Every finding on record at Menorah Home & Hospital For Aged & Infirm

Based on observation, record review, and interviews conducted during an abbreviated survey (625460), the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident for one (1) of two (2) residents (Resident #1) sampled for Injuries of Unknown Origin. Specifically, on 01/06/2024 at 5:45 AM, Resident #1 reported to Home Health Aide #1 that they had pain to their right hip. Resident #1 was assessed by Registered Nurse #1 at 8:23 AM and was observed with their right leg swollen and larger than the left. Resident #1 was transferred to the hospital at 10:25 AM and was diagnosed with an acute traumatic comminuted right femoral intertrochanteric fracture (a break in the thigh bone) with superior displacement of the femoral head (broken hip). There was a Physician's Order dated 12/08/2023 which documented one-to-one supervision for Resident #1 which was not provided on the night shift (10:00 PM - 6:00 AM) on 01/05/2024. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings include:The policy titled 'Fall Prevention Program' with a revision date of 08/17/2017 documented the facility and nursing care identifies risk factors relative to falls and provides adequate supervision and assistance devices to prevent falls or, where appropriate, to decrease injuries from falls. The facility and nursing care recognizes the individual resident's right to choose and to maintain their independence and balances falls prevention with those rights. The purpose is to provide guidelines for the clinical staff in the assessment and identification of resident risk factors, the protocols to follow for care planning and interventions, and the required documentation for each event. To ensure each resident receives care and services in an environment that promotes or maintains the residents highest practicable physical, mental, and psychosocial well-being. The facility did not have a policy on one-to-one supervision prior to the incident that occurred on 01/05/2024.The Policy titled 'Staffing Plan', dated 08/03/2023 documented to plan and provide sufficient staff with the appropriate competencies and skills to ensure that nursing care is provided 24 hours per day, seven (7) days per week. The staffing coordinator/designee reviews and reassigns staff according to unit activity at the beginning of each shift. Daily sick calls or other leave of absences in excess of scheduled margins are covered by part-time or per diem staff who are available for extra hours.Resident #1 was admitted to the facility with diagnoses including non-Alzheimer's dementia (group of symptoms affecting memory, thinking and social abilities that are not associated with Alzheimer's disease) , anxiety disorder, and respiratory failure. The Quarterly Minimum Data Set, (a resident assessment tool) dated 11/20/2023 documented Resident #1 had severe cognitive impairment, required substantial/maximal assistance to roll left and right in bed, and is dependent for transfer from chair/bed-to-chair.A Behavioral Monitoring Note by Licensed Practical Nurse #3 dated 08/09/2023 at 1:55 PM documented that Resident #1 had behaviors including restless and constantly up. Resident #1 was monitored through one-to-one staff supervision. A Behavioral Monitoring Note dated 09/14/2023 documented that Resident #1 had behaviors that include restlessness and continuously attempting to get up from their wheelchair.A Behavioral Monitoring Note dated 10/16/2023 documented that Resident #1 had behaviors including being fidgety, dangling their legs off the bed, and sleeping for short intervals throughout the night.A Falls Risk assessment dated [DATE] documented Resident #1 had a score of 39, denoting high risk for fall. A Psychiatry Progress Note by Psychiatrist #1 dated 12/04/2023 documented that Resident #1 had behaviors including agitation, restlessness, physical aggression towards staff, poor cognitive function, and impaired impulse control and judgement. Recommendations include considering Depakote sprinkles 125 milligram by mouth three (3) times a day, discontinue Valium. Support, reassurance, and redirection.A Fall Care plan dated 12/07/2023 documented interventions for one-to-one supervision due to periods of agitation, provide an obstacle-free and safe environment, and to keep the bed in the lowest position. A Physician's Order by Medical Doctor #2, dated 12/08/2023, documented one-to-one supervision. A Nursing Note by Licensed Practical Nurse #4 dated 01/05/2024 at 9:40 PM documented that Resident #1 had behaviors including periods of confusion and restlessness. Resident #1 was being monitored through one-to-one supervision. The Assignment Sheet dated 01/05/2024 from 10:00 PM to 6:00 AM (night shift) showed one (1) Licensed Practical Nurse, and two (2) Certified Nursing Assistants worked on Resident #1's unit. There was no documented evidence a staff member was assigned to provide one-to-one monitoring for Resident #1 during the 10:00 PM to 6:00 AM shift. The Facility Investigation Summary dated 01/06/2024 documented that Resident #1 was frequently restless and had a history of falls. It further documented that on 01/06/2024 at around 3:30 AM, Licensed Practical Nurse #1 observed Resident #1 awake in their room, holding on to the siderail with one leg off the bed as if they were attempting to get up. Licensed Practical Nurse #1 and Certified Nursing Assistant #1 transferred Resident #1 into their wheelchair and brought them to the nurse's station. Resident #1 remained at the nursing station until at approximately 5:45 AM on 01/06/2024, when Home Health Aide #1 arrived on the unit and was assigned to provide one-to-one supervision to Resident #1. Resident #1 then reported pain in their right leg to Home Health Aide #1. Home Health Aide #1 notified Licensed Practical Nurse #1 of Resident #1's reported pain, and Licensed Practical Nurse #1 instructed Home Health Aide #1 to wait until the next shift's nurse arrived to report the concern to that nurse. The Investigation Summary further documented that on 01/06/2024 at around 6:20 AM, Home Health Aide #1 reported Resident #1's right leg pain to Licensed Practical Nurse #2, who observed Resident #1 with swollen legs [SP1] and provided the resident with pain medication. On 01/06/2024 at around 6:30 AM, Home Health Aide #1 also notified Registered Nurse #1 of Resident #1's severe right leg pain. Registered Nurse #1 immediately assessed Resident #1 and noted Resident #1 to have a swollen right leg that was painful to the touch with limited range of motion. Registered Nursing Supervisor #1 and the on-call physician were then notified, and Resident #1 was transferred to the hospital for further evaluation. The facility concluded that Resident #1 could have fallen and gotten themself back onto the bed using the siderails. It is possible also that Resident #1 could have injured themself, but there is no definitive evidence. There is no reason to believe abuse, neglect, or mistreatment occurred. A History and Physical Medicine Note from the hospital, dated 01/06/2024 at 12:44 PM, documented that Resident #1 was transferred to the hospital with complaints of right hip pain. The resident was found to have an acute right hip fracture. Resident #1's family refused operative intervention. The Hospital Radiology Report dated 01/06/2024 documented Resident #1 had an acute traumatic comminuted right femoral intertrochanteric fracture with superior displacement of the femoral shaft with respect to the femoral head (broken hip). During an interview on 07/02/2025 at 11:46 AM, Home Health Aide #1 stated they regularly worked with Resident #1 providing one-to-one supervision. On 01/05/2024, they stated they provided one-to one supervision for Resident #1 from 2:00 PM to 10:00 PM. Home Health Aide #1 stated that Resident #1 was uncontrollable, was confused, tended to wander, and was difficult to redirect. Home Health Aide #1 stated that Resident #1 did not complain of pain during their 2:00 PM to 10:00 PM shift. Home Health Aide #1 stated at 10:00 PM they notified Licensed Practical Nurse #1 that their shift ended. Home Health Aide #1 stated they returned to the unit on 01/06/2024 at around 5:45 AM to start their new shift and observed Resident #1 sitting in a wheelchair by the nurse's station not wearing any shoes, with no wheelchair footrest, and a bruise on their right elbow. Home Health Aide #1 stated Resident #1 immediately reported to them that they had leg pain. Home Health Aide #1 stated they informed Licensed Practical Nurse #1 that Resident #1 was reporting severe leg pain, and that they were taking the resident to their room to apply the wheelchair footrest and put shoes on the resident's feet. Home Health Aide #1 also stated that Licensed Practical Nurse #1 told them that they did not want to hear anything about Resident #1 because Resident #1 had been giving the staff trouble all night by refusing to stay in bed. Home Health Aide #1 stated that they waited approximately 35 minutes for the next incoming shift to arrive and then reported the pain to the incoming Licensed Practical Nurse #2. Home Health Aide #1 stated that Certified Nursing Assistant #1 informed them that the one-to-one staff did not show up to monitor the resident for the overnight shift.In a subsequent interview on 07/31/2025 at 2:00 PM, Home Health Aide #1 stated that they waited with Resident #1 in their room on 01/06/2024, and when incoming Licensed Practical Nurse #2 came into the room they reported the pain. Home Health Aide #1 stated that they both transferred the resident to bed and Licensed Practical Nurse #2 checked the resident's hip/leg and they were swollen. Home Health Aide #1 stated that Resident #1 kept repeating dolor (pain in Spanish) and Registered Nurse #1 was called. Home Health Aide #1 stated that Resident #1 was not moaning or groaning, just repeating dolor. During an interview on 07/02/2025 at 1:20 PM, the Director of Nursing stated Resident #1 was not provided with one-to-one monitoring on 01/05/2024 on the night shift (10:00 PM to 6:00 AM) because the facility was understaffed on that shift. The Director of Nursing stated the staff on the unit were expected to round on Resident #1 every hour. The Director of Nursing stated they believed that at around 3:30 AM on 01/05/2024, Resident #1 may have gotten out of bed and fallen; was able to get themself back up, and was attempting to get back into bed when Licensed Practical Nurse #1 observed them while rounding. The Director of Nursing stated they believed it was possible Licensed Practical Nurse #1 assumed that Resident #1 was trying to get out of bed at the time, but that Resident #1 may have been trying to get back in bed after the fall. The Director of Nursing stated that Resident #1 was then transferred to the nurse's station (at 3:00 AM) for the remainder of the shift. The Director of Nursing stated that Resident #1 first notified Home Health Aide #1 of their pain at the start of the next shift (6:00 AM on 01/06/2024). The Director of Nursing stated it was wrong for Licensed Practical Nurse #1 to have not immediately checked on Resident #1 after being notified that they were in pain. The Director of Nursing stated it was Licensed Practical Nurse #1's responsibility to immediately check on Resident #1 and alert the supervisor of the concerns so the resident could be assessed. During a follow-up interview on 08/20/2025 at 12:27 PM, the Director of Nursing stated they do not have a one-to-one monitoring sheet. The one-to-one monitoring staff is documented on the unit assignment sheet. The Director of Nursing stated that three (3) Certified Nursing Assistants were scheduled to work on 01/05/2024 on the 10:00 PM to 6:00 AM shift (Resident #1's unit). However, several staff members did not show up for work and the facility was unable to find replacements. The Director of Nursing stated the facility has been experiencing staffing challenges. The Director of Nursing stated staff are aware that when there is a staffing issue, residents who are having sleeping or behavior problems should be brought to the nursing station for frequent monitoring. The Director of Nursing stated Resident #1 was consistently provided with one-to-one monitoring, except for 01/05/2024 on the 10:00 PM to 6:00 AM shift, when Resident #1 was not assigned a one-to-one. During an interview on 07/02/2025 at 1:44 PM, the Administrator stated that on 01/05/2024 on the night shift (10:00 PM to 6:00 AM), the facility was unable to provide enough staff members to allow for Resident #1 to receive one-to-one supervision. The Administrator stated it was inappropriate for Licensed Practical Nurse #1 to not immediately escalate Resident #1's report of pain to the Registered Nurse for assessment.During an interview on 07/03/2025 at 10:06 AM, Licensed Practical Nurse #1 stated that they could not recall why Resident #1 required one-to-one supervision, or why there was no one-to-one supervision on 01/05/2024 during the 10:00 PM to 6:00 AM shift, but that it was likely related to the facility being understaffed that night. Licensed Practical Nurse #1 stated that at around 3:30 AM on 01/06/2024, they were conducting monitoring on the unit and observed Resident #1 trying to get out of bed. Licensed Practical Nurse #1 stated that they and Certified Nursing Assistant #1 transferred Resident #1 into a wheelchair and took them to the nursing station. Licensed Practical Nurse #1 stated that Resident #1 remained at the nursing station from 3:30 AM to 6:00 AM under constant supervision and did not display or report any signs of pain or injury. Licensed Practical Nurse #1 stated at around 6:00 AM, Home Health Aide #1 reported to them that Resident #1 was in pain. Licensed Practical Nurse #1 stated that they did not check on Resident #1 after receiving the report because their shift was almost over. Licensed Practical Nurse #1 stated that they believed they told Home Health Aide #1 that they would report the concern to the incoming nurse. Licensed Practical Nurse #1 could not recall if they had reported to the incoming nurse. Licensed Practical Nurse #1 stated that they were informed of Resident #1's injury a few days after and that they were issued a verbal warning for failing to respond to Resident #1's reported pain in a timely manner. During a follow-up interview on 08/01/2025 at 2:00 PM, Licensed Practical Nurse #1 stated that they informed Registered Nursing Supervisor #1 on the 01/05/2024 2:00 PM to 10:00 PM shift (unsure of name) that they did not have a one-to-one staff for Resident #1. Licensed Practical Nurse #1 stated that they did not inform Registered Nursing Supervisor #2 who supervises the 10:00 PM to 6:00 AM shift that they never have a Home Health Aide to provide one-to-one supervision for Resident #1 on the 10:00 PM to 6:00 AM shift. During an interview on 07/03/2025 at 10:42 AM, Certified Nursing Assistant #1 stated that on 01/05/2024 during the 10:00 PM to 6:00 AM shift, there was no one-to-one staff member assigned to Resident #1. Certified Nursing Assistant #1 stated that the facility was understaffed, and they only had two (2) Certified Nursing Assistants working on the unit on 01/05/2024 during the 10:00 PM to 6:00 AM shift. Certified Nursing Assistant #1 stated that they and Licensed Practical Nurse #1 provided hourly monitoring to Resident #1 during the night shift. Certified Nursing Assistant #1 stated that Licensed Practical Nurse #1 noticed that Resident #1 was awake and asked them to assist with transferring the resident to the nurse's station for supervision. Certified Nursing Assistant #1 stated that they did not observe Resident #1 with any signs of pain or discomfort.During an interview on 07/03/2025 at 11:36 AM, Registered Nurse #1 stated that they do not recall the incident related to Resident #1's fracture. Registered Nurse #1 stated when they arrived on the unit on 01/06/2024 for their 6:00 AM to 2:00 PM shift, they were informed by Home Health Aide #1 that Resident #1 was complaining of pain. Registered Nurse #1 stated they immediately went to Resident #1 and performed a body assessment. Registered Nurse #1 stated Resident #1 was observed with right leg larger than the left leg and swelling to their right hip. Registered Nurse #1 stated they informed the medical doctor of their findings, who then ordered Resident #1 to be transferred to the hospital for evaluation. During an interview on 07/03/2025 at 12:13 PM, Medical Doctor #1 stated that on 01/06/2024, a nurse (unsure of name) notified them at approximately 6:35 AM, that Resident #1 was reporting leg pain. They assessed Resident #1 and observed that the resident's right hip was swollen, tender to the touch, and deformed, so they ordered for the resident to be transferred to the hospital for further evaluation. During an interview on 07/07/2025 at 4:30 PM, Medical Doctor #2 stated they had written a one-to-one supervision order (12/08/2023) for Resident #1 because the resident was a very high fall risk and had behaviors including constantly getting up due to being restless and being agitated. Medical Doctor #2 stated that they were not notified on 01/05/2024 that the one-to-one supervision would not be provided. Medical Doctor #2 stated that they believed Resident #1 had gotten out of bed and fallen, resulting in a fracture because the resident was left unsupervised overnight.During an interview on 08/01/2025 at 1:00 PM, Registered Nurse Supervisor #2 stated they worked from 10:00 PM to 6:00 AM on 01/05/2024. They stated the staffing schedule was done by Registered Nurse Supervisor #1. Registered Nurse Supervisor #2 stated they were not aware Resident #1's one-to-one Home Health Aide called out or that a staff was not assigned to provide one-to-one supervision on the 10:00 PM to 6:00 AM shift. Registered Nursing Supervisor #2 stated they made rounds on the unit on 01/06/2024 (unsure of time) and observed Resident #1 sitting at the nursing station, which was not uncommon. Registered Nursing Supervisor #2 stated they did not ask if Resident #1 had a one-to-one or review the staffing schedule. Registered Nurse Supervisor #2 stated they were not aware of any incident involving Resident #1 on 01/06/2024. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews conducted during an abbreviated survey (625460), the facility failed to ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for each resident. This was evident for one (1) of five (5) residents (Resident #1) sampled. Specifically, on 01/06/2024 at 5:45 AM, Resident #1 complained of pain to their right hip and was assessed by Registered Nurse #1 at 8:23 AM and was observed with swelling to their right leg that was larger than the left. Resident #1 was transferred to the hospital at 10:25 AM on 01/06/2024 and was diagnosed in the hospital with an acute traumatic comminuted right femoral intertrochanteric fracture (a break in the thigh bone) with superior displacement of the femoral head (broken hip). A review of the physician's order dated 12/08/2023, revealed Resident #1 had a physician's order for one-to-one supervision. A review of the Assignment Sheet dated 01/05/2024 for the 10:00 PM to 6:00 AM shift revealed Resident #1 did not have a one-to-one staff assigned to them on 01/05/2024 from 10:00 PM through 01/06/2024 at 5:45 AM. This resulted in actual harm that was not Immediate Jeopardy.The findings include:As per an interview with the Administrator on 11/03/2025 at 1:07 PM, the facility developed a one-to-one 'Observation' policy dated January 2024 after the incident on 01/06/2024. The facility policy titled, 'Staffing Plan,' dated 07/2020 states to plan and provide sufficient staff with the appropriate competencies and skills to ensure nursing care is provided 24-hours a day, seven (7) days per week. The facility policy titled, 'Facility Assessment,' dated 11/14/2023 documented the facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Individuals involved in the facility assessment process will include the administrator, a representative of the governing body, the medical director, the directors of nursing, and other department heads as needed.Resident #1 was admitted to the facility with diagnoses including non-Alzheimer's dementia (group of symptoms affecting memory, thinking and social abilities that are not associated with Alzheimer's disease), anxiety disorder, and respiratory failure. The Quarterly Minimum Data Set (a resident assessment tool) dated 11/20/2023, documented that Resident #1 had severe cognitive impairments. Resident #1 required substantial assistance rolling left and right in bed, and dependent level of assistance for transfers.A review of the Facility Assessment from 11/2023 to 11/2024, revealed a facility capacity of 436 residents with staffing plan by shift as follows: PAR level dated 01/05/2024 for 4-North day shift (6:00 AM - 2:00 PM) showed five (5) Certified Nursing Assistants plus one (1) Home Health Aide assigned/worked. Evening shift (2:00 PM - 10:00 PM) 4-North showed four (4) Certified Nursing Assistants plus one (1) Home Health Aide assigned/worked. Night shift (10:00 PM - 6:00 AM) 4-North showed three (3) Certified Nursing Assistants assigned and one no show. PAR level census showed 38 residents for 01/05/2024. A review of the daily 'Staffing Sheet' from 01/01/2024 to 01/05/2024, revealed that on 01/05/2024 facility had a census of 39 residents on Resident #1's unit (4-North) which had one (1) resident on one-to-one supervision (Resident #1). On 01/05/2024, the 6:00 AM - 2:00 PM shift showed five (5) Certified Nursing