Every finding on record at Monroe Community Hospital

Based on interviews and record review conducted during an Abbreviated Survey (Incident ID: 2640065) from 10/15/2025 to 10/24/2025, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1 had no documented bowel movement from 09/24/2025 through 10/03/2025 and there was no documented evidence any as needed medications for constipation were administered. Resident #1 was hospitalized on [DATE] and found to have severe rectal stool burden (excessive amount of stool in the colon or rectum) requiring manual disimpaction (a procedure used to remove stool from the rectum) and stercoral colitis (an inflammatory condition of the large bowel caused by substantial stool burden). Following return from the hospital on [DATE], Resident #1 had no documented bowel movement through 10/16/2025, and there was no evidence any as needed bowel medications were administered until 10/15/2025. This facility's failure to implement an effective bowel management protocol, to follow care plan interventions, and act on documented alerts and bowel movement reports resulted in actual harm for Resident #1 and a likelihood for serious injury, serious harm, serious impairment, or death for all residents in the facility (census 403), that was Immediate Jeopardy and Substandard Quality of Care. The findings include: The facility policy titled Provision of Resident Care, revised 05/15/2023, included after care such as incontinence and bowel care is performed it is entered into the electronic medical record. The electronic medical record is programmed to provide alerts and reports for specific care-related documentation, including alerts and tasks that would prompt receiving users to initiate proper follow-up. Programmed alerts included, but are not limited to, absent bowel movements. Receiving users are expected to review and act upon alerts each shift. Programmed reports include bowel tracking and receiving users were expected to review and act upon the reports each shift.An undated facility document Bowel Movement (BM) Alert Training included if a resident has not had a documented bowel movement, an alert would trigger under the To Do list in the electronic medical record. Clinical nurse managers, administrative nurse managers, assessment nurses, supervisors, registered nurses, and nursing administration would see these alerts. Nursing should implement an appropriate bowel movement protocol and once the appropriate protocol was in place, the alert should be cleared. The facility could not provide a written bowel regimen policy, procedure, or protocol that provided monitoring timeframes or the parameters for administering as needed bowel medications. Resident #1 had diagnoses including multiple sclerosis (a disease that affects the central nervous system), depression, and generalized weakness. The Minimum Data Set (a resident assessment tool) dated 09/05/2025 included the resident was cognitively intact.Review of the comprehensive care plan last revised on 09/15/2025, revealed the resident had hypothyroidism (a condition where the thyroid gland is underactive) and a history of constipation with the use of laxatives (medications or substances that promote bowel movements) daily. Interventions included, but were not limited to, monitor bowel movements, check bowel sounds as indicated, assess abdomen for distention, and bowel management per medical orders.Review of September 2025 and October 2025 Physician Order Sheets revealed an order dated 08/29/2025 for polyethylene glycol 17 grams oral powder as needed two (2) times daily for constipation and an order dated 10/21/2024 for milk of magnesium 400 milligrams oral suspension once a day as needed for constipation. The physician orders did not specify after how many days without a bowel movement to administer as needed medications or the order in which as needed medications were to be administered.Review of the Activities of Daily Living Verification Worksheet (part of the electronic medical record used to track resident care) revealed Resident #1 had no documented bowel movement from 09/24/2025 through 10/03/2025.Review of bowel movement reports (includes the number of times residents had no bowel movement recorded or had missed documentation during the previous three (3) days), revealed Resident #1 was listed on reports dated 09/26/2025, 09/29/2025, 10/01/2025, and 10/03/2025. There was no documented evidence the reports had been reviewed or acted upon. Review of September 2025 and October 2025 Medication Administration Records revealed the as needed medications prescribed to Resident #1 for constipation were not administered from 09/24/2025 through 10/03/2025.Review of medical provider visit notes from 09/24/2025 to 10/03/2025 did not include evidence Resident #1's bowel status had been addressed. In a progress note dated 10/02/2025, Licensed Practical Nurse #4 documented Resident #1 was found wearing multiple urine-soaked briefs with a stool-contaminated dressing to the sacrum. There was no documented evidence of the size, amount, color, or consistency of the stool.In a Provider Acute Visit note dated 10/03/2025, Physician Assistant #1 documented Resident #1 had developed a fever and tachycardia (rapid heart rate) and there was concern the resident was having a septic response (a life-threatening condition that occurs when the body's immune system overreacts to an infection) to a deeper infection. Resident #1 would be sent to the hospital for further evaluation. There was no documented evidence the resident's abdomen or bowel status were assessed at that time. Resident #1 was hospitalized from [DATE] to 10/09/2025. The Hospital Discharge summary dated [DATE], documented Resident #1 had imaging (a medical technique used to see inside the body to diagnose conditions and plan treatment) on 10/03/2025 with results including severe rectal stool burden. Resident #1 had sepsis secondary to potential intra-abdominal (within the abdominal cavity) infection from stercoral colitis and experienced a high fever and tachycardia following manual disimpaction. Resident #1 was readmitted to the facility on [DATE]. Review of the Activities of Daily Living Verification Worksheet from 10/09/2025 through 10/16/2025 revealed Resident #1 had no documented bowel movement(s).Review of bowel movement reports revealed Resident #1 was listed on reports dated 10/10/2025 and 10/13/2025. There was no documented evidence the reports had been reviewed or acted upon. Review of the Medication Administration Record from 10/09/2025 to 10/14/2025 revealed as needed medications prescribed for constipation had not been administered. A nursing progress note dated 10/15/2025, by Licensed Practical Nurse #5, documented as needed milk of magnesium and polyethylene glycol were administered to Resident #1 at 4:39 PM.During an interview on 10/15/2025 at 11:41 AM, Licensed Practical Nurse #5 stated they were not aware Resident #1 had been treated in the hospital for bowel impaction and most residents had as needed medications ordered for constipation. In a follow-up interview at 3:16 PM, Licensed Practical Nurse #5 stated a report was generated from the electronic medical record listing residents who had not had a bowel movement in three (3) days, and they would follow the bowel protocol which included administering as needed medications for those residents with orders. During an interview on 10/15/2025 at 3:31 PM, Certified Nursing Assistant #1 stated they documented bowel movements in the electronic medical record. They stated printed reports identifying residents with no bowel movement in three (3) days were reviewed during shift huddles to verify whether any documentation of bowel movements was missed.During an interview on 10/15/2025 at 4:06 PM, Medical Director #1 stated they expected nursing staff to administer as needed bowel medications if there was no bowel movement in three (3) days and notify a provider if medications were not effective or not ordered. Medical Director #1 stated they believed there was a bowel alert report listing residents without bowel movements available to nursing staff. They stated if a resident had multiple medications ordered, the orders should specify which medication to administer first. Medical Director #1 stated the facility did not have a written bowel management protocol. During an interview on 10/15/2025 at 4:30 PM, Director of Nursing #1 stated bowel movement reports were printed on Mondays, Wednesdays, and Fridays (automatically by the electronic medical record) and listed residents without a bowel movement. They stated the reports were intended to alert staff for follow-up.During an interview on 10/15/2025 at 5:33 PM, Licensed Practical Nurse #6 stated bowel movement lists were printed daily, identified residents without a bowel movement in three (3) days, and were reviewed during morning report. They stated they would administer bowel medications or notify the provider if no medications were ordered, and certified nursing assistants were instructed to notify them when a bowel movement occurred so it could be documented.During an interview on 10/16/2025 at 1:43 PM, Registered Nurse Manager #1 stated bowel movement reports were printed three (3) times per week and reviewed with certified nursing assistants. They stated the electronic medical record would generate alerts at 24, 48, and 72 hours for residents without a bowel movement. Registered Nurse Manager #1 stated most residents were on bowel regimens and the bowel management process involved the use of as needed medications. They were unable to locate a written bowel protocol upon request.During an interview on 10/16/2025 at 2:56 PM with Director of Nursing #1 and Director of Nursing #2, Director of Nursing #1 stated if a resident had several as needed medications for constipation, the nurse should review the medication indication to determine which medication to use. Director of Nursing #2 stated the nurse should start with the least restrictive medication. Director of Nursing #1 stated there were no bowel movement entries for Resident #1 from 09/24/2025 through 10/03/2025 and believed someone may have forgotten to document a bowel movement. Director of Nursing #1 stated they had no explanation for how this was not identified despite bowel alerts and reports.During a follow-up interview on 10/21/2025 at 11:32 AM, Medical Director #1 stated a resident could have leakage of stool around a bowel impaction. They stated Resident #1's bowel impaction was likely preventable because interventions were not implemented. They stated Resident #1 was at high risk for constipation due to immobility and a neurologic condition and would have expected bowel management to be addressed when Resident #1 returned from the hospital.During a telephone interview on 10/24/2025 at 11:49 AM, Licensed Practical Nurse #2 stated bowel movement reports had been printed daily until a system upgrade six (6) months earlier. After the upgrade, reports were printed every other day and then only on Mondays, Wednesdays, and Fridays. Licensed Practical Nurse #2 stated they had been serving as an interim charge nurse since 08/06/2025 and had not understood the bowel alerts in the electronic medical record until recently receiving education. They were not aware Resident #1 had not had a bowel movement from 09/24/2025 through 10/03/2025 and would have expected to be informed.During a telephone interview on 10/24/2025 at 10:40 AM, Nurse Practitioner #1 stated they expected staff to notify them if a resident had not had a bowel movement in more than two (2) days or was experiencing discomfort. They stated the facility did not have a bowel protocol and most residents were on bowel regimens. Nurse Practitioner #1 stated they specified the order bowel medications were to be administered when prescribing the medications. They stated they were unaware Resident #1 had not had a bowel movement from 09/24/2025 through 10/03/2025 or from 10/09/2025 through 10/16/2025.The survey team identified Immediate Jeopardy, and the facility Administrator was notified on 10/17/2025 at 2:30 PM.On 10/20/2025 at 10:45 AM, the survey team determined the Immediate Jeopardy was removed based on the following corrective actions taken by the facility:The facility provided a copy of the defined Bowel Management Regimen policy and procedure, dated 10/17/2025. The bowel regimen policy was observed in binders on each residential unit along with current bowel movement reports. The facility provided supporting documentation for 85.5% of nursing staff educated on the formal bowel management policy and procedure with an attestation that all remaining nursing staff would receive education prior to their next scheduled shift. Interviews with several staff revealed appropriate knowledge of the bowel management process.A list of all facility residents who did not have a documented bowel movement in three (3) days was provided. Supporting evidence of as needed medications offered and provided was reviewed with no identified concerns. 10 NYCRR 415.12

Based on interviews and record review conducted during an Abbreviated Survey (Incident ID: 2640065) from 10/15/2025 to 10/24/2025, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of three (3) residents (Resident #1) reviewed. Specifically, the facility failed to assess, treat and prevent deterioration of Resident #1's sacral pressure ulcer from 08/30/2025 through 09/22/2025 which resulted in severe pain to the wound and the wound required sharp debridement during a hospitalization. This resulted in actual harm for Resident #1 and a likelihood for serious injury, serious harm, serious impairment, or death for 29 residents in the facility (census 403) identified as having pressure ulcers that was Immediate Jeopardy and Substandard Quality of Care. The findings include:The facility policy Skin Care Program revised 03/04/2025 included, but was not limited to, comprehensive skin assessments are completed by the registered nurse upon admission and with any significant change of condition, skin checks will be performed once weekly by the registered nurse or licensed practical nurse, daily visual checks during routine care should be completed by the certified nursing assistants and if a new area is identified the staff nurse should be notified. The staff nurse should complete an electronic incident report once a new open area is identified which triggers notification to the wound care team. The wound care team will assess the site and recommend an appropriate course of treatment. An individualize skin care plan will be developed and tailored to the resident's clinical condition and risk profile. Resident #1 had diagnoses including multiple sclerosis (a disease that affects the central nervous system), depression, and generalized weakness. The Minimum Data Set (a resident assessment tool) dated 09/05/2025 included the resident was cognitively intact.Review of the Comprehensive Care Plan revised 09/15/2025 revealed Resident #1 had the potential for alterations in their skin related to decreased mobility. Interventions included, but not limited to, assess for new skin breakdown, turn and reposition per policy, keep the skin dry and clean, and provide appropriate skin barriers.There was no documented evidence the care plan included documentation of conversations related to the resident's condition, treatment options, expected outcomes, and consequences of refusing treatment. The Resident Care Summary Assessment (care plan used by certified nursing assistants) reviewed on 10/15/2025, revealed Resident #1 required the limited assistance of one (1) staff for bed mobility, had a specialty mattress, and staff were to apply barrier cream or gel to the intact skin of the buttocks two (2) times a day, and notify the nurse for redness or irritation.The September 2025 Physician Order Sheet included an order dated 12/14/2023 to apply a thick layer of barrier cream to the right and left buttocks two (2) times a day. Resident #1 was hospitalized from [DATE] to 08/30/2025 for evaluation of stroke-like symptoms. In a hospital consult note dated 08/25/2025, Wound Care Registered Nurse #2 documented the resident had a partial thickness/Stage 2 (a type of skin injury that involves damage to the outer layer of skin) wound to their sacrum (the bony area at the top of the buttocks) related to friction and moisture and complicated by pressure and immobility. The wound measured 1.5 centimeters (length) by 0.5 centimeters (width) by 0.1 centimeters (depth). The periwound (skin surrounding the wound) had hyperpigmented (darkened) scar tissue likely related to continuous irritation or friction on the skin.The hospital After-Visit Summary dated 08/30/2025, included wound care instructions to cleanse the sacral wound bed with normal saline moistened gauze, allow to dry, and cover with a foam dressing every three (3) days and as needed. There is no documented evidence new wound care orders were entered for Resident #1 from 08/30/2025 through 09/22/2025.Resident #1 returned to the facility on [DATE]. In a Provider Visit Note dated 09/02/2025, Nurse Practitioner #1 documented Resident #1 was admitted to the hospital on [DATE] with acute encephalopathy (a change in brain function due to injury or disease), underwent a stroke workup, and was treated for a urinary tract infection. There is no documented evidence Nurse Practitioner #1 assessed Resident #1's sacral wound or reviewed the wound care recommendations from the hospital.In a nursing progress note dated 08/30/2025, Licensed Practical Nurse #2 documented the resident's arrival to the facility and an area on the sacrum measuring 2.0 centimeters by 2.0 centimeters with soft, pink, friable (thin, delicate, and easily tears or breaks) skin. A sacral foam dressing was replaced.There is no documented evidence of dressing changes from 08/31/2025 to 09/21/2025. In a Skin Check dated 09/02/2025, Registered Nurse Assistant Director of Nursing #1 documented Resident #1 had a Stage 1 pressure ulcer to the sacrum measuring 2.0 centimeters by 2.0 centimeters. There is no documented evidence additional skin checks were completed until 09/23/2025.In a progress note dated 09/11/2025, Licensed Practical Nurse #1 documented nursing staff found an open area on Resident #1's sacrum, notified the nursing supervisor, and entered a note in the communication log (used by staff to communicate resident status and changes in condition to medical providers). In an incident report (used to trigger notification to the wound care team of a new open skin area) dated 09/11/2025, Licensed Practical Nurse #1 documented the discovery of an open area to the sacrum during care, Nursing Supervisor #1 was notified, and a medical provider was notified via the communication log. The report included it was reviewed at morning report on 09/12/2025.In a Communication Log entry dated 09/11/2025, Licensed Practical Nurse #1 documented Resident #1 had an open area to the sacrum. The provider response section had 'In hospital' handwritten and did not include a date or initials.In a progress note dated 09/12/2025 at 3:41 AM, Licensed Practical Nurse #7 documented Resident #1 was sent to the hospital. The resident returned to the facility on [DATE].In a Communication Log entry dated 09/16/2025, Licensed Practical Nurse #2 documented an open area noted 9/11 by nurse via incident report. The provider response section was initialed by Nurse Practitioner #1 and dated 09/16/2025.The documented evidence revealed the wound was not seen by or documented by a provider until 09/23/2025.In a progress note dated 10/15/2025, documented as a late entry (an addition to the medical record made after the original event, to document information that was missed or forgotten), Wound Care Registered Nurse #1 documented Resident #1 was not seen on 09/12/2025 after initial notification of possible skin breakdown because the resident was out at the hospital and they were unable to assess the resident's skin on 09/17/2025 because the resident was up in a wheelchair and declined to return to bed for assessment. In a progress note dated 09/21/2025, Licensed Practical Nurse #3 documented they were called to change a dressing found on Resident #1's sacrum. The wound measured 1.75 to 2.0 centimeters (length) by 0.5 centimeters (width) by 0.25 centimeters (depth). Licensed Practical Nurse #3 was informed the wound had been brought to other nurses' attention five (5) days earlier and they notified Registered Nurse #2.In an incident report dated 09/21/2025, Licensed Practical Nurse #3 documented the dressing change to Resident #1's sacral wound, Registered Nurse #2 was notified, and a medical provider was notified via the communication log. The report included it was reviewed at morning report on 09/22/2025.In a Communication Log entry dated 09/21/2025, Licensed Practical Nurse #3 documented Resident #1 had an open area to the sacrum. The provider response section had 'Wound to see' handwritten, was initialed by Medical Director #1 and dated 09/22/2025.In a progress note dated 09/21/2025, Registered Nurse #2 documented they were notified Resident #1 had an open area on their sacrum, measured the wound, and placed a dressing. Resident #1 reported they had pain in the sacral area that rated a 5 (moderately strong pain) out of 10 (worst pain possible). The incident was written in the Communication Log for further follow-up.In a Wound Assessment note dated 09/23/2025, Wound Care Registered Nurse #1 documented Resident #1 had a 2.0 centimeter (length) by 2.0 centimeter (width) unstageable (a type of pressure injury where the wound bed is fully or partially covered with dead tissue) sacral wound with slough (dead tissue within a wound) and recommended daily treatment with gelling fiber (a wound dressing) and a foam dressing for autolytic debridement (a wound care technique that breaks down and removes dead tissue) and a pressure-relieving mattress.Review of medical orders dated 09/23/2025 included wound care orders for the sacral pressure ulcer to be completed daily and as needed, and a specialty (ROHO) mattress. In a provider Acute Visit Note dated 09/29/2025, Nurse Practitioner #1 documented Resident #1's sacral wound measured approximately 2.0 centimeters by 3.0 centimeters with surrounding erythema (redness) and tenderness and the resident had severe pain to the wound with no as needed pain medication available. There was no documented evidence a medical provider saw Resident #1 or addressed their sacral wound and related pain from 08/30/2025 to 09/28/2025.In a Wound Assessment note dated 10/02/2025, Wound Care Registered Nurse #1 documented a Stage 4 (a severe pressure injury with full-thickness skin loss and tissue damage that extends into muscle, bone, or tendons) sacral pressure injury measuring 4.5 centimeters (length) by 3.5 centimeters (width) by 1.0 centimeter (depth) with a larger area of periwound erythema and non-blanchable skin (areas of skin that do not turn white when pressure is applied) and recommended a daily Vashe (skin cleanser used for debriding and irrigating wounds) moistened gauze dressing.In a Provider Acute Visit note dated 10/03/2025, Physician Assistant #1 documented the resident was followed for a Stage 4 sacral wound and received one (1) dose of Ceftriaxone (an antibiotic) intramuscularly the previous night. Resident #1 had developed a fever and tachycardia (rapid heart rate) and there was concern the resident was having a septic response (a life-threatening condition that occurs when the body's immune system overreacts to an infection). Resident #1 would be sent to the hospital for further evaluation. Resident #1 was hospitalized from [DATE] to 10/09/2025.Review of a hospital surgical consult note dated 10/08/2025, Physician #2 documented the sacral wound bed was covered with fibrinopurulent exudate (a type of inflammatory fluid that is typically found in areas of infection) and necrotic (dead tissue that has lost its blood supply and is no longer able to function) skin and had sharp debridement (a medical procedure that involves removing dead, infected, or damaged tissue from a wound with sharp instruments such as a scalpel or forceps) at the bedside.During an interview on 10/15/2025 at 11:30 AM, Resident #1 stated they do not get out of bed unless they have an appointment because if they get up, they will have to wait until the next shift to get back in bed. Resident #1 stated sitting for long periods of time is painful at the wound site.During an observation on 10/15/2025 at 12:30 PM, Licensed Practical Nurse #5 performed wound care as ordered. Resident #1 yelled out you are hurting me during the dressing change. Licensed Practical Nurse #5 proceeded with the dressing change and did not address Resident #1's pain.During an interview on 10/20/2025 at 1:55 PM, Registered Nurse Assistant Director of Nursing #1 stated weekly skin checks were required, and certified nursing assistants were expected to report changes so licensed nurses could evaluate the wound, with registered nurses verifying any identified skin concerns. They stated wound issues should be entered in the communication log or referred to the wound team and nursing supervisors complete skin and pain assessments on new admissions or readmissions on weekends and after hours. Registered Nurse Assistant Director of Nursing #1 stated they completed a skin check on 09/02/2025, identifying a Stage 1 (an early-stage skin injury caused by prolonged pressure) wound, applied barrier cream, and did not apply a dressing to the area since the skin was intact. There was no documented evidence a provider was notified of the Stage 1 pressure injury, or an incident report initiated. During an interview on 10/20/2025 at 2:44 PM, Wound Care Occupational Therapist #1 stated the wound team reviewed incident reports daily, attempted to assess residents as scheduling allowed, and prioritized those residents with newly reported skin concerns. Wound Care Occupational Therapist #1 stated if a resident declined to return to bed for a wound assessment, the wound team attempted later the same day or scheduled them first for the next day if still unable to see them.During an interview on 10/20/2025 at 3:49 PM, Wound Care Registered Nurse #1 stated weekly skin checks were expected. They were not informed of Resident #1's skin findings from 08/30/2025 or 09/02/2025 but would have expected to be notified so they could advise on any skin treatments and make a plan to see the resident. Wound Care Registered Nurse #1 stated they attempt to educate residents who refuse evaluations and may document additional notes when needed. Wound Care Registered Nurse #1 stated they recalled a skin concern entered for Resident #1 on 09/11/2025, but Resident #1 was out of the facility on 09/12/2025, and the resident later declined assessment on 09/17/2025. They stated after receiving a second incident report on 09/21/2025 they evaluated the wound on 09/23/2025. The sacral wound had significant slough and drainage, and they ordered daily dressing changes and a specialty mattress. Wound Care Registered Nurse #1 stated they examined the wound again on 10/02/2025 and the dressing was heavily soiled with urine and stool. They stated a day or two (2) prior, Nurse Practitioner #1 informed them the wound was worsening, and Wound Care Registered Nurse #1 was advised by Nurse Practitioner #1 assessment of the wound could wait until the next scheduled wound rounds.During a telephone interview on 10/21/2025 at 8:45 AM, Licensed Practical Nurse #1 stated day shift nurses typically complete weekly skin checks and certified nursing assistants report concerns. They stated new open areas require cleaning, measurements, application of a dressing, supervisor notification, communication log entry, and incident reporting. They recalled a certified nursing assistant reporting Resident #1's open sacral area in September 2025, after which they documented it and notified the provider.During a telephone interview on 10/21/2025 at 11:00 AM, Licensed Practical Nurse #3 stated they were called by a certified nursing assistant to see Resident #1's wound on 09/21/2025. Licensed Practical Nurse #3 stated there was a dressing in place. They cleansed the wound, applied barrier film, used silver gelling fiber, and placed a foam dressing without a provider order, and stated the certified nursing assistant reported notifying another nurse four (4) to five (5) days earlier.During an interview on 10/21/2025 at 11:32 AM, Medical Director #1 stated they expect nursing staff to assess new skin issues, document open wounds with an incident report, and notify the wound team for pressure concerns. They stated Stage 1 wounds do not usually require provider notification, but the wound team should be notified to monitor. Medical Director #1 stated they learned of Resident #1's wound on 09/22/2025, was informed the wound team would see the resident, and documented Wound to see in the communication log. They stated early interventions should occur when a wound is first identified but believed the wound was likely unavoidable due to Resident #1's immobility and inability to tolerate being off the area.During an interview on 10/21/2025 at 9:29 AM with Director of Nursing #1 and Director of Nursing #2, Director of Nursing #1 stated weekly skin checks are expected but not strictly done every seven (7) days. Director of Nursing #1 stated new skin issues should prompt a supervisor check, progress note, and provider communication for pressure wounds, but would not expect an incident report to be created for Stage 1 wounds. Director of Nursing #1 stated the wound team receives alerts in the electronic health record for new pressure wounds and attends morning reports where incident reports are reviewed. Director of Nursing #2 stated Resident #1 returned from the hospital on [DATE], with a fragile skin area covered by a dressing, and an open area was entered in the communication log on 09/11/2025. Director of Nursing #2 stated an open area is not always considered a pressure ulcer and could be moisture associated skin damage (MASD, inflammation or skin erosion caused by long-term exposure to moisture). Director of Nursing #2 stated the wound team first saw Resident #1 for their sacral pressure ulcer on 09/23/2025.During a telephone interview on 10/24/2025 at 10:40 AM, Nurse Practitioner #1 stated they review hospital information and see residents upon return but do not always document the visit. They stated nurses report new concerns through the communication log, which Nurse Practitioner #1 initialed when reviewed, and assessed the resident as needed. Nurse Practitioner #1 stated they recalled seeing Resident #1 for pain and observing a small open area on their sacrum, applying barrier cream, and alerting the wound team; they could not recall the date of the visit. They later saw the worsening wound at the wound team's request; they could not recall the date of the visit. Nurse Practitioner #1 stated they may not document every resident visit and were not aware Resident #1 missed wound assessments on 09/12/2025 and 09/17/2025. They expected the wound team to notify them if the wound team was unable to see a resident.The survey team identified Immediate Jeopardy, and the facility Administrator was notified on 10/21/2025 at 4:38 PM.On 10/21/2025 at 8:15 PM, the survey team determined the Immediate Jeopardy was removed based on the following corrective actions taken by the facility: All residents with pressure ulcers were reassessed and treatment plans were reviewed for appropriateness. The survey team reviewed additional residents with no identified concerns. The Skin Care Program policy and procedure was revised to include all new admissions and readmissions would be screened by a member of the wound care team to ensure appropriate skin care treatment plan was initiated.100% of Wound Care staff received re-education on the revised policy and procedure. The survey team verified the education through staff interviews. 10 NYCRR 415.12(c)(1)(2)

