 stated he has been a resident in this facility since March. He further stated he orders food from the outside and stays in his room to eat it because he was told the food is not Kosher and he is not allowed to eat in the dining room. On 06/06/19 at 04:14 PM, resident #89 stated he has to eat in his room when he orders out. He further stated the reason is because this is a Kosher facility and was told if he didn't like it, to find another facility. On 06/06/19 at 04:18 PM, resident # 67 stated he has to eat in his room when he orders out. On 06/05/19 at 01:23 PM, the Registered Dietitian stated all residents are allowed to order food from outside if they choose to. If the food is non-Kosher, they are not allowed to put it on the dining room table because those are the Rabbi regulations. On 06/05/19 at 01:49 PM, the Administrator stated it is part of the strict Kosher law to not have non-Kosher food on the same table as Kosher food. He further stated he was not aware residents were informed they were only allowed to eat non-Kosher food in their rooms and the facility currently does not have a communal dining area for residents to eat non-Kosher food. On 06/06/19 at 04:31 PM, the FSD stated it is the facility's policy to not serve meat with dairy because it is a Kosher facility. 415.5(e)(1)

Based on observations and staff interview during the re-certification survey, the facility did not ensure garbage and refuse containers by the loading dock were kept clean, free of foul odors, and in good condition. Specifically, an opaque colored leak with a foul odor was observed coming from the garbage dumpster area. The finding is. On 06/04/19 at around 03:30 PM, State surveyor observed a foul odor coming from the garbage dumpster area located on the left side of the building. On 06/05/19 at 09:00 AM, 06/06/19 at 12:43 PM, and on 06/07.19 at 08:45 AM, the base of the dumpster was observed rusted and dirty, with liquid draining out from the dumpster along the side walk to the street and had a foul odor. On 06/07/19 at 09:19 AM, State surveyor observed a leak with a foul odor coming from under the garbage dumpster. Additionally, the side walk on the street was covered with an opaque colored liquid substance. On 06/07/19 at 09:29 AM, the Food Service Director (FSD) was interviewed and stated the foul odor is due to a leak coming from the dumpster. On 06/07/19 at 09:41 AM, the Director of Building Services was interviewed and stated there are two leaks from under the garbage compactor which is causing the smell. He further stated the garbage compactor company was contacted to fix the leak. 415.14(h)

Based on observation, record review, and staff interviews conducted during the re-certification survey, the facility did not ensure a resident with limited range of motion received treatment and services to increase and/or to prevent further decrease in range of motion. Specifically, a resident with physician orders [REDACTED]. This was evident for 1 of 1 resident reviewed for Limited Range of Motion (Resident #32) out of a sample of 35 residents investigated for quality of care/life. The finding is. The facility policy and procedure for Restorative Nursing dated 08/2018 documented the facility will provide interventions that promote the resident's ability to adapt and adjust to living as independently and safe as possible. The facility policy stated that the restorative nursing program must be ordered by physician and daily documentation that the program were provided/performed. The facility policy further documented resident with splint devices will be provided as prescribed by physician. The Certified Nursing Assistant (CNA) will oversee that the resident performs/participates the task and document on the CNA accountability record that the splint devices was applied or indicate R for Refused and U for unable. If the resident refused or was unable to perform the task as indicated in the order, the CNA must report the same to the license nurse by the end of the shift. Resident #32 was initially admitted to the facility on [DATE] with the most recent re-admission on 01/05/18. Resident's [DIAGNOSES REDACTED]. Physician order [REDACTED]. Right hand roll to be worn when OOB. The most recent Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] documented the resident's cognitive status as severely impaired. The MDS also indicated the resident requires extensive assistance with one person in bed mobility, transfer, and toilet use. It also documented that the resident has limited range of motion on one side of both upper and lower extremities. On 06/03/19 at 10:23 AM, the resident was observed with an impairment to his right hand and right leg. On 06/03/19 at 01:59 PM, the resident was observed in his room sitting in a wheel chair watching television with no AFO or hand roll in place. On 06/04/19 at 09:52 AM, the resident was observed sitting in the day room with no AFO or hand toll in place. A review of the CNA accountability record dated from 05/01/19 to 06/04/19 documented that the splint devices were applied. The comprehensive care plan (CCP) for restorative rehab dated 12/24/18 and revised 03/27/19 documented the Right AFO to be worn when out of bed, remove during hygiene and skin care. The CCP also documented a right hand roll to be worn when out of bed and remove during ADLs and Hygiene. On 06/04/19 at 09:53 AM and on 06/05/19 at 10:42 AM, an interview conducted with CNA #2 stated the resident is always on her regular assignment. She stated the resident is weak on the right hand. The 11 AM to 7 AM shift gets him cleaned up and she gets him out of bed. CNA #2 then stated she performs range of motion during care as tolerated. She further stated she was not aware the resident uses a hand device but the one for his foot has been discontinued. CNA #2 stated if a resident needs a splint device it should be reflected on the CNA accountability record where every task will be signed off daily. She further stated it was a mistake that she signed off on the task for applying the splint device on the resident even though it was not done. On 06/04/19 at 10:01 AM, RN #3 stated she does rounds and ensures the staff complete their assignments. She stated the resident has a weakness to the right hand due to history of a stroke. RN #3 stated the resident is on AROM during care. She then stated resident used to receive right AFO but had refused the device. She further stated it is documented on the behavior care plan which was discontinued 12/28/18. On 06/06/19 at 10:35 AM, the Director of Rehab stated the last time the resident received PT was 03/21/19 and 03/20/19 for OT. He stated the resident was seen at that time for the quarterly assessment. On 03/21/19, the PT recommendation at that time was PROM to Right lower extremity, right AFO (Ankle Foot Orthosis). He stated the resident had a foot drop and the AFO was recommended to prevent further contractures. OT recommendation dated 03/20/19 was PROM to right upper extremities and right hand rolls when out of bed. The director stated he did not receive any referral from the nursing staff regarding a re-evaluation for the devices. 415.12(e)(2)