Assistants worked plus one (1) Home Health Aide assigned to provide one-to-one supervision. The 2:00 PM - 10:00 PM shift showed four (4) Certified Nursing Assistants worked. A line is drawn through the one-to-one Home Health Aide's name. The 10:00 PM - 6:00 AM shift showed two (2) Certified Nursing Assistants worked. A line is drawn through the Home Health Aide's name who was scheduled as one-to-one. The physician's order dated 12/08/2023 documented Resident #1 had an order for one-to-one supervision.A review of the physician's orders from 01/01/2024 to 01/30/2024 revealed five (5) residents in the facility had orders for one-to-one supervision. There was no documented evidence Resident #1 had a Home Health Aide or Certified Nursing Assistant assigned to provide one-to-one supervision from 01/05/2024 on the 10:00 PM - 6:00 AM shift (01/06/2024).The Facility Investigation Summary dated 01/06/2024 documented that Resident #1 was frequently restless and had a history of falls. It further documented that on 01/06/2024 at around 3:30 AM, Licensed Practical Nurse #1 observed Resident #1 awake in their room, holding onto the siderail with one (1) leg somewhat off the bed as if the resident was attempting to get up. Licensed Practical Nurse #1 and Certified Nursing Assistant #1 transferred Resident #1 into their wheelchair and brought them to the nurse's station. Resident #1 remained by the nursing station until approximately 5:45 AM when Home Health Aide #1 arrived on the unit and was assigned to provide one-to-one supervision for Resident #1. Resident #1 then reported pain in their right leg to Home Health Aide #1. Home Health Aide #1 notified Licensed Practical Nurse #1 of Resident #1's reported pain, and Licensed Practical Nurse #1 instructed Home Health Aide #1 to wait until the next shift's nurse arrived and to report the concern to that nurse. The Investigation Summary further documented that on 01/06/2024 at around 6:20 AM, Home Health Aide #1 reported Resident #1's right leg pain to Licensed Practical Nurse #2, who responded to Resident #1's room, noted Resident #1 with swollen leg, and provided Resident #1 with pain medication. On 01/06/2024 at around 6:30 AM, Home Health Aide #1 also notified Registered Nurse #1 of Resident #1's severe right leg pain. Registered Nurse #1 immediately assessed Resident #1 and noted Resident #1 to have a swollen right leg that was painful to the touch and had limited range of motion. Registered Nursing Supervisor #2 and the on-call physician were then notified, and Resident #1 was transferred to the hospital for further evaluation. A History and Physical Medicine note completed at the hospital dated 01/06/2024 at 12:44 PM, documented that Resident #1 was transferred to the hospital with complaints of right hip pain. In the emergency department, Resident #1 was found to have an acute right hip fracture.The Hospital Radiology Report dated 01/06/2024 documented that Resident #1 had an acute traumatic comminuted right femoral intertrochanteric fracture (a break in the thigh bone) with superior displacement of the femoral shaft with respect to the femoral head (broken hip).During an interview on 07/02/2025 at 11:46 AM, Home Health Aide #1 stated they regularly worked with Resident #1 providing one-to-one supervision. On 01/05/2024, they stated they provided one-to-one supervision for Resident #1 from 2:00 PM to 10:00 PM. Home Health Aide #1 stated that Resident #1 was uncontrollable, was confused, tended to wander, and was difficult to redirect. Home Health Aide #1 stated that Resident #1 did not complain of pain during their 2:00 PM to 10:00 PM shift. Home Health Aide #1 stated at 10:00 PM they notified Licensed Practical Nurse #1 that their shift ended. Home Health Aide #1 stated they returned to the unit on 01/06/2024 at around 5:45 AM to start their new shift and observed Resident #1 sitting in a wheelchair by the nurse's station not wearing any shoes, with no wheelchair footrest, and a bruise on their right elbow. Home Health Aide #1 stated Resident #1 immediately reported to them that they had leg pain. Home Health Aide #1 stated they informed Licensed Practical Nurse #1 that Resident #1 was reporting severe leg pain, and that they were taking the resident to their room to apply the wheelchair footrest and put shoes on the resident's feet. Home Health Aide #1 also stated that Licensed Practical Nurse #1 told them that they did not want to hear anything about Resident #1 because Resident #1 had been giving the staff trouble all night by refusing to stay in bed. Home Health Aide #1 stated that they waited approximately 35 minutes for the next incoming shift to arrive and then reported the pain to the incoming Licensed Practical Nurse #2. Home Health Aide #1 stated that Certified Nursing Assistant #1 informed them that the one-to-one staff did not show up to monitor the resident for the overnight shift.In a subsequent interview on 07/31/2025 at 2:00 PM, Home Health Aide #1 stated that they waited with Resident #1 in their room on 01/06/2024, and when incoming Licensed Practical Nurse #2 came into the room they reported the pain. Home Health Aide #1 stated that they both transferred the resident to bed and Licensed Practical Nurse #2 checked the resident's hip/leg were both swollen. Home Health Aide #1 stated that Resident #1 kept repeating dolor (pain in Spanish) and Registered Nurse #1 was called. Home Health Aide #1 stated that Resident #1 was not moaning or groaning, just repeating dolor (pain). During an interview on 07/03/2025 at 10:06 AM, Licensed Practical Nurse #1 stated that they could not recall why Resident #1 required one-to-one supervision, or why there was no one-to-one supervision on 01/05/2024 during the 10:00 PM to 6:00 AM shift, but that it was likely related to the facility being understaffed that night. Licensed Practical Nurse #1 stated that at around 3:30 AM on 01/06/2024, they were conducting monitoring on the unit and observed Resident #1 trying to get out of bed. Licensed Practical Nurse #1 stated that they and Certified Nursing Assistant #1 transferred Resident #1 into a wheelchair and took them to the nursing station. Licensed Practical Nurse #1 stated that Resident #1 remained at the nursing station from 3:30 AM to 6:00 AM under constant supervision and did not display or report any signs of pain or injury. Licensed Practical Nurse #1 stated at around 6:00 AM, Home Health Aide #1 reported to them that Resident #1 was in pain. Licensed Practical Nurse #1 stated that they did not check on Resident #1 after receiving the report because their shift was almost over. Licensed Practical Nurse #1 stated that they believed they told Home Health Aide #1 that they would report the concern to the incoming nurse. Licensed Practical Nurse #1 could not recall if they had reported to the incoming nurse. Licensed Practical Nurse #1 stated that they were informed of Resident #1's injury a few days after and that they were issued a verbal warning for failing to respond to Resident #1's reported pain in a timely manner. During an interview on 07/03/2025 at 10:42 AM, Certified Nursing Assistant #1 stated that on 01/05/2024 during the 10:00 PM to 6:00 AM shift, there was no one-to-one staff member assigned to Resident #1. Certified Nursing Assistant #1 stated that the facility was understaffed, and they only had two (2) certified nursing assistants working on the unit on 01/05/2024 during the 10:00 PM to 6:00 AM shift. Certified Nursing Assistant #1 stated that they and Licensed Practical Nurse #1 provided hourly monitoring to Resident #1 during the night shift. Certified Nursing Assistant #1 stated that Licensed Practical Nurse #1 noticed that Resident #1 was awake and asked them to assist with transferring the resident to the nurse's station for supervision. Certified Nursing Assistant #1 stated that they did not observe Resident #1 with any signs of pain or discomfort.During an interview on 07/02/2025 at 1:20 PM, the Director of Nursing stated Resident #1 was not provided with one-to-one monitoring on 01/05/2024 on the night shift (10:00 PM to 6:00 AM) because the facility was understaffed on that shift. The Director of Nursing stated the staff on the unit were expected to round on Resident #1 every hour. The Director of Nursing stated they believed that at around 3:30 AM on 01/05/2024, Resident #1 may have gotten out of bed and fallen; was able to get themself back up, and was attempting to get back into bed when Licensed Practical Nurse #1 observed them while rounding. The Director of Nursing stated they believed it was possible Licensed Practical Nurse #1 assumed that Resident #1 was trying to get out of bed at the time, but that Resident #1 may have been trying to get back in bed after the fall. The Director of Nursing stated that Resident #1 was then transferred to the nurse's station (at 3:00 AM) for the remainder of the shift. The Director of Nursing stated that Resident #1 first notified Home Health Aide #1 of their pain at the start of the next shift (6:00 AM on 01/06/2024). The Director of Nursing stated it was wrong for Licensed Practical Nurse #1 to have not immediately checked on Resident #1 after being notified that they were in pain. The Director of Nursing stated it was Licensed Practical Nurse #1's responsibility to immediately check on Resident #1 and alert the supervisor of the concerns so the resident could be assessed. During a follow-up interview on 08/20/2025 at 12:27 PM, the Director of Nursing stated they do not have a one-to-one monitoring sheet. The one-to-one monitoring staff is documented on the unit assignment sheet. The Director of Nursing stated that three (3) certified nursing assistants were scheduled to work on 01/05/2024 on the 10:00 PM to 6:00 AM shift (Resident #1's unit). However, several staff members did not show up for work and the facility was unable to find replacements. The Director of Nursing stated the facility has been experiencing staffing challenges. The Director of Nursing stated staff are aware that when there is staffing issue, residents who are having sleeping or behavior problems should be brought to the nursing station for frequent monitoring. The Director of Nursing stated Resident #1 was consistently provided with one-to-one monitoring, except for 01/05/2024 on the 10:00 PM to 6:00 AM shift, when Resident #1 was not assigned a one-to-one. During an interview on 07/02/2025 at 1:44 PM, the Administrator stated that on 01/05/2024 on the night shift (10:00 PM to 6:00 AM), the facility was unable to provide enough staff members to allow for Resident #1 to receive one-to-one supervision. The Administrator stated it was inappropriate for Licensed Practical Nurse #1 to not immediately escalate Resident #1's report of pain to the Registered Nurse for assessment.During an interview on 07/07/2025 at 4:30 PM, Medical Doctor #2 stated they had written a one-to-one supervision order (12/08/2023) for Resident #1 because the resident was a very high fall risk and had behaviors including constantly getting up due to being restless and being agitated. Medical Doctor #2 stated that they were not notified on 01/05/2024 that one-to-one supervision would not be provided. Medical Doctor #2 stated that they believed Resident #1 had gotten out of bed and fallen, resulting in a fracture because the resident was left unsupervised overnight.During an interview on 11/02/2025 at 1:36 PM, the President of the Resident Council stated that some of the residents voiced concerns about having three (3) certified nursing assistants on the weekend (morning shift) instead of five (5). The President of the Resident council stated that the residents did not voice any complaints about not receiving care, but that care took a litter longer than normal. The President of the Resident Council stated the facility has made efforts to correct the staffing issue and it has gotten better. The President of the Resident Council stated when a staff member calls out, the facility either floats someone or brings in agency staff. The President of the Resident Council stated that the night shift usually has two (2) to three (3) Certified Nursing Assistants, but they work well together to get the work done. During an interview on 11/02/2025 at 1:58 PM, the Chairman of the Board stated they have Quarterly board meetings where all the board members attended. The Chairman of the Board stated they also have four quality care meeting involving the different disciplines and the medical director who is also physician. The Chairman of the Board stated the administrator would contact them directly and discuss day-to-day activities in the facility. The Chairman of the Board stated they are not aware of any ongoing staffing issues. The Chairman of the Board stated that staff members may call out sometimes but not consistently. The Chairman of the Board stated the facility works with agencies to help with staffing.10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews conducted during an abbreviated survey (625460), the facility failed to ensure a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility did not consider specific staffing needs for each resident and adjust as necessary based on any changes to its resident population. This was evident during review of Staffing from 01/01/2024 - 01/06/2024. Specifically, on 01/06/2024 at 5:45 AM, Resident #1 complained of pain to their right hip and was assessed by Registered Nurse #1 at 8:23 AM and was observed with swelling to their right leg that was larger than the left. Resident #1 was transferred to the hospital at 10:25 AM on 01/06/2024 and was diagnosed with an acute traumatic comminuted right femoral intertrochanteric fracture (a break in the thigh bone) with superior displacement of the femoral head (broken hip). Resident #1 had a physician's order dated 12/08/2023 documenting one-to-one supervision was required. The Assignment Sheet dated 01/05/2024 for the 10:00 PM to 6:00 AM shift, revealed no documented evidence a staff was assigned to provide one-to-one supervision to Resident #1. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.The findings are:The Facility Assessment from 11/2023 to 11/2024 documented the facility has 436 resident beds with an average of 422 beds cumulative and average census 96.74 percentage. Long Term Beds 311 and Subacute Beds 125. Average staff numbers required Licensed nurses providing direct care 124, Certified Nurse Aides 244 and Home Health Aides 9. Department Heads create assignments for their staff based on acuity (Sub-acute and Long Term), staff skills and physical location. Clinical staff have consistent assignments and coverage plans are in place. Staff are floated on an as necessary basis based on status and seniority. Efforts are made to ensure the staff are as consistent as possible.A review of the Facility Assessment from 11/2023 to 11/2024, revealed a facility capacity of 436 residents staffing plan by shift as follows: PAR level dated 01/05/2024 for 4-North day shift (6:00 AM - 2:00 PM) five (5) Certified Nursing Assistants plus one (1) Home Health Aide assigned/worked. Evening shift (2:00 PM - 10:00 PM) four (4) Certified Nursing Assistants plus one (1) Home Health Aide assigned/worked. Night shift (10:00 PM - 6:00 AM) showed three (3) assigned and one (1) no show. PAR level census showed 38 residents for 01/05/2024.A review of the daily 'Staffing Sheet' from 01/01/2024 to 01/05/2024, revealed that on 01/05/2024 facility had a census of 39 residents on Resident #1's unit (4-North) which had one (1) resident on one-to-one supervision (Resident #1). On 01/05/2024, the 6:00 AM - 2:00 PM shift showed five (5) Certified Nursing Assistants worked plus one (1) Home Health Aide assigned to provide one-to-one supervision. The 2:00 PM - 10:00 PM shift showed four (4) Certified Nursing Assistants worked. A line is drawn through the one-to-one Home Health Aide's name. The 10:00 PM - 6:00 AM shift showed two (2) Certified Nursing Assistants worked. A line is drawn through the Home Health Aide's name who was scheduled as one-to-one. Resident #1 was admitted to the facility with diagnoses including non-Alzheimer's dementia (refers to conditions like vascular dementia), anxiety disorder, and respiratory failure.The Quarterly Minimum Data Set (a resident assessment tool) dated 11/20/2023, documented that Resident #1 had severe cognitive impairments. Resident #1 required substantial assistance rolling left and right in bed, and dependent level of assistance for transfers.The Physician's Order dated 12/08/2023, revealed Resident #1 had an order for one-to-one supervision.A review of the physician's orders from 01/01/2024 to 01/30/2024, revealed five (5) residents in the facility had orders for one-to-one supervision. There was no documented evidence Resident #1 had a Home Health Aide or Certified Nursing Assistant assigned to provide one-to-one supervision on 01/05/2024 on the 10:00 PM - 6:00 AM shift (01/06/2024.)During an interview on 07/03/2025 at 10:42 AM, Certified Nursing Assistant #1 stated that on 01/05/2024 during the 10:00 PM to 6:00 AM shift, there was no one-to-one staff member assigned to Resident #1. Certified Nursing Assistant #1 stated the facility was understaffed, and they only had two (2) certified nursing assistants working on the unit on 01/05/2024 during the 10:00 PM to 6:00 AM shift. Certified Nursing Assistant #1 stated that they and Licensed Practical Nurse #1 provided hourly monitoring to Resident #1 during the night shift. Certified Nursing Assistant #1 stated that Licensed Practical Nurse #1 noticed that Resident #1 was awake and asked them to assist with transferring the resident to the nurse's station for supervision.During an interview on 07/02/2025 at 1:20 PM, the Director of Nursing stated Resident #1 was not provided with one-to-one supervision on 01/05/2024 on the night shift (10:00 PM to 6:00 AM) because the facility was understaffed on that shift. The Director of Nursing stated the staff on the unit were expected to round on Resident #1 every hour. The Director of Nursing stated they believed that at around 3:30 AM on 01/05/2024, Resident #1 may have gotten out of bed and fallen; was able to get themself back up and was attempting to get back into bed when Licensed Practical Nurse #1 observed them while rounding. The Director of Nursing stated they believed it was possible Licensed Practical Nurse #1 assumed that Resident #1 was trying to get out of bed at the time, but that Resident #1 may have been trying to get back in bed after the fall. The Director of Nursing stated that Resident #1 was then transferred to the nurse's station (at 3:00 AM) for the remainder of the shift. The Director of Nursing stated that Resident #1 first notified Home Health Aide #1 of their pain at the start of the next shift (6:00 AM on 01/06/2024). The Director of Nursing stated it was wrong for Licensed Practical Nurse #1 to have not immediately checked on Resident #1 after being notified that they were in pain. The Director of Nursing stated it was Licensed Practical Nurse #1's responsibility to immediately check on Resident #1 and alert the supervisor of the concerns so the resident could be assessed. During a follow-up interview on 08/20/2025 at 12:27 PM, the Director of Nursing stated they do not have a one-to-one supervision sheet. The one-to-one supervision staff is documented on the unit assignment sheet. The Director of Nursing stated that three (3) certified nursing assistants were scheduled to work on 01/05/2024 on the 10:00 PM to 6:00 AM shift on Resident #1's unit. However, several staff members did not show up for work and the facility was unable to find replacements. The Director of Nursing stated the facility has been experiencing staffing challenges. The Director of Nursing stated staff are aware that when there is a staffing issue, residents who are having sleeping or behavior problems should be brought to the nursing station for frequent monitoring. The Director of Nursing stated Resident #1 was consistently provided with one-to-one supervision, except for 01/05/2024 on the 10:00 PM to 6:00 AM shift, when Resident #1 was not assigned a one-to-one staff.During an interview on 07/02/2025 at 1:44 PM, the Administrator stated that on 01/05/2024 on the night shift (10:00 PM to 6:00 AM), the facility was unable to provide enough staff members to allow for Resident #1 to receive one-to-one supervision.During a follow-up interview on 11/24/2025 at 3:30 PM, the Administrator stated the Facility Assessment is done by the interdisciplinary team to determine the staffing and equipment necessary to adequately serve residents. The Administrator stated the Facility Assessment staffing plan included nurse staffing par levels reflective of actual numbers of staff and residents' acuity required to provide day-to-day care to residents. The Administrator stated the facility worked with a third-party staffing agency to meet their par levels and address staffing shortages in their schedule.During an interview on 07/07/2025 at 4:30 PM, Medical Doctor #2 stated they had written a one-to-one supervision order (12/08/2023) for Resident #1 because the resident was a very high fall risk and had behaviors including constantly getting up due to being restless and being agitated. Medical Doctor #2 stated that they were not notified on 01/05/2024 that one-to-one supervision would not be provided. Medical Doctor #2 stated that they believed Resident #1 had gotten out of bed and fallen, resulting in a fracture because the resident was left unsupervised overnight. 10 NYCRR 415.26