Based on observations, interviews and record review conducted during an Abbreviated Survey (Complaint #: NY00368800/Intake ID: 466508) from 08/26/2025 to 09/12/2025, the facility failed to ensure residents received the necessary care, treatment, and services, consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for one (1) of three (3) residents (Resident #8) reviewed. Specifically, the facility failed to ensure Resident #8's specialty mattress was in place from 01/04/2025 to 01/10/2025, and the resident was later found to have a stage two (2) (partial-thickness skin loss) and stage three (3) (full-thickness skin loss) pressure ulcer to their buttocks. This resulted in actual harm to Resident #8 that is not Immediate Jeopardy. The findings are:The facility policy, Skin Care Program, with a revision date of 10/01/2023, included all residents with a history of pressure injuries within the past 12 months should be considered to be in the high risk category for prophylactic (preventative) interventions. All wounds will be offloaded (the process of reducing or eliminating pressure on a wound site to promote healing) and advanced wound therapies will be utilized to promote wound healing in accordance with best practices. The undated facility document, How To Check the Proper Placement of ROHO (mattress overlay system for people who require skin or soft tissue protection) and Low Air Loss (LAL) Mattresses for Residents, included specialty mattresses are specifically designed to reduce pressure over the body in order to help prevent and treat pressure injuries (pressure ulcers). All specialty mattresses need to be checked by the nurse every shift to ensure they are in place and functioning properly for the safety of residents. If a resident has an order for a specialty mattress and the mattress is not in place or is malfunctioning, the nursing supervisor should be immediately notified. Resident #8 had diagnoses that included diabetes, pressure ulcers, and muscle weakness. The Minimum Data Set (a resident assessment tool) dated 10/10/2024 included the resident had moderate cognitive impairment, was at risk for developing pressure ulcers, had two (2) unhealed pressure ulcers, was receiving pressure ulcer care, and had pressure reducing devices for their bed and chair. Review of physician orders included an order dated 09/27/2024 for a specialty 42 inch ROHO mattress and to check that the mattress is in place and inflated every shift.In a Wound Assessment form dated 11/13/2024, Wound Care/Registered Nurse #1 documented the left buttock, stage three (3) pressure ulcer was healed with recommendations to continue treatment with barrier cream (adds a protective layer to skin to help prevent damage) and ROHO cushion for prophylaxis. In a Skin Check form dated 01/08/2025, Licensed Practical Nurse #4 documented Resident #8's skin was clear and intact. Review of the Comprehensive Care Plan dated 01/09/2025, revealed Resident #8 was at risk for pressure ulcers. Interventions included but were not limited to: check skin and report any signs of breakdown, use pillows, pads, or wedges to reduce pressure, and to turn and reposition. Additionally, as of 01/10/2025, the care plan included Resident #8 had new wounds, was transferred to another unit without the specialty mattress, and sustained pressure areas to their right and left buttocks. Review of an undated Facility Investigation included during skin rounds on 01/10/2025, Resident #8 was found to have new skin loss over their bilateral buttocks. Resident #8 was transferred on 01/04/2025 from Friendship 3 [NAME] to Friendship 4 East and their ROHO mattress was not transferred with them. Additionally, a statement documented by Licensed Practical Nurse #2 included the resident did not have the ROHO mattress while on Friendship 4 East.In an undated, signed statement, Registered Nurse Supervisor #1 documented they were told on the evening of 01/04/2025 Resident #8 needed to move to another unit after their roommate tested positive for COVID-19. Resident #8 was transported to the receiving unit by wheelchair and Registered Nurse Supervisor #1 was unable to find any staff to help them transfer the resident's bed. Registered Nurse Supervisor #1 reported to the night staff that Resident #8 had been moved but did not have their bed with specialty mattress. In a Witness Statement form dated 01/04/2025 to 01/05/2025, Licensed Practical Nurse #1 documented there was no ROHO mattress, and they notified Licensed Practical Nurse Supervisor #1. Licensed Practical Nurse #1 documented 'not administered' on the Treatment Administration Record for the 01/04/2025 night shift and informed the oncoming day shift nurse. The January 2025 Treatment Administration Record from 01/04/2025 to 01/10/2025 included to check that the specialty mattress was in place and inflated and a review of the documentation revealed the following: The ROHO mattress was documented by nursing staff as 'not administered' on 01/04/2025 night shift, 01/05/2025 evening and night shift. The ROHO mattress was documented by nursing staff as 'administered' on 01/04/2025 (day and evening shift), 01/05/2025 (day shift), 01/06/2025 (day, evening, and night shift), 01/07/2025 (day, evening, and night shift), 01/08/2025 (day, evening, and night shift), 01/09/2025 (day, evening, and night shift), and 01/10/2025 (day shift)In Wound Assessment forms dated 01/10/2025, Wound Care/Registered Nurse #1 documented Resident #8 had facility acquired wounds, to include a stage three (3) full thickness wound to their left buttock measuring 2.5 centimeters in length, 2.0 centimeters in width, 0.2 centimeters in depth and a stage two (2) partial thickness wound to their right buttock measuring 1.0 centimeter in length, 0.3 centimeters in width, and 0.1 cm in depth. Wound Care Registered Nurse #1 documented the wounds resulted from pressure after being transferred to another unit without their specialty mattress. In a Provider Acute Visit note dated 01/14/2025, Physician Assistant #1 documented Resident #8 was seen for pressure related skin breakdown to their bilateral buttocks. The resident was transferred to another unit without their specialty mattress and developed the pressure injuries as they were without the mattress for a period of time. During a telephone interview on 08/27/2025 at 10:00 AM, Licensed Practical Nurse Supervisor #1 stated during an off shift (evening or night), nursing staff would be the ones responsible for transferring a resident's bed to their new room. If it was a specialty bed/mattress, then it should go the same night as the resident. Licensed Practical Nurse Supervisor #1 stated if the specialty bed/mattress could not be transferred, they would pass it on to the next shift. Licensed Practical Nurse Supervisor #1 stated they recalled a resident needed to be transferred to another unit, the resident was out of bed and transported without their specialty mattress. Licensed Practical Nurse Supervisor #1 stated they became aware the resident did not have their bed with specialty mattress at approximately 2:00 AM or 3:00 AM and passed it on to the day shift supervisor to avoid disturbing the resident at that late hour. During a telephone interview on 08/28/2025 at 11:12 AM, Wound Care/Registered Nurse #1 stated Resident #8 was transferred to another room without their specialty mattress which led to the development of pressure injuries. The specialty mattress was ordered to prevent skin breakdown. Wound Care/Registered Nurse #1 stated when they assessed Resident #8 on 01/10/2025, the resident was on a standard foam mattress instead of the ROHO mattress. Wound Care/Registered Nurse #1 stated Resident #8 had a history of pressure ulcers, and they would recommend ROHO mattresses remain in place for six (6) months while the wounds healed. At the time the new wounds were identified, Resident #8 would have been within the six (6) month timeframe for continued use of the specialty mattress. During an interview on 08/28/2025 at 2:21 PM, the Director of Nursing stated when a resident is transferred to another unit, any equipment would go with them. The nursing supervisors would be responsible for ensuring resident belongings, beds, and mattresses went with the resident on evening and night shifts, weekends and holidays. The Director of Nursing stated if a specialty mattress could not be moved with the resident, either the nurse manager or the nursing supervisor should put alternate interventions in place, make the appropriate notifications, and make plans on how to get the mattress to the room. The Director of Nursing stated if there was an order for a specialty mattress, they would expect nursing staff to follow the order, ensure the mattress is checked and functioning, and appropriately document on the treatment administration record. Upon review of the facility's investigation at that time, the Director of Nursing stated Licensed Practical Nurse #2 included in their statement that Resident #8 did not have the ROHO mattress in place when they worked. During a telephone interview on 09/03/2025 at 1:05 PM, Licensed Practical Nurse #2 stated Resident #8 did not have their ROHO mattress when they arrived on the new unit and could not recall if the specialty mattress was in place when they worked on 01/06/2025, 01/08/2025, and 01/09/2025. Licensed Practical Nurse #2 had documented on the January 2025 Treatment Administration Record that the ROHO mattress was 'administered' on 01/06/2025 (evening shift), 01/08/2025 (evening shift) and 01/09/2025 (night shift).During a telephone interview on 09/02/2025 at 10:16 AM, Physician Assistant #1 stated in January 2025, there was a respiratory illness outbreak that required Resident #8 to be moved to another unit. Resident #8 was transferred to another unit temporarily, the mattress was not taken with the resident, and they developed new wounds. Physician Assistant #1 stated not having the specialty mattress put Resident #8 at an increased risk for skin breakdown and the resident's lack of motivation to get out of bed may have also contributed. Physician Assistant #1 stated if an ordered specialty mattress was not available, they would expect nursing staff to notify a medical provider and/or Administration. During a telephone interview on 09/02/2025 at 2:23 PM, Medical Director #1 stated they had examined Resident #8 prior to their temporary transfer to another unit and the resident was at their baseline (usual state of health) with no clinical changes at that time. Medical Director #1 stated Physician Assistant #1 saw Resident #8 shortly after the wounds were identified and attributed the pressure ulcers to the absence of the specialty mattress. Medical Director #1 stated Resident #8 had previously healed pressure injuries in the same areas, was identified as high risk for pressure ulcers, and the specialty mattress was used to reduce the risk of future skin breakdown. Once breakdown happens to an area, the skin never goes back to the same degree of health it had before. Medical Director #1 stated the skin breakdown was largely due to Resident #8's immobility and difficulty moving without assistance, and use of the specialty mattress had been successful in preventing skin breakdown for several months. Medical Director #1 stated there was nothing to indicate Resident #8 was ill or less mobile than their baseline. During a follow-up telephone interview on 09/03/2025 at 1:01 PM, Medical Director #1 stated they believed the pressure ulcers Resident #8 developed in January 2025 were avoidable because there was no change in the resident's condition and there was a good period of time the resident had no skin breakdown, likely due to the interventions, including the specialty mattress, that were in place. Medical Director #1 stated it was unfortunate the specialty mattress was not continued during that timeframe. During a telephone interview on 09/09/2025 at 4:52 PM, Registered Nurse Supervisor #1 stated they were working an evening shift when they were informed Resident #8 needed to move to another room. When they went to transfer the resident, Resident #8 was sitting up in a wheelchair. Registered Nurse Supervisor #1 stated they could not move the specialty mattress on their own. They were unable to find available staff to assist with transferring the resident back to bed prior to the move or to assist with moving the specialty mattress following the resident's transfer. Registered Nurse Supervisor #1 stated during shift change report they informed Licensed Practical Nurse Supervisor #1 they were not able to move the resident's specialty mattress to the new room, and Licensed Practical Nurse Supervisor #1 said they would try to move it when the resident woke up.10 NYCRR 415.12(c)(1)

Based on interviews and record review conducted during the Recertification Survey from 12/16/2024 to 12/20/2024, for 11 (Residents #24, #35, #136, #158, #246, #257, #357, #374, #375, # 378, #380) of 11 residents reviewed, the facility did not ensure that the baseline care plan (care plan developed within 48 hours of admission that includes the minimum healthcare information necessary to properly care of the immediate needs of the resident) was completed within the required time frame and that a summary of the baseline care plan was provided to the resident and/or their representative. Specifically, for Residents #35, #136, and #257, the facility could not provide evidence that a baseline care plan was developed within 48 hours of the residents' admission. For Resident #246, the baseline care plan was not completed within 48 hours of the resident's admission and the facility could not provide evidence that a summary of the baseline care plan, that included the minimum healthcare information such as physician's orders, was provided to the resident and/or resident representative. For Residents #24, #158, #357, #374, #375, #378, and #380, the facility could not provide evidence that a summary of the baseline care plan, that included the minimum healthcare information such as physician's orders, was provided to the resident and/or resident representative. This is evidenced by, but not limited to the following: Review of the facility policy Admission Policy & Procedure, revised August 2023, included the baseline care plan would be developed within 48 hours of admission, and the resident or health care proxy would be provided a copy of the baseline care plan. Review of the facility's electronic baseline care plan form included a statement of acknowledgement that a copy of the baseline care plan would be provided to the resident and/or their representative but did not include confirmation of receipt or reviewed date of the baseline care plan by the resident and/or their representative. 1. Resident #35 had diagnoses that included quadriplegia (a condition where both arms and both legs are paralyzed), dependence on a respirator, and dysphagia (difficulty swallowing). The Minimum Data Set Resident Assessment, dated 09/13/2024, documented the resident was cognitively intact. Review of Resident #35's electronic health record revealed no documented evidence that a baseline care plan had been developed within the required timeframe following admission and the facility was unable to provide evidence of its completion. During an interview on 12/20/2024 at 3:00 PM, Registered Nurse Manager #1 stated Resident #35 should have had a baseline care plan initiated when admitted from the hospital. 2. Resident #257 had diagnoses that included multiple sclerosis (a chronic disease that affects the central nervous system), anxiety, depression, and chronic pain. The Minimum Data Set Resident Assessment, dated 12/02/2024, documented the resident was cognitively intact. Review of Resident #257's electronic health record revealed no documented evidence that a baseline care plan had been developed following the resident's admission within the required timeframe and the facility was unable to provide evidence of its completion. 3. Resident #246 had diagnoses that included Alzheimer's disease, chronic kidney disease, and adult failure to thrive. The Minimum Data Set Resident Assessment, dated 10/09/2024, documented the resident had severely impaired cognition. Review of Resident #246's electronic health record included a baseline care plan, signed by facility staff on 07/25/2023 (greater than 48 hours after the resident's admission). The facility was unable to provide any documented evidence that a summary of Resident #246's baseline care plan, including physician's orders, had been provided to or reviewed with the resident's representative. 4. Resident #24 had diagnoses that included high blood pressure, sarcopenia (gradual loss of muscle strength), and major depressive disorder. The Minimum Data Set Resident Assessment, dated 10/17/2024, documented that the resident was cognitively intact. Review of Resident #24's electronic health record revealed no documented evidence that a summary of the baseline care plan, including physician's orders, had been provided to the resident and/or their representative. During an interview on 12/20/2024 at 9:21 AM, Registered Nurse Manager #3 stated the facility's baseline care plan form was completed by the nurse manager and saved in the computer for reference, but no further documentation was completed. During an interview on 12/20/2024 at 1:25 PM, Registered Nurse Manager #5 stated the baseline care plan was initiated on day two of the resident's admission and focused primarily on nursing care the resident should receive on the unit. Registered Nurse Manager #5 stated the baseline care plan did not include physician's orders or medication orders which were generally reviewed during the initial comprehensive care plan meeting (that could be as late as 21 days after admission) or sooner if the resident/representative had specific medication-related questions or concerns. During an interview on 12/20/2024 at 2:00 PM, the Director of Nursing stated they were aware that the facility's electronic baseline care plan form implied but did not confirm review or receipt of the baseline care plan. 10 NYCRR 415.11