Based on observation, record review, and staff interviews during the re-certification survey, the facility did not ensure an infection prevention and control program was maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident who has an physician order [REDACTED]. This was evident for resident #128 who resides in a four bed room out of a final sample of 35 residents investigated for quality of care/life. The finding is. The facility policy and procedure titled, Infection Prevention and Control Program (Dated 3/2019) was reviewed and documented the following. Resident/Family/Visitor education includes the usage of isolation signs to alert staff, family members, and visitors of isolation precautions (page 3, #11c). The facility policy and procedure titled, Procedure for Isolation: Initiation of Isolation vs. Standard/Universal Precautions (Dated 5/2018) was reviewed and documented the following. Gathering equipment includes placing over the door PPE receptacle and obtain appropriate signage and post outside the door frame. On 06/03/19 at 10:49 AM, resident #128 room was observed with PPE supplies (PPE gown, gloves, and mask) hung over the door. There was no sign specifying the type of precautions needed or a sign directing others to see a nurse before entering. Resident #128 was admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. On 06/07/19 at 08:37 AM, the Certified Nursing Assistant (CNA) #1 was interviewed and stated she was not sure about any signage because she receives morning report from the nurse and was told the resident is on contact precautions and was told what protection to put on. She further stated it is important to put on the equipment to protect herself and others. On 06/07/19 at 08:41 AM, the Licensed Practical Nurse (LPN) #1 was interviewed and stated resident was on contact precautions for VRE in the wound. She further stated there should've been a sign on the PPE box but it might have fell off. LPN #1 stated it is important for the sign to be on there to let not only staff but visitors know what precautions to take. On 06/03/19 at 10:49 AM and on 06/07/19 at 08:45 AM, the Registered Nurse Supervisor (RN) #1 stated resident was on contact precautions for VRE in the wound. She stated a sign is not needed because the supplies are there which will automatically prompt staff to don PPE before entering. RN Supervisor #1 further stated the other residents and/or visitors in the room will not be affected because the infection is in the resident's wound. On 06/07/19 at 11:22 AM, the Infection Control RN #2 was interviewed and stated she a sign should always be placed up with the PPE kit to let both staff and visitors know what kind of precautions are needed and what to put on. She further stated she was not made aware that there was no sign on PPE kit for above resident. If there are no signs, the nurses on the unit knows to get it from her or the Director of Nursing. 415.19(b)(1)

Based on record review and interviews conducted during re-certification survey, the facility failed to ensure the resident's right to be free from abuse and/or neglect. Specifically, Resident #231 was incontinent of bowel and used incontinence briefs. A Certified Nurse Assistant (CNA) willfully neglected to provide care and services to the resident. The CNA admitted that after being asked by the resident's family member to change the resident's soiled incontinence brief on three occasions; at 5:00 PM, 6:00 PM and again at 7:15 PM she willfully chose not to provide incontinence care to the resident. The negligence resulted in the resident sitting in a soiled diaper for 2 and ½ hours. This was evident for one (1) out of a Sample of 35 residents. The Finding is: Complaint # NY 240 The Facility's Policy and Procedure (P&P) on Abuse Prohibition Policy and Procedures of Residents which was revised 1/4/18. The P&P states residents of the facility will be protected against Abuse, Neglect, Mistreatment, of property in accordance with State and Federal Regulations. It further states that all alleged or suspected incidents of Abuse, Neglect, Mistreatment or Misappropriation of residents' property will be thoroughly investigated and findings documented in a report format. It also states that any case in which Abuse, Neglect, Mistreatment, or Misappropriation of residents' property has been identified via the investigation, or a conclusion cannot be drawn will be reported promptly to the State Department of Health for further investigation. Under the definitions of abuse, in the neglect category, it is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to attain or maintain their highest practicable level of physical, mental and psychosocial well- being. Resident # 231 was a [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented resident with moderately impaired cognition. She required extensive assistance with one- person physical assist for bed mobility, transfer, toilet use, personal hygiene and dressing. In addition, she was totally dependent on staff for locomotion on and off the unit. In addition, she required limited assistance with one- person physical assist for eating. The Comprehensive Care Plan (CCP) for the resident 12/27/17, stated that the resident needs assist with bedpan as needed and all aspects of personal hygiene. The Resident Nursing Instructions for the resident dated 12/27/17 stated that the resident needs extensive assistance with one- person physical assist for toilet use. The Comprehensive Care Plan (CCP) dated 12/27/17 included interventions required for this resident during toilet use including assist with bedpan as needed and all aspects of personal hygiene. Facility Record of Corrective Warning for the CNA dated 1/8/18 revealed that the CNA admitted that the resident's daughter asked her to change the resident's diaper at 5:00 PM however, she told the resident's daughter that she was not able to change the diaper because she was serving trays. It is further documented that the CNA stated that she brought the resident's tray to the daughter and then afterwards she went and fed another resident. It is further documented that the CNA admitted that she took care of two other residents, prior to changing the resident around 7:30 PM. On 03/06/18 at 08:56 AM, an interview was conducted with Certified Nursing Assistant (CNA) #1. The CNA stated that around dinner time, while she was feeding a resident, the resident's daughter came to the dining room twice and told her that the resident had another bowel movement. The CNA stated