Every finding on record at Mountainside Residential Care Center

Based on record review and interviews during an abbreviated survey (Case #s NY00347949 and NY00347739), the facility did not ensure the resident had the right to be free from abuse for 2 (Resident #s 1 and 2) of 4 residents reviewed for abuse. Specifically, on 7/08/2024, Resident #2 was observed in Resident #1's room with their hand down the front of Resident #1's gown holding their left breast and attempting to kiss the resident. Both residents had severe cognitive impairment and could not consent. This is evidenced by: The Policy and Procedure titled, Nursing Services: Resident Abuse, Neglect, Mistreatment, Exploitation, Misappropriation, Reporting and Elder Justice Act dated August 2001, documented the resident would be free from all sexual abuse. It documented sexual abuse in the case of resident-to-resident was defined as any form of sexual contact without the other resident's consent when the other resident was incapable of giving informed consent, when the perpetrator was incapable of giving consent, or of understanding the implications of their actions. Resident #1 was admitted to the facility with diagnoses of dementia, high blood pressure, and pain. The Minimum Data Set (an assessment tool) dated 5/23/2024, documented the resident was cognitively intact; however, the incident report provided to New York State Department of Health documented the resident had severe cognitive impairment which aligned with the surveyor's observation of the resident, could usually be understood, and could usually understand others. The Comprehensive Care Plan for The Potential to Present with Sad, Pained, Anxious Facial Expressions related to Fluctuations in Mood updated 7/08/2024, documented Resident #1 was kissed and their breast was exposed and fondled by Resident #2. It documented to be aware of residual effects from Resident #2's sexual touching, the resident did remember the event, and to assure their comfort. The Comprehensive Care Plan for At Risk for Abuse by Other Residents updated on 7/08/2024, documented the resident was kissed and their breast was exposed and fondled by Resident #2. It documented if accosted, to monitor for adverse reactions. A stop alarm banner was placed across Resident #1's door. The Certified Nurse Aide Kardex as of 7/25/2024 (a document that provided the Certified Nurse Aides with the directions for the care a resident needed) documented a stop alarm banner was to up at all times when the resident was in their room. A Resident and Family Services Note dated 7/09/2024 at 5:08 PM, documented Director of Resident and Family Services #1 interviewed Resident #1 regarding the incident with Resident #2 who inappropriately kissed and sexually touched Resident #1. The staff who witnessed the incident intervened immediately and removed Resident #2 from the room. Resident #1 had no memory of the event. During an interview on 7/23/2024 at 11:32 AM, Certified Nurse Aide #4 stated Resident #1 had difficulty communicating and had not said anything to them about the incident that occurred with Resident #2. During an interview on 7/23/2024 at 12:31 PM, Resident Care Coordinator #1 stated Resident #1 did not recall the incident when they spoke with them. Resident Care Coordinator #1 stated they notified the family who agreed to a stop sign banner across the resident's door to discourage others from entering their room. During an interview on 7/23/2024 at 1:56 PM, Resident #1 was unable to answer any questions and repeated their name numerous times. Resident #2 was admitted to the facility with diagnoses of a stroke, dementia, and depression. The Minimum Data Set, dated dated dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could understand others. The Comprehensive Care Plan for Mood/Affect/Behavior revised on 7/09/2024, documented the resident inappropriately sexually touched and kissed a non-consenting resident (Resident #1) on 7/08/2024. An intervention was added on 7/08/2024 to remind Resident #2 to stay away from residents who could not defend themselves. It documented on 7/09/2024 1-to-1 supervision was started and on 7/10/2024, a beam alarm was placed on Resident #2's door (an alarm to alert staff when the resident was leaving their room). The Certified Nurse Aide Kardex as of 7/25/2024 (a document that provided the Certified Nurse Aides with the directions for the care a resident needed) documented the resident was on 1-to-1 supervision and on 07/10/2024, a beam alarm was placed on the resident's doorway. A Resident and Family Services Note dated 7/09/2024 at 8:51 PM, documented Director of Resident and Family Services #1 received report Resident #2 was found by Certified Nurse Aide #1 to be kissing Resident #1 on the mouth, exposing their left breast and touching it. Swift intervention was taken, and Resident #2 quickly left the scene and returned to their room. Resident #1 was unable to consent to the activity and had limited ability to defend themselves. Discussions with Resident #2 to set boundaries and expectations were to no avail due to moderate cognitive impairment, poor insight/judgement, and dementia diagnosis. The resident was started on 1-to-1 supervision due to acting in an opportunistic manner and crossing the line to predatory behavior. A Medical Provider Note dated 7/09/2024 at 6:58 PM, documented Physician Assistant #1 was aware of the 07/08/2024 incident between Resident #s 1 and 2. The facility was working on a discharge plan for Resident #2 to return to their country and in the meantime, the resident was on 1-to-1 supervision. Physician Assistant #1 documented they did not feel medication for Resident #1's sexual desire was indicated. Such medical interventions typically take a relatively long time to become effective. In summary, Physician Assistant #1 documented that safe discharge home would be the most logical and ethical plan considering all options. During an interview on 7/23/2024 at 11:32 AM, Certified Nurse Aide #4 stated Resident #2 tired to kiss 2 residents when in the common area and staff needed to keep an eye on them to redirect them. The stated Resident #2 was now on 1-to-1 supervision. It was on their assignment sheet, so they knew who was assigned for the shift. They had been updated in report regarding the incident between Resident #s 1 and 2 so they could keep them and the other residents safe. During an interview on 7/23/2024 at 12:31 PM, Resident Care