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00331104), the facility failed to ensure pain management was provided to a resident who requires such services, consistent with professional standards of practices, the comprehensive person-centered care plan, and the residents' choices. This was evident in one (1) of two (2) residents (Resident #1) sampled. Specifically, on 01/06/2024 at 5:45 AM, Resident #1 reported to Home Health Aide #1 that they had pain to their right hip. Home Health Aide #1 reported the pain to Licensed Practical Nurse #1 who instructed them to wait for the incoming shift. Licensed Practical Nurse #1 did not immediately check on Resident #1 and the resident was not immediately assessed by a Registered Nurse. Tylenol 650 milligrams were administered to the resident by incoming Licensed Practical Nurse #2 at 6:25 AM, 40 minutes after they complained of pain. Resident #1 was assessed by Registered Nurse #1 at 8:23 AM and observed with swelling to their right leg that was larger than the left. Resident #1 was transferred to the hospital at 10:25 AM on 01/06/2024 and was diagnosed in the hospital with an acute traumatic comminuted right femoral intertrochanteric fracture (a break in the thigh bone) with superior displacement of the femoral head (broken hip). The findings include:The policy titled 'Pain Management', dated 07/30/2023 documented all residents have the right to an accurate assessment and appropriate management of their pain. All residents are assessed for the presence of pain and the adequacy of pain-relieving strategies upon admission and on a regular basis. Personal, spiritual, cultural and ethnic beliefs of residents, family and staff are considered in the management of pain as well as non-pharmacologic treatment. Resident #1 was admitted to the facility with diagnoses including non-Alzheimer's dementia (group of symptoms affecting memory, thinking and social abilities that are not associated with Alzheimer's disease) , anxiety disorder, and respiratory failure. The Quarterly Minimum Data Set, (a resident assessment tool) dated 11/20/2023 documented Resident #1 had severe cognitive impairment, required substantial/maximal assistance to roll left and right in bed, and is dependent for transfer from chair/bed-to-chair.A care plan titled Pain dated 11/06/2023, documented interventions to evaluate for the presence of pain, determine the frequency of pain and to provide medical management of underlying cause. The Facility Investigation Summary dated 01/06/2024 documented that Resident #1 was frequently restless and had a history of falls. It further documented that on 01/06/2024 at around 3:30 AM, Licensed Practical Nurse #1 observed Resident #1 awake in their room, holding on to the siderail with one leg off the bed as if they were attempting to get up. Licensed Practical Nurse #1 and Certified Nursing Assistant #1 transferred Resident #1 into their wheelchair and brought them to the nurse's station. Resident #1 remained at the nursing station until at approximately 5:45 AM on 01/06/2024, when Home Health Aide #1 arrived on the unit and was assigned to provide one-to-one supervision to Resident #1. Resident #1 then reported pain in their right leg to Home Health Aide #1. Home Health Aide #1 notified Licensed Practical Nurse #1 of Resident #1's reported pain, and Licensed Practical Nurse #1 instructed Home Health Aide #1 to wait until the next shift's nurse arrived to report the concern to that nurse. The Investigation Summary further documented that on 01/06/2024 at around 6:20 AM, Home Health Aide #1 reported Resident #1's right leg pain to Licensed Practical Nurse #2, who observed Resident #1 with swollen legs and provided the resident with pain medication. On 01/06/2024 at around 6:30 AM, Home Health Aide #1 also notified Registered Nurse #1 of Resident #1's severe right leg pain. Registered Nurse #1 immediately assessed Resident #1 and noted Resident #1 to have a swollen right leg that was painful to the touch with limited range of motion. Registered Nursing Supervisor #1 and the on-call physician were then notified, and Resident #1 was transferred to the hospital for further evaluation. The facility concluded that Resident #1 could have fallen and gotten themself back onto the bed using the siderails. It is possible also that Resident #1 could have injured themself, but there is no definitive evidence. There is no reason to believe abuse, neglect, or mistreatment occurred.There was no documented evidence of any interventions being implemented by Licensed Practical Nurse #1 when they first became aware of Resident #1's complaint of pain. A Medication Administration Record for 01/06/2024 documented that Resident #1 received Tylenol 650 milligrams orally for pain at 6:25 AM on 01/06/2024.A nursing progress note dated 01/06/2024 at 8:23 AM by Registered Nurse #1, documented Resident #1's family was informed of resident complaining of severe pain to right leg. Upon assessing the resident, resident's right leg was noted larger than the left leg, noted with swelling to right hip, resident unable to move right leg on their own. When right leg was moved, the resident complained of severe pain. The note documented that the resident was unable to apply weight to right leg. The resident was also noted with an open senile purpura (reddish-brown bruises on the skin of older adults) 0.5 x 0.5 centimeter to the right elbow. Tylenol was administered for pain. The medical doctor was notified and order x-ray and transfer to the hospital. A History and Physical Medicine Note from the hospital, dated 01/06/2024 at 12:44 PM, documented that Resident #1 was transferred to the hospital with complaints of right hip pain. The resident was found to have an acute right hip fracture. Resident #1's family refused operative intervention. The Hospital Radiology Report dated 01/06/2024 documented Resident #1 had an acute traumatic comminuted right femoral intertrochanteric fracture with superior displacement of the femoral shaft with respect to the femoral head (broken hip).Nursing progress note dated 01/09/2024 at 3:55 AM by Registered Nurse #2, documented that Resident #1 returned to the facility from the hospital on 1/09/2024 at 10:33 PM by Emergency Medical transportation. The resident was readmitted with the primary diagnosis of right hip fracture. During an interview on 07/02/2025 at 11:46 AM, Home Health Aide #1 stated they regularly worked with Resident #1 providing one-to-one supervision. On 01/05/2024, they stated they provided one-to one supervision for Resident #1 from 2:00 PM to 10:00 PM. Home Health Aide #1 stated that Resident #1 was uncontrollable, was confused, tended to wander, and was difficult to redirect. Home Health Aide #1 stated that Resident #1 did not complain of pain during their 2:00 PM to 10:00 PM shift. Home Health Aide #1 stated at 10:00 PM they notified Licensed Practical Nurse #1 that their shift ended. Home Health Aide #1 stated they returned to the unit on 01/06/2024 at around 5:45 AM to start their new shift and observed Resident #1 sitting in a wheelchair by the nurse's station not wearing any shoes, with no wheelchair footrest, and a bruise on their right elbow. Home Health Aide #1 stated Resident #1 immediately reported to them that they had leg pain. Home Health Aide #1 stated they informed Licensed Practical Nurse #1 that Resident #1 was reporting severe leg pain, and that they were taking the resident to their room to apply the wheelchair footrest and put shoes on the resident's feet. Home Health Aide #1 also stated that Licensed Practical Nurse #1 told them that they did not want to hear anything about Resident #1 because Resident #1 had been giving the staff trouble all night by refusing to stay in bed. Home Health Aide #1 stated that they waited approximately 35 minutes for the next incoming shift to arrive and then reported the pain to the incoming Licensed Practical Nurse #2. Home Health Aide #1 stated that Certified Nursing Assistant #1 informed them that the one-to-one staff did not show up to monitor the resident for the overnight shift.In a subsequent interview on 07/31/2025 at 2:00 PM, Home Health Aide #1 stated that they waited with Resident #1 in their room on 01/06/2024, and when incoming Licensed Practical Nurse #2 came into the room they reported the pain. Home Health Aide #1 stated that they both transferred the resident to bed and Licensed Practical Nurse #2 checked the resident's hip/leg and they were swollen. Home Health Aide #1 stated that Resident #1 kept repeating dolor (pain in Spanish) and Registered Nurse #1 was called. Home Health Aide #1 stated that Resident #1 was not moaning or groaning, just repeating dolor.During an interview on 07/02/2025 at 1:20 PM, the Director of Nursing stated Resident #1 was not provided with one-to-one monitoring on 01/05/2024 on the night shift (10:00 PM to 6:00 AM) because the facility was understaffed on that shift. The Director of Nursing stated the staff on the unit were expected to round on Resident #1 every hour. The Director of Nursing stated they believed that at around 3:30 AM on 01/05/2024, Resident #1 may have gotten out of bed and fallen; was able to get themself back up, and was attempting to get back into bed when Licensed Practical Nurse #1 observed them while rounding. The Director of Nursing stated they believed it was possible Licensed Practical Nurse #1 assumed that Resident #1 was trying to get out of bed at the time, but that Resident #1 may have been trying to get back in bed after the fall. The Director of Nursing stated that Resident #1 was then transferred to the nurse's station (at 3:00 AM) for the remainder of the shift. The Director of Nursing stated that Resident #1 first notified Home Health Aide #1 of their pain at the start of the next shift (6:00 AM on 01/06/2024). The Director of Nursing stated it was wrong for Licensed Practical Nurse #1 to have not immediately checked on Resident #1 after being notified that they were in pain. The Director of Nursing stated it was Licensed Practical Nurse #1's responsibility to immediately check on Resident #1 and alert the supervisor of the concerns so the resident could be assessed. During an interview on 07/03/2025 at 10:06 AM, Licensed Practical Nurse #1 stated that they could not recall why Resident #1 required one-to-one supervision, or why there was no one-to-one supervision on 01/05/2024 during the 10:00 PM to 6:00 AM shift, but that it was likely related to the facility being understaffed that night. Licensed Practical Nurse #1 stated that at around 3:30 AM on 01/06/2024, they were conducting monitoring on the unit and observed Resident #1 trying to get out of bed. Licensed Practical Nurse #1 stated that they and Certified Nursing Assistant #1 transferred Resident #1 into a wheelchair and took them to the nursing station. Licensed Practical Nurse #1 stated that Resident #1 remained at the nursing station from 3:30 AM to 6:00 AM under constant supervision and did not display or report any signs of pain or injury. Licensed Practical Nurse #1 stated at around 6:00 AM, Home Health Aide #1 reported to them that Resident #1 was in pain. Licensed Practical Nurse #1 stated that they did not check on Resident #1 after receiving the report because their shift was almost over. Licensed Practical Nurse #1 stated that they believed they told Home Health Aide #1 that they would report the concern to the incoming nurse. Licensed Practical Nurse #1 could not recall if they had reported to the incoming nurse. Licensed Practical Nurse #1 stated that they were informed of Resident #1's injury a few days after and that they were issued a verbal warning for failing to respond to Resident #1's reported pain in a timely manner. During an interview on 07/03/2025 at 10:42 AM, Certified Nursing Assistant #1 stated that on 01/05/2024 during the 10:00 PM to 6:00 AM shift, there was no one-to-one staff member assigned to Resident #1. Certified Nursing Assistant #1 stated that the facility was understaffed, and they only had two (2) Certified Nursing Assistants working on the unit on 01/05/2024 during the 10:00 PM to 6:00 AM shift. Certified Nursing Assistant #1 stated that they and Licensed Practical Nurse #1 provided hourly monitoring to Resident #1 during the night shift. Certified Nursing Assistant #1 stated that Licensed Practical Nurse #1 noticed that Resident #1 was awake and asked them to assist with transferring the resident to the nurse's station for supervision. Certified Nursing Assistant #1 stated that they did not observe Resident #1 with any signs of pain or discomfort.During an interview on 07/02/2025 at 1:44 PM, the Administrator stated that it was inappropriate for Licensed Practical Nurse #1 not to immediately escalate Resident #1's report of pain to the Registered Nurse for further assessment. The Administrator stated that Licensed Practical Nurse #1 was in-serviced on prompt reporting following the incident.During an interview on 07/03/2025 at 12:13 PM, Medical Doctor #1 stated that on 01/06/2024 a nurse (unsure of name) notified them at 6:35 AM that Resident #1 was reporting leg pain. They assessed Resident #1 (unsure of time) and observed that their right hip was swollen, tender to the touch, and deformed, so they ordered for the resident to be transferred to the hospital for further evaluation. During an interview on 08/01/2025 at 1:00 PM, Registered Nursing Supervisor #1 stated that they worked on the 10:00 PM to 6:00 AM shift on 01/05/2024 and was not aware of any incidents concerning Resident #1. 10 NYCRR 415.12 [