that she told the daughter that she would change her mother's diaper when she was finished feeding a resident. The CNA stated that she did not tell other staff on the unit about the resident's daughter's request. The CNA stated that after dinner, another CNA told her that it was her turn to monitor a resident on the floor who was allegedly getting out of his chair. When asked, she stated that at this point she did not advise other staff on the unit of the resident's daughter's request. She stated that around 6:30 PM or 7:00 PM, she went to the resident and noted that she had another bowel movement which was watery. The CNA further stated that that her actions on 12/30/17 was neglect. On 03/07/18 at 12:49 PM, an interview was conducted with LPN #1. She stated that CNA # 1 did not advise her of the resident's daughter's request. The LPN stated that if the CNA had reported that the family member requested that the resident 's diaper be changed that she would reassign the CNA or have another CNA change the resident. On 03/05/18 at 03:52 PM, an interview was conducted with LPN #2. She stated that they were not short of staff that day. She stated that upon rounds at the beginning of the shift, the resident's daughter advised her that the resident's brief needed to be changed. LPN # 2 stated that she told CNA # 1 to change the resident, and the CNA changed the resident's brief. On 03/06/18 at 11:56 AM, an interview was conducted with the Director of Nursing (DON). She stated that she was responsible for the investigation. The DON stated on 1/3/18, the resident's granddaughter came to her and was upset with what transpired on 12/30/17. The DON stated that the resident's granddaughter advised her that her mother had asked CNA # 1 to change the resident's diaper several times however, the CNA did not respond to the requests. The DON stated that the CNA changed the resident's diaper around 3:00 PM however, as per investigation, the resident's daughter asked the CNA to change the resident's diaper at 5:00 PM, 6:00 PM and at 7:15 PM. The DON stated that it was at this point the resident's mother called the granddaughter and told her that she was having a problem getting the resident's diaper changed. The DON stated that the granddaughter spoke with CNA #1 in regard to having her grandmother's diaper being changed. The DON went on to state that the resident's granddaughter was upset and angry when the CNA told her that she was tired and had 12 residents to provide care. She further asked the granddaughter what do you want me to do. The DON stated that the CNA admitted to not changing the resident on time and that she was terminated. On 03/06/18 at 12:08 PM and interview was conducted with the Administrator. He stated that an investigation was conducted, the accused CNA was removed from the assignment immediately. He stated that the CNA stated that she was asked three times to change the resident's diaper and that she did not do it. The Administrator stated that it was determined that neglect occurred. The Administrator further stated that the CNA was terminated on 1/8/18. He added that the facility has a zero tolerance for this type of behavior. The Administrator stated that the staff received education on abuse and neglect pre and post incident. 415.4(b)(1)(i)

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 (135) residents from the potential [MEDICAL CONDITION] scalding related to excessive hot water temperatures from the facility's domestic hot water system. This deficient practice was evident at the resident sinks and common shower rooms on all 3 of 3 resident units. (See F323) This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to Resident Health and Safety. The findings are: During the environmental and unit tours conducted on 10/12/16 between 8:30 AM and 10:50 AM, the following was noted: During the phase 1 tour conducted on 10/12/16 between 8:30- 10:35 AM, the sinks in the following resident rooms: #103, 105, 106, 109, 111, 112, 114, 115, 117, 203, 204, 206, 208, 209, 217, 218, & 219 were observed with extremely hot water. The surveyors tested the hot water by running the water over their hands, after approximately 25-30 seconds the hot water became so hot that the surveyors had to remove their hands. The Sanitarian measured the water temperature using a digital stem- type thermometer. Hot water readings were noted to range from 127 to 137 degrees Fahrenheit (F) at sinks in the residents' bathrooms and common unit shower rooms. Examples of hot water temperatures taken at the hand washing sinks at various locations included but were not limited to the following: 1st floor: Common Unit Shower room [ROOM NUMBER]F Resident room # 103 - 129F Resident room # 114 - 129F 2nd floor: Common Unit Shower room [ROOM NUMBER]F Resident room # 201 - 134F Resident room # 117 - 131F 3rd floor: Common Unit Shower room [ROOM NUMBER]F Resident room # 306 - 134F Resident room # 317 - 136F The maintenance director was advised of the concerns and stated that the system was recently changed over from summer to winter phase on 10/11/16 (the evening before) and that temperature logs were taken daily but were not taken on this day (10/12/16) because the sanitarians were touring the facility with the maintenance staff. He suggested that the increased temperatures may have been the result of the changeover. An inspection of the mixing valve and temperature gauge at the valve was requested and granted. The mixing valve temperature at that time, 10:45 AM was 122F. The temperature gauge was a mechanical gauge situated above the mixing valve. The maintenance director stated that the temperatures are manually adjusted based on temperature reading at the gauge with the expectation of some heat loss in the water system after the valve and gauge areas in the boiler room. The maintenance director further stated that in the summer a small boiler is used to heat the hot water system leading to the mixing valve, temperature gauge and building. In the winter a large boiler is used to heat the hot water system leading to the mixing valve, temperature gauge and building. Both systems shared the same mixing valve and temperature gauge. The policy and procedure on Heating System and Water Temperature, dated September 2015 was reviewed. It documented that it was the policy of the facility to maintain a safe and consistent source of hot water for both heating and domestic use along with maintenance of a temperature log. It documented the presence of one electronically controlled mixing valve that supplies both the kitchen and resident areas with set points at 110F and 120F. It notes that isolation and bypass valves will assure safe temperatures in the event of a mixing valve failure. On 10/12/16 at approximately 11:30 AM, the Director of Building Services was interviewed. He stated that he was in charge of overseeing the day to day maintenance activities. 