Coordinator #1 stated Resident #2 had cognitive impairment and was forgetful. They stated they started 1-to-1 supervision for Resident #1 on 7/09/2024 due to the 7/08/2024. They stated they were off from work on 7/10/2024 and when they returned to work on 7/11/2024, Resident #2 had been put back on 15-minute checks. Resident Care Coordinator stated they reimplemented 1-to-1 supervision for Resident #2 and put the intervention in their care plan. During an interview on 07/23/2024 at 12:58 PM, Certified Nurse Aide #1 stated (on 7/08/2024) Resident #1's call light was on and when they entered their room, they saw Resident #2's hand in Resident #1's gown holding their breast. Resident #2 was trying to kiss Resident #1. Certified Nurse Aide #1 stated they yelled at Resident #2 that was not okay and told them to get out of the room. Certified Nurse Aide #1 stated they yelled for help and Certified Nurse Aide #3 came to the room. They stated they told Certified Nurse Aide #3 to keep an eye on Resident #2 and not let them out of their sight. Certified Nurse Aide #1 stated they reported the incident to Licensed Practical Nurse #1. They stated Resident #1 looked afraid. Resident #1 was unable to verbally respond. During an interview on 7/23/2024 at 1:16 PM, Licensed Practical Nurse #1 stated immediately upon report of the 07/08/2024 incident between Resident #s 1 and 2, Certified Nurse Aide #3 was assigned to provide 1-to-1 supervision for Resident #2. They stated both residents had dementia and could not consent to a sexual relationship. During an interview on 07/23/2024 at 3:11 PM, Director of Resident and Family Services #1 stated at some point in time, Resident #2 turned a corner and became predatory. Director of Resident and Family Services #1 stated the incident with between Resident #s 1 and 2 occurred on 7/08/2024. Resident #1 was unable to recall the incident when the Social Worker talked with them after the incident. Director of Resident and Family Services #1 stated if people were able to give consent, had capacity, insight, and judgement for a sexual relationship, they could decide if they wanted one. If a person could not say yes or no or be able to defend themselves, they should not have a sexual relationship. Dementia was progressive and a resident who may have consented to a sexual relationship prior to their dementia, may no longer be able to do so, so that needed to be watched to protect the resident. The Social Worker stated everyone was aware eyes had to be on Resident #1 and they were on 1-to-1 supervision. Staff were to have an awareness of the where about of the vulnerable residents. During an interview on 7/24/2024 at 8:54 AM, Director of Nursing #1 stated on 7/08/2024 at 1:45 PM Certified Nurse Aide #1 witnessed the inappropriate touching of Resident #1 by Resident #2. They saw Resident #2's hand down Resident #1's gown fondling their breast and trying to kiss them. Certified Nurse Aide #1 reported it to the nurse immediately and the nurse reported it to them. Director of Nursing #1 stated an investigation was started right away and the Administrator was made aware. They stated they had a Spanish interpreter to interview Resident #2. They stated neither Residents #1 nor #2 could recall the incident. Director of Nursing #1 stated Resident #1 would not have been able to tell Resident #2 they did not want to be touched. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (Case #s NY00347949 NY00347739), the facility did not ensure in response to allegations of abuse that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse for 3 (Resident #s 1, 2, and 3) of 4 residents reviewed for abuse. Specifically, the facility did not report witnessed resident-to-resident sexual abuse between Resident #s 1 and 2, neither of whom were cognitively intact within 2 hours. Additionally, the facility did not report suspected sexual abuse within 2 hours for an alleged resident-to-resident incident that involved Resident #s 2 and 3. Resident #2 was not cognitively intact. This is evidence by: The Policy and Procedure titled, 483.35 Nursing Services: Resident Abuse, Neglect, Mistreatment, Exploitation, Misappropriation, Reporting & Elder Justice Act effective 08/2001, documented if an incident or allegation was considered reportable, the Administrator or designee would make an initial (immediately or within 24 hours) report to New York State Department of Health via the Health Commerce System. Resident #1 was admitted to the facility with diagnoses of dementia, high blood pressure, and pain. The Minimum Data Set (an assessment tool) dated 5/23/2024, documented the resident was cognitively intact; however, the incident report provided to New York State Department of Health documented the resident had severe cognitive impairment which aligned with the surveyor's observation of the resident, could usually be understood, and could usually understand others. Resident #2 was admitted to the facility with diagnoses of a stroke, dementia, and depression. The Minimum Data Set (an assessment tool) dated 4/18/2024, documented the resident had severe cognitive impairment, could be understood, and could understand others. Resident #3 was admitted to the facility with diagnoses of spinal cord injury in the neck, seizures, and chronic yeast infection of the vagina. The Minimum Data Set (an assessment tool) dated, documented the resident was cognitively intact, could be understood, and could understand others. The New York State Department of Health Intake Information form documented an incident of alleged resident-to-resident sexual abuse that occurred on 7/07/2024 at 7:30 PM was submitted incorrectly to New York State Department of Health on 7/10/2024 at 11:13 AM. It was submitted via an attachment to an email rather than via the required form through the Health Commerce System. The New York State Department of Health Intake Information form documented an incident of alleged resident-to-resident sexual abuse that occurred on 7/08/2024 at 12:24 PM was reported to Department of Health on 7/11/2024 at 9:02 AM. During an interview on 7/24/2024 at 8:54 AM, Director of Nursing #1 stated the Administrator was the person who reported incidents to New York State Department of Health. Director of Nursing #1 stated abuse had to be reported to Department of Health within 24 hours. During an interview on 7/25/2024 at 10:41 PM, Interim Administrator #1 stated they thought they had 24 hours to report abuse/suspected abuse to New York State Department of Health. The Interim Administrator stated they were not aware of the first alleged incident (that occurred on 7/07/2024) until after they were made aware of the second incident (that occurred 7/08/2024). 10 New York Codes, Rules, and Regulations 415.4(b)