Based on observation, record review, and interviews during an abbreviated survey (NY 00328412), the facility did not ensure that all residents received the necessary care to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This was evident in two out of three residents sampled (Resident #1 and Resident #2). Specifically, on 11/16/2023, Resident #1 reported to Registered Nurse Supervisor #1 they requested pain medication at 7:30 PM and did not receive it. Resident #2 informed Registered Nurse Supervisor #1 they received some medication at 5:00 PM on 11/16/2023 but did not receive the blue tablet (sleeping medication). In both instances, the narcotic logbook documented the medications were dispensed, but there was no documentation that the medications were administered on the electronic medication administration record. All residents were assessed and there were no adverse reactions. The facility took immediate corrective actions and was found to be in substantial compliance on 11/17/2023 at 9:00 AM prior to the Surveyor's onsite visit on 07/15/2024 at 9:00 AM. This resulted in Past Noncompliance with no potential for serious harm. The findings include: The facility's policy and procedure on Medication Administration-General Procedure dated 08/07/2022, documented medications will be administered following standard procedures and infection control policies. The policy further documented the Licensed Nurse's responsibility are to administer the medication and remain with the resident until it is swallowed and document the medication administration immediately after administration on the electronic medication administration record. Resident #1 was admitted to the facility with diagnoses including Hypertension, Diabetes Mellitus, Hyponatremia, and Malignant Neoplasm. The Minimum Data Set (an assessment tool), dated 01/07/2023, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 12 associated with moderately impaired cognition. Risk for victimization care plan dated 11/03/2023, included intervention to anticipate resident's needs and explain all procedures. Resident #2 was admitted to the facility with diagnoses including Hypertension (high blood pressure), and Fracture. The Minimum Data Set (an assessment tool), dated 11/03/2023, documented Resident #2 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 13 associated with intact cognition. Risk for victimization care plan dated 10/31/2023, included intervention to anticipate Resident #2's needs. The facility's investigation dated 12/15/2023 documented Registered Nurse Supervisor #1 informed Director of Nursing on 11/17/2023 at 12:34 AM, Resident #1 and Resident #2 reported they did not receive their medications. While investigating the above incident, other affected residents were identified with medication not administered. The facility concluded Licensed Practical Nurse #1 did not administer the medications to multiple assigned residents. Based on the investigation and resident's statements, narcotic diversion could not be excluded. Licensed Practical Nurse #1 was terminated. During an interview on 07/15/2024 at 5:48 PM, Director of Nursing stated two residents (Resident #1 and #2), complained of not receiving their medications and investigation was initiated. Director of Nursing stated an audit of other residents were done after the complaints were made and the Medication Administration Record reveal that the medications were not electronically signed. The Director of Nursing stated Licensed Practical Nurse #1 dispensed the narcotics as the count was accurate but Resident #1 and Resident #2 reported they did not receive it and the electronic record was not signed. During a telephone interview on 10/22/2024 at 10:15 AM, Registered Nurse Supervisor #1 stated they were called by Licensed Practical Nurse #3 (night shift) to the unit about Resident #1's complaint of not receiving their sleeping medication. Registered Nurse Supervisor #1 stated it was a little before midnight when they responded to the unit and Resident #2 had also made the same complaint about not receiving pain medication. Registered Nurse Supervisor #1 stated the residents were describing the medication by color. They checked the narcotic record log and observed that Licensed Practical Nurse #1 signed the medication out, the count was accurate, however, Licensed Practical Nurse #1 did not sign the electronic medication administration record to indicate they administered the medication. Registered Nurse Supervisor #1 stated they called Licensed Practical Nurse #1 to inquire about Resident #1 and #2's complaint of not receiving their medication and they stated, all medications were administered to the residents. Registered Nurse Supervisor #1 stated they checked the electronic medication administration record system, and observed many medications were not documented for other residents. Registered Nurse Supervisor #1 stated they called and inform the Director of Nursing and the Medical Doctor Based on the following corrective actions taken, there were sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to this survey. A Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to be in substantial compliance on 11/17/2023 at 9:00 AM prior to the Surveyor's onsite visit on 07/15/2024 at 9:00 AM. Facility started in-service on 11/17/2023 and completed in-services for all Nurses. Lesson plan included the six medication rights, compliance, and narcotic administration. All residents were assessed and there were no adverse reactions. Audit of other residents' medical records done and there was no adverse reaction for missing medications. 94% of Licensed Practical and Registered Nurses were in-serviced on Medication Administration. Licensed Practical Nurse #1 was terminated and reported to the Department of Health, New York City Police Department, the Bureau of Narcotic Enforcement and Office of Professions. Quality Assurance and Performance Improvement meeting was conducted 11/20/2023, addressing medication administration error audit results and ongoing audits. During interviews four License Practical Nurses and three Registered Nurses, stated understanding of the six medication rights, medication compliance, and narcotic administration. They were knowledgeable of the medication administration policy and the importance of documentation. 10 NYCRR 415.12

Based on observation, record review, and interviews during an abbreviated survey (NY00320606), the facility failed to protect a resident's right to be free from physical abuse by a nursing home staff. This was evident in one out of three residents sampled for abuse (Resident #1). Specifically, on 07/22/2023 at approximately 8:50 PM, Resident #1 told Registered Nurse #1 that Certified Nursing Assistant #1 threw them in the bed from the wheelchair and they hit their head on the headboard. Resident #1 was assessed by Registered Nurse #1 and there were no visible injuries. This resulted in Past Noncompliance with no potential for serious harm. The findings include: The facility's policy and procedure on Abuse Prohibition dated 10/24/2022, documented the facility shall not use or permit verbal, mental, sexual, or physical abuse, including corporal punishment and involuntary seclusion of residents/patients, misappropriation of resident property, exploitation or other mistreatment or neglect. It also stated, the facility will report no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or results in serious body injury. Resident #1 was admitted to the facility on [DATE], with diagnoses of Dementia, Depression, Cancer of stomach and kidney. The Minimum Data Set (an assessment tool), dated 06/25/2023, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of three associated with severe impaired cognition. The Facility's investigation dated 07/22/2023, documented Resident #1 requested to go to the bathroom because they were wet. Certified Nursing Assistant #1 toileted them and when returning them back to the bed, Certified Nursing Assistant #1 threw them in the bed from the wheelchair and they hit their head on the headboard. Resident #1 reported to Registered Nursing Supervisor #1 that when they asked Certified Nursing Assistant #1 why you hit them, Certified Nursing Assistant #1 replied you hit yourself. A Risk for Victimization Care Plan dated 06/22/2023, with interventions to anticipate resident's needs, to approach calmly, speak slowly clearly and allow resident to guide activities to the extent capable. A Nursing Progress Note dated 07/22/2023 at 10:30 PM, written by Registered Nurse #1 documented at approximately 8:50 PM, Registered Nurse #1 called to report that Resident #1 stated they were transferred to the bed roughly by Certified Nursing Assistant #1. Registered Nurse #1 interviewed Resident #1 and they stated that when Certified Nursing Assistant #1 placed them in the bed after toileting, Certified Nursing Assistant #1 placed them in the bed in a rough manner and they hit their head on the headboard. A head-to-toe assessment of Resident #1 revealed no visible injuries. A Physician's progress note dated 07/23/2023 at 9:51 AM, documented Resident #1 was seen Resident #1 was awake, alert, verbally responsive. Denied pain. Resident #1 had no visible signs of injury. Certified Nursing Assistant #1 provided a written statement to the facility dated 07/22/2023, documented that they were working on the morning shift and was assigned to Resident #1. Certified Nursing Assistant #1 documented that Registered Nurse #1 informed them that Resident #1 wanted to use the bathroom. Certified Nursing Assistant #1 documented that they went to Resident #1's room and assisted Resident #1 to the bathroom. Certified Nursing Assistant #1 documented that they assisted Resident #1 in the bathroom and after Resident #1 was finished using the bathroom they provide care to Resident #1, then assisted Resident #1 back to their bed. Certified Nursing Assistant #1 documented Resident #1 sat on the edge of the bed, and they lift Resident #1 feet in the bed. During an interview on 10/25/2024 at 3:20 PM, Registered Nursing #1 stated that on 07/22/2023 at 11:20 AM, they responded to Resident #1's call bell and Resident #1 requested to go to the bathroom. Registered Nursing #1 stated that they informed Certified Nursing Assistant #1 who was assigned to Resident #1. Registered Nursing #1 stated that Certified Nursing Assistant #1 immediately went to Resident #1's room. Registered Nursing #1 stated that at approximately 11:55 AM, they observer Certified Nursing Assistant #1 serving trays and there was no mention of any incident. Registered Nursing #1 stated that they also saw Resident #1 and talk with Resident #1 after Certified Nursing Assistant #1 completed care to Resident #1. Registered Nursing #1 stated Resident never complain about Certified Nursing Assistant #1 being rough and hit their head. Resident #1 never reported anything during the shift. Registered Nurse #1 stated body assessment was done and there were no discoloration, redness or injuries observed and Resident #1 denied having any pain or discomfort. Registered Nurse #1 stated that they make frequent rounds on the unit to monitor staff and residents to ensure staff members are providing timely care and that there was no abuse. During an interview on 10/24/2024 at 2.55 pm, Director of Nursing stated they were informed by Registered Nursing Supervisor #1 on 07/22/2023 (not sure of the time), Resident #1 reported that they were rough handled by Certified Nursing Assistant #1. Director of Nursing stated that Resident #1 was assessed by Registered Nursing Supervisor #1 and the Medical Doctor and there were no visible signs of redness, discoloration, or injuries. Director of Nursing stated that facility investigated the alleged incident and determined that Resident #1 was mishandled by Certified Nursing Assistant #1. The Director of Nursing stated that Certified Nursing Assistant #1 was removed from the schedule and Resident #1 was placed on two people approach and staff members were re-educated on abuse prevention. The Director of Nursing stated the unit nurse and the nursing supervisor monitored residents and staff on the unit to ensure that there is no abuse. Director of Nursing stated that they make rounds twice daily to monitor the staff. Based on the following corrective actions taken, there were sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to surveyors' s onsite visit on 07/15/2024. A Plan of Correction is not required for this citation. The facility implemented the following corrective action prior to surveyor entrance on 07/15/2024. The facility's Director of Nursing investigated the allegation of abuse and the team concluded that abuse did occur. The facility developed an action plan on 07/22/2023 which includes the following: On 07/22/2023 Resident #1 was assessed by Registered Nursing Supervisor #1 and Medical Doctor and there were no visible injuries. 0n 07/22/2023 Resident #1's abuse care plan was updated to reflect on the allegation of abuse. Additional interventions included two people during care and ensure that resident is always transferred safely. Local law enforcement was called on 07/22/2023 and responded. Neuro Checked was implemented for 48 hours. Facility interviewed and assessed other residents on Certified Nursing Assistant #1 assignment for evidence for abuse. Certified Nursing Assistant #1 was removed from schedule pending investigation and subsequently terminated. On 07/23/2023, Policy/Procedure on Abuse Prohibition was reviewed. No revisions were done to the policy. On 07/26/2023, the Quality Assurance Committee held a meeting where the incident was discussed. Attendees included the Administrator, Director of Nursing, Assistant Director of Nursing, and other departmental heads. On 07/23/2023, multiple residents on Certified Nursing Assistant #1's assignment was interviewed by Social Worker and there were no abuse, neglect, or mistreatment issues identified. The facility re-in-service staff members on 07/23/2023. Lesson plan: Abuse Facility has 385 nursing staff of which 86% was in-serviced by the Assistant Director of Nursing. In-service on-going on a monthly and annually. 201 out of 236 Certified Nursing Assistants were in-serviced. 61 out of 61 License Practical Nurses were in-serviced. 70 out of 88 Registered Nurses were in-serviced. During interviews with multiple staff members including 10 Certified Nursing Assistants, 3 License Practical Nurses and 3 Registered Nurses stated knowledgeable of the abuse policy. 10 NYCRR 415.4(b)(1)(i)

Based on observations, record review, and staff interviews conducted during the Recertification Survey from 10/8/2024 to 10/16/2024, the facility did not ensure that the survey results were posted in a place readily accessible to residents, visitors, or legal representatives where individuals wishing to examine survey results do not have to ask to see them. Specifically, the survey results were located inside a binder placed behind a glass partition at the Security desk. The finding is: The facility policy and procedure titled Right to Survey Results, reviewed 11/22/2023, documented that the facility will ensure that the resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of corrections in effect with respect to the facility. The Facility must: Have reports with respect to any surveys, certifications, and complaint investigations made respective to the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. The facility will post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility in areas such as the lobby and the units. During multiple observations from 10/08/2024 to 10/15/2024, a sign was observed on the wall at the Security Desk stating that survey results were survey results were available at the security desk. The binder was not visible or accessible on the counter at the desk but was observed to be located inside a labeled binder located behind a glass partition at the security desk in the front lobby. In addition, there was no signage observed on the resident units indicating where survey results could be located in the facility. On 10/15/2024 at 3:00 PM, a binder labeled survey results was observed located in a bin on the side of the security desk in the front lobby. On 10/15/2024 at 3:05 PM, an interview was conducted with the Safety and Security Officer who stated that the survey results had been moved today from behind the glass partition at the security desk to a bin on the side of the security desk. On 10/15/2024 at 3:10 PM, the Security Supervisor was interviewed and stated that on 10/14/2024, the book that contains the survey results was behind glass at the security desk. The Security Supervisor also stated that if someone wanted the book, they may feel that they must ask. On 10/16/2024 at 10:28 AM, an interview was conducted with the Administrator who stated that the previous placement of survey results, was a location behind glass at the security desk and in order for someone to have access, they would have to ask. The Administrator also stated that the location of the survey results as of 10/15/2024, had been moved to the side of the security desk at wheelchair height where no one will have to ask for access. 10 NYCRR 415.3(d)(1)(v)

Based on record review and interview conducted during the Recertification survey conducted from 10/08/2024 to 10/16/1024, the facility did not ensure they provided the appropriate liability and appeal notice to Medicare beneficiaries at the termination coverage. This was evident for 1 (Resident #404) of 3 residents reviewed for Beneficiary Notification. Specifically, the Notice of Medicare Non-Coverage was not mailed out to Resident #404's designated representative on the same day that telephone notification was made. The findings are: The facility policy titled Notice of Medicare Non- Coverage (NOMNC) dated 4/9/2024 that a copy of the signed Notice of Medicare Non-Coverage will be provided to the beneficiary or representative. The policy also documented that in the event that the beneficiary is not able to comprehend the information in the Notice of Medicare Non-Coverage, the Notice of Medicare Non-Coverage notification must be delivered to the beneficiary's representative. If the Notice of Medicare Non-Coverage notification is unable to be personally delivered to the beneficiary's representative, the Minimum Data Set Coordinator shall telephone the representative to provide notice of when the beneficiary's services are no longer covered. The date of the telephone conversation is the date of the representative's receipt of the notice, and the Notice of Medicare Non-Coverage will be mailed to the representative by certified mail, return receipt requested, on the same date as the telephone conversation. The form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 states that if the provider is personally unable to deliver a Notice of Medicare Non-Coverage to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise them when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. Resident # 404 was admitted to the facility on [DATE]. Review of the Notice of Medicare Non-Coverage form dated 7/3/24, documented the last covered day for Medicare Part A Services was 7/9/24. The Notice of Medicare Non-Coverage form also documented that Resident #404's representative was spoken with by telephone and a copy of the notice was placed in the chart and given to Resident #404. The area for signature of Patient or Representative and date were blank. There was no documented evidence that the Notice of Medicare Non-Coverage form was mailed to Resident #404's representative after telephone notification was made. On 10/09/2024 at 02:13 PM, an interview was conducted with the Minimum Data Set Coordinator/Case Manager who stated that when residents are being discharged from skilled services, they look at the resident's cognitive status and if the resident is not able to understand the information they speak to family members. The Minimum Data Set Coordinator/Case Manager also stated that they ask the family members how they want to receive the information, whether they want it mailed or if they will come to the facility to pick it up. The Minimum Data Set Coordinator/Case Manager further stated that sometimes family members ask for the notice to be sent by email, but it is a waste of time to send by email as there are a lot of notices given. the Minimum Data Set Coordinator/Case Manager stated Resident #404's representative told them to leave the notice in Resident #404's room so that is what they did. On 10/09/24 at 02:19 PM, an interview was conducted with the Minimum Data Set Supervisor who stated that generally the Coordinator is responsible for providing notices and they only get involved if the Coordinator is not in or there is a large volume of notices to be given. The Minimum Data Set Supervisor also stated that when telephone notification is made, family members ask for the information to be left in the resident's room. The Minimum Data Set Supervisor further stated that when family members are told the notice will be sent Certified Mail, they say they are not going to pick up the mail. The Minimum Data Set Supervisor stated that they know that notices are supposed to be mailed on the same day but if they know the family members are coming to the facility they hold the letter and then give them the letter at that point. The Minimum Data Set Supervisor also stated that notices cannot be sent by email because of encryption which prevents family members from opening the emails. 10 NYCRR 415.3(g)(2)(i)