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. Daily maintenance check logs for the past month were reviewed with the most recent one, dated 10/11/16 documenting a temperature of 120F at 7:00 AM at an undisclosed location in the building. The Director of Building Services stated that no concerns were apparent at that time despite the temperature being at the upper threshold of acceptable limits. He stated that temperatures are typically taken in the morning but were not taken on this day (10/12/16) because the survey had started. He stated that the heating system had just been switched from the summer to winter cycle which involved transitioning hot water production from a small boiler unit to a significantly larger one with the capacity to heat the water and building at the same time. He stated that nursing and other department heads are generally notified of the changeover from summer to winter boiler cycles during the morning report the day after the transition. He added that nursing is immediately notified if the hot water monitoring reveals temperatures above 120F. Temperatures were taken again at 2:00 PM on the 3rd. floor in rooms 306 at 125F and room [ROOM NUMBER] at 122F.The mixing valve gauge reading (boiler room in the basement) was checked again at 2:10 PM with a temperature of 120F shown (5 degrees lower than sink outlet temperature shown 3 floors above in room [ROOM NUMBER] which was 125F) supportive of a concern for defective boiler equipment and inadequate monitoring of water temperatures in the building. The plumber was called by the facility and arrived in the late afternoon. The plumber stated that the temperature gauge was fried and that it would have to be replaced. He stated that the system was being reverted back to the summer setting (smaller boiler) until the repairs could be made the following day. On 10/12/16 at 5 PM the Director of Nursing was interviewed. She stated that she was the Administrator on Duty in the absence of the Administrator due to the Holiday. She stated that she was not aware of the problem stated that she should have been made aware. She stated that she became aware of the problem today when the director of building services brought the matter to her attention. She stated that her role was to ensure that all of the residents are safe. She checks with nurses and supervisors regularly. She states that she is a regular member of the QA team and that a matter like this one would be discussed at the regular QA meetings held quarterly. On 10/12/16 from 1:00 PM - 3:00 PM Certified Nursing Aides from the 1st, 2nd & 3rd floors were interviewed. Certified Nurse Aides # 1-8 denied being notified of any water temperature issue or a transition from summer to winter heating cycle. All the CNAs interviewed stated that they check the water with their hands before exposing their residents to it. CNA #7 stated that she did notice the water temperature to be hotter today than yesterday but did not notify anyone. On 10/12/16 from 1:00 PM - 3:00 PM all licensed nursing staff from all units were interviewed. The Licensed Practical Nurses #1-6 (LPN) and the Registered Nurse #1 all denied being notified of any water temperature issue, or informed of the transition from summer to winter heating cycle. On 10/12/16 an invoice from the plumber was obtained which documented that the domestic hot water temperature was too high at 130F with plans to replace the temperature gauge on the unit. Hot water production was diverted to the smaller heating unit at 115F. Hourly monitoring of temperatures by the facility was conducted beginning at 7:00 PM on 10/12/16 with logs provided to the survey team through 10/17/16 when the immediate jeopardy was removed. Plans to remove the immediacy which included revisions to the policy and procedure on the Heating System and hot water temperature were submitted to the on-site survey team between the hours of 2:00 PM and 8:15 PM on 10/12/16. At 8:15 PM, a final revision to the plan to remove the immediacy was submitted and accepted by the on-site team. The plans included hourly monitoring of water temperatures to resident areas and diversion of the hot water system to the smaller heating unit with a setting of 115F. On 10/13/16 an invoice from the plumber was obtained which documented replacement of 2 defective components of the boiler. A defective temperature gauge and cross tee was replaced. On 10/13/16 at 11:45 AM, the Administrator was interviewed he stated that he is a member of the Quality Assurance Team. He stated that he was not aware of any hot water issue before last night (10/12/16 at 7:45 PM) when he was called and informed by the facility. When asked if he should have been aware of the problem, he responded, no. He stated that his role is to ensure the safety and wellbeing of the residents and that the QA practice is to bring matters of concern from the morning report and 24 hour report to the quality assurance committee when appropriate. The Administrator stated that he was not aware of the hot water issue or of the fact that they were changing over to the winter cycle from the summer cycle on the boiler system. He stated that the following morning the matter would have come to his attention during the morning report. He stated that he knew that a transition was to occur soon but was unaware of exactly when it was scheduled to happen. He added that the department heads would have been notified the next morning during the regular morning report. Monitoring of the facility continued through the weekend with temperatures taken on all floors and staff interviewed to verify provision of in-service by the facility to its staff. The Immediate Jeopardy was removed on 10/17/2016. The team exited the facility on 10/19/2016. Prior to the team's exit the following concerns were addressed to remove the immediate jeopardy status: 1) Repairs were made to the boiler which included replacement of the temperature gauge and cross tee. 2) The maintenance staff tested the water temperatures in all resident rooms and common areas on an hourly basis. Temperatures were monitored daily by the survey team as well and were within acceptable range since the time that immediacy was removed. 3) Evidence of 97% completion of in-service to staff regarding revisions to the policy and procedure on the Heating System. 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 (135) residents from the potential for burns and scalding related to excessive hot water temperatures from the facility's domestic hot water system. This deficient practice was evident at the resident sinks and common shower rooms on all 3 of 3 resident units. 