Based on record review and interview during an abbreviated survey (Case #s NY00347949 and NY00347739), the facility did not ensure a resident who displayed or was diagnosed with a mental disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 2 (Resident #s 1 and 2) of 4 residents reviewed. Specifically, Resident #1's care plan documented to notify a mental health provider if they had signs of post- traumatic stress disorder following a witnessed incident of sexual abuse by Resident #2. Additionally, it was documented Resident #2 had a diagnosis of depression, had become predatory and staff were concerned about their escalating sexual activity accompanied by opportunistic behavior/lack of judgement, insight, and impulsivity. There was no documented evidence that Resident #2 received psychiatry services. This is evidenced by: The Policy and Procedure titled, Psychotropic Drug (medications used to treat mental health disorders) Usage Review revised on 2/25/2022, documented the facility recognized the significance of depression and anxiety among nursing home residents and strove to meet the needs of any resident who may be suffering. It documented Nursing, Social Work, and medical staff would attempt the following as appropriate or applicable; counseling, referral for Psychiatric evaluation and/o referral to a Licensed Clinical Social Work or Licensed Mental Health Clinician for evaluation. Resident #1 was admitted to the facility with diagnoses of dementia, high blood pressure, and pain. The Minimum Data Set (an assessment tool) dated 5/23/2024, documented the resident was cognitively intact; however, the incident report provided to New York State Department of Health documented the resident had severe cognitive impairment which aligned with the surveyor's observation of the resident, could usually be understood, and could usually understand others. The Comprehensive Care Plan for At Risk for Abuse by Other Residents updated on 7/08/2024, documented the resident was kissed and their breast was exposed and fondled by Resident #2. It documented if accosted, to monitor for adverse reactions and make a mental health referral if they had symptoms of post- traumatic stress syndrome. Resident #2 was admitted to the facility with diagnoses of a stroke, dementia, and depression. The Minimum Data Set, dated dated dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could understand others. The July 2024 Medication Administration Record documented the resident was prescribed Lexapro (a drug to treat depression) 20 milligrams by mouth one time a day. A Late Entry Note written by Director of Resident and Family Services #1 dated 7/08/2024 at 5:21 PM, Resident #2's cognitive deficits were evident. The Interdisciplinary Team and staff were concerned regarding escalating sexual activity accompanied by opportunistic behavior/lack of judgement, insight, and impulsivity. Review of Resident #2's medical records revealed no documented evidence that the resident received psychiatry services. During an interview on 7/23/2024 at 11:29 AM, Director of Nursing #1 stated the facility did not have psychiatric services or a psychologist to see the residents. They stated they were advocating for tele-psych services to have someone that their Physician Assistant and Medical Doctors could consult with for medication management. They stated the Medical Doctors (internists and family practitioners) did not feel comfortable managing psychotropic medications for residents with psychiatric diagnoses and prescribed the medications in low doses. They stated the staff provided alternative interventions to manage resident behaviors. 10 New York Codes, Rules, Regulations 415.12(f)(1)

Based on observations, record review, and interviews during a recertification and abbreviated survey (Case #NY00338924), the facility did not ensure the resident environment remained free of accident hazards for one resident (Resident #25) out of six sampled residents. Specifically, on 4/11/2024 a windowpane on the third floor care unit, which had previously been identified as a potential hazard and in need of repair; fell inward when Resident #25 tried to close the window. Subsequently, Resident #25 sustain a laceration to their scalp which required six stables to close the wound. This resulted in actual harm that was not immediate jeopardy for Resident #25. This is evidenced by: Resident #25 was admitted to the facility with diagnoses of dementia without behavioral disturbance, age-related reticular degeneration of retina (a group of diseases that cause the retina of the eye to deteriorate), and age-related osteoporosis (a skeletal disorder characterized by low bone density). The Minimum Data (an assessment tool) dated 5/16/2024 documented the resident had severe cognitive impairment for decisions of daily living, could sometimes be understood, and could sometimes understand others. The Policy and Procedure titled, Near Miss Reporting Tool, last revised November 2022, documented the facility's goal was to promote a safe care and living environment for residents and work environment for staff by addressing potential concerns before they caused harm or injury. The Policy and Procedure titled Fall Prevention, Fall Risk Assessment, and Registered Nurse Notification, last revised 6/23/2022, documented the purpose of the policy was to provide residents with an environment as free of accident hazards as possible. The procedure included the identification of environmental hazards that could contribute to falls. The Policy and Procedure titled, Maintenance Work Request System effective date 01/2011 documented the maintenance department would carry out a program to effectively maintain all real property, capital, and non-capital equipment, and to identify the types of work orders and procedures for requesting the services. Work orders would be scheduled by the maintenance department according to the following priorities: urgent, routine, and deferred. Urgent repairs or corrective actions to equipment involving patient care were those which required immediate attention and could affect patient services, endanger life, or seriously damage campus equipment. Maintenance