Based on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00356480) from 12/16/2024 to 12/20/2024, for two (Residents #27 and #640) of five residents reviewed for dignity, the facility did not ensure that the residents were treated in a dignified manner. Specifically, Resident #27 could be heard moaning from the hallway with their call light on. Multiple staff members were observed walking by the resident's room without answering the call light or turned the call light off without addressing the resident's concerns or requests. Resident #640 had their call light on for an extended period of time and multiple staff went in the resident's room and turned the call light off without addressing the resident's concerns. This was evidence by the following: 1. Resident #640 had diagnoses including quadriplegia (unable to move all four limbs), neurogenic bladder (a urinary condition causing a lack of bladder control), and diabetes. The Minimum Data Set Resident Assessment, dated 09/25/2024, documented the resident was cognitively intact and incontinent of bowels. During continuous observations on 12/19/2024 starting at 9:40 AM, Resident #640's call light went on and Certified Nursing Assistant #2 walked into the resident's room, turned off the call light without addressing the resident's concerns, and walked back to nurses' station and sat down. At 9:50 AM, Resident #640 put their call light on again and Certified Nursing Assistant #2 went into the resident's room, turned off the call light, and told Resident #640 they would let their assigned nurse know they needed assist. At 9:59 AM, Resident #640 put their call light back on, Certified Nursing Assistant #2 walked in and out of room in less than a minute. At 10:09 AM, Resident #640 put their call light back on. Unit Administrator #1 entered Resident #640's room, exited, and returned with a cup of water. During an immediate interview at 10:14 AM, Resident #640 stated they have been asking staff if they could get cleaned up and that they do not feel good and have a headache. A foul odor (stool) was present in the room at the time. The resident stated that staff often turn off their light, leave the room without assisting them, and do not come back. Observations continued, at 10:28 AM, Resident #640 put their call light on and a staff member entered the room stating they would find a nurse. At 11:00 AM, a nursing staff exited Resident #640 room. Resident #640 remained not washed up. During an immediate interview at 11:01 AM, Resident #640 stated they were still not changed, that their blood pressure was high, and it was upsetting them and pissing me off. At 11:06 AM, Resident #640 put their call light on and several different nursing staff walked into the resident's room and turned the call light off without providing assist. At 11:37 AM, Certified Nursing Assistant #4 returned to Resident #640's room with bathing supplies to assist the resident with morning care (approximately two hours after Resident #640 first put their call light on). During an interview on 12/19/24 at 12:02 PM, Certified Nursing Assistant #4 stated they floated to this unit today and have nine residents on their assignment with six residents going out for appointments. Certified Nursing Assistant #4 stated they were made aware that Resident #640 needed assistance around 9:00 AM, but it was difficult to find staff to assist when staffing is so short. During an interview on 12/20/24 at 9:25 AM, Certified Nursing Assistant #5 stated everyone is responsible for answering call lights and meeting the resident's needs. During an interview on 12/20/2024 at 10:33 AM, Licensed Practical Nurse Manager #1 stated Resident #640 can advocate for themself. They also stated the unit has a higher acuity as everyone is a two person assist, and they have recently lost multiple Certified Nurse Assistants, but all staff should answer call lights. During an interview on 12/20/24 at 11:19 AM, Unit Administrator #1 stated their primary role is a liaison between administration and the units for family and resident concerns to mitigate and provide service so that it does not happen again. They also stated they knew Resident #640 needed care in a timely manner and were told that it had been completed, but then found out later that it was not done. If a call bell goes off it should not be ignored and staff should address it promptly. 2. Resident #27 had diagnoses including dementia, diabetes, and high blood pressure. The Minimum Data Set Resident Assessment, dated 10/15/2024, documented the resident had moderately impaired cognition. During continuous observations on 12/16/2024 starting at 10:01 AM, Resident #27 could be heard moaning from the hallway and their call light was on. At 10:04 AM, Unit Administrator #1 went into room answered the call light and told Resident #27 they would find an aide for them. At 10:08 AM, a Certified Nursing Assistant entered the room and told the resident they would be back (call light still on). At 10:12 AM, Resident #27 could be heard moaning and a staff member walked by the room without seeing what the resident needed. At 10:23 AM, the unit's nurse manager entered Resident #27's room, turned off the call light, and walked out of room. At 10:50 AM, staff were assisting Resident #27 with care. During an immediate interview, Resident #27 stated they had just been changed. During an interview on 12/20/2024 at 12:46 PM, the Director of Nursing stated call lights should be answered when they go off. If a resident is asking to get cleaned up and changed, we do our best to do the assignments and to get to the person that is asking for help. The Director of Nursing stated if a staff member is available, they should help the resident at that time. 10 NYCRR 415.3

Based on observations, record review, and interviews conducted during the Recertification Survey from 12/16/2024 to 12/20/2024, the facility did not ensure that the medical team was notified when there was a significant change in the resident's condition for one (Resident #186) of one resident reviewed. Specifically, Resident #186 had a potential serious complication with their tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway to assist with breathing) tube. This is evidenced by the following: The facility policy Notification of Change, revised April 2021, documented the appropriate department will immediately consult with the resident's physician when there is a significant change in the resident's physical status. Resident #186 had diagnoses including anoxic brain damage (a condition when the brain has a lack of oxygen), dysphagia (difficulty swallowing), gastrostomy (a surgical procedure to create an external opening into the stomach to receive nutrition), and a tracheostomy tube. The Minimum Data Set Resident Assessment, dated 11/18/2024, documented the resident had severely impaired cognition, was dependent for all activities of daily living and tracheostomy care, including suctioning of the tracheostomy tube, and the resident had a feeding tube. Review of Resident #186's current physician's orders revealed tracheostomy suctioning every four hours and as needed and tube feeding (via the feeding tube) four times a day. The orders also included that the resident was on aspiration precautions (interventions in place to prevent substances from entering the airway or lungs). During observations on 12/18/2024 at 9:27 AM and again on 12/19/2024 at 11:35 AM, Resident #186's tracheostomy cannister (container to collect secretions suctioned from the tracheostomy tube) had greater than 450 milliliters of tan colored secretions. During an observation on 12/20/2024 at 9:36 AM, Resident #186 had thick tan/yellow secretions in their oxygen tubing that was attached to Resident #186's tracheostomy. In a medical progress note, dated 11/14/2024, Nurse Practitioner #1 documented Resident #186 had clear sputum (mucous) and to continue to monitor the resident and report changes in condition. In an interdisciplinary progress note, dated 12/13/2024 at 10:46 AM, Respiratory Therapist #1 documented Resident #186 was suctioned for thin, tan secretions. In an interdisciplinary progress note, dated 12/13/2024 at 8:48 PM, Licensed Practical Nurse #3 documented that Resident #186 was suctioned for tan secretions with tube feeding chunks in it. In an interdisciplinary progress note, dated 12/15/2024 at 4:20 PM, Respiratory Therapist #2 documented that Resident #186 was suctioned five times for large amounts of thick secretions possibly mixed with tube feeding liquid (also tan in color) and Resident #186 appeared to continue to aspirate (inhalation of food/liquids into the airway). In an interdisciplinary progress note, dated 12/17/2024 at 9:59 AM, Respiratory Therapist #3 documented that Resident #186 was suctioned for large amounts of tan secretions. During an interview on 12/19/2024 at 9:19 AM, Licensed Practical Nurse #3 stated the medical provider should be notified if anything was not at baseline for the resident or the possibility of aspiration (inhalation of tube feeding into the resident's airway). During an interview on 12/19/2024 at 12:10 PM, Licensed Practical Nurse Manager #1 stated that a physician should be notified if a resident had excessive sputum, more than usual, as the resident is at risk for aspiration more than other residents. If the medical team had been notified, it should be documented in the communication log (a log to communicate information to the medical team). During a follow-up interview on 12/20/2024 at 9:23 AM, Licensed Practical Nurse Manager #1 stated they were unable to find any documentation that the physician has been notified about Resident #186's excessive secretions or potential aspiration. During an interview on 12/19/2024 at 11:08 AM, Physician #1 stated they were not aware that Resident #186 may have tube feeding liquid in their tracheostomy tubing which is a serious complication, and they should have been notified if this was a possibility. During an interview on 12/20/2024 at 11:07 AM, the Respiratory Therapy Manager stated that if a resident had secretions that looked like tube feeding, the respiratory therapists should have notified the nurse manager, and the nurse manager should have notified the medical provider. 10 NYCRR 415.3(f)(2)(ii)(b)

Based on interviews and record review conducted during an Abbreviated Survey (#NY00321703), the facility did not ensure the resident's right to be free from physical abuse for one (Resident #1) of three residents reviewed. Specifically, Resident #1 was slapped on the hand by a staff member that was observed by other staff and on video. The is evidenced by the following: The facility policy, Abuse Prohibition Program, dated revised on 9/15/22, included that under no circumstances would the facility tolerate resident abuse, neglect, mistreatment, misappropriation of resident property, or resident exploitation. Physical abuse would include hitting, slapping, pinching, and kicking, or controlling behavior through the use of corporal punishment. Resident #1 had diagnoses that included Alzheimer's disease, dementia, and lack of coordination. The Minimum Data Set Assessment, dated 7/7/23, included that the resident had severe impairment of cognitive function. The MDS did not include that the resident had any behaviors (such as physical behaviors towards others). The current Comprehensive Care Plan (CCP) included Resident #1's history of trauma, for which staff are to ensure that the resident is provided with a safe and supportive environment that protects against physical harm and re-traumatization. The CCP included that Resident #1 had a history of resisting care and physical aggression towards staff. Interventions included but not limited to that if resident is resistive, staff are to provide a calm environment, and maintain a personable, respectful, kind, and honest manner. The facility Resident Incident Reporting Form dated 8/8/23 and signed by Registered Nurse #1 documented that on 8/8/23 at 2:45 PM Resident #1 appeared to have been struck on the left hand by a staff member after Resident #1 touched the staff member's face. The resident appeared to be unharmed by the encounter and no [NAME] injury was noted however the resident did appear to recall the incident. Review of the facility's Investigation Report dated 8/8/23 revealed that Material Service Worker (MSW) #1, while picking up Resident #1 for their medical appointment, observed LPN #1 placing footrests on the resident's wheelchair. Resident #1 reached out and touched LPN #1's face and LPN #1 slapped Resident #1's hand. The report documented that the resident repeated twice to MSW #1 that (they) slapped my hand so hard. Resident #1 was promptly assessed by Assistant Director of Nursing (ADON) #1 following the incident and no injuries were noted. Once the incident was reported to facility leadership, LPN #1 was escorted out of the facility and placed on administrative leave. The facility's investigation concluded that the allegation of resident abuse by a staff member was verified through security video footage and eyewitness testimony. In an unsigned transcript from an investigatory hearing by the facility held on 8/11/23 and attended by several staff members and the accused, Licensed Practical Nurse #1 had stated that they were putting a footrest on (the resident's wheelchair) when Resident #1 smacked them in the face. LPN #1 stated that they went to restrain the resident's hand (by placing their hand down on the resident's hand) and told the resident never to hit them again. LPN #1 stated that Resident #1 said, Oh, (they) hit me on my hand. Review of video surveillance of the incident revealed LPN #1 bent over at the waist, facing Resident #1, while Resident #1 was sitting in a wheelchair looking in a forward direction. While pending over, LPN #1 raised their head quickly, looked at the resident, and moved their head and neck away from the resident. At the time, Resident #1 remained looking in a forward direction. LPN #1's right hand appeared raised, then came down in a quick slapping motion towards where the resident's raised hand was and then stood in front of Resident #1 for approximately 11 seconds (unable to visualize what LPN #1 said). During an interview on 8/17/23 at 9:25 AM, MSW #1 stated that on 8/8/23, they went to the unit to pick up Resident #1 (to transport to an appointment). MSW #1 stated that LPN #1 was putting footrests on the resident's wheelchair when Resident #1 touched LPN #1's face. MSW #1 stated that it was not a hitting or slapping motion and demonstrated by placing the palm on their hand on their cheek and resting it there. MSW #1 stated that LPN #1 then grabbed Resident #1's fingers and slapped the back of the resident's hand. MSW #1 stated that they could hear the slap and that Resident #1 said to them twice, (They) hit me so hard. MSW #1 stated that they took Resident #1 to their appointment and then immediately reported the incident to their supervisor. During an interview on 8/17/23 at 2:30 PM Environmental Service Worker #1 stated that they were doing rounds and holding the elevator for a transporter (Material Service Worker #1) who was waiting for foot pedals for a resident (Resident #1) when they saw a nurse tap the resident's hand and pointed their finger at the resident and said don't do that again while applying the foot pedals. During an interview on 8/18/23 at 12:54 PM with the Director of Nursing (DON) and the Acting Administrator, the DON stated that they would never expect a staff member to strike, slap or hit a resident. The DON stated that once aware of the incident, LPN #1 was immediately exited out of the building, the incident was investigated, an investigatory hearing was held, and the staff member was terminated. The Acting Administrator stated that at no time under any circumstances is it acceptable for a staff member to strike a resident. During an interview on 9/18/23 at 12:56 PM, LPN #1 stated they were putting the left foot pedal on Resident #1's wheelchair when the resident became combative and back handed LPN#1's face. LPN #1 stated that they smacked Resident #1's hand and said to never do that again. LPN #1 stated that Resident #1 was always combative, not directable, and that staff would usually just walk away. LPN #1 stated that they had never done something like that (smack a resident's hand), and that it was just a reflex. The last documented evidence of abuse training for LPN #1 provided by the facility was 8/12/21. 10 NYCRR 415.4 (b)(1)(i)

Based on observations, interviews and record reviews conducted during the Recertification Survey 4/24/23 to 5/1/23, it was determined that for 1 (Resident #328) of 35 residents reviewed for care plans, the facility did not ensure that a resident's care plan was revised to reflect the resident's current condition. Specifically, the residents comprehensive care plan (CCP) was not revised related to the resident's smoking habits, a history of burns to the hands and fingers sustained while smoking, interventions for staff to utilize and any refusals of interventions. This is evidenced by the following: The facility policy, Smoking Policy, dated as revised 4/4/22, documented that the facility was a smoke free environment where smoking will not be allowed by residents on the facility campus. All new admissions after 4/20/22 shall be informed during the admission process that the facility prohibits smoking on its campus. Those residents who are determined to have a preference to smoke, will be offered a smoking cessation program. Resident #328 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, diabetes, and nicotine addiction. The Minimum Data Set Assessment, dated 3/3/23 revealed that the resident was cognitively intact and did not currently use tobacco. The Certified Nursing Assistant (CNA) Activities of Daily Living Care Card (care plan used by the CNAs to direct daily care) dated 4/14/23, documented that the resident was not a smoker. The CCP, dated 5/1/23, included that Resident #328 went outside to smoke and had a specialized glove and cigarette holder. The CCP did not include multiple burns sustained while smoking, the resident's person-centered goals related to smoking, storage of smoking materials or refusals of any interventions until after surveyor intervention. Review of a Nursing Progress Note, dated 1/27/23, revealed the resident had a new open area, full thickness loss of tissue measuring 0.5 centimeters (cm) by 0.4 cm on the left index finger and was being treated by the wound nurse. The resident said they burned themselves while smoking. During observation and interview on 4/26/23 at 9:25 a.m., Resident #328 had a pack of cigarettes and a lighter in their coat pocket. The resident stated at the time that this was where they always kept their cigarettes and lighter and their vape materials and never in their locked box in their room. The resident stated that they smoke on the sidewalk outside of the building with other facility residents. Resident #328 stated they are supposed to sign out, but they forget. In an observation on 4/27/23 at approximately 10:00-11:00 a.m. Resident #328 was outside smoking cigarettes. The resident appeared to be wearing a 'glove' but no cigarette holder was present. During an interview on 4/26/23 at 11:22 a.m., Certified Nursing Assistant (CNA) #2 said Resident #328 spends a lot of time outside smoking but did not know where they keep their cigarettes and lighter. During an interview on 4/26/23 at 11:43 a.m., Licensed Practical Nurse (LPN) #1 said they often see the resident in front of the building smoking with other residents smoking and that Resident #328 has often burned their hands with cigarettes. During an interview on 5/1/23 at 9:55 a.m., the Social Worker (SW) stated that they were aware Resident #328 smoked and that they had informed them that the facility had a no smoking policy. The SW stated that they were working with Behavioral Health to help the resident stop smoking. The SW stated that when Resident #328 was burned from smoking, there was no change to their care plan and was aware that the current care plan was not resident-centered nor specific to their needs. The SW stated the cigarettes and lighter should be locked in a safe place. During an interview on 5/1/23 at 9:55 a.m., Registered Nurse Manger (RNM) #1 said Resident #328 had reported their cigarette burns and that the resident has diabetic neuropathy causing poor feeling in their hands creating an increased risk for burns. RNM#1 said they are responsible for updating the resident's care plan. During an interview on 5/1/23 at 10:24 a.m., the Assistant Director of Nursing (ADON) stated they, in conjunction with the RNMs revise resident's care plans. The ADON stated that following actual burns from cigarettes, the care plan should be updated to include reinforcement of wearing the special glove, any skin issues related to burns and resident education. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, interviews and record review conducted during the Recertification Survey 4/21/23 to 5/1/23, it was determined that the facility did not ensure that the environment remained as free of accident hazards as possible for one (Resident #202) of 10 residents reviewed for accidents. Specifically, Resident #202 who had a history of keeping vaping materials in their room, and was suspected of vaping in their room, had 6 vape pens with cartridges in their room. Additionally, during a room search on 4/27/23, a security officer recovered several containers of marijuana, 2 boxes of vape liquid, 2 lighters, 1 torch lighter, and 1 marijuana pipe. The finding is: The facility Smoking Policy, revision dated 4/4/22, documented the facility designated itself a smoke-free campus as of 5/1/22. The use of cigars, pipes, marijuana, e-cigarettes and/or vaping devices is strictly prohibited within the facility, in the outdoor smoking area or on facility grounds. Resident #202 had diagnoses including quadriplegia (paralysis of all four limbs), polyneuropathy (a disease process involving a number of nerves), and neuralgia (severe pain due to damaged nerves)/neuritis (inflammation of peripheral nerves causing pain and loss of function). The Minimum Data Set (MDS, a resident assessment tool) dated 3/7/23 documented the resident was cognitively intact, exhibited no mood/behaviors, no current tobacco use, and required extensive assistance of one staff member for personal hygiene. In a nursing progress note, dated 2/2/23, Registered Nurse (RN) #2 documented Resident #202 was using their vape pen in their room and the resident released the vape pen to security. Additionally, Resident #202 stated they understood the rules, regulations and policies set forth by the facility and that they would continue to use vape pen at the facility when they had the opportunity. The Care Plan Report dated 4/28/23 included the following: - Problem area: smoking - not an approved smoker, uses vape pen; Resident chooses to use THC (compound that is the main active ingredient of cannabis) in vape pen. - Goals: Resident has been made aware that vape pens are not permitted at facility. Resident has been suspected of vaping in their room, with fire alarm going off. - Interventions: If staff note vape pens in the room, alert nursing supervisor or nurse manager and/or security; Vape pens are to be kept with security or with family; Visitor education on 4/2/23 that facility is a smoke free facility; Remind resident that marijuana (cannabis) use on site is not acceptable practice. During observations on 4/24/23 at 11:32 AM, 4/25/23 at 9:00 AM, 4/25/23 at 10:08 AM, 4/26/23 at 7:08 AM, and 4/27/23 at 9:33 AM there was a strong skunk like odor noted at the doorway of, and inside Resident #202s' room. During an interview on 4/25/23 at 9:00 AM, Resident #202 stated they vaped marijuana outside of the facility, and that security holds all their vaping materials. During an interview on 4/26/23 at 9:45 AM Certified Nurse Aide (CNA) #1 (assigned CNA) stated they have never witnessed Resident #202 vaping in room but have observed vape pens on the residents over the bed table. Additionally, CNA #1 stated they have reported the vape pens to the Unit Manager (UM). During an interview on 4/26/23 at 9:49 AM, the RN Assistant Director of Nursing (ADON) stated Resident #202 has been suspected of using vape pens in their room and has had vape pens removed from their room in the past. Additionally, Resident #202 was not an approved smoker, and their vaping materials were to be locked with the security department. During an interview on 4/26/23 at 10:07 AM, The ADON stated they had just removed 6 vape pens with cartridges from Resident #202's room. During an interview on 4/26/23 at 11:07 AM, RN/UM (Unit Manager) for Hope 4 resident unit, stated they were aware Resident #202 vaped, had a history of keeping vape materials in their room, and the resident was supposed to keep vaping materials with security. Additionally, the RN/UM stated there had been no recent reports of vaping materials in Resident 202's room. During an interview on 4/28/23 at 7:30 AM, the Security Director stated a room search of Resident #202's room was conducted on 4/27/23 after surveyor intervention with vaping and smoking materials recovered by security. Additionally, the Security Director stated vaping and marijuana were prohibited within the facility and on facility grounds. The Room Search Incident dated 4/27/23 at 9:45 AM documented the following items were recovered from Resident 202's room: - Three (3) sandwich bags containing marijuana - Two (2) (face cream size) containers filled with marijuana - One (1) cigarette cigar filled with marijuana - One (1) cigarette cigar filled with tobacco - Two (2) boxes liquid for vapes - Two (2) disposable lighters - One (1) torch lighter - One (1) marijuana pipe 10NYCRR 415.12(h)(1)