Based on record review and interviews conducted during the Recertification and Complaint Survey (NY00343354) from 10/8/2024 to 10/16/2024, the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency in accordance with State law through established procedures. This was evident for 1 (Resident #357) of 4 residents investigated for Abuse out of an investigative sample of 38 total residents. Specifically, the facility received a report that Resident #357 was allegedly missing cash totaling approximately $900 and did not report to the New York State Department of Health in a timely manner. The findings are: The facility policy titled Abuse Prohibition dated 10/24/2022, documented that the facility shall not use or permit verbal, mental, sexual, or physical abuse, including corporal punishment and involuntary seclusion of residents/patients, misappropriation of resident property, exploitation or other mistreatment or neglect. Section 1150B establishes two-time limits for the reporting of reasonable suspicion of a crime. One of the time frames is Immediately: Means as soon as possible, in the absence of shorter state time frame requirement, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or results in serious bodily injury. All staff members have an obligation to report any reasonable suspicion of a crime to the State Survey Agency (New York State Department of Health's Nursing Home Complaint Hotline). The facility shall ensure that alleged violations involving mistreatment, neglect, misappropriation of resident property, exploitation, or abuse, including significant injuries of unknown source, are reported immediately to the Administrator of the facility or his/her designee. When required by law or regulation, the facility shall ensure timely notification to the Department of Health. Resident #357 was admitted to the facility with diagnoses that included Cerebral Infarction and Depression. The Minimum Data Set assessment dated [DATE], documented that Resident #357 had intact cognition. On 10/09/2024 at 12:38 PM, an interview was conducted with Resident #357 who stated, that after the aide cleaned them up, their wallet and envelope were missing. Resident #357 also stated that the items were near a pillow in their bed and after a search the wallet was recovered but the envelope containing approximately $900 was missing. The facility complaint investigation, initiated 05/24/2024 and submitted 05/31/2024, documented Resident #357 reported an allegation of missing between $700-$900 on 05/24/2024 at 04:00 hours after receiving care from the Certified Nursing Assistant who allegedly removed an envelope containing cash from the bed pillow and never returned it. The police were notified on 05/24/2024. The New York State Department of Health Aspen Complaint Tracking System Intake Information documented that the allegation was reported on 05/25/2024 at 00:36. There was no documented evidence that the facility reported Resident #357's allegation of misappropriation of property on 05/24/2024 to the New York State Department of Health within 2 hours. On 10/15/2024 at 03:13 PM, an interview was conducted with the Director of Nursing who stated that they received a telephone call at approximately 5 AM or 6 AM on 05/24/2024, reporting that Resident #357 was missing a wallet and an envelope with $700-$900 in cash. The Director of Nursing also stated that they reported the incident to the New York State within 24 hours. The Director of Nursing further stated that they believed the 2 two-hour reporting requirement is only for serious bodily injury and most other reporting is a 24-hour reporting requirement. On 10/16/2024 at 10:35 AM, an interview was conducted with the facility Administrator who stated, on abuse reporting as is for misappropriation of property, this report was not submitted within 2hrs. The Administrator stated they are aware, and the staff has updated the policy to reflect reporting no later than 2 hours after an allegation of abuse. 10 NYCRR 415.4(b)(2)

Based on record reviews and interviews conducted during the Recertification survey from 10/8/2024 to 10/16/2024, the facility did not ensure that comprehensive care plans were developed and implemented to meet each resident's needs. This was evident for 1 (Resident # 64) of 5 residents reviewed for Unnecessary Medications. Specifically, a care plan for use of anticoagulant medication was not developed for Resident #64. The findings are: The facility policy titled Care Plan with creation date 8/6/2020 and last reviewed date 8/6/2024 documented the interdisciplinary team will conduct a comprehensive assessment upon admission to develop a comprehensive care plan for the resident. The policy also documented that the interdisciplinary team would ensure that the care plans include the appropriate treatments and services to attain or maintain a resident's highest practicable physical, mental, and psychological well-being. Resident #64 was admitted to the facility with diagnoses that included Chronic Atrial Fibrillation and Dysrhythmias. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #64 had active diagnoses which included Atrial Fibrillation or Dysrhythmias and was taking an anticoagulant. The Physician's Orders documented Resident #64 was prescribed Pradaxa 75 mg capsule twice daily beginning on 08/07/2024. The Medication Administration Record dated August 2024 documented Pradaxa 75 mg capsule was administered to Resident #64 two times a day as ordered starting on 08/07/2024. There was no documented evidence a comprehensive care plan related to anticoagulant use was developed and implemented for Resident #64. On 10/11/2024 at 11:19 AM, Registered Nurse #1 was interviewed and stated the Registered Nurses on floor were responsible for creating the care plans related to residents' care according to their comprehensive assessment. Registered Nurse #1 also stated a resident taking anticoagulant medication should have a care plan to address the resident's needs and the interventions taken to meet these needs. Registered Nurse #1 further stated that Pradaxa was considered an anticoagulant which Resident #64 had been receiving twice daily since their admission to facility in August 2024. Registered Nurse #1 stated that they were not able to locate a care plan related to the anticoagulant use after reviewing Resident #64's medical record. Registered Nurse #1 also stated it was an error care plan to address use of anticoagulant for Resident #64 was not created. On 10/11/2024 at 12:05 PM, the Director of Nursing was interviewed and stated that they and the Registered Nurse managers on the units review the care plans for all newly admitted residents. The Director of Nursing also stated that a resident taking anticoagulant medication had to have a care plan in place to address the potential bleeding concern. The Director of Nursing further stated that Resident #64 was newly admitted in August 2024 and they and the Registered Nurse manager on the unit should have already reviewed Resident #64 care plans , and they were not able to find a care plan related to anticoagulant use in Resident #64's medical record. The Director of Nursing stated they were not able to explain why a care plan related to anticoagulant use was not created. 10 NYCRR 415.11(c)(1)

Based on observation, interviews, and record reviews conducted during the Recertification and Complaint (NY00317447) survey from 10/08/2024 to 10/16/2024, the facility did not ensure resident's person-centered, Comprehensive Care Plans were reviewed and revised with each assessment and as needed to reflect the resident's changing needs. This was evident for 1 (Resident #389) of 5 residents reviewed for Unnecessary Medication, and 1 (Resident 84) of 4 residents reviewed for Abuse out of an investigative sample of 38 residents. Specifically, the Psychoactive Drug Use Comprehensive care plan for Resident #389 was not reviewed or revised after each assessment, and Risk for Victimization Comprehensive care plan for Resident # 84 was not review or revised after annual or quarterly assessments. The findings are: The facility policy titled Care Plan revised 08/06/2024 documented that the care plan is reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessments. The policy further documented that the care plan should be reviewed and revised Quarterly, Annually, at a Significant change and medical status changes, with changes to the care plan as needed. 1. Resident #389 was admitted to the facility with diagnoses which included Non-Alzheimer's Dementia, Vascular Dementia with Psychotic features, and Depression. The Annual Minimum Data Set, dated dated dated [DATE] and the Quarterly Minimum Data Set, dated dated dated [DATE] documented that the resident had short and long-term memory impairment, no memory recall and was severely impaired-never/rarely made decisions. The Physician orders reviewed 09/30/2024 documented orders for Rexulti 1 mg tablet by oral route once daily for Vascular Dementia with Psychotic disturbances, Trazodone 50 mg tablet by oral route every night for Depression, Lexapro Escitalopram 10 mg tablet by oral route once daily for Depression, and Melatonin 3 mg tablet by oral route once daily at bedtime for Insomnia. The Comprehensive Care Plan titled Psychoactive Drug Use Etiology: Use of any medication that affects mood, function, behavior, or cognition as evidenced by: Psychoactive drug use dated was effective 01/14/2024 and last evaluation note was completed on 04/14/2024. Goal was maximizing functional potential and well-being while minimizing use of medication and side effects, all interventions implemented on 01/18/2024 included encourage verbalization of feelings, monitor for changes in behavior or mood, observe for any signs of decline in functional or cognitive status, psychiatry consultation. The Comprehensive Care Plan for Psychoactive Drug Use was last reviewed on 4/14/2024. There was no documented evidence that Resident # 389 Psychoactive Drug Use care plan had been reviewed and revised by the interdisciplinary team after the quarterly review assessments were completed on 09/19/2024 and 06/26/2024. On 10/15/24 at 11:22 AM, an interview was completed with Registered Nurse #2, who was the Nursing supervisor for the Unit. Registered Nurse #2 reviewed Resident #389's medical record and stated that the care plan was not updated last quarter. Registered Nurse #2 also stated that the supervisors and Registered Nurses are all responsible for updating the care plans. Registered Nurse #2 also stated care plans are updated quarterly, annually, episodic due to behaviors and as needed. Registered Nurse #2 further stated that the night shift usually updates the Psychotropic care plans, and they are not sure why Resident #389's care plan was not updated. Registered Nurse #2 further stated that at times the updating of the care plan is missed although the care plan meeting was completed. Registered Nurse #2 gave no reason why the care plan was not updated. On 10/16/24 at 11:16 AM, an interview was completed with the Director of Nursing who stated that care plans are updated quarterly, annually, and as needed. The Director of Nursing also stated that the Registered Nurses on the units are responsible for initiating and updating all care plans, and that night shift is not the only shift responsible for updating the care plans, but all nurses on every shift are responsible for updating the care plans. The Director of Nursing further stated that they monitor that the supervisors and nurses are reviewing care plans by doing random audits on the units and gave no reason why this care plan for Resident #389 was not reviewed or revised timely. 44843 2. Resident # 84 (NY00317447) was admitted to the facility with diagnoses that included Alzheimer's Disease and Closed fracture of unspecified part of left clavicle. The Annual Minimum Data Set assessment dated [DATE] documented Resident #84 had moderately impaired cognition, had no behavior symptoms, and was always incontinent in of bladder. The Annual Minimum Data Set also documented that Resident #84 required supervision to walk in room and had not fallen since admission. The Comprehensive Care Plan related to Resident is at Risk for Victimization was initiated 3/23/2023 and was reviewed and updated on 06/16/2023 and 05/30/2024. A Nursing note dated 5/30/2023 documented that a Certified Nursing Assistant noticed Resident #84 had discoloration to the left shoulder when providing care to Resident #84. The note also documented that Resident #84 had pain at the left shoulder and left shoulder movement was limited. The note also documented Resident #84 stated they fell at night on 05/29/2023 when going to bathroom by themselves and had pain in the left shoulder. A Nursing note dated 5/30/2023 documented that Resident #84 was transferred to the hospital to rule out a left humerus fracture. The Hospital After Visit Summary dated 5/30/2023 documented that Resident #84 had a closed nondisplaced fracture of left clavicle. Quarterly Minimum Data Set assessments were completed on 09/06/2023, 11/27/2023, 02/21/2024, and 8/12/2024, and an Annual Minimum Data Set assessment was completed on 05/15/2024. There was no documented evidence that the Comprehensive Care Plan titled At risk for Victimization was reviewed or revised after multiple Quarterly and Annual Minimum Data Set assessments had been completed. On 10/11/2024 at 10:13 AM, Registered Nurse #2 was interviewed and stated the Registered Nurses on the floor are responsible for reviewing and updating residents' care plans at least every 3 months and as needed. Registered Nurse #2 also stated that the electronic medical record system gave them alert when the care plans were due for review, and the Registered Nurse reviewing the care plans should either update the care plan, or document to continue current care plan if no change was required as evidence that the care plan was reviewed. After review of Resident #64's medical record, Registered Nurse #2 stated that there was no evidence that the care plan was reviewed between 6/17/2023 and 5/29/2024, and after 5/30/2024. Registered Nurse #2 further stated that they were not able to explain why the care plan was not reviewed and updated at least every three months. On 10/11/2024 at 10:39 AM, the Director of Nursing was interviewed and stated the registered nurses on the unit were responsible to review and update care plans at least every 3 months and as needed. The Director of Nursing also stated that the Registered Nurse is to document to continue the care plan if no change was needed. The Director of Nursing further stated that it was an error that the care plan was not updated at least every 3 months and after the Minimum Data Set assessments had been completed. The Director of Nursing also stated that the Registered Nurses were professional, and they did not monitor to see if the Registered Nurses reviewed and updated the care plans. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observations, record review, and staff interviews conducted during the Recertification survey between 10/08/2024 and 10/16/2024, the facility did not ensure that needed services, care and equipment are provided to assure that residents with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. This was evident for 1 out of 3 residents reviewed for Position and Mobility, (Resident #382) out of 38 sampled residents. Specifically, Resident #382 had an order to apply bilateral splints to resident's hands to be worn at all times and was observed on multiple occasions without the device in place as per Physician's order. The findings are: The facility's policy and procedure titled Splint/Brace/Assistive devices dated 4/9/2024 documented the purpose is to ensure the correct application of the brace/splint. The policy further documented that the Certified Nursing Assistant applies the splint/brace as per instructions. Resident #382 was admitted to the facility with diagnoses that included Coronary Artery Disease, and Respiratory Failure, with Tracheostomy status. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #382 was in a persistent vegetative state and was dependent on staff for all activities of daily living. On 10/08/24 at 12:10 PM and 10/08/24 at 02:45 PM, Resident #382 was observed in bed with contractures on both hands and there was no device observed in Resident #382's hands. On 10/10/24 at 09:58 AM, Resident #382 was observed in bed with eyes closed. Resident #382 hands had closed fists and there was no device observed in place. On 10/11/24 at 10:56 AM, Resident #382 was observed in bed on lying in bed on their back with tracheostomy in place receiving oxygen. Both of Resident #382's hands were resting on the upper part of their stomach. Resident #382's hands remained in a closed fist and no device was observed in either hand. The Physician's Order dated last reviewed 9/24/2024 documented apply bilateral splints to resident's hands. Wearing Schedule: At all times. Instructions: Remove every shift for skin inspection, and during meals as needed for feeding. Provide Range of Motion prior to splint/brace application. Goals: To promote optimal positioning and maintain joint integrity. The Comprehensive Care Plan titled Dressing/Grooming Self Care Deficit dated 10/28/2023 with last evaluation note dated 7/27/2024 included an intervention of apply bilateral Splints to resident's hands. The Occupational Therapy progress notes dated 11/09/2023 at 01:56 pm, documented Issued Bilateral hand splints to be worn at all times. Remove every shift for pressure relief. The Occupational Therapy progress note dated 01/29/2024 at 01:54 pm, documented applied bilateral splints to the patient's hands. The Occupational Therapy progress note dated 04/02/2024 at 03:13 pm, documented left message for daughter, bilateral resting hand splints applied. The Resident Nursing Instructions Record dated 10/2024 documented under section titled monitoring Nursing Rehabilitation Splint/Brace Notes: Apply bilateral Splints to resident's hands. Wearing Schedule: At all times. Instructions: Remove every shift for skin inspection, and during meals as needed for feeding. Provide Range of Motion prior to splint/brace application. Schedule: Every Day at 6:00 am-2:00 pm; 2:00 pm-10:00 pm; 10:00 pm-6:00 am On 10/11/24 at 11:06 AM, an interview was completed with Certified Nursing Assistant #6 who stated they are assigned to Resident #382. Certified Nursing Assistant #6 stated Resident #382 requires total assistance with all activities of daily living, and their hands are clenched like a fist and so something like a splint must be placed in Resident #382's hand. Certified Nursing Assistant #6 also stated they did not receive in-service on the splint, and they were not sure how long Resident #382 must keep the splint on, or when to take the splint off. Certified Nursing Assistant #6 further stated that they take the brace off when administering care, and when finished care with care they are supposed to put the splint back on. On 10/11/24 at 11:12 AM, Certified Nursing Assistant #6 and State Surveyor entered Resident #382's room where Resident #382 was lying in bed without splint devices in place. Certified Nursing Assistant #6 stated the bilateral splints were in Resident #382's Geri chair located at the foot of their bed. Certified Nursing Assistant #6 also stated they forgot to put the brace back on after completing care this morning, and they were leaving for lunch now and would replace splints for Resident #382 when they returned from their break. On 10/11/24 at 11:13 AM, Certified Nursing Assistant #6 exited Resident #382's room with the State Surveyor and did not apply the splints for Resident #382. On 10/11/24 at 11:37 AM, an interview was completed with Registered Nurse #4 who stated they are aware that Resident #382 should always have a splint in place which is to be removed for skin inspection and or skin care. Registered Nurse #4 was unable to explain why on multiple occasions the splint was observed not to be in in place. Registered Nurse #4 also stated they take the splint off every two hours, and at times every 15 minutes for skin inspection and that is the reason why the splint was off. Registered Nurse #4 reviewed the physician orders for Resident #382 and stated there was no order for 15 minutes and or two hours removal of splint, but there was an order to remove as needed. Registered Professional Nurse #4 then stated that they did remove the splint, but they will reapply the splint soon. Registered Nurse #4 stated skin checks are completed during activities of daily living and was unable to explain why the splint was not in place after activities of daily living care was completed this morning. On 10/16/24 at 10:15 AM, a follow up interview was completed with Registered Nurse #4, who stated they became aware that Resident #382 has a splint through the doctor's order. Once orders are in place, Occupational Therapy staff will come to the unit and show staff how to put the splint on and staff will follow the instructions. Registered Nurse #4 also stated the splint for Resident #382 is to be removed for skin inspection only, not for 15 minutes or every two hours as previously stated, and this was an error. On 10/11/24 at 11:44 AM, an interview was completed with Registered Nurse #3, who was the Unit Manager. Registered Nurse #3 stated any splints, rolls, or devices are ordered for the resident after Physical and or Occupational Therapy assessment. Registered Nurse #3 also stated that once the splint and or roll is recommended the physician is made aware and an order is placed in the medical record of the resident. Therapy will then come to unit to in-service staff on how to apply the splint. Registered Nurse #3 further stated as per the doctors' orders the splint is removed for skin inspection and meals, however Resident #382 feeds by G-Tube. Registered Nurse #3 stated the skin inspection is usually done during activities of daily living. Registered Nurse #3 also stated that the charge nurse monitors that the splint is in place and Registered Nurse #3 also monitors, by making rounds at times. Registered Nurse #3 stated that they make rounds in the mornings, afternoons, and as needed, and they ask the staff if there are any concerns. Registered Nurse #3 further stated the staff must follow the doctors' orders to remove splint for skin inspection only, and the nurse on the unit is to ensure that the staff is applying the splint. On 10/11/24 at 02:32 PM, an interview was completed with the Rehabilitation Director who stated all resident who have an assistive device such as splints, are evaluated by the Occupational Therapist, and if the Occupational Therapist deem the resident will benefit from a device such as a splint it will be ordered. An order will be obtained from the doctor and placed into the resident's medical record. Once the device is received and the medical order is in place, the Occupational Therapist will go to the unit and show the staff the splint and provide in-service to the staff on how to place the splint on the resident and when to take the splint off. The Rehabilitation Director also stated that all the instructions for putting on and removing the splint device are in the medical orders. The Rehabilitation Director further stated that the Rehabilitation staff do not document the in-service that is provided to staff on the unit, and they have no record of the in-service, but the therapist does go to the unit and shows staff how to apply the splint. The Rehabilitation Director stated that the splint is usually to be removed once per shift for skin inspection such as redness, and during meals. On 10/16/24 at 11:10 AM, an interview was completed with the Director of Nursing who stated after the Rehabilitation staff evaluates the resident's for the need for a splint or device, an order is placed in the medical record, and placed in the Certified Nursing Assistant Instructions and the Certified Nursing Assistant is then responsible for putting the splint on as per medical orders and recommendations as per Rehabilitation. The Director of Nursing also stated that once all orders and recommendations are in place, the Rehabilitation Therapist will go to the unit and in-service the staff on the use of the device. The Director of Nursing further stated the order to remove the splint every 15 minutes or every two hours depends on the resident, the physician order, and the therapy recommendations. The Director of Nursing reviewed the order for Resident #382 and stated that the order is remove every shift for skin inspection and for meals as needed. The Director of Nursing stated the nurse on the unit monitors and completes audits to monitor that splint is in place. 10 NYCRR 415.12(e)(2)