personnel were to respond immediately to urgent work orders, assess the situation and render repair or remove equipment/system from service as needed. The Director of Maintenance should be notified immediately of any urgent work orders. The Facility's Incident and Accident Investigation dated 4/11/2024, documented per witness statements, Resident #25 had attempted to shut a common area window on the third floor and as they were pushing down, the window came out of the frame towards the resident which resulted in them losing their balance and fell backwards with the back of their head hitting the floor. Staff were unable to intervene quick enough to prevent the fall. The investigation concluded that Resident #25's fall and injury were the result of the clips on the window being broken which allowed the windowpane to fall and caused Resident #25 to lose their balance. A work order was placed on 4/09/2024 (two days prior to the incident) by the Director of Nursing stating the window was a safety concern and needed to be fixed immediately. The work order was marked as completed on 4/09/2024. Upon further investigation, per the maintenance department, completed meant they locked the window on 4/09/2024. The investigation documented the resident's fall could have been prevented if the window was fixed properly and the injury was the result of a faulty environment. Corrective actions taken were documented to include that the window was immediately secured, education was provided to the maintenance department, a review of the maintenance work order process was completed, and a building wide window audit was conducted immediately following the incident and any window with a similar problem was fixed. A Maintenance Work order dated 4/09/2024, documented a window on the third-floor common area required that the clips that held the window in place needed to be replaced. The window clips were documented to require replacement as soon as possible due to the window being a safety concern. A Nursing Progress Note dated 4/11/2024 at 2:00 PM written by Registered Nurse #2, documented Resident #25 was heard to call out Oh my from the common area and then a thump was heard. The resident was found lying on their left side on the floor in the common area. A small amount of bleeding was noted to the left side of the back of the resident's head with a hematoma (collection of blood outside of the blood vessels due to injury/trauma) developing. The area was cleansed, ice, and pressure were applied. Resident #25 complained of their head and left elbow hurting. A hematoma was also noted to the resident's left elbow. The resident was seen by Physician Assistant #1 and an order was given to send the resident to the emergency room . A Medical-Acute Problem progress notes dated 4/11/2024 written by Physician Assistant #1 documented Resident #25 was evaluated in the third-floor common area following a fall. The resident sustained a 1.5-centimeter laceration and surrounding hematoma to their mid posterior scalp. Resident #25 was transported to the emergency room for imaging of their head and treatment for the laceration that the resident sustained. A Nursing Progress Note dated 4/11/2024 at 5:11 PM written by Registered Nurse #3 documented Resident #25 returned from the emergency room at 5:00 PM. Imaging completed at the emergency room was negative for abnormalities. The laceration to the back of their scalp was approximated (closed) with six staples and a new order to cleanse the wound and apply anti-bacterial ointment for two days and to then clean and dress daily as needed. Staples were to be removed after ten days. Upon request on several attempts, the facility could not produce documentation that a facility-wide audit of all windows was conducted immediately following the incident to prevent recurrence. Environmental rounding of the facility was conducted on 4/17/2024 (six days after the incident) and documented seven resident rooms were observed. Four of the seven rooms observed during the rounding (Room #'s 314, 315, 316, and 321) were documented to have broken window clips. During an interview on 7/25/2024 at 10:50 AM, Director of Maintenance #1 stated maintenance had received a work order for the window on the third-floor common room prior to the incident with the window falling in and causing Resident #25 to fall on 4/11/2024. They stated after the incident occurred; the facility had implemented a new work order system to triage work orders that could present a hazard to residents. They stated maintenance staff received education on the prioritization of environmental hazards and immediately completed an environmental audit to identify any other windows in need of repair. During an interview on 7/25/2024 11:33 AM, Registered Nurse #2 stated they were working on the third-floor care unit on 4/11/2024 when they heard Resident #25 state oh my and then they heard a thump. They stated Resident #25 had attempted to close the window in the common area of the unit, and it fell in on Resident #25. They stated the resident was assessed to have a laceration to their scalp and was sent to the emergency room where they required six staples to close the wound. They stated the window had a sign placed on it for a long time which indicated the window should not be opened due to need of repair. They stated it had previously been identified that the window needed repair and presented a potential hazard to residents. They stated when they had previously inquired about the repair of the window, they were told the facility was waiting on parts to complete the work order. They stated Resident #25 had dementia and due to cognitive limitations, would not be able to comprehend the signage left on the window which indicated that it was a hazard. They stated the incident was preventable and should not have occurred. During an interview on 7/25/2024 at 1:53 PM, Physician Assistant #1 stated they were called to assess Resident #25 following their fall on 4/11/2024, observed that the resident had sustained a laceration and bruising to their head and gave the order for Resident #25 to be sent out to the emergency room . They stated Resident #25 had advanced dementia and would not be able to comprehend signage indicating a window was broken or recognize potential hazards. Physician Assistant #1 stated Resident #25 had attempted to open the window which broke and caused them to fall back. They stated they were aware of the window needing repair and that nursing staff had asked to have the window repaired prior to the incident. During an interview on 7/26/2024 at 9:17 AM, Director of Nursing #1 stated the root cause of Resident #25's fall/injury on 4/11/2024 was due to an unstable window in the common area of the resident's care unit. They stated the window needed repair for a long time approximately a year. They stated Resident #25 was sent to the emergency room following the incident and required staples to treat the laceration to their head. They stated following the incident, the facility changed how work orders were prioritized and environmental rounding was completed to ensure that no other windows could present a risk to the residents and that issues with windows were given high priority due the potential of being hazardous. 10 New York Codes, Rules, and Regulations 415.4(b)