Based on interviews, and record reviews, conducted during an Abbreviated Survey (#NY 992, #NY 747, #NY 670, #NY 949, #NY 048, #NY 946), completed on 8/12/22, it was determined that for one of seven residents reviewed, the facility did not ensure residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene. Specifically, Resident #27 did not receive a tub bath or shower consistently per their preference or comprehensive care plan (CCP). This is evidenced by the following: The facility policy, Assignment of Resident Care, dated 2/1/14, documented that the patient care assignment on each nursing unit provided a plan for organizing the nursing staff to provide optimal resident centered care. The Administrative Nurse Manager or designated charge nurse was responsible for the completion of the master resident care assignment sheets. Staff were to utilize the care card information to provide care to residents and update the hand-held care tracking devices once care was performed. Resident #27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 5/9/22, documented that Resident #27 was cognitively intact, was totally dependent on staff for bathing and that it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the current CCP revealed Resident #27 was to receive daily bathing, that staff were to encourage Resident #27's independence and provide assistance as needed, and to offer a tub bath or shower weekly. Resident #27's Care Summary Assessment (care plan used by the Certified Nursing Assistants (CNAs) for daily care), dated 8/9/22, included that the resident required extensive assistance of one person with bathing and their shower days were Tuesday evenings and Friday days. Review of the Activities of Daily Living (ADL) verification worksheet, dated 7/1/22 through 8/8/22, revealed no documentation that Resident #27 had received a tub bath or shower on 9 of 11 opportunities. On 7/29/22 the documentation listed 'refused' under shower. In an interview on 8/8/22 at 9:00 a.m., Resident #27 stated that they had complained about not getting showers which made them feel dirty. Resident #27 stated that they had not received a shower for three weeks but had recently gotten a new CNA on the unit and had received a shower a couple of days ago, so maybe it is going to be better. In an interview on 8/10/22 at 9:30 a.m., The Unit Clerk stated that the CNAs have a schedule sheet to show what shower/baths or sponge baths are to be given on each day or evening shift. They stated that the CNAs are supposed to document the care that they provide into the Electronic Medical Record (EMR) but sometimes they get busy and forget to document. The Unit Clerk stated that the Unit Nurse Manager used to print a list to check that bath/showers were done and documented, however the Unit Nurse Manger is currently out on an extended leave. In an interview on 8/10/22 at 9:45 a.m., CNA #1 stated that they had only been transferred to the unit a couple of weeks ago, and that they had given Resident #27 a shower on 8/8/22 but had failed to document the care as sometimes they get very busy and forget to document. In an interview on 8/10/22 at 10:15 a.m., CNA #2 stated that they are new to the unit having recently been transferred to this unit and that they are working as a team to get the residents back on the proper shower/bath schedules. In an interview on 8/10/22 at 10:40 a.m., Licensed Practical Nurse #1 stated that the Unit Nurse Manager is responsible for checking resident ADL sheets and assignments to ensure that care had occurred as assigned, however the unit is currently without a Unit Nurse Manager and the task has been delegated to the nurses. In an interview on 8/10/22 at 7:55 a.m., the Director of Nursing (DON) stated that it was the expectation that care would be provided based on a resident's preference and as directed on the care card. The DON further stated that the CNA staff are expected to document the care that they provide on each shift. If care was not provided, the CNAs should make the nurse or Unit Manager aware so they can document in a progress note the refusal or reason care was not provided. The DON stated that they could not provide evidence to indicate that the showers were being provided to Resident #27 during the requested time period. 10 NYCRR 415.12 (a)(3)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (#NY 190 and #NY 467), completed 8/12/22, it was determined that for one of five residents reviewed, the facility did not ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents. Specifically, Resident #32 had a history of elopement and was care planned for supervision when off their unit. The facility did not ensure the resident was provided supervision while off their unit resulting in an elopement out of the facility undetected and unsupervised and was found by a staff member coming to work outside near a busy roadway. This is evidenced by the following: Review of the facility policy Missing Resident, dated 2/9/22, revealed the goal was to provide a safe and secure environment for all residents. An elopement occurs when a resident leaves the premises or safe area without authorization and/or any necessary supervision to do so. Unsafe wandering included a resident's inability to independently return to their nursing unit. All occurrences of elopement and high-risk residents found off their unit unattended will be documented on a facility resident incident report. Resident #32 had diagnoses including [CONDITION(S)], dementia, and [CONDITION(S)]. The Minimum Data Set Assessment, dated 4/8/22, documented that the resident had moderately impaired cognition and required supervision with locomotion on and off the unit utilizing a wheelchair. The 'Resident Elopement Risk Assessments', dated 1/5/22, 4/5/22, 6/3/22 and 6/28/22 all documented that Resident #32 had a history of elopement and that staff should develop an interdisciplinary plan of care and monitoring level for high-risk behavior that differentiates strategies for cognitively intact versus cognitively impaired individuals. The Assessment also included, but not limited to, that staff should consider the use of electronic or physical interventions to reduce the risk of resident wandering. The current Comprehensive Care Plan and Resident Care Summary Assessment (the care plan used by the Certified Nursing Assistants (CNAs) for daily care) included that Resident #32's was at risk for wandering and elopement. Interventions included electronic monitoring with a wander guard bracelet, red lanyard when escorted off the unit with a responsible party, and supervision for locomotion off the unit. Review of interdisciplinary progress notes included a late entry note dated 5/4/22 and signed by Licensed Practical Nurse (LPN) #1, documented that on 4/29/22 Resident #32 was found off the unit (on a different unit three floors away) lost (unsupervised) but not injured and was returned to their unit/floor. Review of the 'Resident Incident Reporting Form', signed by the Registered Nurse (RN) #1 documented that on 4/29/22 Resident #32 had left the unit unsupervised and was found on the first floor. The 'Resident Incident Reporting Form' included that the resident's care plan was followed and remained appropriate with no changes. Review of a facility 'Incident #5361' 'Resident Issue' (security report form) dated 5/28/22, revealed that Resident #32 was observed on security video attempting to exit a secured area. The video showed the exit doors eventually opening and Resident #32 was allowed to exit. Security responded and found Resident #32 outdoors with their wheelchair stuck in the mud. Review of a facility work order revealed that on 5/31/22 the wander guard company was notified, and the system adjusted so there was no longer a delay in activating the wander guard to lock the exit door. The resolution included that there were some weak spots, most notable close to the floor around the bottom of one of the doors, and the 'roam alert mode' was adjusted. Review of a nursing progress note, dated 6/17/22 and signed by LPN #2, revealed Resident #32 was again found off their unit/floor and was unable to find their way back to their unit requiring assistance. The resident was unsupervised at that time. Review of the facility 'Resident Incident Reporting Form' and 'Investigative Report', dated 6/27/22, revealed that Resident #32 again left the facility undetected through the Friendship Unit lobby doors and was observed unsupervised outside by a staff member at approximately 5:55 p.m. near a busy roadway. Resident #32 stated at the time that they were going to their mother's home. At that time, the Security Officer reported that the wander guard alarm did not go off but when tested after the incident it did function correctly. The report concluded the resident left undetected and unsupervised and staff were unable to determine how. Following this incident, the resident's wander guard bracelet was relocated from the ankle to the wrist and the resident was moved to a secure unit. There was no evidence provided that the doors were checked at this time for inconsistent functioning. When interviewed on 8/10/22 at 11:16 a.m., the Director of Safety and Security (DSS) stated the wander guard system alarms in the security office if a possible elopement is in progress and they track the resident on camera to maintain a visual. The DSS said that the door did not alarm on 6/27/22 and they were unable to determine why. When interviewed 8/11/22 at 8:11 a.m., the Registered Nurse Manger stated if a resident is unable to find their way back to their unit, the CCP would include the resident's need for supervision off the unit. When interviewed on 8/11/27 at 9:27 a.m., the Clinical Risk Coordinator stated after Resident #32 got out of the facility in May 2022 they had the exit doors serviced and were told they were ok, and that they felt the situation in June 2022 appeared to be the same situation. When interviewed on 8/12/22 at 11:57 a.m., the Director of Nursing (DON) stated nursing assesses a resident's ability to leave their unit through the 'Resident Elopement Risk Assessment' and the CCP would reflect the need for supervision off the unit. The DON stated if the care card included locomotion off the unit with supervision, then the expectation was the resident would be supervised when off their unit. 10NYCRR415.12(h)(1)(2)

Based on interviews and record reviews conducted during an Abbreviated Survey (#NY 670) completed on 8/12/22, it was determined that for one (Resident #22) of three residents reviewed, the facility did not ensure services provided by the facility met professional standards of quality. Specifically, Resident #22 had multiple medications administered four and a half hours past the scheduled time (three and a half hours after the professional standard acceptance time) and in conjunction with the afternoon dose of two medications. This is evidenced by the following: The facility policy 'Nursing Policy Number VI-01Title: Administration and Charting of Medications,' dated 1/5/18, documented under 'General Statement' that the right medications are administered to the right resident via the correct route, with the correct dose at the correct time. Under 'Nursing Action': Report any missed dose to Nurse Manager or Charge Nurse as soon as possible so the appropriate action can be taken. Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 3/6/22, documented that the resident was cognitively intact. Current (as of January 2022) Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .m, and 10 mg at bedtime for cramps and spasms , tamsulosin 0.4 mg daily scheduled at 9:00 a.m., for bladder dysfunction and senna 2 tablets daily scheduled daily at 9:00 a.m., for constipation. Review of Resident #22 electronic medical record (EMR) Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In a nursing progress note, dated 1/11/22 (time unknown), the Assistant Director of Nursing (ADON) documented that they had received an email from a family member that Resident #22 had not received any of their 9:00 a.m. medications which was verified by staff. Resident #22 then requested their 9:00 a.m. medications be given with their 1:00 p.m. medications including both doses of [MEDICATION(S)] and [MEDICATION(S)]. Review of a facility 'Resident Incidence Reporting Form', dated 1/11/22, documented that the unit staff nurse left at 9:00 a.m., and did not alert anyone that no medications had been administered on the nurse's assignment. Therefore all of Resident #22's 9:00 a.m. medications (including [MEDICATION(S)] and [MEDICATION(S)]) were administered at 1:30 p.m. and the 1:00 scheduled medications ([MEDICATION(S)] and [MEDICATION(S)]) were also administered. Recommendations included staff education on who to alert when help is needed. In an interview on 8/8/22 at 11:00 a.m., the Unit Nurse Manager stated that if medications are late then the next dose should be adjusted which should be passed on to the next shift and the supervisor. In an interview on 8/9/22 at 2:05 p.m., the ADON stated that they had administered Resident #22 9:00 a.m. [MEDICATION(S)] and [MEDICATION(S)] at the same time as the 1:00 doses on 1/11/22 because the resident requested it. The ADON stated they had administered all the 9: 00 a.m. medications with the 1:00 p.m. medications and had communicated this to the Nurse Practitioner (NP) but did not document this. 10NYCRR 415.11 (c)(3)(i)

Based on interviews and record reviews conducted during an Abbreviated Survey (NY 493) completed on [DATE], it was determined that for one (Licensed Practical Nurse (LPN)) of four nurses reviewed for licensure or certification, the facility did not ensure that services provided or arranged were delivered by individuals who have the skills, experience, and knowledge to do a particular task or activity, including proper licensure or certification. Specifically, LPN#1 worked at the facility for 19 months and 26 days without current licensure. This is evidenced by the following: The New York State (NYS) Office of the Professionals license information for LPN#1 printed [DATE], included date of licensure: [DATE] and registered through last day of: [DATE]. The current status on the license information revealed that the LPN's status was NOT REGISTERED. Review of LPN's personnel file revealed that LPN#1 was hired by the facility on [DATE]. The facility LPN job description, revised [DATE], documented that LPNs must be in possession of a valid NYS LPN license. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Accident/Incident (A/I) Report Form, dated [DATE], documented that the medical provider (Physician's Assistant) reported to the Assistant Director of Nursing (ADON) that Resident #1's LLE wound dressing had not been changed since [DATE]. The A/I Report documented that LPN#1 had signed for the treatments (indicating the treatments were completed) on several occasions from [DATE] to [DATE] but that on [DATE] (night shift) another staff member reported that the dressing to Resident #1's LLE had a date as completed written on it of [DATE]. The A/I Report concluded that LPN#1 failed to follow the facility policy and procedure for documentation in a resident's medical record and signed that they had completed treatments on [DATE], [DATE], [DATE], [DATE] and [DATE] that they had in fact not completed. When interviewed on [DATE] at 3:10 p.m., the Director of Nursing (DON) stated that upon review of LPN#1's license, it was discovered that the license had expired [DATE]. The DON stated that they had just discovered this today and the DON was unsure if the LPN was aware of the lapse in licensure. The DON stated that LPN#1 worked nights full-time on ,d+[DATE] hour shifts at the facility for the full period of time when LPN#1's license had expired up until [DATE] when LPN#1 was suspended. When interviewed on [DATE] at 3:15 p.m., the Administrator stated that licensed personnel were responsible for taking care of their own license renewals. The Administrator stated that Human Resources did not have a process in place for checking license renewals for staff that the Administrator was aware of. When interviewed on [DATE] at 11:20 a.m., LPN #1 stated that they had not received notification from the facility or from NYS regarding renewal for their license and had not realized it had expired. The LPN stated that they had worked full time up to 16 hours a day at the facility for that period. [10 NYCRR 415.11(c)(3)(ii)]

Based on observations, interviews and record review conducted during a Recertification Survey and complaint investigation (NY 844), completed on 7/15/21, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for one of two residents reviewed. Specifically, Resident #243 was assessed for safe smoking on 11/30/20, 3/8/21 and again 5/28/21 and determined to be unsafe to smoke unattended. On 4/23/21 Resident #243 went outside unsupervised, obtained cigarettes from another resident, asked another resident to help light the cigarette and Resident #243's hair caught on fire. The fire was put out by another resident and Resident #243 sustained a partial thickness burn to the forehead. There was no Comprehensive Care Plan (CCP) related to smoking or [CONDITION(S)] due to smoking. There were no documented interventions following the 4/23/21 incident. On 7/13/21 survey staff observed Resident #243 smoking outside unsupervised at approximately 10:30 a.m. Both hands had significant hand tremors while holding the cigarette. There was no staff present. During interview the unit Certified Nursing Assistant (CNA) said the resident is allowed to smoke. The Licensed Practical Nurse (LPN) said the resident can leave the unit unsupervised but is not allowed to smoke and they check on the resident as frequently as they can. This resulted in Immediate Jeopardy and Substandard Quality of Care with the potential for serious harm to Resident #243's health and safety. Findings include: The facility policy Smoking, dated 3/3/20, revealed all new admissions shall have a Smoking Safety Assessment completed on admission, annually and as the interdisciplinary team (IDT) feels necessary. The use of cigars, e-cigarettes, pipes and or vaping devices are strictly prohibited in the outdoor smoking enclosure or on facility grounds. Resident #243 was admitted to the facility 10/7/20 with diagnosis that included progressive [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. The Minimum Data Set Assessment, dated 3/9/21, revealed the resident was cognitively intact, required supervision for locomotion on and off the unit and was a current tobacco user. The CCP, dated effective 5/24/21 to present, included to provide a safe environment and constantly assess possible intent to harm. Goals for behavioral health and trauma included that Resident #243 had a history of smoking cigarettes and opioid dependence. Interventions included to provide direction as needed for inappropriate behavior, to refer to counseling and/or psychotherapy as needed and to provide assistance as needed. The CCP did not include any interventions related to the resident's wishes to smoke or plans to provide safe smoking or smoking cessation. The current Resident Care Summary (care plan used by the Certified Nursing Assistants to direct daily care) documented that the resident required staff assist for locomotion off the unit using a manual wheelchair and under smoking, it documented 'no'. An Occupational Therapy (OT) evaluation, dated 11/30/20, documented that Resident #243 was not safe to go outside independently and did not demonstrate safety or independence with aspects required to have smoking privileges. A Physical Therapy (PT) evaluation, dated 3/2/21, documented the resident was unable to safely propel outside or over any thresholds independently. An Incident/Accident (I/A) report, dated 3/3/21, documented that Resident #243 was found outside near the smoking [NAME], alone and on the ground. The resident fell out of their wheelchair. The I/A report summary included that the Resident #243 struggled with uneven surfaces, was unable to safely propel outside and was not following safety recommendations. An OT evaluation, dated 3/8/21, documented that Resident #243 was found outside by therapy, requiring assistance to re-enter the building. The resident had been smoking. Resident #243 reported to the therapist that they had received assistance by other residents to light, smoke and ash their cigarettes. This was confirmed by other residents. A Smoking Safety Assessment, dated 3/9/21 and signed by the Registered Nurse (RN), documented that Resident #243 stated they were smoking. The Assessment included that the resident could not safely simulate smoking, including but not limited to, accessing smoking materials, lighting a cigarette, disposal of ashes or the cigarette in an appropriate receptacle. The Assessment did not include any interventions or plans to assist the resident with safe smoking. An I/A report, dated 4/23/21 at 10:19 p.m., documented the CNA #1 saw Resident #243 in the smoking [NAME] falling asleep. Multiple cigarette [CONDITION(S)] were observed on the resident's clothing with holes in their pants and jacket and a red area noted on the resident's forehead. The report included that Resident #243's hair caught on fire when they requested a 2nd resident to assist in lighting their cigarette. The fire was put out by the 2nd resident. The red area noted on the resident's forehead was not reported to medical until 4/26/21. A Medical provider note, dated 4/26/21 and signed by the Nurse Practitioner (NP) documented that Resident #243 had sustained a superficial partial thickness burn to the forehead while smoking outside in the smoke [NAME]. The NP documented the resident's hair was noted to be singed and that the resident had been deemed an unsafe candidate for smoking without staff assistance and had been preciously educated on this. A physician note, dated 5/27/21, documented that Resident #243 had progressive [CONDITION(S)] with associated muscle spasm and was being seen for an evaluation of capacity after setting off the smoke alarm in their room due to vaping. Resident #243 was evaluated by physical therapy who again deemed the resident to be unsafe to navigate to the smoking [NAME]. Two physicians determined the resident continued to hold adequate decision-making capacity and was able to understand the risk of smoking to their health and the potential safety to the facility. Resident #243 declined a [MEDICATION(S)] patch and was informed of the New York State Smoker's Quit Hotline. In a nursing progress note, dated 5/27/21, the RN#1 documented that Resident #243 was informed that their smoking privileges were denied (cigarettes outside and vaping in their room). The Investigation Summary, dated 6/2/21, related to the 4/23/21 incident included that Resident #243 had a history of unsafe smoking behaviors at other facilities and that a behavioral plan would be initiated and the facility would monitor the resident's smoking habits and behaviors through the medical record. The conclusion included that the Interdisciplinary Team met on 5/27/21 and determined that Resident #243 was no longer safe to smoke and smoking privileges were denied. A Wellness Plan document, dated 6/3/21, included a statement signed by Resident #243 that they acknowledged they had been evaluated by therapies to be unsafe to go outside and smoke, and was not allowed to smoke or vape in their room or anywhere on the facility campus. A nursing progress note dated, 6/4/21, documented the resident was found vaping in their room. There was no documented evidence that an investigation was completed or that the CCP was changed or updated following this incident. A nursing progress note, dated 6/13/21, documented the resident was found outside the building unsupervised. There was no documentation that the CCP was updated following this incident. During an observation on 7/9/21 at 10:56 a.m., Resident #243 was observed by surveyor outside the building, propelling their wheelchair towards the smoking [NAME] with a lit cigarette in their hand. During an observation on 7/13/21 at 10:35 a.m., Resident #243 was sitting in a wheelchair in front of the smoking [NAME] holding a cigarette in their hand smoking. Significant tremors were visible to both of the resident's hands. A 2nd resident wheeled up next to Resident #243 and handed Resident #243 a cigarette. Resident #243 proceeded to smoke the second cigarette. There were no staff in sight. During an interview on 7/13/21 at 11:12 a.m. the Unit Clerk stated that the residents do not need to sign out when leaving the unit. The Unit Clerk stated they thought that Resident #243 was allowed to smoke. During an interview on 7/13/21 at 12:02 p.m., Resident #243 stated that they like to go outside and that they do smoke occasionally. Resident #243 stated, in order to go out, they would just wait by the outside door for another resident to go in and out of the building. Resident #243 added they had not burned themselves smoking. During as interview on 7/13/21 at 2:09 p.m. the Unit Aide stated they did not know who was able to smoke or who was able to leave the unit independently. During an interview on 7/13/21 at 2:12 p.m. CNA#2 stated that Resident #243 was able to smoke. CNA#2 stated that they did not know which residents were able to leave the unit independently. CNA #2 stated that Resident #243 did not let staff know when the resident was leaving the unit. During an interview on 7/13/21 at 2:16 p.m. LPN#1 stated after therapy evaluated a resident for smoking it would be documented in the resident's care plan. LPN#1 said if a resident was not able to leave the facility unassisted, they would have a wander guard bracelet on and if they were approved to smoke, they would wear a lanyard indicating that. LPN#1 stated Resident #243 was not allowed to smoke but the resident does leave the unit unassisted and staff try to check on the residents as often as they can. During an interview on 7/13/21 at 5:30 p.m. LPN #2 stated there were three residents on the unit who smoked including Resident #243. LPN #2 stated those residents should have lanyards or passes to access in and out of the building. During an interview on 7/13/21 at 5:48 p.m., CNA #3 stated that they were unaware of the residents who smoked and that there was no list of smokers that CNA#3 was aware of. During an interview on 7/13/21 06:14 p.m., the Administrator stated that Resident #243's care plan should have been revised following the burn if indicated. During an interview on 7/13/21 at 6:27 p.m. the Assistant Director of Nursing (ADON) stated Resident #243 was aware that they were not allowed to go outside and smoke. The ADON stated the resident vaped. The ADON stated the resident was not allowed to go out of the building by themself as they need assistance. On 7/13/21 at 8:49 p.m., the survey team declared that the IJ was removed based on the following corrective actions taken by the facility. On 7/13/21 the facility provided 1:1 supervision to Resident #243 to prevent the resident from leaving the unit unattended and smoking unsupervised. The facility's security department was provided an updated list of residents who had been assessed and approved for smoking independently. Security will monitor the designated smoking location effective immediately for all residents who have access to the smoking area to verify that they are on the approved smoking list. All unit staff were educated on the updated smoking list and the procedures to follow for each resident. On 7/14/21 Resident #243 agreed to wear a wander guard bracelet on their wheelchair. Resident #243 was provided re-education on the unit sign in and sign out procedures and agreed to this. 10 NYCRR 415.12(h)(1)(2)