Based on interviews and record review conducted during a Recertification and Complaint survey (NY00328780) from 10/08/2024 to 10/16/2024, the facility failed to ensure each resident received adequate supervision to prevent elopement. This was evident for 1 (Resident #369) of 3 residents investigated for Accidents out of an investigative sample of 38 residents. Specifically, on 11/23/2023, Resident #369 who was not identified as a high risk for elopement, was able to exit the front doors of the facility and walk down to the guard booth where Resident#369 was then redirected and taken back into the facility. The findings are: The facility's Elopement Policy titled Elopement Prevention and Management, created 8/11/2015 and last reviewed 11/27/2023, documented that the facility maintains measures to ensure safety and well-being of residents within the confines of the facility. The policy also documented that elopement occurs when a resident successfully leaves the nursing facility undetected and unsupervised and enters harm's way. The New York State Department of Health Aspen Complaint Tracking System intake documented that on 11/24/2023, the Security Coordinator reported that on 11/23/2023, at approximately 3:47 p.m., Resident #369 left the facility and returned a few minutes later. Resident #369 was observed by a Security Officer in the booth to be close to the guard booth, and then another Security Officer followed the resident back to the front entrance of the facility. Resident #369 was admitted to the facility with diagnoses that include Alzheimer's Disease, Non-Alzheimer's Dementia, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #369's cognition as severely impaired-never/rarely made decisions, wanders with behavior of this type occurring 1 to 3 days, ambulates with walker, and uses a wheelchair. The Quarterly Minimum Data Set assessment also documented that Resident #369 has no wander or elopement alarm. The Elopement Risk assessment dated [DATE] documented that Resident #369 is independently mobile, with or without an assistive device, has a primary diagnosis of Alzheimer's Disease or Dementia, and has an active Mental Illness. The Elopement Risk Assessment also documented that Resident #369 was not an elopement risk. A Nursing note dated 11/24/2023 documented that Resident #369's family member was notified that Resident #369 went out of the lobby on 11/23/2023 around 3:40pm. A Nursing note dated 11/24/2023 documented that Resident #369 was alert and responsive to all stimuli but had occasional confusion. Resident #369 has left ankle wander-Guard in place due to elopement risk. Resident #369 made no attempts to leave unit on shift and was observed ambulating on the unit with a rolling walker and supervision. A Physician's note dated 11/24/2023 documented Resident #369 was awake, alert, verbally responsive with periods of confusion denied pain, has no visible signs of injury, and no changes in range of motion. The Physician's note also documented Resident #369 was stable with no injury and is able ambulate on unit with a rolling walker and supervision. The facility's investigation report dated 11/30/2023, documented the event as an elopement and that on 11/23/2023, Resident #369 went outside the lobby to take fresh air. The incident report further stated that on 11/23/2023, Resident #369 attended a Thanksgiving event in the facility auditorium and when the activity ended, Resident #369 was sitting on a chair waiting to be transported. Resident #369 was not observed leaving the event. The incident report further stated that it appears that Resident #369 stepped outside of the auditorium into the lobby and that the security officers at the entrance to the facility, were distracted and did not notice the resident walking outside the facility. The resident was identified by the security staff outside the facility looking for an entrance to come back into the facility. On 10/16/2024 at 01:19 PM, Certified Nursing Assistant #2 was interviewed and stated that they had been assigned to Resident #369 on 11/23/2023, and on that day, they had just started their shift 2 PM-10 PM, when the recreation staff came and took Resident #369 off the unit for recreation. Certified Nursing Assistant #2 also stated that Resident #369 was alert and oriented and needed supervision with their activities of daily living. Certified Nursing Assistant #2 further stated that they were not aware that Resident #369 went outside until later that day. On 10/15/2024 at 10:19 AM, Recreation Leader #1 was interviewed and stated that on 11/23/2023, they had signed out Resident #369 off the unit, and brought them to the auditorium on the 1st floor, for the Thanksgiving Day program. Recreation Leader #1 also stated that Resident #369 was at the program, sitting at the back of the Auditorium, and it was when they came back from transporting other residents back to their units at the end of the program, that they were notified that the Resident#369 went outside and was brought back in. Recreation Leader #1 further stated that the recreation staff usually transport the residents that are an elopement risk back to their rooms first, but at the time of the incident, Resident#369 was not an elopement risk. of residents and that they never exhibited any exit seeking behaviors prior to that incident. On 10/15/2024 at 11:20 AM, Recreation Leader #2 was interviewed and stated that they worked on 11/23/2023, and was made aware on the next day, 11/24/23, that Resident #369 went out the building. Recreation Leader #2 said that they recalled Resident #369 was sitting by the door of the auditorium during the Thanksgiving Day program, and that Resident #369 always came down for programs but never displayed any exit seeking behaviors. Recreation Leader #2 said that when the residents who are an elopement risks come off the units for programs on the 1st floor, they are placed in the middle of the room, and are taken back to their units first. Recreation Leader #2 stated that since Resident #369 was not an elopement risk, they were sitting at the end of the room. On 10/15/2024 at 10:26 AM Social Worker #1 was interviewed and stated that they were the Social Worker for the Resident #369 at the time of the elopement, 11/23/2023. The Social Worker stated that an initial elopement risk is done by the nurse on the unit when residents are initially admitted . The Social Worker stated that upon interview with Resident #369 when the incident occurred on 11/23/2023, Resident #369 said that they were going for a walk and that they (Resident #369), was not trying to leave the facility. The Social Worker stated that the interdisciplinary team then had a meeting it was decided that Resident #369 would be placed on a long-term floor, the Dementia unit, since Resident #369 had Dementia and had been more confused recently. On 10/15/2024 at 04:07 PM, Security Officer #1 was interviewed and stated that they were stationed at the front desk on 11/23/2023. It was a shift change, when they saw Resident #369 coming back into the front door, as Security Officer #2 approached Resident #369. Security Officer #1 stated that when the Security Coordinator who worked the day shift 8 AM-4 PM shift, returned to the desk, Security Coordinator said that they would report the elopement incident to the facility Administrator. Security Officer #1 also stated that there is a wander guard list in a binder that has residents' pictures on it, located at the front desk. On 10/15/2024 at 03:42 PM, Security Officer #2 was interviewed and stated that on 11/23/2023, at the time the elopement incident occurred, they were looking in the opposite direction, writing up a day pass. and was facing the opposite direction. Security Officer #2 also stated that when they raised up their head, they saw the Resident #369 coming back inside, and went to the door to Resident #369. Security Officer #2 further stated that at the same time, the Security Coordinator came back to the desk, and they notified the Security Coordinator. Security Officer #2 stated that they do not think that Resident #369 had a wander guard on because the alarm would have been triggered as the resident walked through the door, and that at the security desk, they have a list of residents that are elopement risk and have wander guards. On 10/15/2024 at 09:45 AM, the Security Supervisor was interviewed and stated that on the day that the elopement occurred on 11/23/2023, they did not work. The Security Supervisor stated that as the security supervisor, they are responsible to make sure that the all the processes are followed, as it pertains to the security. The Security Supervisor stated that on 11/24/2023, the Security Coordinator told them that the elopement occurred the day before, 11/23/2023, so the Security Supervisor told the Security Coordinator that they needed to report it immediately. The Security Supervisor also stated that they were made aware that Resident #369 went through the main entrance, and that they did not have a wander guard at the time. The Security Supervisor also stated that if Resident #369 did have a wander guard on, the alert would have been sounded and the resident would have shown up on the camera. On 11/23/2023 when the elopement occurred, there were 2 security officers and the Security Coordinator on the 8 AM-4 PM shift. At the time the incident occurred, the Security Coordinator had stepped away from the desk, so there were only 2 Security Officers at the desk, one was occupied signing in a resident, and the other security was probably signing in another visitor. On 10/16/2024 at 10:37 AM, the Administrator was interviewed and stated that on Friday, 11/24/2023, they were made aware that Resident #369 went out the front door, by the Security Coordinator who worked on 11/23/2023, on the 8 AM -4 PM shift. The Administrator also stated that they should have been notified immediately when the incident occurred on 11/23/2023 and that once they were notified, they started an investigation, notified the family, and had the Resident #369 seen by the physician. The Administrator stated that the recreation leader had had brought Resident #369 to the auditorium for the Thanksgiving program on 11/23/2023 and that Resident #369 was sitting closer to the door so none of the recreation staff saw Resident # 369 leave the auditorium. The Administrator also stated that on the day that the elopement occurred, one of the security guards did not show did not show up for that shift, and the other security guard at the front desk was not as focused as they should have been when the Resident #369 went outside. That security guard and the Security Coordinator who failed to report the elopement timely, are no longer employed by the facility. The Administrator also stated that they reviewed the cameras footage to see what really transpired and started doing in-services immediately on Elopement with all the departments, and that the facility started to ensure that all departments had a wander guard list with residents who were at risk for elopement, including the guard at the booth at the facility's parking lot entrance. The Administrator also stated that the recreation staff had the list of residents who were elopement risks and that the nurses on the units were notified of residents who were elopement risks who leave the units, prior to the residents leaving the units. When residents who were elopement risks attend the programs in the auditorium, they are now placed at the center of the room and transported back to their units first. The Administrator also stated that they did a facility wide evaluation on all residents to ensure that all at risk residents are identified. All corrective actions and interventions were implemented by 12/13/2023. On 10/16/2024 at 12:55 PM, the Director of Nursing was interviewed and stated that they were first made aware of Resident #369 going through the front entrance on 11/24/2023. The Director of Nursing also stated that they immediately started the investigation, interviewed Resident #369, and started in-services on Elopement. The Director of Nursing further stated that the physician evaluated Resident #369 who had no injuries. The Director of Nursing stated that Resident #369 had an initial assessment for Elopement on 08/04/2023 and one on 11/4/2023, but was not deemed an Elopement risk, however after an assessment was done on 11/24/2023, they determined that Resident #369 was an Elopement Risk and was given a wander guard. The Director of Nursing also stated that they initially checked all the residents with a Dementia diagnosis and who were ambulatory and did a facility wide evaluation for residents at risk for elopement. The Director of Nursing also stated that they reviewed the policy and procedures on Elopement, did an assessment every week for 4 weeks, then quarterly for elopement risks. The facility implemented corrective actions and was found to be in substantial compliance on 12/13/2023 prior to the start of the Recertification Survey on 10/08/2024. Resident #369 was redirected back to the front entrance and walked back into the facility unharmed on 11/23/2023. The Comprehensive Care plan for Elopement for Resident #163 was implemented on 11/24/2023. The policy and procedure on Elopement Prevention and Management was reviewed 11/27/2023, and no changes were made to the policy? An ad hoc Quality Assurance Performance Improvement meeting on Elopement Review and Planning was held on 11/27/2023 with the Administrator, Assistant Administrator, the Director of Nursing, Security Supervisor and Director of Social Work. Details included the in-service on Elopement for all facility staff in progress, in service security specific for security staff in progress, and replacement staff for security for further discussion. Security to send current wander guard list to all department heads for review with the updated list to be sent weekly to all departments. Recreation to review and post in the office so recreation staff are aware when residents are off unit. Managers must review the plan of care for all residents identified as wanderers and to identify any other residents that may be affected. Residents that have a diagnosis of Dementia in conjunction with ambulatory status will be reviewed. The recommendation for system improvement documented that Resident #369 was reassessed for elopement risk, and that a wander guard was applied. The corrective action included that Resident #369's chart was reviewed, family notified, the Security Coordinator was removed from schedule and terminated for the delay in reporting the elopement wandering event to Administration and appropriate staff. The relieving Security Coordinator was counselled and reeducated since they stated that they believed the other Security Coordinator reported the incident. The Security Guard was relieved from duty pending investigation and was no longer employed at the facility. The facility's Plan of Prevention was reviewed and was acceptable. 1. On 11/24/2023 the Resident #369's risk of wandering and elopement was reassessed. Wander guard was applied, Resident #369's photo was added to the Elopement risk binder. 2. Medical evaluation post incident. 3. Family was notified. 4. Resident #369's chart was reviewed and revised the plan of care for Elopement which was implemented on 11/24/2023. 5. Personnel involved were subject to disciplinary action: documentation of terminations and counselling reviewed. 6. Policy and procedure on Elopement and Wandering was reviewed and revised on 11/27/2023. 7. Facility wide staff re-education on Elopement, code green/missing resident and timely reporting initiated on 11/24/23 and completed on 12/13/2023 8. On 11/28/2023 recreation specific education was conducted and included the revision of transporting residents to the auditorium initiated, including reviewing all residents with a wander guard, and communicating with nursing for residents at risk for wandering and being transported off the units 9. On 11/24/2023 implemented a Security specific in-service regarding elopement prevention and reporting. 10. Wander guard lists distributed to all departments. 11. Additional elopement risk binder issued to the guard booth. 12. Nursing staff reviewed all other residents that may be affected, reviewed the plan of care for all residents identified as wanderers, audits were completed for evaluations on residents at risks for Elopement. 15. On 11/27/2023 and 11/28/2023 an interdisciplinary team meeting was held to review the incident. 16. On 12/21/2023 the Allied security assisted the facility to perform a drill and reenacted the same scenario. 17. Elopement Review incorporated into the 2024 Quality Assurance Performance Improvement 18. On 01/18/2024, the Quality Assurance Performance Improvement core committee met and reviewed the incident plan and prevention. 19. On 02/16/2024, the Elopement incident was reviewed with the full Quality Assurance Performance Improvement committee. 20. The nursing team continues to evaluate newly admitted residents for risk of elopement and reevaluate at least quarterly and as needed 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00337987), the facility failed to adequately supervise a resident to prevent accidents. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 04/02/2024 at 2:20 pm, during recreational social hour in the dining room, Resident #1, accidentally spilled hot tea on their person. Subsequently, Resident #1 was assessed to have redness to two areas on the left side of the lower abdomen and left upper inner thigh. This resulted in actual harm to Resident #1 that was not immediate jeopardy. The findings are: The facility's Policy and Procedure on Resident's safety during recreation programs involving food and beverages dated 04/03/2024, documented this facility is committed to providing each resident with safety during recreational programs involving food and beverages. Also, documented Recreation staff to check diet orders and confirm with nursing staff that residents can feed themselves. Resident #1 was admitted to the facility on [DATE] with diagnoses of Diabetes (high blood sugar) with peripheral neuropathy (weakness to the legs) and impaired cognition (memory loss, difficulty understanding). The Minimum Data assessment dated [DATE] documented Resident #1 had severely impaired cognition. Resident #1 required setup assistance with eating and can feed themself. The Facility's Investigation documented on 04/02/2024 at 2:20 pm, during recreational social hour in the dining room, Recreation Leader #1 placed a Styrofoam cup with tea on a table in front of Resident #1. Resident #1 attempted to pick up the cup and spilled the tea. Resident #1 was evaluated by Registered Nurse #1 and first aid treatment of cool compresses were placed on the red areas of the left side of the lower abdomen and left inner upper thigh. The Medical Doctor assessed Resident #1 and ordered wound care treatment and pain management. Resident #1's skin was treated daily by the Registered Nurse/ Wound Care Nurse #1 and was completely healed on 04/16/2024. The Medical Doctor's progress note dated 04/02/2024 at 3:15 pm, documented Resident #1 spilled hot tea on the left side of their abdomen. During the physical exam erythema (redness) of the abdomen and left upper inner thigh with burns of the skin was observed. The Treatment Care Plan was to apply cream for burns to the affected area daily. Nursing progress note dated 04/03/2024 at 1:57 pm, documented by Licensed Practical Nurse #1 on 04/02/2024, at around 2:20 pm, Resident #1 spilled hot tea on their stomach area (abdomen) and left upper inner thigh. Recreational Therapist #1 stated while they were serving tea and cookies to the residents, Resident #1 took the cup and the hot tea spilled on themselves. On assessment, Resident #1 was observed with redness to left side of low abdomen 9-centimeter by 11-centimeter by 0.1 centimeter with 30 percent of open skin and redness 2-centimeter x 10.8-centimeter x 0.1 centimeter to left upper thigh with peeling of the outer skin. Cold compresses were applied until the Medical Doctors evaluation. Pain management with Acetaminophen 650 milligram was provided. Resident #1 was seen by the Medical Doctor and treatment started. During an interview on 4/16/2024 at 10:42 am, Recreation Leader #1 stated they served tea to Resident #1 at the time of the incident. An electric kettle was used to boil the water. The water was boiled in the recreation's staff office and not used until 15-20 minutes later. A Styrofoam cup with tea was placed on a table in front of Resident #1. The tea bag was not hot to touch when removed from the cup therefore they gave it to Resident #1. The cup of tea was placed in front of Resident #1 when they heard Resident #1 make some noise ow and Resident #1 said they got tea on them. They took Resident #1 to the nursing station. During an interview on 04/16/2024 at 1:00 pm, Registered Nurse #1 stated on 04/02/2024 at approximately 2:22 pm they were informed by Licensed Practical Nurse #1 that hot tea spilled on Resident #1. Registered Nurse #1 stated a body assessment was done. Resident #1 was observed with redness and an open area to left lower abdomen and left inner thigh. Registered Nurse #1 stated they immediately applied a cold compress. The Medical Doctor was in the facility and was notified. The Medical Doctor examined, treated and Resident #1 received pain medicine for pain. Registered Nurse #1 stated Resident #1 received acetaminophen for pain. Registered Nurse #1 stated all staff members were in-serviced on handling of hot beverages and all Styrofoam cups were removed from the unit and replaced with insulated plastic mugs with lids. During an interview on 04/16/2024 at 1:30 pm, the Medical Doctor stated they were at the facility when they received a call from Registered Nurse #1 informing them about Resident #1's burn. The Medical Doctor stated they immediately went to assess Resident # 1, performed a body assessment, and observed Resident # 1 with redness on the abdomen and left inner thigh with some of the skin peeled off. The Medical Doctor stated they ordered a cream for treatment of the burns. The Medical Doctor stated Resident #1 did not complain of any pain or discomfort to the area, however, Resident #1 was on acetaminophen for pain. The Medical Doctor stated the incident was discussed extensively in an interdisciplinary team meeting and the team decided to replace the Styrofoam cups with insulated plastic mugs with lids. The Medical Doctor also stated the team decided to stop serving hot beverages in between meals on all the units. During an interview on 04/22/2024 at 10:30 am, the Director of Nursing stated they were informed by the Registered Nurse #1 on 04/02/2024 at approximately 2:25 pm, Resident #1 spilled their hot tea on themselves. Director of Nursing stated that first aid, and a cold compress was applied immediately. The Director of Nursing stated they immediately stopped the tea and cookies program. The Director of Nursing stated Resident #1 was assessed and the Medical Doctor was called. The Medical Doctor was in the building and immediately went and examined Resident #1, ordering to apply a cream daily to treat the burns. Resident #1 was to be followed by wound care per the Medical Doctor order. The Director of Nursing stated an interdisciplinary team meeting was held and they agreed to discontinue the Styrofoam cups off all the units and replaced them with insulated mugs with covered lids. A facility wide in-service was provided to staff members on burns and safe handling of hot foods and hot beverages. The Director of Nursing stated they informed the Facility's Administrator of the incident, and they continued to monitor Resident #1. The Director of Nursing stated Resident #1's burns were completely healed. During an interview on 04/22/2024 at 11:00 am, the Assistant Administrator stated they were informed of Resident #1's burns on 04/02/2024 at approximately 3:30 pm. The Assistant Administrator stated they immediately started an investigation. The Assistant Administrator stated an interdisciplinary team meeting was held on 04/03/2024 where the burn was discussed. The Assistant Administrator stated they implemented new interventions and an in-service with the staff members on safe handling of hot foods and hot beverages. Immediate Jeopardy was not identified, Facility Past Noncompliance was identified on 04/16/2024. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the Past noncompliance and was in substantial compliance for this specified regulatory requirement prior to surveyor's onsite visit on 04/16/2024. The facility implemented the following correction action prior to surveyor entrance date on 04/16/2024. Interdisciplinary team meeting was conducted on 04/04/2024, and the incident was discussed. New interventions were implemented to include: Discontinue usage of all Styrofoam cups for serving hot beverages. Use insulated plastic cups for all hot beverages. Inservice of staff across all disciplines for safe handling of hot beverages. The facility in-service staff members on safe handling food and beverages as follows. Administration 3 staffs = 100 %, Housekeeping 31/44 = 70 %, Dietary 34/48 = 71 % Plant operation 10/10 = 100 %, Recreation 10/10 = 100%, Human Resource 3/4 = 75% Nursing-Certified Nursing Assistant = 88, Licensed Practical Nurse =38, Registered Nurse = 46, a total of 172/319 = 53%. In-services ongoing, any staff members out on vacation will be in-service upon return. Three residents were interviewed on the use of Styrofoam cups on the unit. The residents stated the Styrofoam cups were removed and were replaced with insulated plastic cups. Seventeen staff members were interviewed, and they all stated that they received in-service on safe handling of food and beverages two weeks ago. They are knowledgeable on where to find the thermometer on the unit to test the hot foods. They are also knowledgeable of the acceptable temperature for hot beverages. Quality Assurance and Performance Improvement meeting is schedule for 4/18/2024, however, an interdisciplinary team meeting was held on 04/04/2024 on resident sustained burns during recreation program. The in-service coordinator will in-service staff members who are out on vacation on safe handling food and beverages upon return to work. 10 NYCRR 415.4(b)(1)(i)