Based on observations, record review, and interviews during a recertification and abbreviated survey (Case #NY00338924), the facility did not ensure the resident environment remained free of accident hazards for one resident (Resident #25) out of six sampled residents. Specifically, on 4/11/2024 a windowpane on the third floor care unit, which had previously been identified as a potential hazard and in need of repair; fell inward when Resident #25 tried to close the window. Subsequently, Resident #25 sustain a laceration to their scalp which required six stables to close the wound. This resulted in actual harm that was not immediate jeopardy for Resident #25. This is evidenced by: Resident #25 was admitted to the facility with diagnoses of dementia without behavioral disturbance, age-related reticular degeneration of retina (a group of diseases that cause the retina of the eye to deteriorate), and age-related osteoporosis (a skeletal disorder characterized by low bone density). The Minimum Data (an assessment tool) dated 5/16/2024 documented the resident had severe cognitive impairment for decisions of daily living, could sometimes be understood, and could sometimes understand others. The Policy and Procedure titled, Near Miss Reporting Tool, last revised November 2022, documented the facility's goal was to promote a safe care and living environment for residents and work environment for staff by addressing potential concerns before they caused harm or injury. The Policy and Procedure titled Fall Prevention, Fall Risk Assessment, and Registered Nurse Notification, last revised 6/23/2022, documented the purpose of the policy was to provide residents with an environment as free of accident hazards as possible. The procedure included the identification of environmental hazards that could contribute to falls. The Policy and Procedure titled, Maintenance Work Request System effective date 01/2011 documented the maintenance department would carry out a program to effectively maintain all real property, capital, and non-capital equipment, and to identify the types of work orders and procedures for requesting the services. Work orders would be scheduled by the maintenance department according to the following priorities: urgent, routine, and deferred. Urgent repairs or corrective actions to equipment involving patient care were those which required immediate attention and could affect patient services, endanger life, or seriously damage campus equipment. Maintenance personnel were to respond immediately to urgent work orders, assess the situation and render repair or remove equipment/system from service as needed. The Director of Maintenance should be notified immediately of any urgent work orders. The Facility's Incident and Accident Investigation dated 4/11/2024, documented per witness statements, Resident #25 had attempted to shut a common area window on the third floor and as they were pushing down, the window came out of the frame towards the resident which resulted in them losing their balance and fell backwards with the back of their head hitting the floor. Staff were unable to intervene quick enough to prevent the fall. The investigation concluded that Resident #25's fall and injury were the result of the clips on the window being broken which allowed the windowpane to fall and caused Resident #25 to lose their balance. A work order was placed on 4/09/2024 (two days prior to the incident) by the Director of Nursing stating the window was a safety concern and needed to be fixed immediately. The work order was marked as completed on 4/09/2024. Upon further investigation, per the maintenance department, completed meant they locked the window on 4/09/2024. The investigation documented the resident's fall could have been prevented if the window was fixed properly and the injury was the result of a faulty environment. Corrective actions taken were documented to include that the window was immediately secured, education was provided to the maintenance department, a review of the maintenance work order process was completed, and a building wide window audit was conducted immediately following the incident and any window with a similar problem was fixed. A Maintenance Work order dated 4/09/2024, documented a window on the third-floor common area required that the clips that held the window in place needed to be replaced. The window clips were documented to require replacement as soon as possible due to the window being a safety concern. A Nursing Progress Note dated 4/11/2024 at 2:00 PM written by Registered Nurse #2, documented Resident #25 was heard to call out Oh my from the common area and then a thump was heard. The resident was found lying on their left side on the floor in the common area. A small amount of bleeding was noted to the left side of the back of the resident's head with a hematoma (collection of blood outside of the blood vessels due to injury/trauma) developing. The area was cleansed, ice, and pressure were applied. Resident #25 complained of their head and left elbow hurting. A hematoma was also noted to the resident's left elbow. The resident was seen by Physician Assistant #1 and an order was given to send the resident to the emergency room. A Medical-Acute Problem progress notes dated 4/11/2024 written by Physician Assistant #1 documented Resident #25 was evaluated in the third-floor common area following a fall. The resident sustained a 1.5-centimeter laceration and surrounding hematoma to their mid posterior scalp. Resident #25 was transported to the emergency room for imaging of their head and treatment for the