Based on observations, interviews and record review conducted during a Recertification Survey and complaint investigation (NY 844), completed on 7/15/21, it was determined that for one resident (Resident #243) of three residents, the facility did not ensure that alleged violations of abuse, neglect, or mistreatment, including injuries of unknow origin were reported to the Administrator and the State Agency in a timely manner. Specifically, the facility did not report to the New York State Department of Health (NYSDOH) that Resident #243 sustained an injury while smoking unsupervised until 5 weeks after it occurred. This was evidenced by the following: The facility policy, Accident and Incident Review and Prevention- Residents included all reportable events would be electronically reported per regulatory requirements. Resident #243 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 3/9/21, revealed the resident was cognitively intact and required supervision of staff for locomotion on and off the unit. The MDS documented the resident was a current tobacco user. A Smoking Safety Assessment, dated 3/9/21 and signed by the Registered Nurse, documented that Resident #243 stated they were smoking. The Assessment included that the resident could not safely simulate smoking, including but not limited to, accessing smoking materials, lighting a cigarette, disposal of ashes or the cigarette in an appropriate receptacle. An Incident/Accident report, dated 4/23/21 at 10:19 p.m., documented that a Certified Nursing Assistant saw Resident #243 in the smoking [NAME] falling asleep. Multiple cigarette [CONDITION(S)] were observed on the resident's clothing with holes in their pants and jacket and a red area noted on the resident's forehead. The report included that Resident #243's hair caught on fire when they requested a 2nd resident to assist them in lighting their cigarette. The fire was put out by the 2nd resident. The red area noted on the resident's forehead was not reported to medical until 4/26/21. A Medical provider note, dated 4/26/21 and signed by the Nurse Practitioner (NP) documented that Resident #243 had sustained a superficial partial thickness burn to the forehead while smoking outside in the smoke [NAME]. The NP documented the resident's hair was noted to be singed and that the resident had been deemed an unsafe candidate for use of the smoke [NAME] and had been preciously educated on this. The Health Electronic Response Data System - a reporting system where health facilities report incidents to the state revealed that the incident was not submitted until 5/27/21. During an interview with the Administrator, the Director of Nursing, the Quality Assurance Manager, and the Assistant Administrator on 7/15/21 at 10:33 a.m., the Administrator stated that administration had not been made aware of the incident as it had not been brought to morning report and was not included on the 24 hour-report. It was stated that the incident report was found on the unit on 5/27/21 and brought to the attention of administration who reported it at that time. [10NYCRR 415.4(b)(2)]

Based on observations, interviews and record reviews conducted during an Abbreviated Survey (complaints #NY 984, NY 615, NY 493, NY 614, NY 553, NY 224, NY 132, NY 109 and NY 407) completed on 3/19/21, it was determined that for 9 of 15 residential living units (Faith 3 East, Hope 2, Hope 3, Hope 4, Friendship 2 East, Friendship 2 West, Friendship 3 East, Friendship 4 East and Friendship 4 West) the facility did not have sufficient nursing staff on a 24 hour basis to care for residents' needs. Specifically, nursing ratios were not adequate. Medications and treatments were not provided as ordered within the required time frame (Resident #8 and Resident #9). Residents did not receive personal care per their choice including bathing, showers, and incontinence care (Resident #9 and #29). Observations and interviews revealed residents were not assisted out of bed or dressed the entire shift or late (Resident #4 and Resident #29). This is evidenced by, but not limited to the following: A review of the Facility Assessment, dated 12/10/20, revealed the facility uses the following general guidelines to establish its various direct care and support services staffing levels on their 16 resident units (total current house census of 442) to include that a minimum of one Registered Nurse (RN) is assigned to work the facility at all times. Nursing ratios per 24 to 40 bed units (indicated by full time equivalents per day) include: a minimum of one RN Manager (RNM) 5 days per week, 5 Licensed Practical Nurse (LPNs) per day (all three shifts combined) and 10 Certified Nursing Assistants (CNAs) per day (all three shifts combined for residents care). Review of staffing schedule, dated 2/25/21 through 3/16/21, revealed that for 9 of 15 residential units (census of 36-40 bed units), on 20 days/60 shifts the facility did not meet CNA staffing goals of 10 CNAs per day and did not meet the LPNs staffing goal of five LPNs per unit per day per the Facility Assessment. In addition, there was no RNs scheduled in the building on 10 of the evening shifts and 17 of the night shifts. 1.Resident #8 (resides on Faith 3 East) had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact, required extensive physical assist of one staff for personal hygiene and is dependent on staff for all other activities of daily living. In an interview on 3/16/21 at 10:27 a.m., LPN #1 said they were the only nurse on the unit at that time for 36 residents and two CNAs to provide care. LPN #1 said that they were unable to administer medications timely for 36 residents. In an interview on 3/16/21 at 10:54 a.m., CNA#1 said that they still had 13 residents that day to provide morning care to. At 12:21 p.m. CNA #1 and CNA #2 said they had not had a break or lunch and had not yet completed morning care for all residents. CNA#1 added that administration tells them they will send someone to help, but then no one comes. At 2:54 p.m., CNA#1 stated they had just finished morning cares at 2:45 p.m. Review Resident #8's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During observations of the unit on 3/19/21 at 10:43 a.m., twelve residents, remained in bed, wearing hospital gowns, window curtains drawn, and morning care not yet provided. When interviewed on 3/19/21 at approximately 10:45 a.m., Resident #8 remained in bed without care having been provided. Resident #8 stated that they were supposed to be gotten out of bed at 8:00 a.m., (per their care plan) and that it was important today as their family was coming for a visit. Resident #8 said their medications were given late on 3/16/21 but that it happens often and as long as they get them at some time during the day, they guess it is okay. 2.Resident #4 (resided on Hope 3) had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 1/23/2021, revealed the resident was cognitively intact and required extensive assist of one staff for personal hygiene and bed mobility and was non-ambulatory. In an interview on 3/16/21 at 10:40 a.m., Resident #4 said they do not get up every day because there are not enough aides. Resident #4 said that they missed their therapy appointment that day due to not being up and they were told that there was only one aide working on their side of the unit and was unable to provide care prior to the appointment. In an interview on 3/16/21 at 10:45 a.m., LPN #7 stated they knew Resident #4 had missed a therapy appointment at 10 a.m. and it was due to not receiving morning care or getting out of bed. LPN #7 said there were only two aides to provide cares for 39 residents and that is too many residents for two CNAs to provide care timely. In an interview on 3/16/21 at 11:36 a.m., LPN #3 said they are often not able to get medications administered in a timely manner because they have to provide and/or assist with resident's personal care. 3.Resident #9 (resided on Hope 4) had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 2/11/21, revealed Resident #9 was cognitively intact, frequently incontinent of bladder, always incontinent of bowel, required the extensive assistance of two for toileting and required the use of a power standing lift for transfers. The current Resident Care Summary Assessment (care plan used by CNAs) directs staff to toilet the resident after meals, at bedtime and as needed. During an observation and interview on 3/16/21 at 12:56 p.m., Resident #9, said they were upset that no one had changed them that morning before they left the unit for an appointment and that they went soiled. Resident #9 added that they came back to the unit and there was still no one to change them. Resident #9's sweatpants were visibly soaked with urine. When interviewed on 3/16/21 at 1:02 p.m., CNA #3 said they had 20 residents requiring care including Resident #9, and that they could not get to them all. At 2:54 p.m., CNA #3 said they had just finished morning cares at 2:44 p.m. Review of Resident #9's MAR, dated 3/16/21 revealed that all evening medications scheduled for 9:00 p.m. were administered at 11:18 p.m. and included but not limited to a sleeping medication, an antidepressant, a [MEDICATION(S)] and an anti-[CONDITION(S)] medication that was prescribed for three times daily In an interview on 3/16/21 at 11:41 a.m., RNM#1 said there were 39 residents on the unit with two LPNs and two CNAs on day shift and generally has only one nurse and one CNA on the evening shift. RNM#1 said staff do not get any breaks and sometimes have to put off resident cares (such as showers) to the following day as the unit is a heavy care load and heavy medication passes. RNM#1 said medication pass is often held up due to assist with passing trays, feeding and caring for residents. During an observation and interview on 3/17/21 at 11:18 a.m., twelve residents remained in bed, wearing hospital gowns and no morning care yet provided. Resident #29 (identified on the 3/12/21 MDS Assessment as cognitively intact and totally dependent on staff for toileting) stated at this time that if they could not have morning care provided, they would at least like a bed pan. 4. Resident #27 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 3/15/21, revealed the resident was cognitively intact, required total dependence of two staff for toileting, is occasionally incontinent of bladder, and is continent of bowel. The current Comprehensive Care Plan and Resident Care Summary for urinary and bowel function revealed that Resident #27 required total dependence on staff with use of a bed pan at night for toileting, to check and change as needed during incontinence rounds, and to wake at 4:00 a.m., per request for incontinence care. In an interview on 3/19/21 at 1:33 p.m., Resident #27 said they were extremely upset to have been put in bed on 3/18/21 at 7:00 p.m. and not gotten out of bed until 3/19/21 at 11:20 a.m. Resident #27 said they had not been changed or toileted and did not make it to breakfast. The resident said their brief was saturated and the call bell went unanswered. Resident #27 said they finally used a telephone to contact someone in Administration who called the unit and directed staff to assist them. Resident #27 reported that only two CNAs worked the day shift for 34 residents. Resident #27 said that they also reported to the administration offices on 3/15/21 that there was only one agency nurse on the unit for most of the evening shift. In an interview on 3/18/21 at 2:38 p.m., the Administrator stated that staffing has been a concern. The Administer said that the Medical Director has started to review the medication pass in an effort to reduce administration times or number of medications. The Administrator also stated that a shift differential had been approved for qualified staff as incentive and that they are working with community resources to improve staffing. When interviewed on 3/19/21 at 2:24 p.m., the Assistant Director of Nursing (ADON)/Scheduler stated that they had started having two RNs on the evening shift (whole house with a census of 422) to increase supervision during that shift, pass medications and assist as needed. The ADON added they have tapped the auxiliary to help with staff appreciation because staff have reported feeling undervalued in an effort to help the staffing issue. [10 NYCRR 415.13(a)(1)(i-iii)]

Based on interviews and record reviews conducted during an Abbreviated Survey (Complaints #NY 872, #NY 882, and #NY 815) it was determined for three (Residents #2, #21, #22) of four residents reviewed, the facility did not immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly, or a decision to transfer or discharge the resident from the facility. Specifically, the facility did not notify Resident #2's representative of the resident's transfer to the hospital, did not notify the medical provider in a timely manner of an injury of unknown origin for Resident #21, and did not notify Resident #22's representative in a timely manner following a new onset infection with treatments. This is evidenced by the following: Review of the facility policy Notification of Change, dated 7/15/20, revealed the appropriate department representative will immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly (discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility. 1. Resident #21 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 3/1/21, revealed the resident had severely impaired cognition and was dependent on staff for activities of daily living. Review of an investigative report, dated 2/26/21, included a Physical Therapy Assistant (PTA) witness account that stated she assisted Resident #21 with care on 2/18/21 at approximately 9:00 a.m. and noticed the resident's right upper thigh was swollen, discolored and did not look right. She immediately reported it to the Registered Nurse (RN). The RN's witness account stated she assessed the resident's leg describing the area as raised and firm, appearing to be a spasm. There was no discoloration or abnormal temperature change. The resident denied any pain. The RN stated there was no indication of a fracture. Review of a provider visit note, dated 2/19/21 at 4:13 p.m., revealed the resident was seen for concern of a right femur fracture. The physical exam revealed a grapefruit sized mass in the mid-lateral thigh with redness, swelling and crepitus (a cracking sound that may be indicative of a fracture) and external rotation of the right hip. The plan was to transfer the resident to the hospital for further evaluation with concern for fracture of the femur. Review of the hospital history and physical, dated 2/19/21, revealed an x-ray confirmed a severely comminuted (broken ends of the bone are shattered into many pieces) and impacted (broken ends of the bone are jammed together by the force of the injury) fracture of the right leg. When interviewed on 3/18/21 at 10:41 a.m., the RN stated that the PTA showed her the resident's right leg on 2/18/21 because the PTA thought it was out of the ordinary. The RN said the bump on the resident's right leg did not look like a fracture but instead thought it was a spasm. She said she did not know Resident #21 who had previously resided on another unit and did not remember seeing the bump on the resident's right leg when she cared for her on the previous day (2/17/21). The RN stated she did not notify the provider of the bump after assessing the resident on 2/18/21. When interviewed on 3/18/21 at 10:48 a.m., the Physical Therapist (PT) stated that the PTA who had provided care for Resident #21 on 2/18/21, noticed the bump on the resident's right leg and reported it to a nurse on the unit at that time. The PTA asked the PT to check the resident's leg on 2/19/21 because she did not feel that anyone had followed up on her concerns. The PT and PTA went to the resident's room together and observed a large swollen area on the right thigh. The PT stated that when she performed range of motion on the resident's leg she felt crepitus near the resident's femur. She immediately notified two nurses on the unit, one of whom evaluated the resident and notified the medical provider who arrived shortly after to evaluate. When interviewed on 3/18/21 at 3:44 p.m., the Nurse Practitioner (NP) stated she was notified on 2/19/21 that Resident #21 had a bump on the leg with a concern for a fracture. She examined the resident and agreed there was a possible fracture. The NP stated that if a staff member did not know the resident and the resident was having this type of issue, she would expect that the staff member would notify medical immediately. She stated that if she had been notified on 2/18/21 and based on her assessment she would have sent Resident #21 to the hospital at that time for further evaluation of a possible fracture. 2. Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 12/15/20, revealed the resident was in a persistent vegetative state and cognition was not evaluated. Review of a provider visit note, dated 1/29/21, revealed Resident #22 was suctioned for thick green sputum (a mixture of saliva and mucous coughed up from the respiratory tract, typically indicative of infection or other disease). The provider's assessment revealed concerns for tracheitis (inflammation of the trachea), and the plan was to check blood work, culture the sputum, start antibiotics, follow-up on the culture and if the resident had a decline to send them to the hospital. Review of Medication Administration Records for January 2021 and February 2021 revealed the resident was prescribed [MEDICATION(S)] (antibiotic) 750 mg daily for 7 days on 1/29/21 for tracheitis but received it on only five days on 1/30/21 and on 2/1/21 through 2/4/21. Review of interdisciplinary progress notes from 1/29/21 to 2/8/21 revealed no documentation that Resident #22 representative was updated with the resident's condition until 2/8/21 at 4:07 p.m., after Resident #22 continued to decline and a chest x-ray confirmed pneumonia. When interviewed on 3/16/21 at 2:29 p.m., the Registered Nurse Manager (RNM) stated that on 1/29/21 she had suctioned Resident #22 for a large amount of green secretions which the resident did not usually have. The RNM said she had not notified the resident representative at that time and was not sure if she or the provider was supposed to notify the family. She assumed the provider had not notified the family following a phone conversation she had with the resident's representative on 2/8/21 where she stated she had not been notified of the resident's change in condition. When interviewed on 3/16/21 at 3:08 p.m., the Physician Assistant (PA) stated that she evaluated Resident #22 on 1/29/21, ordered lab work and started the resident on an antibiotic for concerns of tracheitis but could not remember if she had contacted the resident's representative. The PA said that either she or nursing would traditionally contact the family when there is a change in a resident's condition. When interviewed on 3/19/21 at 2:16 p.m., the Director of Nursing (DON) stated that in general, if there is a change in a resident's condition on an off shift, she would expect the nursing supervisor to notify the family. During normal business hours, the provider will usually reach out to the family directly to notify them of the change. The DON stated that notification of a change in condition is handled individually for each resident, however, for a resident who was not well and required an antibiotic, someone should have been notified. 3. Resident #2 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 6/19/2020, revealed the resident had severely impaired cognition. Review of a provider visit note, dated 8/4/20, revealed Resident #2 was seen for a worsening, unstageable (full thickness tissue loss with the base of the wound covered with damaged tissue) sacral wound and [CONDITION(S)] (slow heart rate). The plan included to send the resident to the hospital for urgent lab work, monitoring of [CONDITION(S)], and a plastic surgery consult for possible sharp debridement (surgical removal of damaged tissue from a wound) of the sacral wound. Review of interdisciplinary progress notes for 8/4/20 did not include any documented evidence that the Resident #2's representative had been notified of the hospital transfer. When interviewed on 3/19/21 at 12:54 p.m., the Licensed Practical Nurse (LPN) stated that she remembered caring for Resident #2. She said the wound declined quickly and the resident was sent to the hospital and did not return. The LPN stated she could not remember if the family was notified of the transfer. When interviewed on 3/19/21 at 3:28 p.m., the Administrator stated that she spoke with the Director of Social Work and that no information could be found related to notifying the resident's representative of the hospital transfer. 415.3 (C) (2) (ii) (a) 415.3 (c) (2) (ii) (c)