Based on observations, record review, and interviews conducted during the Recertification and Complaint survey, the facility did not ensure safe food storage was practiced to prevent food-borne illness. This was evident during the initial tour of the Kitchen. Specifically, expired enteral feed nutritional supplement was observed in the Kitchen's emergency food supply storage area. The findings are: The facility policy titled Storage Policy revised ,d+[DATE] documented the Food Service Director (FSD) maintains adequate inventory, appropriate for rate of usage and emergency needs. On [DATE] at 10:10AM, the Kitchen's emergency food supply storage area was observed with an open cardboard box containing eight 1.1 quart Glucerna enteral feed with use by date of [DATE] on a shelf. On [DATE] at 2:57 PM, an interview was conducted with Dietary Aide (DA) #2 who stated they have been in charge of the supply of enteral feed in the Kitchen for more than a year and checks the supplies expiration dates. DA #2 last checked the enteral feed supply approximately 4 weeks ago and discarded expired items. DA #2 did not notice the expired enteral feed in the emergency supply storage area and it should have been discarded because it could have be served to a resident. On [DATE] at 4:04 PM, the Assistant Food Service Director (AFSD) was interviewed and stated they do daily rounds in the Kitchen to ensure expired food is not stored and served. The enteral feed delivery just came in and the AFSD does not know the reason it is expired. 415.14 (h)

Based on record review and interview conducted during the recertification survey, the facility did not ensure a person-centered comprehensive care plan (CCP) was developed to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. This was evident for 1 (Resident #31) of 38 sampled residents. Specifically, Resident #31's Dementia CCPs were not person-centered and did not include interventions to address Resident #31's Dementia-related behavioral symptoms of hitting, spitting, and scratching during care. The findings are: The facility policy titled Comprehensive Care Plan dated 06/2022 documented: The facility develops and maintains an individualized person-centered Comprehensive Care Plan to meet identified needs/goals. The resident care plan will include measurable goals and timeframes to meet medical, nursing, mental and psychological needs. The care plan also illustrates educational interventions provided for the resident/representative. 1) Resident #31 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS) dated [DATE], documented the resident had severe cognitive impairment with Short-term and Long-term Memory problems and no Memory/Recall Ability. The MDS further documented the resident had no Behavioral Symptoms, no Rejection of care, no wandering. A CCP titled Dementia Cognitive Loss As Evidenced By: Short term memory problems, Long term memory problems, and Limited performance initiated 5/16/2022 included only one intervention: Avoid situations that might precipitate negative behavior. There were no evaluation notes documented on the CCP. A second CCP titled Dementia Cognitive Loss As Evidenced By: Evidence by: Short term memory problems, Long term memory problems, and Limited performance initiated 5/16/2022 documented a goal to demonstrate reduced agitation. The CCP also included one intervention to avoid situations that might precipitate negative behavior. There were no evaluation notes on the CCP. Nursing admission note dated 5/4/2022 documented Resident #31 was admitted after being hospitalized secondary to Altered Mental Status and combativeness at home. Family reports recent escalation of agitation and overall symptoms of cognitive decline. Resident #31 was alert and oriented x (times) one, confused and agitated at times. On 8/31/2022 surveyor requested behavior notes and the facility provided the following behavior notes: A Medical progress note dated 5/10/2022 documented Resident #31 had with low urine output and dark urine. Resident #31 had a poor desire to drink. Resident #31's daughter-in-law was informed. It was impossible to put in any IV-line, as Resident #31 pulled it out immediately due to outburst. The Recreation quarterly note dated 8/13/2022 documented Resident #31 was alert, verbally responsive to stimuli, with agitation at times, and confusion. The Social services quarterly progress note dated 8/16/2022 documented Resident #31 was verbally responsive to all stimuli, with periods of agitation and confusion. Review of progress notes with dates range 5/22/2022 through 8/31/2022 had no documentation describing the specific behaviors of hitting, kicking, and spitting during care reported by staff during interviews. Nursing progress note dated 9/1/2022 documented Resident Behavior Note: Resident alert and responsive with confusion. Noted scratching, hitting, and spitting on staff while receiving care. Resident #31 refused to come out bed on regular basis, and the writer was unable to redirect resident due to constant confusion. Close monitoring continues. Behavioral Symptoms: Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). The resident's behaviors put the resident at significant risk for physical illness or injury, significantly interfere with the resident's care, and significantly interfere with the resident's participation in activities or social interactions. Impact on others- The resident's behavior puts others at risk for physical injury. On 09/01/22 at 12:49 PM, an interview was conducted with Certified Nursing Assistant (CNA#2), who cares for Resident #31. CNA #2 stated the resident is alert but very confused. CNA #2 stated the resident tends to lash out during care by hitting, grabbing, and scratching, hitting, spitting at staff hands during care. CNA #2 stated the resident is total care with all ADLS and required two persons to assist in care secondary to behaviors. CNA #2 stated these behaviors of hitting, scratching, spitting, occurred most of the time during care, and is not new. CNA #2 stated he/she always reports this to the nurse in charge and documents the behaviors in the CNA Accountability Record. CNA #2 was unable to show where this behavior was documented in the CNA Accountability record. CNA #2 stated redirect the resident by gently touching hands and although hard of hearing always speaks to the resident during care. CNA # 2 added this is not new behavior. On 09/02/22 at 10:16 AM, an interview was conducted with Registered Nurse Manager, RNM (RN#4). RN #4 stated all care plans are initiated upon admission and updated at the CCP meeting. RN#4 stated at the CCP meeting, the team discusses the resident and will initiate as well as update the CCP with any new behaviors. RN #4 stated Resident #31 was admitted with behaviors of hitting, kicking, and spitting during care, and was place on antipsychotic medications as a result. RN#4 stated spoke to the staff and the staff reported the resident was biting, hitting, spitting, scratching, and kicking during care. RN #4 stated the CNA should document any behavior issue on the CNA Accountability Record, but the task was not initiated. RN #4 stated staff should be writing notes on the resident's behavior as it occurred. RN #4 stated the resident transferred from another floor, and the staff assumed this was the resident baseline behaviors and did not document it. RN #4 stated he/she missed the behaviors and did not include the behaviors on the CCP. RN #4 stated he/she wrote a behavior note on 9/1/2022 and will continue to write behavior notes going forward. RN #4 also stated all RNs are responsible for initiating and updating CCPs, not only the night shift. RN #4 added it is the responsibility of all RNs to document and include interventions to address behaviors in the CCP but somehow this was missed. On 09/02/22 at 10:15 AM, an interview was conducted with Registered Nurse (RN #5). RN #5 stated all CCPs are initiated on the shift that the resident is admitted , and the night shift assists in updating care plans. RN #5 stated he/she is a floating charge nurse and is only responsible to initiate a CCP when have an admission on the shift worked. The night shift will update all CCPs. RN #5 stated Resident #31 had behavior of scratching, hitting, kicking, and stated saw a note was written on 9/1/2022. RN #5 stated per CNA, the resident always has this behavior. RN #5 stated when the behavior occurs, he/she will assist in calming the resident down and report the behavior to the Nursing Supervisor. RN #5 stated he/she was not sure what happened here. 415.11(c)(1)