laceration that the resident sustained. A Nursing Progress Note dated 4/11/2024 at 5:11 PM written by Registered Nurse #3 documented Resident #25 returned from the emergency room at 5:00 PM. Imaging completed at the emergency room was negative for abnormalities. The laceration to the back of their scalp was approximated (closed) with six staples and a new order to cleanse the wound and apply anti-bacterial ointment for two days and to then clean and dress daily as needed. Staples were to be removed after ten days. Upon request on several attempts, the facility could not produce documentation that a facility-wide audit of all windows was conducted immediately following the incident to prevent recurrence. Environmental rounding of the facility was conducted on 4/17/2024 (six days after the incident) and documented seven resident rooms were observed. Four of the seven rooms observed during the rounding (Room #'s 314, 315, 316, and 321) were documented to have broken window clips. During an interview on 7/25/2024 at 10:50 AM, Director of Maintenance #1 stated maintenance had received a work order for the window on the third-floor common room prior to the incident with the window falling in and causing Resident #25 to fall on 4/11/2024. They stated after the incident occurred; the facility had implemented a new work order system to triage work orders that could present a hazard to residents. They stated maintenance staff received education on the prioritization of environmental hazards and immediately completed an environmental audit to identify any other windows in need of repair. During an interview on 7/25/2024 11:33 AM, Registered Nurse #2 stated they were working on the third-floor care unit on 4/11/2024 when they heard Resident #25 state oh my and then they heard a thump. They stated Resident #25 had attempted to close the window in the common area of the unit, and it fell in on Resident #25. They stated the resident was assessed to have a laceration to their scalp and was sent to the emergency room where they required six staples to close the wound. They stated the window had a sign placed on it for a long time which indicated the window should not be opened due to need of repair. They stated it had previously been identified that the window needed repair and presented a potential hazard to residents. They stated when they had previously inquired about the repair of the window, they were told the facility was waiting on parts to complete the work order. They stated Resident #25 had dementia and due to cognitive limitations, would not be able to comprehend the signage left on the window which indicated that it was a hazard. They stated the incident was preventable and should not have occurred. During an interview on 7/25/2024 at 1:53 PM, Physician Assistant #1 stated they were called to assess Resident #25 following their fall on 4/11/2024, observed that the resident had sustained a laceration and bruising to their head and gave the order for Resident #25 to be sent out to the emergency room. They stated Resident #25 had advanced dementia and would not be able to comprehend signage indicating a window was broken or recognize potential hazards. Physician Assistant #1 stated Resident #25 had attempted to open the window which broke and caused them to fall back. They stated they were aware of the window needing repair and that nursing staff had asked to have the window repaired prior to the incident. During an interview on 7/26/2024 at 9:17 AM, Director of Nursing #1 stated the root cause of Resident #25's fall/injury on 4/11/2024 was due to an unstable window in the common area of the resident's care unit. They stated the window needed repair for a long time approximately a year. They stated Resident #25 was sent to the emergency room following the incident and required staples to treat the laceration to their head. They stated following the incident, the facility changed how work orders were prioritized and environmental rounding was completed to ensure that no other windows could present a risk to the residents and that issues with windows were given high priority due the potential of being hazardous. 10 New York Codes, Rules, and Regulations 415.4(b) Based on observations, record review, and interview during a post-survey revisit completed on 9/30/2024, the facility was determined not to be in compliance with this citation. Specifically, the facility's plan of correction and documented evidence of implementation of this citation did not satisfy what corrective actions would be accomplished for those residents found to have been affected by the deficient practice; how the provider would identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; what measures would be put in place or what systemic changes you will make to ensure that the deficient practice does not recur; and how the corrective actions would be monitored to ensure the deficient practice would not recur, i.e., what quality assurance program will be put into practice. This is evidenced by: During an onsite post survey review conducted on 9/26/2024, the facility had not addressed the deficient practice concerns for addressing environmental hazards to prevent reoccurrences of accidents. Mainly, education for the new process to report defective equipment and environmental hazards to prevent a recurrence of accidents had not been provided to all staff and the Policy and Procedure on identifying accident hazards was not provided by end of business on 9/30/2024. During an observation on the 2nd floor Unit on 9/26/2024 at 1:18 PM, a window in the lounge area by the nurses station a lock on that window was found to be broken. A Certified Nurse Aide #1 was unable to verbalize what the process was to correct the problem. During an interview on 9/26/2024 at 11:40 AM, Maintenance Director #1 stated a whole house Audit was being conducted on the windows and the ones defective were repaired. A new system to report defective equipment and hazards with the environment had been implemented. The maintenance staff had been in serviced but not all staff in the facility had been in serviced on the new plan to report hazards. A copy of the new work plan process, any education given to staff, and Audits completed were requested from the Director of Maintenance #1. As of 9/30/2024 at 10:45 AM the documents have not been provided. During an interview on 9/26/2024 at 12:48 PM, Director of Nursing #1 stated they couldn't find any Policy and