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. The findings are: During the environmental and unit tours conducted on 10/12/16 between 8:30 AM and 10:50 AM, the following was noted: During the phase 1 tour conducted on 10/12/16 between 8:30- 10:35 AM, the water from the sinks in the following resident rooms: #103, 105, 106, 109, 111, 112, 114, 115, 117, 203, 204, 206, 208, 209, 217, 218, & 219 were observed by touch to be extremely hot. The surveyors tested the hot water by running the water over their hands, after approximately 25-30 seconds the hot water became so hot that the surveyors had to remove their hands. The Sanitarian measured the water temperature using a digital stem- type thermometer. Hot water readings were noted to range from 127 to 137 degrees Fahrenheit (F) at sinks in the residents' bathrooms and common unit shower rooms. The acceptable water temperature range is between 90F and 120F. Examples of hot water temperatures taken at the hand washing sinks at various locations included but were not limited to the following: 1st floor: Common Unit Shower Room 133F Resident room # 103 - 129F Resident room # 114 - 129F 2nd floor: Common Unit Shower Room 137F Resident room # 201 - 134F Resident room # 117 - 131F 3rd floor: Common Unit Shower Room 127F Resident room # 306 - 134F Resident room # 317 - 136F The Maintenance Director was advised of the concerns and stated that on 10/11/16 (the evening before) the system was recently changed over from the summer to the winter phase. The Maintenance temperature logs were taken daily but were not taken on this day (10/12/16), because the sanitarians were touring the facility with the maintenance staff. He suggested that the increased temperatures may have been the result of the changeover from the summer to winter boiler. An inspection of the mixing valve and temperature gauge at the valve was requested and granted. The mixing valve temperature at that time, 10:45 AM was 122F. The temperature gauge was a mechanical gauge situated above the mixing valve. The maintenance director stated that the temperatures are manually adjusted based on temperature reading at the gauge with the expectation of some heat loss in the water system after the valve and gauge areas in the boiler room. The maintenance director further stated that in the summer a small boiler is used to heat the hot water system leading to the mixing valve, temperature gauge and building. In the winter a large boiler is used to heat the hot water system leading to the mixing valve, temperature gauge and building. Both systems shared the same mixing valve and temperature gauge. The policy and procedure on Heating System and Water Temperature, dated September 2015 was reviewed. It documented that it was the policy of the facility to maintain a safe and consistent source of hot water for both heating and domestic use along with maintenance of a temperature log. It documented the presence of one electronically controlled mixing valve that supplies both the kitchen and resident areas with set points at 110F and 120F. It notes that isolation and bypass valves will assure safe temperatures in the event of a mixing valve failure. On 10/12/16 at approximately 11:30 AM, the Director of Building Services was interviewed. He stated that he was in charge of overseeing the day to day maintenance activities. 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. Daily maintenance check logs for the past month were reviewed with the most recent one, dated 10/11/16 documenting a temperature of 120F at 7:00 AM at an undisclosed location in the building. The Director of Building Services stated that no concerns were apparent at that time despite the temperature being at the upper threshold of acceptable limits. He stated that temperatures are typically taken in the morning but were not taken on this day (10/12/16) because the survey had started. He stated that the heating system had just been switched from the summer to winter cycle which involved transitioning hot water production from a small boiler unit to a significantly larger one with the capacity to heat the water and building at the same time. Temperatures were taken again at 2:00 PM on the 3rd. floor in rooms 306 and 305, the temperatures were measured 125F and122F respectively. The mixing valve gauge (boiler room in the basement) reading was checked again at 2:10 PM with a temperature of 120F shown (5 degrees lower than sink outlet temperature shown 3 floors above in room 306 which was 125F). On 10/12/16 from 1:00 PM - 3:00 PM Certified Nursing Aides from the 1st, 2nd & 3rd floors were interviewed. Certified Nurse Aides # 1-8 denied being notified of any water temperature issue or a transition from summer to winter heating cycle. All the CNAs interviewed stated that they check the water with their hands before exposing their residents to it. CNA #7 stated that she did notice the water temperature to be hotter today than yesterday but did not notify anyone. On 10/12/16 from 1:00 PM - 3:00 PM all licensed nursing staff from all units were interviewed. The Licensed Practical Nurses #1-6 (LPN) and the Registered Nurse #1 all denied being notified of any water temperature issue, or informed of the transition from summer to winter heating cycle. The plumber was called by the facility and arrived in the late afternoon. The plumber stated that the temperature gauge was fried and that it would have to be replaced. He stated that the system was being reverted back to the summer setting (smaller boiler) until the repairs could be made the following day. On 10/12/16 at 5 PM the Director of Nursing was interviewed. She stated that she was the Administrator on Duty in the absence of the Administrator due to the Holiday. She stated that she was not aware of the problem, but stated that she should have been made aware. She stated that she became aware of the problem today when the director of building services brought the matter to her attention after the surveyor notified him. She stated that her role was to ensure that all of the residents are safe. She checks with nurses and supervisors regularly. She states that she is a regular member of the QA team and that a matter like this one would be discussed at the regular QA meetings held quarterly. She stated that no issues related to hot water were recently discussed the QA meetings she attended. On 10/12/16 an invoice from the plumber was obtained which documented that the domestic hot water temperature was too high at 130F (at the boiler) with plans to replace the temperature gauge on the unit. Hot water production was diverted to the smaller heating unit at 115F. The policy and procedure on Heating System and Water Temperature, dated September 2015 was reviewed. It documented that it was the policy of the facility to maintain a safe and consistent source of hot water for both heating and domestic use along with maintenance of a temperature log. It documented the presence of one