Based on interview and record review conducted during an Abbreviated Survey (#NY 815) the facility did not ensure that a potential violation of abuse mistreatment or neglect, including an injury of unknown source, was thoroughly investigated for one (Resident #2) of one resident reviewed. Specifically, Resident #2 was found on the floor sustaining an injury and the facility was unable to provide a thorough investigation in order to rule out abuse, mistreatment, or neglect. This is evidenced by the following: Review of the facility policy, Abuse Prohibition Program, dated 12/11/19, revealed that an injury of unknown origin is when the source or origin of the injury was not observed or could not be explained by the resident. Investigations must include interviews from all involved persons. Resident #2 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 3/5/20, revealed the resident had severely impaired cognition, was totally dependent on two staff for bed mobility and did not walk. The current Care Plan Report included cognitive loss, dementia and a problem with functional status that included a history of falls and required a mechanical lift with two staff for transfers. Interventions, including but not limited to, were to keep areas free of obstructions to reduce the risk of fall or injury, keep call light within easy reach, and keep the bed in the lowest position with wheels locked. In a clinical note, dated 7/18/20 at 12:44 a.m., the Registered Nurse documented that she was called to assess Resident #2 after a fall and that the resident was bleeding. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound was cleansed and steri strips were applied. Review of the accident/incident report form included that on 7/17/2020 at 6:15 p.m., Resident #2's roommate alerted staff that Resident #2 fell out of bed. The root cause of the occurrence was a history of falling and poor safety awareness. The investigation did not include any witness statements, environmental factors or any review of possible care plan violations. During an interview on 3/19/21 at 11:30 a.m., the Director of Nursing (DON) said no one interviewed the resident or staff regarding the injury. She did not have any investigative information regarding what the resident may have hit to sustain the laceration. She said she did not have any further information on the circumstances surrounding the fall. The DON said the fall was witnessed by the roommate, but there was no statement obtained from the roommate either. 415.4(b)(2)

Based on observations, interviews and record review conducted during an Abbreviated Survey (Complaint's #: NY 407, NY 614, NY 493, and NY 984) it was determined for one (Resident #1) of six residents reviewed, the facility did not implement a comprehensive person-centered care plan for each resident that meets a resident's medical, nursing, mental and psychosocial needs. Specifically, the facility did not assist Resident #1 with showers according to their care plan. This is evidenced by the following: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 2/5/21, revealed the resident was cognitively intact. Review of the current Comprehensive Care Plan revealed the resident required assistance with bathing and staff were to offer a shower or tub bath weekly. Review of the current Resident Care Summary (care plan used by Certified Nurse Assistants- CNAs) revealed the resident required the limited assistance of one staff for bathing and their showers were scheduled on Wednesday day shift and Saturday evening shift. Review of Resident #1's medical record 7/30/20 to 9/1/20 revealed that on 7/30/20 a nursing progress note documented that Resident #1 was upset because their shower day had been changed. From 8/1/20 through 9/2/20 Resident #1's medical record did not include any documentation that Resident#1 had received or refused any showers. During an observation and interview on 3/17/21 at 1:50 p.m., Resident #1 stated they had not had a shower in three weeks. During a quarterly care plan meeting, about 3-4 weeks ago, their family pushed for a shower and one was given. Resident #1 stated they go to [CONDITION(S)], so their showers are scheduled on Wednesdays and Saturdays, but they would be happy to get one shower a week but is not. On 3/18/21 at 12:00 p.m., the resident stated they did not receive their scheduled shower on Wednesday, 3/17/21. Resident #1 was appropriately dressed and free from odors at the time. A review of the Activities of Daily Living (ADL) Verification Worksheet from 8/1/20 to 8/31/20 and again from 2/1/21 to 3/18/21 revealed that bathing was coded as activity did not occur. Review of progress notes from 2/1/21 to 3/18/21 did not include any documentation related to refusals of care. When interviewed on 3/16/21 at 9:05 a.m., the Registered Nurse Manager (RNM) stated a resident's scheduled shower days are on the Resident Care Summary. On 3/17/21 at 2:06 p.m., the RNM stated she would expect the nurses to document if a resident did not receive a shower. When interviewed on 3/17/21 at 2:06 p.m., the Licensed Practical Nurse stated she stayed past her shift to give the resident a shower about three weeks ago. When interviewed on 3/17/21 at 2:02 p.m., the CNA stated there is a shower schedule but she does not document when a resident receives a shower. The CNA stated the ADL code 8,8 indicates the activity did not occur. 10NYCRR 415.11(c)(1)

Based on observations, interviews and record reviews conducted during an Abbreviated Survey (#NY 109) it was determined that for one (Resident #15) of five residents reviewed, the facility failed to ensure that the resident received adequate supervision and assisted devices to prevent accidents. Specifically, the facility failed to implement the person-centered plan of care to prevent an actual elopement by Resident #15 who exited the building and was observed by several staff members before being returned to the facility. This was evidenced by the following: The current facility policy Exit Roam Alert Wander Guard System revealed that residents identified as high risk for unsafe wandering will have a roam alert tag. The roam alert tags will be removed and stored in a lock box when a resident is sent to the emergency room and re-issued upon their return. Tags will be visually checked daily to ensure they are worn appropriately. The current policy Missing Resident, included roam alert wander guard bracelets or anklets and identification red lanyards with name and picture are issued to all residents assessed and care planned as having increased risk of unsafe wandering or elopement and require an escort when off their unit. Resident #15 had diagnoses including, [CONDITION(S)] with left [CONDITION(S)] (weakness on one side of the body), and severe depression with psychotic symptoms. The Minimum Data Set Assessment, dated 11/5/20, revealed that the resident had moderately impaired cognitive function and that wandering behavior was not exhibited at that time. The current Comprehensive Care Plan included that Resident #15 was at risk for unsafe wandering and elopement due to being found off the unit alone on 11/21/19 and a wander guard bracelet had been placed. Interventions included wander guard checks every shift and that the security department was to replace equipment as needed. Review of the Resident Care Summary, the care plan used by the Certified Nursing Assistants (CNAs), dated 12/9/20, revealed Resident #15's locomotion on the unit was independent, they required one person assist off the unit, use of a wander guard bracelet as identified by wearing a red lanyard, and an escort when off the unit. Current physician orders included a wander guard bracelet, with a start date of 11/22/19 and to be checked every shift for placement. Review of interdisciplinary progress notes revealed the following: a. On 12/7/20 at 3:35 pm., the progress note documented that Resident #15 was observed getting off the elevator, stating they did not know which way to go and was returned to the unit by Occupational Therapy (OT). b. On 12/9/20 at 8:36 p.m., a Licensed Practical Nurse documented that at 4:30 p.m., the secretary notified her that Resident #15 was found downstairs and was escorted back to the unit. c. On 12/20/20 at 8:03 am., the resident was lethargic, medical was notified and the resident was sent to the hospital for an evaluation and returned to the facility at 4:00 p.m that day. d. On 12/21/20 at 8:47 a.m., OT evaluated the resident for off unit orientation and documented that the resident continued to demonstrate need for supervision off the unit due to cognitive deficits that required cueing and to continue with the wander guard for safety. Review of the Treatment Administration Record (TAR), dated 12/20/20 evening shift through 12/23/20 day shift revealed an entry for a wander guard bracelet to be checked on days, evenings, and night. The entry was initialed on 8 of 9 opportunities to indicate the bracelet was in place. Review of the security incident report dated 12/23/20 at 2:55 p.m., and facility investigation, dated 12/28/20 revealed that on 12/23/20 at approximately 3:00 p.m., Resident #15 was found outside the building without a wander guard bracelet on or a red lanyard. The investigation summary included that on 12/20/20 Resident #15 was transferred to the hospital without the wander guard being removed and it was possible that it was removed in the hospital and not replaced when the resident returned later in the day. The summary also included that the December 2020 TAR entry for checking the wander guard was signed by five nurses, indicating the bracelet was in place. In addition, several staff members passed the resident outside unaware the resident was at risk for elopement before a third staff member returned the resident to the unit approximately 15 minutes later. The investigation included staff on the unit were to busy to notice the resident leave the unit. In an observation on 3/18/21 at 11:00 a.m., the resident was participating in an activity in the dining room. A wander guard bracelet was observed on the right ankle, but no red lanyard was visible. In an interview on 3/17/21 at 11:12 a.m., the Director of Nursing (DON) stated the nurse readmitting the resident from the hospital would be responsible for ensuring the wander guard bracelet was in place. The DON stated her expectations were that the CNAs ensure anything on the care card was in place or provided. She said that a resident at risk for elopement is identified with a red lanyard which signified the resident should have a staff escort when off the unit. The DON stated that Resident #15's care cards dated 11/22/19 and 11/5/20 included a wander guard bracelet and a red lanyard to be worn and the resident should have had both on at the time of the elopement. In an interview on 3/18/21 at 3:03 p.m., the CNA who cared for Resident #15 on 12/20/20 and 12/21/20 stated that if the resident care card included a wander guard bracelet then they would ensure the resident had one on. The CNA stated a red lanyard indicated the resident stayed on the unit and this would also be on the care card. The CNA said that Resident #15 did wear a wander guard bracelet but they could not recall if the resident wore a red lanyard. In an interview on 3/19/21 at 9:27 a.m., the Security Guard stated security issues the wander guard bracelets for residents deemed a security risk and when a resident is transferred to the hospital the nurse calls to take the resident out of the system and calls when the resident returns to reactivate the bracelet. In an interview on 3/19/20 at 10:09 a.m., the Registered Nurse Manager (RNM) stated that Resident #15 went to the hospital where the bracelet was removed and when the resident returned the bracelet was not reapplied. The RNM stated the nurse who assessed the resident on return from the hospital should have reapplied the wander guard bracelet. The RNM stated that when the TAR is initialed it indicates that the nurse visualized the bracelet on the resident. The RNM stated she did not visualize the bracelet in place but signed for it because the bracelet is always on and she did not know it had been removed. The RNM stated she was unaware of what a red lanyard indicated. 10NYCRR 415.12(h)(2)

Based on observations, interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY 445), it was determined that for one (Resident #1) of three residents reviewed for accidents, the facility did not ensure that a resident received adequate supervision to prevent an accident. The issue involved a second degree cold weather injury requiring hospitalization . This is evidenced by the following: Resident #1 was admitted to the facility's third floor on 6/26/17 with a [DIAGNOSES REDACTED]. skills for daily decision making as severely impaired, independent with set up, help only for walking in the room and corridor, locomotion off the unit occurred once or twice, and required one person physical assist. A Social Work note, dated 12/21/17, revealed that the resident's BIMS score was 10 (moderately impaired cognition). The Montreal Cognitive Assessment, dated 6/27/17, includes that the resident scored 4/30 (normal score is greater than 26). The Wandering Assessment, signed by the Registered Nurse (RN) on 6/28/17, revealed the first two questions under unsafe wandering potential were coded as Yes, (Does the resident appear to lack decision making capacity and does he exhibit signs of cognitive impairment? Is the resident in any way independently mobile?) The next paragraph includes if the answer to both questions above are yes, the resident poses a high risk for unsafe wandering behaviors and initial care planning to address that risk must be initiated immediately. An interim nursing care plan, dated 6/26/17, revealed the resident was a fall risk and the goal was to be free from injury. The Care Plan Report, dated 12/20/17 to present, revealed under facility safety that the resident has the potential for injury related to falls/behaviors, dementia second to cognition/ability/[MEDICAL CONDITION]. Interventions include to perform frequent checks, and to attempt to leave the resident in an easily visualized area after any off unit appointments. The Care Plan Report for Cognition revealed that the resident has impaired cognitive function, was easily disoriented with changes in routine, had a lack of/or poor insight, disorganized thought process, and self-care deficit due to poor insight and/or ability to initiate, understand and/or complete a task. Interventions included to provide for a safe environment, risk of injury due to poor or lack of insight, and the resident will be supervised by staff when off the unit. The goal for both Care Plan Reports was the resident will be free from injury. The Resident Care Summary Assessment, revised 12/21/17, revealed the resident was independent for mobility with a rolling walker and supervision for off unit orientation assistance. Review of facility interdisciplinary/progress notes included the following: a. On 6/26/17 at 10:30 p.m., the resident was asking, Where is my wife? She is suppose to pick me up here. b. A Behavior Flow Sheet, dated 7/5/17, revealed that the resident's target behaviors were attempting to get on the elevator or leaving the unit. The resident was on the elevator at 3:00 p.m. and was easily redirected off the elevator. c. A Resident Update Form, dated 7/25/17, includes behavioral concerns with a behavior log initiated and the resident was monitored for attempts to get on the elevator or to leave the unit until 7/30/17. d. A Physical Therapy Note, dated 8/16/17, includes that the resident may benefit from supervision off the unit for orientation assistance. e. A nursing progress note, dated 10/13/17, revealed that the resident got on the elevator. The writer noticed the resident was not sitting in the chair near the nursing station. Staff found the resident had taken the elevator down to the first floor lobby area. The resident was brought back to the third floor unit and went to his room. Will continue to monitor. f. A psychiatry follow-up note, dated 11/13/17, revealed that the resident's insight and judgement were poor, he had delusions, heard voices, and asked, How long do I have to stay here? Review of the Incident/Accident and Investigation Report, dated 1/4/18 through 1/8/18, revealed a Certified Nursing Assistant (CNA) was on break, sitting in her car on 1/4/18 at 1:08 a.m. While walking back to the facility, she heard the resident cry out for help. The CNA found the resident laying on the ground and called the nursing supervisor. The resident was dressed in a shirt, pajama bottom, socks and shoes. He had several abrasions down his left side. His temperature was 94.8 degrees Fahrenheit initially. The resident was outside between 28 and 31 minutes. He was last seen by staff at 12:10 a.m. in his bed. The resident did get on the elevator in (MONTH) (YEAR) and (MONTH) (YEAR) but did not appear to be trying to leave the facility. At the time of the second event in (MONTH) (YEAR), the resident was determined to lack capacity. He hears voices and has delusions. The surveyor viewed the video footage prior to and during the elopement with the Supervisor of Safety and Security on 1/12/18 at 2:24 p.m. which revealed the resident exited the elevator at 12:39 a.m., exited the building and walked to parking lot 1 at 12:41 a.m., he walked to the third row of cars, walked into the back bumper of an automobile, fell , got up and fell again, he then walked to the fourth row and fell next to a vehicle where he was found at 1:07 a.m. The resident was returned to the facility at 1:13 a.m. The outside temperature was 22*F. The resident sustained [REDACTED]. Review of the Emergency Department provider note, dated 1/4/18, revealed the resident sustained [REDACTED]. He had redness and swelling of the right hand and the fourth and fifth digits on the left hand. The resident had significant pain with even slight movement. Over time, he developed blisters to the fingers on his right hand. They became progressively worse over about 45 minutes. The resident will need to see burn surgery as soon as possible. The service was not available at the current hospital and the resident was transferred to another hospital for burn management. The Burn Center History and Physical, dated 1/4/18, revealed that the resident had a second degree frostbite injury to hands and arms, right worse than left, and was admitted to the Burn surgery for [REDACTED]. The resident was discharged back to the facility on [DATE]. A Facility Restraint Quarterly review included that the resident eloped on 1/4/18 outside and was found in the parking lot. This elopement resulted in frostbite to several locations on the resident's body and he needed acute care. The resident was sent to the hospital on [DATE] and was returned to the facility on [DATE] to a secured unit with a wanderguard bracelet. Interviews conducted on 1/12/18 included the following: a. At 9:00 a.m., the Administrator, Quality Assurance Representative, Associate Director of Nursing, and the Director of Nursing (DON) said the resident was sent to the hospital and has not returned. They said the resident was not considered an elopement risk and that he did not have exit seeking behavior. b. At 12:00 p.m., the Administrative Nurse Manager (ANM) said the resident did not go past the unit dining room. The ANM said that she was under the impression that the resident would not be able to find his way back if he left the third floor unit. c. At 3:14 p.m., the DON said that if a resident gets on the elevator and makes it to the first floor, it is not considered an incident. He said they would not have a care plan for the resident because the other answers on the Wandering Assessment were no. d. At 3:29 p.m., the ANM and the Clinical Nurse Manager (CNM) both said in (MONTH) a behavior log was completed for the resident because he stated he wanted to leave and got on the elevator but he was easily redirected. They said there were no other wandering assessments completed because the physician did not deem him incapacitated. They said if a resident tries to get on the elevator, it is not considered an incident. They said the resident could not leave the unit because he would not remember how to get back. They said if he was looking for an exit, they would have placed a wanderguard. They said the resident would not have received a wanderguard for the two times he tried to get on the elevator. They said a wanderguard was considered a restraint and would be restrictive. e. At 5:30 p.m., the Deputy Director and DON said that because the first two questions on the Wandering Assessment were answered yes, does not mean a care plan has to be done, it would be a nursing judgement. They said they did not have a policy for wandering residents or guidelines on how to complete the assessment. Interviews conducted on 1/16/18 included the following: a. At 12:35 p.m., the Deputy Director said the resident could get off the unit because he was not restricted, and he was not a wandering resident. The Deputy Director said the resident had one time when he made it on the elevator to the first floor. She did not think that was exit seeking unless they walk to an exit. b. At 1:05 p.m., the ANM said that a reassessment was not done when the resident was found on the elevator in (MONTH) because he did not go off the unit. She said the Wandering Assessment was done initially, annually, and with a significant change. She said the facility was looking to change that. c. At 1:56 p.m., the Utilization Review Nurse, who completed the Wandering Assessment, said if she answers yes to the first two questions, she tells the Clinical Care Coordinator to include it in the care plan. The Utilization Review Nurse said she would expect a care plan to be done but she did not consider the resident an elopement risk. d. At 2:09 p.m., Licensed Practical Nurse #1 said there was an incident where the resident went on the elevator. She said we all were looking for the resident. She said he was sitting on the first floor near the Hope elevators on a bench. She said he did not want to return with the aide so another aide had to bring him back. e. At 2:28 p.m., assigned evening CNA #1 said that on 1/3/18 she saw the resident in bed at 10:30 p.m. talking to himself but she does not know what he was saying. f. At 3:10 p.m., the DON said that in (MONTH) the resident was found on the first floor but it was not considered an incident because the resident did not try to go out the door, so the resident would not be considered an elopement risk. g. At 5:45 p.m., the Deputy Director, Administrator, DON and Associate DON said they did not agree that the resident exhibited wandering behavior just because he made it to the first floor. They did not agree with making the unit the most restrictive for the resident. They said the conclusion not to include wandering in the care plan was based on nursing judgement. Telephone interviews conducted on 1/23/18 included the following: a. At 9:43 a.m., night LPN #2 said she saw the resident between 11:30 p.m. and midnight. she did not know the resident was off the unit until she was called by the supervisor. The resident told the supervisor that someone was waiting for him outside. She said when the resident returned to the unit, his fingers were beet red and he was shivering. LPN #2 said she remembers one night in (MONTH) when the resident said he was leaving to get his wife and had to be redirected several times. LPN #2 said she heard the resident left the unit once but did not know when. b. At 10:48 a.m., CNA #2 said on 1/4/18 when she was leaving her car she heard someone say help me. She walked to where the voice was coming from and found the resident. She said his pants and brief were half way down his legs. She said the resident stated he was from Hope 3, that he was waiting for a ride, and someone was coming to pick him up. CNA #2 said the resident also said he hit his head on the car and lost his glasses. CNA #2 said she immediately called the supervisor. Interviews conducted on 1/25/18 included the following: a. At 6:45 a.m., the night Registered Nurse (RN) Supervisor said she became aware the resident left the building when she was called by CNA #2. The RN Supervisor said she immediately went to the parking lot and the resident told her that he was supposed to meet them there and he had to get the car. The RN Supervisor said she returned the resident to the unit. She said both of the resident's hands were red and when his clothes were removed, the left side of his body was red. The resident was shaking and shivering, and we raised his legs to get the blood flowing and placed him in bed with blankets. She said the resident hit his head hard enough to bend his glasses and pop a lens out, and there was a laceration on the left side of his forehead. She said it was slushy outside. b. At 7:20 a.m., the night security guard said he was in the security office when the resident went out. He said after the incident he reviewed the video, he said the resident was walking without a cane, he was wearing sneakers and socks. He said he would not have necessarily known it was a resident. The door will not alarm unless the resident is wearing a wanderguard. c. At 7:45 a.m., CNA #3 and CNA #4 said they last saw the resident at 11:30 p.m. and were not aware he left the unit. They were assisting another resident that required two for care. d. At 9:04 a.m., the primary Social Worker (SW) said she was not aware the resident's psychiatric note included that the resident heard voices. The SW said he should not have been off the unit. She said she knew the resident made it to the ground floor once but would not have considered him an elopement risk because you should have two incidents to be considered an elopement risk. After reviewing the Wandering Assessment, she said the resident definitely should have had an initial care plan for wandering. e. At 10:10 a.m., the primary physician said she was notified when the resident was found on 1/4/18 and was surprised he made it outside. The physician said the resident has never said he was looking for his wife or that he wanted to leave. When she reviewed the Montreal Cognitive Assessment, she said it indicates the resident had significant dementia. The physician said she did not consider him an elopement risk because he did not perseverate on leaving. When asked if a resident with significant dementia should be allowed to wander unsupervised off the unit, she said probably not. During an observation and interview on 1/25/18 at 1:25 p.m., the resident said he felt weak. He said he was trying to get to his car to get something out in below zero degree weather, then it turned into a disaster. He said his hands took a beating. The resident said that his hands hurt but they give him pain medicine. He said they let him get out to go to his car but the trick was getting back into the facility. The resident had an Ace wrap on both hands. The right hand had zeroform gauze and stretch gauze covering his fingers, left wrist and thumb. The undated General Safety (YEAR) Mandatory Inservice Program revealed that elopement occurs when a resident successfully leaves the nursing facility undetected and unsupervised, and enters into harms way. Unsafe wandering is wandering that is disruptive to other residents or place the wandering resident or other residents at risk for harm. All residents upon admission, annually, and with change of condition, undergo a comprehensive assessment of their functional capacity, including elopement risk. This process also includes a restraint assessment conducted by the clinical operations team. Based upon the results of these assessments, the interdisciplinary care team will develop and keep current an individualized plan of care to meet each resident's safety needs, including appropriate interventions on the day of admission to minimize the risk of elopement and/or unsafe wandering. (10 NYCRR 415.12(h)(1)(2))