Procedure that documented changes made that addressed the work plan reporting method that demonstrated all the facility staff had been made aware of how to report concerns with equipment and or the environment. The Director of Nursing was asked to provide the documentation of work orders and education related to this deficiency. As of 9/30/2024 at 10:45 AM, the documents had not been provided. During an interview on 9/26/2024 at 2:15 PM, Licensed Practical Nurse #1 stated tehy had not been educated ob how to place a work order into the new computer system. They would just tell the Supervisor if something needed to be fixed. The Licensed Practical Nurse #1 stated this was how things got missed in the past. The facility was cited for the following deficiencies during the initial recertification and complaints survey conducted on 7/26/2024. Based on observations, record review, and interviews during a recertification and abbreviated survey (Case #NY00338924), the facility did not ensure the resident environment remained free of accident hazards for one resident (Resident #25) out of six sampled residents. Specifically, on 4/11/2024 a windowpane on the third-floor care unit, which had previously been identified as a potential hazard and in need of repair; fell inward when Resident #25 tried to close the window. Subsequently, Resident #25 sustain a laceration to their scalp which required six stables to close the wound. This resulted in actual harm that was not immediate jeopardy for Resident #25. This is evidenced by: Resident #25 was admitted to the facility with diagnoses of dementia without behavioral disturbance, age-related reticular degeneration of retina (a group of diseases that cause the retina of the eye to deteriorate), and age-related osteoporosis (a skeletal disorder characterized by low bone density). The Minimum Data (an assessment tool) dated 5/16/2024 documented the resident had severe cognitive impairment for decisions of daily living, could sometimes be understood, and could sometimes understand others. A Revised Policy and Procedure for addressing corrective action on communication and timely repairs needed to address repairs for resident equipment and resident's environment from staff to the Director of Maintenance #1 was not provided. Proof of education to staff on how to communicate environmental concerns to ensure resident safety and notifying maintenance using the new system was not provided. During an interview on 7/25/2024 at 10:50 AM, During an interview on 9/26/2024 at 11:35 AM, Director of Maintenance #1 stated the maintenance department had made all the repairs needed to the windows to ensure the safety of the residents. They had a new system in place for work orders for environmental and equipment repairs to ensure prompt response of needed repairs. They stated maintenance staff received education on the prioritization of environmental hazards and immediately completed an environmental audit to identify any other windows in need of repair. No education to the facility staff had been given to ensure they were aware of how to use the new system for informing the maintenance department of repairs needed. Audits were being done on monitoring the safety and functioning of the windows. During an interview on 9/26/2024 at 1:25 PM, the Licensed Practical Nurse #1 stated they had no way to document the maintenance repairs other than to tell the supervisor. They stated not everyone has access to the work order system on the computer. Frequently the Registered Nurse Supervisor was the only person that could put a new work order in. We can call maintenance but that was how things got missed before. During an interview on 9/26/2024 at 3:06 PM, The Director of Nursing #1 stated the Administrator did not complete all the plans of corrections for the deficient practices found during the recertification survey conducted in July 2024. They were unaware of any education given to the staff to address the new method of placing work orders to ensure repairs were done as needed for the safety of the residents. They had no Policy and Procedure to provide the surveyors that addressed the new system detailed by the Director of Maintenance #1. Work on the building was going slowly because of the financial situation of the facility. The Policy and Procedure titled, Near Miss Reporting Tool, last revised November 2022, documented the facility's goal was to promote a safe care and living environment for residents and work environment for staff by addressing potential concerns before they caused harm or injury. The policy and procedure near miss reporting tool had not been updated or revised by 9/26/2024. The Policy and Procedure titled Fall Prevention, Fall Risk Assessment, and Registered Nurse Notification, last revised 6/23/2022, documented the purpose of the policy was to provide residents with an environment as free of accident hazards as possible. The procedure included the identification of environmental hazards that could contribute to falls. No updating or revision to the policy was provided on 9/26/2024. The Policy and Procedure titled, Maintenance Work Request System effective date 01/2011 documented the maintenance department would carry out a program to effectively maintain all real property, capital, and non-capital equipment, and to identify the types of work orders and procedures for requesting the services. Work orders would be scheduled by the maintenance department according to the following priorities: urgent, routine, and deferred. Urgent repairs or corrective actions to equipment involving patient care were those which required immediate attention and could affect patient services, endanger life, or seriously damage campus equipment. Maintenance personnel were to respond immediately to urgent work orders, assess the situation and render repair or remove equipment/system from service as needed. The Director of Maintenance #1 should be notified immediately of any urgent work orders. No updating or revision to the policy had been provided on 9/26/2024. 