electronically controlled mixing valve that supplies both the kitchen and resident areas with set points at 110F and 120F. It notes that isolation and bypass valves will assure safe temperatures in the event of a mixing valve failure. Plans to remove the immediacy which included revisions to the policy and procedure on the Heating System and hot water temperature were submitted to the on-site survey team between the hours of 2:00 PM and 8:15 PM on 10/12/16. At 8:15 PM, a final revision to the plan to remove the immediacy was submitted and accepted by the on-site team. The plans included hourly monitoring of water temperatures to resident areas and diversion of the hot water system to the smaller heating unit with a setting of 115F. On 10/13/16 an invoice from the plumber was obtained which documented replacement of 2 defective components of the boiler. A defective temperature gauge and cross tee pipe was replaced. The Administrator stated that he was not aware of the hot water issue or of the fact that they were changing over to the winter cycle from the summer cycle on the boiler system. He stated that the following morning the matter would have come to his attention during the morning report. He stated that the Director of building services would have notified him as well as the Director of Nursing during the morning meeting. He denied any issues during last year's transition from Winter to Summer cycle. Monitoring of the facility continued through the weekend with temperatures taken on all floors and staff interviewed to verify provision of in-service by the facility to its staff. The Immediate Jeopardy was removed on 10/17/2016 following receipt of documentation which included staff sign in sheets to evidence 97% completion of in-service as well monitoring sheets to evidence of hourly temperature monitoring within acceptable ranges. The team exited the facility on 10/19/2016. Prior to the team's exit the following concerns were addressed to remove the immediate jeopardy status: 1) Repairs were made to the boiler which included replacement of the temperature gauge and cross tee pipe. 2) The maintenance staff tested the water temperatures in all resident rooms and common areas on an hourly basis. Temperatures were monitored daily by the survey team as well and were within acceptable range since the time that IJ was removed. 3) Evidence of 97% completion of in-service to staff regarding revisions to the policy and procedure on the Heating System. 4) Hourly monitoring of temperatures by the facility were conducted beginning at 7:00 PM on 10/12/16 with logs provided to the survey team through 10/17/16 when the immediate jeopardy was removed. Examples included: 10/12/16 97.1F-116F 10/13/16 95.4F-115.7F 10/14/16 97.3F-116.1F 10/15/16 100.5F-118F 10/16/16 100.3F-116.9F 10/17/16 98.9F-110.6F 415.12(h)(l)

Based on record review, observation, and staff interview during the recertification survey, the facility did not prevent the development of a pressure ulcer for one of three residents reviewed for pressure ulcers in a total sample of thirty residents. This resulted in actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #116 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Risk Factor Sheet - Assessment of Pressure Ulcer Potential form dated 12/2/11 documented the resident with a score of 13 which indicated "high risk pressure ulcer precautions". The Skin Integrity - Prevention Comprehensive Care Plan (CCP) dated 12/2/11 revealed that the resident was a high risk (score 6-18). The goal was for the resident to not develop any new pressure ulcers over the next 90 days. Interventions included, but are not limited to: Keep skin clean and dry; Keep skin well lubricated; Prevent skin-to-skin contact using pillows or positioning device. The Consultation Form dated 12/5/11 requested a consultation from Occupational Therapy (OT). The reason for the consultation was for better head/neck positioning. The Admission Minimum Data Set ((MDS) dated [DATE] documented that the resident had no speech, rarely/never understood others, and had severely impaired cognitive skills for daily decision making with long and short-term memory problems. The resident was totally dependent on two or more persons for physical assistance in bed mobility, transfers, toilet use, and bathing. The resident was totally dependent on one person for physical assistance in locomotion on and off the unit, dressing, eating, and personal hygiene. The OT (Occupational Therapy)/Rehab (Rehabilitation) Progress Note dated 12/13/11 documented that the resident was seen as per Nursing request. The resident presented with moderate to severe rigidity to the head/neck. Passive stretching would be incorporated and a neck collar would be provided for use when the resident was OOB (out of bed) in a geri recliner. The Occupational Therapy (OT) ADLs (Activities of Daily Living) Rehabilitative Services Comprehensive Care Plan (CCP) dated 12/3/11 revealed under Evaluation Outcomes dated 12/13/11: Incorporate gentle head/neck stretching. Provide neck collar for use OOB. Review of Physician order [REDACTED]. Review of the OT Progress Summary and Goal Tracking Report dated 12/14/11 revealed that the resident received OT services from 12/5/11 through 12/14/11. The report revealed no documented evidence that the resident was receiving any treatment to her head/neck. Review of the OT Discharge Summary dated 12/26/11 revealed that the resident received OT services from 12/19/11 through 12/22/11. The report revealed no documented evidence that the resident was receiving any treatment to her head/neck. The Certified Nursing Assistant (CNA) Resident Care Profile/Accountability Record for December 2011 revealed no documentation to provide a neck collar to the resident or to provide any ROM (range of motion) to the resident's neck. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the OT Progress Summary and Goal Tracking Report dated 1/12/12 revealed that the resident received OT services from 12/29/11 through 1/12/12. The report revealed no documented evidence that the resident was receiving any treatment to her head/neck. Review of the OT Discharge Summary dated 1/19/12 revealed that the resident received OT services from 1/2/12 through 1/19/12. The report revealed no documented evidence that the resident was receiving any treatment to her head/neck. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. The Readmission Rehabilitation Screening Form dated 1/31/12 revealed that the resident had partial loss of voluntary movement of her neck. No recommendations were made to Nursing in reference to the resident's neck. The CNA Resident Care Profile/Accountability Record for January 2012 revealed no documentation to provide a neck collar to the resident or to provide any ROM (range of motion) to the resident's neck. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. The CNA Resident Care Profile/Accountability Record for February 2012 revealed no documentation to provide a neck collar to the resident or to provide any ROM (range of motion) to the resident's neck. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. The Risk Factor Sheet - Assessment of Pressure Ulcer Potential form dated 3/5/12 documented the resident with a score of 13 which indicated high risk pressure ulcer precautions. The Readmission Rehabilitation Screening Form dated 3/6/12 revealed that the resident had partial loss of voluntary movement of her neck. No recommendations were made to Nursing in reference to the resident's neck. The Quarterly MDS dated [DATE] documented that the resident had no speech, rarely/never understood others, and had severely impaired cognitive skills for daily decision making with long and short-term memory problems. The resident was totally dependent on two or more persons for physical assistance in bed mobility, transfers, toilet use, and bathing. The resident was totally dependent on one person for physical assistance in locomotion on and off the unit, dressing, eating, and personal hygiene. The CNA Resident Care Profile/Accountability Record for March 2012 revealed no documentation to provide a neck collar to the resident or to provide any ROM (range of motion) to the resident's neck. A physician's orders [REDACTED]. The OT/Rehab Progress Note dated 4/3/12 revealed that the resident presented with an ulcer at the underside of her chin and chest. There was moderate to severe [DIAGNOSES REDACTED] at head/neck. A "head master" neck collar was to be ordered to position the resident's head and neck and relieve pressure at her chin and neck. The resident was to be evaluated for skilled OT services to accommodate use of the splint (neck collar). The OT ADLs Rehabilitative Services CCP updated on 4/3/12 revealed under Interventions: head master collar (presently on order) and PROM (passive range of motion) to head/neck BID for 15 minutes. The Nursing Progress Note dated 4/4/12 revealed that the resident was seen on rounds. An ulcerated area under her chin was opened now to a stage II pressure ulcer. The resident's chest presented with a small excoriation due to chin pressing. The treatment was changed to [MEDICATION NAME] cream. A physician's orders [REDACTED]. The Wound Evaluation Flow Sheet dated 4/4/12 revealed a stage II mandible (under chin) pressure ulcer measuring 1.5 x 3.0 centimeters (cm) and the surrounding tissue was a SDTI (suspected deep tissue injury) 1 cm at 3 o'clock. The Wound Care Progress Note dated 4/4/12 revealed a stage II mandible pressure ulcer measuring 1.5 x 3.0 cm with a SDTI periwound (2 cm radius). The OT ADLs Rehabilitative Services CCP revealed under Interventions that the head master collar on order was discontinued on 4/7/12. Review of the OT Discharge Summary dated 4/9/12 revealed that the resident received OT services from 4/3/12 through 4/7/12. The report revealed no documented evidence that the resident was receiving any treatment to her head/neck. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. The Wound Evaluation Flow Sheet dated 4/18/12 revealed a stage IV mandible (under chin) pressure ulcer measuring 3.5 x 5.0 x 0.5 cm. The Readmission Rehabilitation Screening Form dated 4/18/12 revealed that the resident had ROM limitations on both sides of her neck, partial loss of voluntary movement of her neck, and severe forward flex limitation of the neck. No recommendations were made to Nursing in reference to the resident's neck. The OT ADLs Rehabilitative Services CCP dated 4/18/11 revealed under Problems/Needs/Strengths: Head/neck limitations with pressure ulcers at underside of chin and chest. The CNA Resident Care Profile/Accountability Record for April 2012 revealed no documentation to provide a neck collar to the resident or to provide any ROM (range of motion) to the resident's neck. Review of the OT Progress Summary and Goal Tracking Report dated 5/2/12 revealed that the resident received OT services from 4/18/12 through 5/2/12. The report revealed that the resident was receiving PROM (passive range of motion) to increase neck extension and decrease pressure to her chin/chest area to decrease the pressure sore. The long term goal for the resident was to decrease pressure and increase extension of her head to prevent further pressure ulcer breakdown. The Wound Evaluation Flow Sheet dated 5/1/12 revealed a stage IV mandible (under chin) pressure ulcer measuring 3.0 x 5.0 x 0.5 cm. The Wound Care Progress Note dated 5/1/12 revealed a stage IV mandible pressure ulcer measuring 5.0 x 5.0 x 0.5 cm and the periwound (2 cm radius) WNL (within normal limits). Review of the OT Progress Summary and Goal Tracking Report dated 5/16/12 revealed that the resident received OT services from 5/3/12 through 5/16/12. The report revealed that the resident had mild [DIAGNOSES REDACTED] to the left head/neck and was receiving OT services to accommodate a head master (neck) collar for pressure relief to her chin and chest. The Rehab-Nursing Communication Form dated 5/17/12 revealed that the resident was given a head master (neck) collar to be worn when OOB. Remove during ADLs, hygiene, and skin care. The OT ADLs Rehabilitative Services CCP updated on 5/17/12 revealed under Interventions: head master collar on when OOB in geri recliner. The Rehab-Nursing Communication Form dated 5/24/12 documented to discontinue the head master (neck) collar. The OT ADLs Rehabilitative Services CCP revealed under Interventions that the head master collar to be worn OOB was discontinued on 5/24/12. Review of the OT Progress Summary and Goal Tracking Report dated 5/30/12 revealed that the resident received OT services from 5/16/12 through 5/31/12. The report revealed that the resident had mild [DIAGNOSES REDACTED] to the left head/neck and was receiving OT services to accommodate a head master (neck) collar for pressure relief to her chin and chest. The CNA Resident Care Profile/Accountability Record for May 2012 revealed no documentation to provide a neck collar to the resident or to provide any ROM (range of motion) to the resident's neck. Review of the OT Discharge Summary dated 6/8/12 revealed that the resident received OT services from 5/25/12 through 6/8/12. The report revealed that the resident had mild [DIAGNOSES REDACTED] to the left head/neck and was receiving OT services to accommodate a head master (neck) collar for pressure relief to her chin and chest. The Summary also documented that the resident was being discharged from OT because the resident was no longer a candidate for OT services. The CNA Resident Care Profile/Accountability Record for June 2012 revealed no documentation to provide any ROM (range of motion) to the resident's neck. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. The Readmission Rehabilitation Screening Form dated 7/10/12 revealed that the resident had ROM limitations on both sides of her neck, partial loss of voluntary movement of her neck, and severe forward flex limitation of the neck. The recommendations to Nursing was for the resident to receive gentle PROM to the head/neck. The Rehab-Nursing Communication Form dated 7/10/12 documented gentle PROM to the resident's head/neck twice daily for 15 minutes. The Contractures/Decreased ROM CCP dated 7/10/12 revealed under Goals: Resident will maintain ROM in uninvolved joints. The Interventions were: Proper body positioning and alignment; PROM twice daily for 10 minutes per session; Splints: left hand roll. The Evaluation was: OT Screen performed. Limitation (severe) in head/neck. Both shoulders and elbows remain with no significant change since last admission. History of poor tolerance with head and neck collar. Continue goals and interventions. The physician's orders [REDACTED]. Wound observation was conducted with the Registered Nurse (RN) Unit Manager on the second floor nursing unit on 8/1/12 at 11:00 AM. The dressing had been removed prior to the observation. The wound on the mandible (chin) was observed to be approximately 2 cm red opened area surrounded by scar tissue. The RN was observed to set up for the treatment, cleanse the area with NS (normal saline), apply [MEDICATION NAME] powder and cover with calcium alginate dressing. The Assistant Director of Nursing (ADON), who is also responsible for conducting weekly wound rounds in the facility, was interviewed on 7/30/12 10:30 AM and stated that when she first saw the resident's wound on 4/4/12, the center of the wound was a stage II and the skin surrounding it was a SDTI. The resident's regular 7:00 AM-3:00 PM CNA who cared for the resident during March 2012 and April 2012 was interviewed on 7/30/12 at 12:50 PM and stated that she was the one who had first discovered the pressure ulcer when she noticed blood on the wash cloth she was using to clean under the resident's chin. The CNA stated that there is no place on the CNA Resident Care Profile/Accountability Record to document skin checks, but if she noticed a change in one of her residents' skin condition she would notify the Nurse as she did when she noticed the blood on the wash cloth that she was using to clean this resident. The CNA also stated that the resident's neck was always stiff and that prior to the development of the pressure ulcer under her chin she always placed a towel on the side of the resident's mouth because she drooled. The Director of OT was interviewed on 7/30/12 at 1:35 PM. The OT Director stated that the resident had [DIAGNOSES REDACTED] to her neck back in December when she was admitted and that was why she had ordered for her to wear a soft neck collar. The OT stated that she did not know why a physician's orders [REDACTED]. The OT stated that she had also told the Nurse on the unit to try to position the resident with pillows, but had never done a formal inservice with any of the staff on the unit. The OT also stated that she did not know why she had not put the resident on an OT program during February 2012 and March 2012 despite indicating partial loss in voluntary movement in the resident's neck on the readmission Rehabilitation Screening Forms dated 1/31/12 and 3/612 that she had completed. Partial loss in voluntary movement of the resident's neck indicates [DIAGNOSES REDACTED] and rigidity in the resident's neck. The OT stated that she did not write an order for [REDACTED]. The OT stated that the resident's neck tightness was so severe that she had to put the resident back on program on 4/3/12 to try and stretch the resident's neck muscles before she could issue the resident the head master collar. The resident was discharged from OT on 6/8/12 because her head could not accommodate the head master collar for pressure relief. The OT further stated that it was an oversight on her part to not obtain a physician's orders [REDACTED]. therapy on 6/8/12. The regular 8:00 AM-4:00 PM Licensed Practical Nurse (LPN) Medication Nurse was interviewed on 7/31/12 at 10:25 AM and stated that the resident always had a rigid neck. The LPN stated that prior to the development of the resident's mandible pressure ulcer, the resident usually had a towel or a washcloth by her face because she had a lot of secretions. The LPN remembered that the resident had a soft neck collar in December, but did not know when she stopped wearing it or why. The LPN also stated that it would be up to OT to decide when the resident needed a neck collar because they reassessed the resident every time she came back from the hospital. The Medical Director, who also does Wound Rounds in the facility every other week, was interviewed on 7/31/12 at 10:35 AM and stated that since admission the resident's neck was chronically contracted and the ROM was minimal. The Medical Director also stated that when he would see the resident on Wound Rounds there was a towel or a pillow in place by her neck. The Medical Director further stated that the pillow was not really under the resident's neck, but more on the side so she could not be suffocated by it. The Medical Director stated that the restriction in the resident's neck was so advanced that nothing would help it and that it was almost in a stuck position. The pressure ulcer was unavoidable because the contracture was too deep. The RN Unit Manager was interviewed on 7/31/12 at 12:25 PM and stated that the resident's neck was already contracted when she was admitted to the facility in December 2011. The RN stated that the CNAs tried to put a pillow on the side of the resident's neck to try and give it a little space and would also put a towel there because the resident would drool. The RN also stated that she could not recall the resident ever wearing a neck brace prior to the development of the mandible pressure ulcer in April 2012. The resident's Primary Physician was interviewed on 7/31/12 at 2:55 PM and stated that it was hard to get any flexibility in the resident's neck area with her contracted position and anything that the staff tried to use did not stay in place for long. The Primary Physician also stated that probably a thin towel rolled up could have been used as a barrier to prevent skin to skin contact while not hyperextending the resident's neck. The resident's Primary Physician further stated that the resident's neck was always like that since admission. The Director of Nursing (DON) was interviewed on 8/1/12 at 12:50 PM and stated she did not know that the resident's neck was that rigid. The DON also stated that the resident was supposed to have her soft (neck) collar from the time of admission, but there were no notes in the record when she had it. 415.12(c)(1)