Resident #31 Dementia Care Based on observations, interviews and record review conducted during a recertification survey, the facility did not ensure residents' comprehensive care plan (CCP) was reviewed and revised after each assessments. This was evident for 2 resident (Resident #31 and Resident #246) of 38 sampled residents. Specifically, Resident #31 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Resident #246 CCP was not reviewed and revised to address recommendations to remove hoyer lift canvas when out of bed to prevent friction and skin breakdown. The findings are: The facility policy titled Comprehensive Care dated 06/2022 documented The facility develops and maintains an individualized person-centered Comprehensive Care Plan to meet identified needs/goals. The Policy further documented the resident care plan will include measurable goals and time frame to meet medical, nursing, mental and psychological needs. The care plan also illustrates educational interventions provided for the resident/representative. 1) Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #31 had severe cognitive impairment. The CCP related to dementia was initiated on 5/16/22 and documented Resident #31 had short and long term memory problems. Interventions documented to avoid situations that might precipitate negative behavior. CCP related to Psychosocial Well Being- Adjustment was initiated 5/16/22 and documented Resident #31 displayed difficult behaviors and had impaired cognition. Interventions included orientation to room, roommate, and facility. Social services progress notes dated 8/16/2022 documented the quarterly assessment of Resident #31 who displayed periods of agitation and confusion. Recreation quarterly note dated 8/13/2022 documented Resident #31 had confusion and agitation at time. Resident #31 had limited decision-making capacity and all needs are anticipated by family and staff. Psychiatry progress notes dated 6/20/2022 documented Resident #31 had periods of confusion/agitation, and received [MEDICATION(S)] .25mg at night. There was no documented evidence Resident #31's CCP related to dementia was person-centered and reviewed and revised to reflect interventions that would address dementia and dementia related behaviors. On 09/01/22 at 12:49 PM, an interview was conducted with Certified Nursing Assistant (CNA) #2 who is assigned to Resident #31. CNA #2 stated Resident #31 is confused out during care by hitting, grabbing, and scratching staff. CNA #2 informed the nurse of the resident's behavior but did not have a place to document in their accountability record. CNA #2 redirects Resident #31's behavior. On 09/02/22 at 10:16 AM, an interview was Registered Nurse #5 who stated the SW is responsible for updating the Dementia CCP. RN #5 reviews the CCPs and missed Resident #31 and did not realize the CCP was not updated to reflect person-centered interventions for dementia. On 09/02/22 at 10:32 AM, an interview was conducted with the Director of Social work (DSW). DSW stated the Social Worker responsible for completing the Comprehensive Care Plan (CCP) is on vacation and not available. DSW stated is familiar with the resident, and the behaviors. DSW stated the Social Worker (SW) is responsible for the Dementia Care Plan, but it is a shared responsibility with nursing. DSW stated all CCP are reviewed and revised as needed Initially, Quarterly, Annually, significant changes and as needed. DSW stated Resident #31's CCPs were not individualized or person centered to address dementia and she will confer with the resident's SW. 2) Resident #246 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented resident was severely cognitively impaired, had impairment on one side to the upper extremity, was at risk for developing PU/injuries, and had one or more unhealed PU/injuries. On 08/26/22 at 02:31 PM, 09/01/22 at 09:20 AM, and 09/02/22 at 10:10 AM Resident #246 was observed laying on their right side on a hoyer list canvas while out of bed to their Geri-chair. The Comprehensive Care Plan (CCP) related to skin integrity was initiated 08.11.22 and documented Resident #246 developed a stage 2 PU to the right upper lateral arm. Resident prefers to lay on right side and reinforcement will be provided to prevent skin breakdown. The CCP related to bed mobility was initiated on 3/23/22 and documented to maintain Resident #246 skin integrity. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Registered Nurse (RN) note dated 8/12/22 documented Resident #246 prefers to lay on their right side. Resident #246 gets repositioned and will turn back to their right side. A Registered Nurse (RN) nursing note dated 8/12/22 documented Resident #246's right shoulder stage 2 PU was unavoidable as a result of having severe contractures and poor skin turgor. Resident #246 is also totally dependent on staff for activities of daily living and is non-ambulatory. Occupational Therapy (OT) note dated 8/19/22 documented Resident #246 prefers to lay on their right side and has developed a stage 2 PU on the right shoulder. Resident was assessed and observed positioning themselves on their right side on top of the hoyer lift canvas. It is highly recommended that hoyer lift canvas be removed when Resident #246 is in the Geri-chair to decrease the risks of skin breakdown. There was no documented evidence Resident #246's CCP to address risk for PU development was reviewed and revised to include the intervention to remove the hoyer lift canvas when Resident #246 is out of bed to their Geri-chair. There was no documented evidence the Certified Nursing Assistant Accountability Record (CNAAR) for August 2022 included OT recommendations to remove hoyer lift canvas. On 09/02/22 at 12:36 PM, Certified Nursing Assistant (CNA) #1 was interviewed who stated that they follow the plan of care on the CNAAR. CNA #1 transferred Resident #246 out of bed to the Geri-chair and kept the hoyer lift canvas under Resident #246 because it was not in the computer to remove it. On 09/02/22 at 12:05PM, the OT was interviewed and stated it was recommended that they remove Resident #246's Hoyer lift pad when in Geri-chair to reduce friction. The OT cannot recall if the nursing staff was made aware of the recommendation. On 09/02/22 at 11:09 AM, Registered Nurse (RN) #2 was interviewed and stated they are responsible for assessing Resident #246's wound and the interdisciplinary team recommends the interventions are done by the team. OT recommendations are supposed to reflected on CNAAR. On 09/02/22 at 11:30 AM RN #1 was interviewed and stated that there was a miscommunication with OT and their recommendations should have been reflected in Resident #246's CCP and CNAAR. On 09/02/22 at 12:44 PM RN #3 was assigned interviewed and stated Resident #246's CCP should be updated with any recommendations to prevent skin breakdown. On 09/02/22 at 01:35 PM, the Director of Nursing (DNS) was interviewed and stated CCP are reviewed and revised to ensure appropriate interventions are in place. The OT communicates with the RN to ensure recommendations and interventions are in place. The DNS stated they were not aware the referral for hoyer lift canvas removal was not implemented for Resident #246. 415.11 (c) (2) (i-iii)

Based on record review and interview conducted during the Recertification Survey from 8/25/22 to 09/02/22, the facility did not ensure a resident with mobility issues received treatment and care in accordance with the Comprehensive Care Plan (CCP). This was evident for 1 (Resident #246) of 1 resident reviewed for Pressure Ulcer (PU) out of a sample of 39 residents. Specifically, Resident #246 had contractures and required assistance with Activities of Daily Living and did not have hoyer lift canvas removed when out of bed in accordance with OT recommendations to prevent skin friction. The findings are: The facility's policy titled: Pressure Ulcer/Injury Prevention and Management, created on 03/09/15 and reviewed on 06/11/22, documented that 'this facility is committed to providing each resident/patient with comprehensive prevention and management of pressure ulcer/injuries. The policy also documented that the purpose is to prevent the development of new, or deterioration of existing pressure ulcer/injury(s) by individualized care plan and maintaining an active treatment plan Resident #246 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented resident was severely cognitively impaired, required total assistance of 2 people to transfer out of bed, required the use of a Geri-chair, had impairment on one side to the upper extremity, was at risk for developing PU/injuries, and had one or more unhealed PU/injuries. On 08/26/22 at 02:31 PM, 09/01/22 at 09:20 AM, and 09/02/22 at 10:10 AM Resident #246 was observed laying on their right side on a hoyer list canvas while out of bed to their Geri-chair. The Comprehensive Care Plan (CCP) related to skin integrity was initiated 08.11.22 and documented Resident #246 developed a stage 2 PU to the right upper lateral arm. Resident prefers to lay on right side and reinforcement will be provided to prevent skin breakdown. The CCP related to bed mobility was initiated on 3/23/22 and documented to maintain Resident #246 skin integrity. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Registered Nurse (RN) note dated 8/12/22 documented Resident #246 prefers to lay on their right side. Resident #246 gets repositioned and will turn back to their right side. A Registered Nurse (RN) nursing note dated 8/12/22 documented Resident #246's right shoulder stage 2 PU was unavoidable as a result of having severe contractures and poor skin turgor. Resident #246 is also totally dependent on staff for activities of daily living and is non-ambulatory. Occupational Therapy (OT) note dated 8/19/22 documented Resident #246 prefers to lay on their right side and has developed a stage 2 PU on the right shoulder. Resident was assessed and observed positioning themselves on their right side on top of the hoyer lift canvas. It is highly recommended that hoyer lift canvas be removed when Resident #246 is in the Geri-chair to decrease the risks of skin breakdown. There was no documented evidence the Certified Nursing Assistant Accountability Record (CNAAR) for August 2022 included OT recommendations to remove hoyer lift canvas. There was no documented evidence Resident #246's CCP related to mobility was reviewed and revised to address Resident preference to lay on right side and for hoyer lift canvas to be removed when transferred out of bed to their Geri-chair. On 09/02/22 at 12:36 PM, Certified Nursing Assistant (CNA) #1 was interviewed who stated that they follow the plan of care on the CNAAR. CNA #1 transferred Resident #246 out of bed to the Geri-chair and kept the hoyer lift canvas under Resident #246 because it was not in the computer to remove it. On 09/02/22 at 12:05PM, the OT was interviewed and stated it was recommended that they remove Resident #246's Hoyer lift pad when in Geri-chair to reduce friction. The OT cannot recall if the nursing staff was made aware of the recommendation. On 09/02/22 at 11:09 AM, Registered Nurse (RN) #2 was interviewed and stated they are responsible for assessing Resident #246's wound and the interdisciplinary team recommends the interventions are done by the team. OT recommendations are supposed to reflected on CNAAR. On 09/02/22 at 11:30 AM RN #1 was interviewed and stated that there was a miscommunication with OT and their recommendations should have been reflected in Resident #246's CCP and CNAAR. On 09/02/22 at 12:44 PM RN #3 was assigned interviewed and stated Resident #246's CCP should be updated with any recommendations to prevent skin breakdown. On 09/02/22 at 01:35 PM, the Director of Nursing (DNS) was interviewed and stated CCP are reviewed and revised to ensure appropriate interventions are in place. The OT communicates with the RN to ensure recommendations and interventions are in place. The DNS stated they were not aware the referral for hoyer lift canvas removal was not implemented for Resident #246. 415.12

Based on observations, interviews, and record review conducted during the Recertification Survey from 8/25/22 to 09/02/22, the facility did not ensure a resident at risk for pressure ulcer (PU) received appropriate treatment and services to prevent future PU. This was evident for 1 (Resident #246) of 1 resident(s) reviewed for PU/Injury out of 39 total sampled residents. Specifically, Resident #246 was observed on multiple occasions sitting on a hoyer lifter canvas after Occupational Therapy (OT) recommended hoyer lift canvas be removed to prevent friction. The findings are: The facility's policy titled: PU/Injury Prevention and Management, created on 03/09/15 and reviewed on 06/11/22, documented that 'this facility is committed to providing each resident/patient with comprehensive prevention and management of PU/injuries. The policy also documented that the purpose is to prevent the development of new, or deterioration of existing PU/injury(s) by individualized care plan and maintaining an active treatment plan Resident #246 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented resident was severely cognitively impaired, had impairment on one side to the upper extremity, was at risk for developing PU/injuries, and had one or more unhealed PU/injuries. On 08/26/22 at 02:31 PM, 09/01/22 at 09:20 AM, and 09/02/22 at 10:10 AM Resident #246 was observed laying on their right side on a hoyer list canvas while out of bed to their Geri-chair. The Comprehensive Care Plan (CCP) related to skin integrity was initiated 08.11.22 and documented Resident #246 developed a stage 2 PU to the right upper lateral arm. Resident prefers to lay on right side and reinforcement will be provided to prevent skin breakdown. The CCP related to bed mobility was initiated on 3/23/22 and documented to maintain Resident #246 skin integrity. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Registered Nurse (RN) note dated 8/12/22 documented Resident #246 prefers to lay on their right side. Resident #246 gets repositioned and will turn back to their right side. A Registered Nurse (RN) nursing note dated 8/12/22 documented Resident #246's right shoulder stage 2 PU was unavoidable as a result of having severe contractures and poor skin turgor. Resident #246 is also totally dependent on staff for activities of daily living and is non-ambulatory. Occupational Therapy (OT) note dated 8/19/22 documented Resident #246 prefers to lay on their right side and has developed a stage 2 PU on the right shoulder. Resident was assessed and observed positioning themselves on their right side on top of the hoyer lift canvas. It is highly recommended that hoyer lift canvas be removed when Resident #246 is in the Geri-chair to decrease the risks of skin breakdown. There was no documented evidence Resident #246's CCP to address risk for PU development was reviewed and revised to include the intervention to remove the hoyer lift canvas when Resident #246 is out of bed to their Geri-chair. There was no documented evidence the Certified Nursing Assistant Accountability Record (CNAAR) for August 2022 included OT recommendations to remove hoyer lift canvas. On 09/02/22 at 12:36 PM, Certified Nursing Assistant (CNA) #1 was interviewed who stated that they follow the plan of care on the CNAAR. CNA #1 transferred Resident #246 out of bed to the Geri-chair and kept the hoyer lift canvas under Resident #246 because it was not in the computer to remove it. On 09/02/22 at 12:05PM, the OT was interviewed and stated it was recommended that they remove Resident #246's Hoyer lift pad when in Geri-chair to reduce friction. The OT cannot recall if the nursing staff was made aware of the recommendation. On 09/02/22 at 11:09 AM, Registered Nurse (RN) #2 was interviewed and stated they are responsible for assessing Resident #246's wound and the interdisciplinary team recommends the interventions are done by the team. OT recommendations are supposed to reflected on CNAAR. On 09/02/22 at 11:30 AM RN #1 was interviewed and stated that there was a miscommunication with OT and their recommendations should have been reflected in Resident #246's CCP and CNAAR. On 09/02/22 at 12:44 PM RN #3 was assigned interviewed and stated Resident #246's CCP should be updated with any recommendations to prevent skin breakdown. On 09/02/22 at 01:35 PM, the Director of Nursing (DNS) was interviewed and stated CCP are reviewed and revised to ensure appropriate interventions are in place. The OT communicates with the RN to ensure recommendations and interventions are in place. The DNS stated they were not aware the referral for hoyer lift canvas removal was not implemented for Resident #246. 415.12(c) 1

Based on observations, interviews, and record review conducted during the recertification survey from 8/25/22 to 9/2/22, the facility did not ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #31) of 1 resident(s) reviewed for Dementia Care out of a sample of 38 residents. Specifically, a Comprehensive Care Plan (CCP) related to Dementia was not individualized and revised with person-centered intervention to address Resident #31's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The findings are: The facility policy titled Comprehensive Care dated 06/2022 documented The facility develops and maintains an individualized person-centered Comprehensive Care Plan to meet identified needs/goals. The Policy further documented the resident care plan will include measurable goals and time frame to meet medical, nursing, mental and psychological needs. The care plan also illustrates educational interventions provided for the resident/representative. The Facility Policy titled Dementia Resident assessment dated [DATE] documented the policy is to provide optimal medical and psychological support to residents with Dementia based on an assessment of their needs. Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #31 had severe cognitive impairment. The CCP related to dementia was initiated on 5/16/22 and documented Resident #31 had short and long term memory problems. Interventions documented to avoid situations that might precipitate negative behavior. CCP related to Psychosocial Well Being- Adjustment was initiated 5/16/22 and documented Resident #31 displayed difficult behaviors and had impaired cognition. Interventions included orientation to room, roommate, and facility. Social services progress notes dated 8/16/2022 documented the quarterly assessment of Resident #31 who displayed periods of agitation and confusion. Recreation quarterly note dated 8/13/2022 documented Resident #31 had confusion and agitation at time. Resident #31 had limited decision-making capacity and all needs are anticipated by family and staff. Psychiatry progress notes dated 6/20/2022 documented Resident #31 had periods of confusion/agitation, and received [MEDICATION(S)] .25mg at night. There was no documented evidence Resident #31's CCP related to dementia was person-centered and reviewed and revised to reflect interventions that would address dementia and dementia related behaviors. On 09/01/22 at 12:49 PM, an interview was conducted with Certified Nursing Assistant (CNA) #2 who is assigned to Resident #31. CNA #2 stated Resident #31 is confused out during care by hitting, grabbing, and scratching staff. CNA #2 informed the nurse of the resident's behavior but did not have a place to document in their accountability record. CNA #2 redirects Resident #31's behavior. On 09/02/22 at 10:16 AM, an interview was Registered Nurse #5 who stated the SW is responsible for updating the Dementia CCP. RN #5 reviews the CCPs and missed Resident #31 and did not realize the CCP was not updated to reflect person-centered interventions for dementia. On 09/02/22 at 10:32 AM, an interview was conducted with the Director of Social work (DSW). DSW stated the Social Worker responsible for completing the Comprehensive Care Plan (CCP) is on vacation and not available. DSW stated is familiar with the resident, and the behaviors. DSW stated the Social Worker (SW) is responsible for the Dementia Care Plan, but it is a shared responsibility with nursing. DSW stated all CCP are reviewed and revised as needed Initially, Quarterly, Annually, significant changes and as needed. DSW stated Resident #31's CCPs were not individualized or person centered to address dementia and she will confer with the resident's SW. 415.12