Based on staff interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 671), it was determined that the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the administration failed to ensure that verbal abuse and removal of a resident's independent mobility were not occurring and that facility policies and procedures regarding Abuse Reporting and Abuse Investigations were operationalized. This resulted in actual harm that is IMMEDIATE JEOPARDY to RESIDENT HEALTH AND SAFETY, and is evidenced by the following: The Immediate Jeopardy was removed on 3/29/13 prior to the exit. The following citations are being presented in this Statement of Deficiencies: F223, Abuse S/S = K; F226, Abuse S/S = K; and, F309, Quality of Care S/S = G. Resident #394 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 10/27/12, revealed that this resident's cognitive skills for daily decision making were intact. Review of the Comprehensive Care Plan, dated 12/6/12 (morning), revealed that the resident's smoking and power wheelchair privileges had been revoked. The resident was given a manually operated wheelchair with a Wanderguard and was told he could not leave the facility with friends. In an interview on 3/20/13 at 5:30 p.m., Employee #2 reported that at the beginning of her shift, she found a note posted at the nursing station with directions from the Adminstrator (Executive Director) that the resident was not to leave the unit after 3:00 p.m. or there would be consequences. The resident was not on the unit, so she left to find him. Upon return to the unit, the resident was exiting the elevator onto the unit. At that time, the Administrator requested that the resident be put in bed. Employee #2 stated that the door to the resident's room was open and she could see that the resident was in bed. Employee #2 said she witnessed the Administrator, standing over the resident, pointing his finger at the resident and speaking in an intimidating tone. This was described as an "unjustified attack." In a progress note, dated 12/5/12, the Director of Social Work (DSW) documented concerns regarding resident behaviors. These included drinking alcohol to excess, repeatedly smoking in nonsmoking areas, removing the safety device (orange flag) on his power wheelchair, and using the power wheelchair in an erratic way. The DSW noted that these behaviors place the resident and those around him at a safety risk. Also, the Administrator has directed that the resident's room be searched for alcohol/cigarettes and that the power wheelchair and smoking privileges be removed. The DSW noted that the resident was out of the building at that time. Review of a progress note signed by the Nurse Practitioner (NP) written at 11:25 a.m. on 12/6/12 revealed that a care plan meeting had been held that morning and attended by the Administrato, NP, Social Work Director, the primary SW, Registered Nurse Manager, Medical Director, and the resident that day. Decisions made during this meeting resulted in the resident's loss of use of a power wheelchair, loss of smoking privileges, and loss of ability to go outside with his friends. He was given a manually operated wheelchair that would be monitored with a Wanderguard. The resident could go out on pass with a responsible party, example was family, or family designee, and would be monitored for smoking and alcohol withdrawal. The NP documented that this plan had been discussed with the resident, who was not happy about the loss of smoking privileges. The NP also documented that she saw the resident after the meeting, and the resident declined to talk, nodded his head to show he was upset about the loss of smoking privileges, and shrugged his shoulders when the nicotine patch was explained. The resident had emesis after the meeting and declined to be examined. In a progress note, dated 12/10/12, the Social Worker (SW) noted that the resident's manual wheelchair had been returned at 8:40 a.m. that day. The SW documented that the resident was instructed that the parameters of wheelchair use would be no smoking, no outside of the building, and no alcohol to maintain his safety. The resident did not have use of a wheelchair from 12/6/12 to 12/10/12. There were no documented medical orders for loss of independent mobility. In an interview on 3/20/13 at 11:30 a.m., the Director of Nursing (DON) stated he was not aware that anything was happening until the Administrator said he wanted to take care of it himself. He said Human Resources are interviewing the staff, and he was not aware of any outcome. During an interview on 3/22/13 at 9:45 a.m., the Administrator stated that Human Resources did an investigation, and from his perspective, things said were 100 percent fabrication. He was not sure whom Human Resources interviewed. The Administrator stated that the DON is responsible for investigating allegations of abuse. The Administrator said he did not have any information on an investigation. In an interview on 3/25/13 at 2:30 p.m., the Assistant DON (ADON) said typically when there is an issue, we would have a file. He was unable to find one. In an interview on 3/26/13 at 11:40 a.m., the Human Resource Manager said she did not recall receiving abuse prohibition training. She stated that the investigation she was doing was not an abuse investigation. The facility presented a letter alleging compliance to remove the Immediate Jeopardy on 3/28/13. The actions being taken to do this included the following: 1. At that time, no residents at the facility were subject to an imposed loss of mobility. 2. All decisions made regarding the restriction of a resident's freedom of movement, removal or protection from the company of any other, or similar plan, shall be made only with the agreement of the care team and only after all less restrictive measures have been considered and/or attempted. Such a plan shall only involve situations where a resident's actions or behavior poses an imminent risk to self or others. The care team will include the Director of Nursing, Nurse Manager (or surrogate), Social Worker, medical provider, and Deputy Director. 3. All direct care staff will be inserviced on the legal requirement to report patient abuse, the ability to do so without fear of retribution, and the availability of both the State and County hotlines to report patient abuse. 4. The training for clinical staff including Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, and Social Workers will include the following: a. Types of abuse. b. Legal requirements to report any and all patient abuse. c. Expectation that all staff can and must speak up when they feel any measures taken to address a resident care situation infringes on a resident's rights or freedoms and that they can do so without fear of retribution. d. While this Department of Health survey is being completed and until it is resolved, the Administrator will avoid any contact with residents without other staff present and will not discuss the survey or its underlying facts with any staff member. In addition, staff will be informed that they are not to have any communication with the Administrator concerning the survey or its underlying facts until it has been completed and that they should report any communication contrary to this directive to the County [MEDICATION NAME] hotline at [PHONE NUMBER]. On 3/29/13 it was determined that the immediate jeopardy had been removed as a result of the facility's actions taken as outlined in their allegation of compliance letter of 3/28/13. This determination was made on 3/29/13 after surveyors: a. verified that on 3/28/13 the Administrator was removed from the survey process and investigation of complaint #NY 671. b. reviewed inservice records, completed interviews with staff to verify that 289 of 309 staff members or 93.5 percent had been retrained and that off duty staff would be retrained within the first two hours of their shift or would not be allowed to work. This training included receipt of an outline that included the requirements described in the credible allegation of compliance letter. c. verified that nursing staff were trained on the requirement that behavior care plans must specify what behaviors are targeted for modification and in all cases the least restrictive means must be chosen and adhered to. d. verified that audit tools are in the process of being developed. (10 NYCRR 415.26)

Based on staff interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 671), it was determined that for one (Resident #394) of nine residents reviewed for abuse, neglect, or mistreatment, the facility failed to put their Resident Abuse, Neglect, or Mistreatment Policy into operation. Specifically, the facility failed to recognize that abuse occurred, failed adequately intervene to protect the resident, and failed to ensure adequate intervention to protect all other residents who could have been affected over a three-month period and failed to report this incident to the NYS Department of Health hotline. Additionally, Employees #1, #2, #3, #4, #5, #6, #7, #8, and #9, voiced knowledge of the facility's policy/procedure regarding abuse reporting and at the same time voiced fear of retribution from facility administration if they were to report this issue to facility administration or to the New York State Department of Health for investigation. This resulted in actual harm that is IMMEDIATE JEOPARDY to RESIDENT HEALTH and SAFETY and SUBSTANDARD QUALITY of CARE. This is evidenced by, but not limited to, the following: The Immediate Jeopardy was removed on 3/29/13 prior to exit. Review of the facility's policy, "Resident Abuse, Neglect, or Mistreatment," dated June 2012, revealed that the term mistreatment is defined as inappropriate use of physical restraints for a nursing home resident, while such is under the supervision of the facility. This policy directs that all county and contract employees employed by the facility, whether licensed or unlicensed, are required to report resident abuse in accordance with Public Health Law 2803-D. This policy also requires that investigations of allegations of abuse,neglect, or mistreatment will be completed by a staff member who is trained on investigative techniques and will be done immediately, regardless of the time of day or day of the week. Resident #394 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 10/27/12, revealed that the resident's cognitive skills for daily decision making were intact, that he was understood by and did understand others. Documentation in the MDS Assessment shows that the resident used a wheelchair as a mobility device, liked to go outside to get fresh air in good weather, liked to choose his bedtime, and did not present behaviors as a wander risk. Documentation on Comprehensive Care Plans (CCP), dated from 3/28/11 through 11/8/12, show that the resident had a signed smoking contract and had demonstrated safety and independence with smoking. In a progress note, dated 12/5/12, the Director of Social Work (DSW) documented concerns regarding resident behaviors. These included drinking alcohol to excess, repeatedly smoking in nonsmoking areas, removing the safety device (orange flag) on his power wheelchair, and using the power wheelchair in an erratic way. The DSW noted that these behaviors place the resident and those around him at a safety risk. Also, the Administrator has directed that the resident's room be searched for alcohol/cigarettes and that the power wheelchair and smoking privileges be removed. The DSW noted that the resident was out of the building at that time. In an interview on 3/20/13 at 4:30 p.m., Employee #1 said that on 12/6/12 while passing medication witnessed the resident being followed by the Administrator, Associate Director of Nursing (ADON), evening Registered Nurse Supervisor, and the Director of Security. Employee #1 heard the Administrator yelling, while other staff members stood outside the resident's room. Employee #1 reported two residents that were seated in the hallway at that time stated Resident #394 was in trouble. Employee #1 said that the resident was observed, after the group named above left the unit, lying in a fetal position and would not respond to questions. Employee #1 stated that the resident did not have access to a wheelchair for three days, and during that time remained in his room. Employee #1 voiced that the resident should not have been treated that way. Employee #1 reported that the group involved were supervisory staff and that reporting this incident to them as alleged mistreatment could cause issues with her employment status. Review of a progress note signed by the Nurse Practitioner (NP) at 11:25 a.m. on 12/6/12 revealed that a care plan meeting had been held that morning and attended by the Executive Director (Administrator), NP, Social Work Director, primary Social Worker (SW), Registered Nurse Manager (RNM), Medical Director, and the resident that day. Decisions made at this meeting included the resident's loss of use of a power wheelchair, loss of smoking privileges, and loss of ability to go outside with friends. The resident would be given a manual wheelchair monitored with a Wanderguard, would be allowed to go out with family, or designee, and would be monitored for smoking and alcohol withdrawal. There were no documented Incident/Accident reports or security reports of smoking infractions between 10/1/12 and 12/6/12. Review of the CCP, dated 12/6/12, revealed that the residents smoking and power wheelchair privileges had been revoked. The resident was given a manually operated wheelchair, with a Wanderguard to reduce the possibility of the resident leaving the facility without appropriate safety monitoring. A Licensed Practical Nurse (LPN) progress note, dated 12/6/12 at 10:00 p.m. revealed that the resident's manual wheelchair was removed by the Administrator because the resident left the unit to smoke (after the earlier care plan decisions). The resident remained in bed the entire shift. There were no corresponding medical orders at that time to show medical need for removing the resident's access to independent mobility. There were no medical orders or care plan changes written to show that the resident could not have a manual wheelchair. A LPN progress note, dated 12/9/12 at 3:00 p.m., revealed that the resident voiced frustration and anger and stated, "This is cruel and inhumane treatment, this punishment is too extreme." The resident spent the shift in bed, watching television. Interviews regarding the alleged incident of abuse include the following: a. On 3/20/13 at 5:05 p.m., Employee #2 said that there was a big meeting held on 12/6/12 in the morning regarding the resident's non-compliance with smoking. The resident has a manual wheelchair with a Wanderguard. A note posted at the nursing desk revealed that the resident was not to leave the unit after 3:00 p.m. or there would be consequences per the Administrator. The secretary received a call around 4:00 p.m. from security to notify the unit that the resident's Wanderguard was alarming. Employee #2 then left the unit and went outside the facility to look for the resident. Employee #2 returned to the building and took the stairs. At the top of the stairs, she met the Administrator and Security Director. When they entered the unit they met the resident exiting the elevator onto the unit. At that time, the Administrator requested that the resident be put into his bed. Employee #2 stated that the resident's room door was open and the Administrator was standing over the resident, pointing his finger, and speaking in an intimidating tone. Employee #2 did not recall what was said. There were no others in the room. Employee #2 described this interaction as an "unjustified attack" on the resident. Employee #2 stated that after the incident, she programmed the resident's cell phone with the Department of Health hotline number and thought someone else was going to report this incident. Employee #2 stated that if she had treated a resident like that, her supervisors would have escorted her out of the building. b. On 3/26/13 at 12:55 p.m., Employee #5 reported lack of awareness that an investigation had been completed regarding this incident. c. When interviewed on 3/27/13 at 10:30 a.m., the Administrator stated that he received a call at approximately 4:00 p.m. that the resident was off the unit. He stated that he and the ADON went to the unit and took the manual wheelchair from the resident. The resident was in bed. The Administrator stated that the resident had been cooperative with the smoking contract over the past year. Also, the Administrator reported that he does not usually get involved in CCP decisions and did not know what else could have been done for this resident's quality of life. The Administrator explained that the DON coordinates abuse investigations, that Human Resources staff would receive abuse training during mandatory inservices but would not be responsible for doing abuse investigations. d. On 3/28/13 at 11:40 a.m., the Human Resources (HR) Director said she spoke to the Administrator concerning allegations that had been brought up against him by facility staff. The HR Director stated that she does not attend abuse training. On 3/20/13 through 3/28/13, Employees #1, #2, #3, #4, #5, #6, #7, #8, and #9, all requested anonymity while making statements voicing fear of retribution related to employment. The facility presented a letter alleging compliance to remove the Immediate Jeopardy on 3/28/13. The actions being taken to do this included the following: 1. At that time, no residents at the facility were confined to their rooms or subject to an imposed loss of independent mobility. 2. All decisions made regarding the restriction of a resident's freedom of movement, removal or protection from the company of any other, or similar plan, shall be made only with the agreement of the care team and only after all less restrictive measures have been considered and/or attempted. Such a plan shall only involve situations where a resident's actions or behavior poses an imminent risk to self or others. The care team will include the Director of Nursing, Nurse Manager (or surrogate), Social Worker, medical provider, and Deputy Director. 3. All direct care staff will be inserviced on the requirements of F tag 223, the legal requirement to report patient abuse, the ability to do so without fear of retribution, and the availability of both the State and County hotlines to report patient abuse. 4. The training for clinical staff including Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, and Social Workers will include the following: a. Types of abuse. b. Legal requirements to report any and all patient abuse. c. Expectation that all staff can and must speak up when they feel any measures taken to address a resident care situation infringes on a resident's rights or freedoms and that they can do so without fear of retribution. d. While this Department of Health survey is being completed and until it is resolved, the Administrator will avoid any contact with residents without other staff present and will not discuss the survey or its underlying facts with any staff member. In addition, staff will be informed that they are not to have any communication with the Admnistrator concerning the survey or its underlying facts until it has been completed and that they should report any communication contrary to this directive to the County [MEDICATION NAME] hotline at [PHONE NUMBER]. On 3/29/13 it was determined that the immediate jeopardy had been removed as a result of the facility's actions taken as outlined in their allegation of compliance letter of 3/28/13. This determination was made on 3/29/13 after surveyors: a. verified that on 3/28/13 the Administrator was removed from the survey process and investigation of complaint #NY 671. b. reviewed inservice records, completed interviews with staff to verify that 289 of 309 staff members or 93.5 percent had been retrained and that off duty staff would be retrained within the first two hours of their shift or would not be allowed to work. This training included receipt of an outline that included the requirements described in the credible allegation of compliance letter. c. verified that nursing staff were trained on the requirement that behavior care plans must specify what behaviors are targeted for modification and in all cases the least restrictive means must be chosen and adhered to. d. verified that audit tools are in the process of being developed. (10 NYCRR 415.4(b)(2)&(3))

Based on staff interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 671), it was determined that for one (Resident #394) of nine residents reviewed for abuse, neglect, or mistreatment, the facility failed to ensure that each resident was free from verbal, physical, and/or mental abuse. Specifically, the facility failed to recognize that abuse occurred, failed to adequately intervene to the protect the resident from loss of his independent mobility, and failed to implement policies and procedures to ensure that all other residents were not subjected to abuse/loss of independent mobility from 12/6/12 through 3/28/13. This resulted in actual harm that is IMMEDIATE JEOPARDY and is SUBSTANDARD QUALITY OF CARE. This is evidenced by the following: The Immediate Jeopardy was removed on 3/29/13 prior to exit. Resident #394 had [DIAGNOSES REDACTED]. The resident signed a facility smoking contract on 4/22/11. This contract includes that the resident agreed to smoke in designated areas during designated hours (6:00 a.m. to 11:00 p.m.), and acknowledged that violation of rules may result in loss of smoking privileges. This contract does not include loss of mobility as a consequence of violating the smoking contract. Review of the Minimum Data Set (MDS) Assessment, dated 10/27/12, revealed that the resident was competent, understood others, and was understood. This MDS Assessment also documented a lack of behavioral symptoms, that the resident liked to choose his bedtime, really enjoyed going outside to get fresh air in good weather, and used a wheelchair for mobility. In an interview on 3/22/13 at 9:45 a.m., the Administrator (Executive Director) said that he had seen the resident with a newspaper and oxygen on the back of the resident's wheelchair that was off. At that time, the resident flicked off the head of the cigarette on the grass. He stated he told the resident that we would need to talk to the care team. The Administrator stated that he is not normally involved in comprehensive care planning. However, he does get involved with repeat violators and when staff do not know what else to do. The Administrator stated he was convinced the resident was noncompliant with smoking. He stated that the resident was a safe smoker but not in the right areas. Documentation on Comprehensive Care Plans (CCP), dated from 3/28/11 through 11/8/12, show that the resident had a signed smoking contract and had demonstrated safety and independence with smoking. Review of a Social Worker (SW) progress note, dated 11/30/12, revealed that the resident was terminally ill, had consistently declined hospice, had a history of [REDACTED]. The resident continued to smoke and had met with the Administrator regarding incidents where the resident had been smoking in undesignated areas. There had been no recent incidents related to smoking. In a progress note, dated 12/5/12, the Director of Social Work (DSW) documented concerns regarding resident behaviors. These included drinking alcohol to excess, repeatedly smoking in nonsmoking areas, removing the safety device (orange flag) on his power wheelchair, and using the power wheelchair in an erratic way. The DSW noted that these behaviors place the resident and those around him at a safety risk. Also, the Administrator has directed that the resident's room be searched for alcohol/cigarettes and that the power wheelchair and smoking privileges be removed. The DSW noted that the resident was out of the building at that time. There were no documented Incident/Accident reports or security reports related to smoking infractions between 10/1/12 and 12/6/12. Review of a progress note signed by the Nurse Practitioner (NP) written at 11:25 a.m. on 12/6/12 revealed that a care plan meeting had been held that morning and attended by the Administrato, NP, Social Work Director, the primary SW, Registered Nurse Manager, Medical Director, and the resident that day. Decisions made during this meeting resulted in the resident's loss of use of a power wheelchair, loss of smoking privileges, and loss of ability to go outside with his friends. He was given a manually operated wheelchair that would be monitored with a Wanderguard. The resident could go out on pass with a responsible party, example was family, or family designee, and would be monitored for smoking and alcohol withdrawal. The NP documented that this plan had been discussed with the resident, who was not happy about the loss of smoking privileges. The NP also documented that she saw the resident after the meeting, and the resident declined to talk, nodded his head to show he was upset about the loss of smoking privileges, and shrugged his shoulders when the nicotine patch was explained. The resident had emesis after the meeting and declined to be examined. Review of the CCP, dated 12/6/12, revealed that the resident's smoking and power wheelchair privileges had been revoked. At that time, the resident was given a manually operated wheelchair with a Wanderguard to reduce the possibility that the resident could leave the facility without appropriate safety monitoring. Review of a progress note written and signed on 12/6/12 at 10:00 p.m. by Licensed Practical Nurse (LPN) #2 revealed that the resident's manually operated wheelchair had been taken away from the resident by the Administrator because the resident left the unit (after the care conference earlier in the day) to smoke. The resident remained in bed the entire shift. There were no medical orders or care plan changes made by the Interdisciplinary Team to show that the resident could not have a manual wheelchair, or that the resident could not leave the unit after 3:00 p.m. Review of a progress note, written and signed on 12/9/12 at 3:00 p.m. by the unit LPN, revealed that the resident had voiced frustration and anger. The resident stated, "This is cruel and inhumane treatment, this punishment is too extreme. I really want a cigarette." The resident spent the shift in bed, watching television. Review of a progress note, written and signed on 12/10/12 at 3:00 p.m. by the unit LPN, revealed that the resident's manually operated wheelchair was returned at 9:00 a.m. that morning, and a Wanderguard alert was placed on the chair. Interviews conducted on 3/20/12 include the following: a. At 11:30 a.m., the Director of Nursing (DON) stated that he had been advised that the Administrator was planning to address an issue regarding Resident #394 on 12/6/12 and that this issue/incident upset several people. b. At 4:30 p.m., Employee #1 said on 12/6/12, while passing medication, she witnessed the resident being followed by the Administrator, Assistant DON (ADON), evening RN supervisor, and the Security Director. She was instructed to help place the resident in bed. She could hear the Administrator yelling while other staff members were outside. Employee #1 said she was "scared" and was not sure what the resident had done. Employee #1 said two residents were in the hall and heard them say the resident was in trouble. After all of the staff disbursed on 12/6/12, she checked on the resident. He was in a fetal position and would not answer her questions. Employee #1 said that the manually operated wheelchair was removed for three days, and during those three days, the resident remained in his room. c. At 5:05 p.m., Employee #2 said there was a big meeting held on 12/6/12 in the morning regarding the resident's noncompliance with smoking. The resident was given a manually operated wheelchair with a Wanderguard alert tag. A note was posted at the nursing station with directions that the resident was not to leave the unit after 3:00 p.m. or there would be consequences per the Administrato. The secretary received a call around 4:00 p.m. from security to notify the unit that the resident's Wanderguard was alarming. Employee #2 then left the unit to find the resident. Employee #2 returned to the building and took the stairs, met the Administrator and Security Director. When they entered the unit, they met the resident exiting the elevator to the unit. At that time, the Administrator gave instructions to put the resident to bed. She said the door to the resident's room was open and she could see that the resident was in bed. Employee #2 said she saw the Administrator standing over the resident, pointing his finger at the resident, and speaking in an intimidating tone, but could not remember what was said. She said there was no one in the room to advocate for the resident. Employee #2 described this interaction as an"unjustified attack." In an interview on 3/21/13 at 9:00 a.m., the DON stated that he did not have any investigatory information regarding the incident that occurred on 12/6/12 regarding Resident #394. When interviewed on 3/25/13 at 3:30 p.m., the ADON said he believed the resident remained in bed the entire weekend. When interviewed on 3/27/13 at 10:30 a.m., the Administrator stated that he received a call at approximately 4:00 p.m. that the resident was off the unit. He said that he and the ADON went to the unit and took the manual wheelchair from the resident. The resident was in bed. The Administrator stated that the resident had been cooperative with the smoking contract over the past year. During an interview on 3/27/12 at 2:45 p.m. and again on 3/28/13 at 11:30 a.m., the SW said the resident was alert and oriented and able to make his own decisions. The SW said that on 12/6/12 the resident's smoking privileges were revoked indefinitely. She said that after the resident's manually operated wheelchair was taken away for four days, the resident's behaviors accelerated. He was agitated, upset, and swearing in conversation. The SW stated that when the resident was at baseline, he was independent and spent time out in the community. In an interview on 3/27/13 at 2:45 p.m., Employee #9 stated that a care plan meeting was held at 10:00 a.m. on 12/6/12. Employee #9 said that the meeting was called to discuss safe smoking because the resident had been seen smoking with a newspaper in his hands. Employee #9 did not witness this smoking infraction. When interviewed on 3/27/13 at 5:00 p.m., an evening Certified Nursing Assistant (CNA) said she starts her shift at 2:30 p.m. and was aware the resident's wheelchair had been taken away. She said she found the resident in bed when she arrived for her shift. The CNA said that was not normal for this resident. The resident was typically "up and all over." She also said the resident would not sit in a geri chair. On 3/28/13 at 11:40 a.m., the Human Resources (HR) Director said she spoke to the Administrator concerning allegations that had been brought up against him by facility staff. The HR Director stated that she does not attend abuse training. When interviewed on 3/28/13 at 11:50 a.m., Employee #8 said that at baseline the resident would get up around 6:00 a.m. to 7:00 a.m. He was independent in using a slide board transfer to get in his wheelchair. He would have a cigarette, pick up a newspaper, and spend six of eight hours off the unit. Employee #8 stated that when he spoke to the resident on Friday, 12/7/12, the resident was upset, depressed, disappointed, and refused to get out of bed that day. He reported that the resident commented that the only thing he wanted to do was smoke. Employee #8 said that staff felt the interaction that occurred on 12/6/12, when the manually operated wheelchair was taken from the resident, was condescending and punitive. Employee #8 stated that after the resident got his manually operated wheelchair back, he did not leave the unit much; all he wanted to do was smoke. The facility presented a letter alleging compliance to remove the Immediate Jeopardy on 3/28/13. The actions being taken to do this included the following: 1. At that time, no residents at the facility were subject to imposed loss of independent mobility. 2. All decisions made regarding the restriction of a resident's freedom of movement, removal or protection from the company of any other, or similar plan, shall be made only with the agreement of the care team and only after all less restrictive measures have been considered and/or attempted. Such a plan shall only involve situations where a resident's actions or behavior poses an imminent risk to self or others. The care team will include the Director of Nursing, Nurse Manager (or surrogate), Social Worker, medical provider, and Deputy Director. 3. All direct care staff will be inserviced on the requirements of F tag 223, the legal requirement to report patient abuse, the ability to do so without fear of retribution, and the availability of both the State and County hotlines to report patient abuse. 4. The training for clinical staff including Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, and Social Workers will include the following: a. Types of abuse. b. Legal requirements to report any and all patient abuse. c. Expectation that all staff can and must speak up when they feel any measures taken to address a resident care situation infringes on a resident's rights or freedoms and that they can do so without fear of retribution. d. While this Department of Health survey is being completed and until it is resolved, the Administrator will avoid any contact with residents without other staff present and will not discuss the survey or its underlying facts with any staff member. In addition, staff will be informed that they are not to have any communication with the Administrator concerning the survey or its underlying facts until it has been completed and that they should report any communication contrary to this directive to the County [MEDICATION NAME] hotline at [PHONE NUMBER]. On 3/29/13 it was determined that the immediate jeopardy had been removed as a result of the facility's actions taken as outlined in their allegation of compliance letter of 3/28/13. This determination was made on 3/29/13 after surveyors: a. verified that on 3/28/13 the Administrator was removed from the survey process and investigation of complaint #NY 671. b. reviewed inservice records, completed interviews with staff to verify that 289 of 309 staff members or 93.5 percent had been retrained and that off duty staff would be retrained within the first two hours of their shift or would not be allowed to work. This training included receipt of an outline that included the requirements described in the credible allegation of compliance letter. c. verified that nursing staff were trained on the requirement that behavior care plans must specify what behaviors are targeted for modification and in all cases the least restrictive means must be chosen and adhered to. d. verified that audit tools are in the process of being developed. (10 NYCRR 415.4(b)(1)(i))

Based on resident and staff interviews, and record reviews, conducted during the Recertification Survey and complaint investigation(#NY 671), it was determined that for two of ten residents reviewed for behaviors, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, Resident #394, lost access to independent mobility, exhibited a significant decline in former social patterns, social withdrawal, anxiety, and expressed feelings of dehumanization. Resident #519, did not receive a timely safety evaluation for smoking and was not given timely treatment for [REDACTED].#394 that is not immediate jeopardy, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #519. This is evidenced by the following: 1. Resident #394 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 10/27/12, revealed that the resident's cognitive skills for daily decision making were intact. The current signed physician orders [REDACTED]. In a progress note, dated 11/30/12, the Social Worker (SW) documented that the resident is terminally ill and has been known to use alcohol when out on pass. The resident also continues to smoke and had met with the Administrator (Executive Director) regarding instances where he smoked in nondesignated areas. The SW noted that there had not been recent smoking related incidents. In a progress note, dated 12/5/12, the Director of Social Work (DSW) documented concerns regarding resident behaviors. These included drinking alcohol to excess, repeatedly smoking in nonsmoking areas, removing the safety device (orange flag) on his power wheelchair, and using the power wheelchair in an erratic way. The DSW noted that these behaviors place the resident and those around him at a safety risk. Also, the Administrator has directed that the resident's room be searched for alcohol/cigarettes and that the power wheelchair and smoking privileges be removed. The DSW noted that the resident was out of the building at that time. There were no documented Incident and Accident Reports or security reports dated from 11/30/12 through 12/6/12. In a progress note, dated 12/6/12 at 11:25 a.m., the Nurse Practitioner (NP) documented that a care plan meeting was held that morning and attended by the Admnistrator, NP, Social Work Director, primary SW, Registered Nurse Manager (RNM), Medical Director, and the resident. Decisions made at this meeting included the resident's loss of smoking privileges, loss of use of a power wheelchair, and loss of ability to go out of the building with friends. The resident would be given a manual wheelchair monitored with a Wanderguard, could go out on pass with family or designated others, and would be monitored for smoking and alcohol withdrawal. A nicotine patch was provided for smoking cessation. The NP documented that these changes were discussed with the resident, who was not happy about the loss of smoking privileges. Also, the resident had emesis after the meeting. The resident would not talk, but nodded his head up and down when asked if he was upset about not smoking. He shrugged his shoulders when the nicotine patch was explained to him. He refused an examination at that time. The Comprehensive Care Plan (CCP), updated 12/6/12, included that smoking privileges were rescinded due to repeated (greater or equal to four occasions) violations of the facility's smoking policy (smoking in nondesignated smoking areas). Review of interdisciplinary progress notes revealed the following: a. On 12/6/12 at 10:00 p.m., a Licensed Practical Nurse (LPN) noted that the resident's manual wheelchair was removed by the Administrator because the resident left the unit to smoke. The resident accepted the nicotine patch, nicotine [MEDICATION NAME], medications, and tube feeding. The resident remained in bed the entire shift. b. On 12/7/12, the SW noted that the resident granted permission to notify his family regarding the outcome of the care plan meeting. The family member asked if the resident could have his wheelchair and his cigarettes back in a few days. The family was informed that the resident will need to earn back these privileges. c. On 12/8/12 at 2:25 p.m., nursing noted that the resident was given a dose of Trazadone for increased restlessness and anxiety with effect. d. On 12/9/12 at 3:00 p.m., a LPN noted that the resident voiced frustration and anger and stated, "This is cruel and inhumane treatment, this punishment is too extreme. I really want a cigarette." Writer provided him with two nicotine [MEDICATION NAME]. The resident spent the shift in bed, watching television. e. On 12/10/12 at 8:40 a.m., the SW noted that the resident had been given a manual wheelchair with a Wanderguard placed on the cross piece. The SW reiterated to the resident the parameters of his wheelchair use are no smoking, no outside the building, and no alcohol for his safety. An addendum to this note revealed that the resident was offered alcohol treatment and he declined. The resident stated his alcohol use is not problematic, he can cope without the alcohol, but the nicotine is a huge issue for him. The SW note indicated this would be discussed with the team. f. On 12/10/12 at 3:00 p.m., the LPN noted that the resident complained of wanting a cigarette. Nicotine [MEDICATION NAME] was provided twice this shift. g. On 12/13/12 at 3:00 p.m., the LPN noted that the resident was upset and requested to speak with the Administrator. The RNM and the SW were aware of this and spoke with the resident. The resident voiced his continued frustration about the punishment being, "unfair---how much longer is this charade going to go on?" The resident remained in bed and stated, "I'm depressed." h. On 12/13/12 at 11:00 p.m., the LPN documented that the resident continued to voice, "I want a cigarette. I'm depressed, this is just unfair, does anyone even care that I'm dying? I have rights, I'm an adult, not a child. If he doesn't come and see me soon, then I'll have to make some phone calls." i. On 12/16/12 at 11:00 p.m., the LPN documented that the resident was outside at 4:30 p.m. with another resident per security. The LPN went to get the resident and found him to be returning to the unit. The LPN reminded him that he must stay on the unit after 3:00 p.m. The resident's family member was in to visit at 6:00 p.m., and the resident asked the LPN to explain his punishment to his family. The family member appeared upset regarding the smoking and leaving the unit. The LPN directed the family member to contact the RNM or Director of Nursing (DON) to get further information. The family member asked, "Now how long is he not allowed to smoke or leave the unit?" The resident remains upset about this continued issue. j. On 12/18/12, the NP documented that the resident, with [DIAGNOSES REDACTED]. The resident is currently very angry and upset and perceives these actions as punitive. The resident stated, "I have a pain in my head," and the NP noted this indicated mental anguish. The NP indicated she will try after 30 days to discuss this with the Administrator. The NP noted that the resident is currently feeling distrustful about everyone. k. On 12/19/12, the SW noted that the resident stated, "You know I am a dying man, the least they can do is let me have a cigarette." The SW suggested that the resident present himself to the Administrator to discuss his smoking privileges as we did not make the decision and it was based on his safety. She noted that the resident had increased confusion and decreased orientation during this visit. Interviews are as follows: a. On 3/20/13 at 4:30 p.m., Employee #1 stated that when staff left the unit after the 12/6/12 incident where the resident was placed in bed and lost use of his manual wheelchair, the resident was observed lying in a fetal position in bed and would not speak. b. On 3/20/13 at 6:00 p.m., Employee #3 stated that after the 12/6/12 incident, she checked on the resident throughout the shift and he was "very quiet." She said that being quiet was very unusual for this resident, he always spoke. c. On 3/26/13 at 2:35 p.m. and on 3/28/13 at 11:40 a.m., Employee #6 reported that there had been no safety issues related to the resident's use of a power scooter, and that the resident enjoyed smoking. Also, the resident was angry about his punishment and said he had a "pain in his head." Employee #6 noted this was mental anguish, meaning the situation was giving the resident problems. d. On 3/27/12 at 2:45 p.m. and again on 3/28/13 at 11:30 a.m., Employee #7 described the resident as able to make his own decisions. She said that after the resident lost his manual wheelchair for four days, he was very angry, agitated, upset, and swearing in conversation. He stated, "I can take not having alcohol, but not cigarettes." She reported he was not yelling or loud. She said his behaviors were worse than usual. She said when the resident was at baseline, he was independent and out in the community. e. On 3/28/13 at 11:50 a.m., Employee #8 said that at baseline the resident would get up around 6:00 a.m. to 7:00 a.m. He was independent in using a slide board transfer to get in his wheelchair. He would have a cigarette, pick up a newspaper, and spend six of eight hours off the unit. He said he talked to the resident on Friday (12/7/12), and the resident was upset, depressed, disappointed, and refused to get out of bed that day. He reported that the resident commented that the only thing he wanted to do was smoke. He said once the resident got the manual wheelchair back, he did not leave the unit too much; all he wanted to do was smoke. f. On 3/28/13 at 10:40 a.m., the Medical Director said that the medical record reflects that the resident was upset. The Medical Director stated that the loss of the manuel wheelchair was a major change in this resident's treatment plan because he cannot walk. The care team should have met to address the resident's loss of mobility. 2. Resident #519 was admitted to the facility for rehabilitation on 1/18/13 with [DIAGNOSES REDACTED]. Review of the nursing admission note, dated 1/18/13 (12:00 noon), revealed that the resident had been hospitalized for [REDACTED]. Also, the resident denied being able to manage cigarettes independently, stating that [MEDICAL CONDITION] her legs were caused by the IPad tablet she used, later stating that she has had ashes fall in her lap. This nursing note reflects that nursing will wait for physician input and await further orders. In a note, dated 1/18/13 at 2:45 p.m., nursing documented that 11 packages of cigarettes and a lighter were removed from the resident's room and stored in the medication room. Review of the General Multisystem Exam, dated 1/22/13, revealed that the resident was counseled not to smoke until Physical Therapy (PT)/Occupational Therapy (OT) did an evaluation for safety. Physician orders, dated 1/22/13, included [MEDICATION NAME] (antidepressant) 25 milligrams (mgs) one tablet daily, and Levoflaxacin (antibiotic) 500 mgs once daily for seven days. These orders did not include an order for [REDACTED]. The 1/25/13 admission Minimum Data Set Assessment revealed that the resident understands, is understood, and was cognitively intact. The resident had no behaviors, believed it is very important to do things she likes to do, and go outside for fresh air. Her locomotion on the unit was independent after set up and independent off the unit. Review of the Interim Nursing Care Plan for 1/18/13 to 1/31/13 revealed that smoking is listed under Medical Problems. An entry on "1/23," shows that the "resident - noncompliant - has smoked with no assessment, assessment not done per policy d/[MEDICAL CONDITION]- staff to document noncompliance r/t smoking." Review of an OT Encounter Log, dated 1/23/13, revealed under therapeutic intervention that the resident struggled with her right hand completing coordination tasks and has a need to work with adaptive equipment for self feeding. In an OT progress note, dated 1/28/13, it was documented that the resident continues to struggle with small objects less than 2 inches in diameter. Neither of these OT notes made reference to a smoking safety assessment. A Smoking Assessment, dated 1/28/13 completed by nursing, documented that the resident's clothes/possessions were not free of unsafe smoking. This form includes the statement, "If the answer to any question is NO the resident is considered unsafe until further documentation is presented to refute the supposition." Review of a PT Restorative Progress Note, PT Treatment Encounter Log, and PT Discharge Summary all revealed that the resident's rehabilitation services began on 1/18/13 and ended on 2/15/13. None of these documents include a smoking safety assessment. On 2/15/13, the PT recommended that the resident continue to receive Maintenance PT to continue to work on upper extremity strengthening. The facility's "Smoking policy," dated March 2013, directs staff to attempt to offer smoking/treatment and counseling to residents that have been deemed unable to smoke on the facility's premises. (10 NYCRR 412.12(f)(1)(2))