10 New York Codes, Rules, and Regulations 415.4(b) F- 689 Original Citation on 7/26/2024 CS Based on observations, record review, and interviews during a recertification and abbreviated survey (Case #NY00338924), the facility did not ensure the resident environment remained free of accident hazards for one resident (Resident #25) out of six sampled residents. Specifically, on 4/11/2024 a windowpane on the third-floor care unit, which had previously been identified as a potential hazard and in need of repair; fell inward when Resident #25 tried to close the window. Subsequently, Resident #25 sustain a laceration to their scalp which required six stables to close the wound. This resulted in actual harm that was not immediate jeopardy for Resident #25. This is evidenced by: Resident #25 was admitted to the facility with diagnoses of dementia without behavioral disturbance, age-related reticular degeneration of retina (a group of diseases that cause the retina of the eye to deteriorate), and age-related osteoporosis (a skeletal disorder characterized by low bone density). The Minimum Data (an assessment tool) dated 5/16/2024 documented the resident had severe cognitive impairment for decisions of daily living, could sometimes be understood, and could sometimes understand others. The Policy and Procedure titled, Near Miss Reporting Tool, last revised November 2022, documented the facility's goal was to promote a safe care and living environment for residents and work environment for staff by addressing potential concerns before they caused harm or injury. The Policy and Procedure titled Fall Prevention, Fall Risk Assessment, and Registered Nurse Notification, last revised 6/23/2022, documented the purpose of the policy was to provide residents with an environment as free of accident hazards as possible. The procedure included the identification of environmental hazards that could contribute to falls. The Policy and Procedure titled, Maintenance Work Request System effective date 01/2011 documented the maintenance department would carry out a program to effectively maintain all real property, capital, and non-capital equipment, and to identify the types of work orders and procedures for requesting the services. Work orders would be scheduled by the maintenance department according to the following priorities: urgent, routine, and deferred. Urgent repairs or corrective actions to equipment involving patient care were those which required immediate attention and could affect patient services, endanger life, or seriously damage campus equipment. Maintenance personnel were to respond immediately to urgent work orders, assess the situation and render repair or remove equipment/system from service as needed. The Director of Maintenance should be notified immediately of any urgent work orders. The Facility's Incident and Accident Investigation dated 4/11/2024, documented per witness statements, Resident #25 had attempted to shut a common area window on the third floor and as they were pushing down, the window came out of the frame towards the resident which resulted in them losing their balance and fell backwards with the back of their head hitting the floor. Staff were unable to intervene quick enough to prevent the fall. The investigation concluded that Resident #25's fall and injury were the result of the clips on the window being broken which allowed the windowpane to fall and caused Resident #25 to lose their balance. A work order was placed on 4/09/2024 (two days prior to the incident) by the Director of Nursing stating the window was a safety concern and needed to be fixed immediately. The work order was marked as completed on 4/09/2024. Upon further investigation, per the maintenance department, completed meant they locked the window on 4/09/2024. The investigation documented the resident's fall could have been prevented if the window was fixed properly and the injury was the result of a faulty environment. Corrective actions taken were documented to include that the window was immediately secured, education was provided to the maintenance department, a review of the maintenance work order process was completed, and a building wide window audit was conducted immediately following the incident and any window with a similar problem was fixed. A Maintenance Work order dated 4/09/2024, documented a window on the third-floor common area required that the clips that held the window in place needed to be replaced. The window clips were documented to require replacement as soon as possible due to the window being a safety concern. A Nursing Progress Note dated 4/11/2024 at 2:00 PM written by Registered Nurse #2, documented Resident #25 was heard to call out Oh my from the common area and then a thump was heard. The resident was found lying on their left side on the floor in the common area. A small amount of bleeding was noted to the left side of the back of the resident's head with a hematoma (collection of blood outside of the blood vessels due to injury/trauma) developing. The area was cleansed, ice, and pressure were applied. Resident #25 complained of their head and left elbow hurting. A hematoma was also noted to the resident's left elbow. The resident was seen by Physician Assistant #1 and an order was given to send the resident to the emergency room. A Medical-Acute Problem progress notes dated 4/11/2024 written by Physician Assistant #1 documented Resident #25 was evaluated in the third-floor common area following a fall. The resident sustained a 1.5-centimeter laceration and surrounding hematoma to their mid posterior scalp. Resident #25 was transported to the emergency room for imaging of their head and treatment for the laceration that the resident sustained. A Nursing Progress Note dated 4/11/2024 at 5:11 PM written by Registered Nurse #3 documented Resident #25 returned from the emergency room at 5:00 PM. Imaging completed at the emergency room was negative for abnormalities. The laceration to the back of their scalp was approximated (closed) with six staples and a new order to cleanse the wound and apply anti-bacterial ointment for two days and to then clean and dress daily as needed. Staples were to be removed after ten days. Upon request on several attempts, the facility could not produce documentation that a facility-wide audit of all windows was conducted immediately following the incident to prevent recurrence. Environmental rounding of the facility was conducted on 4/17/2024 (six days after the incident) and documented seven resident rooms were observed. Four of the seven rooms observed during the rounding (Room #'s 314, 315, 316, and 321) were documented to have broken window clips. During an interview on 7/25/2024 at 10:50 AM, Director of Maintenance #1 stated maintenance had received a work order for the window on the third-floor common room prior to the incident with the window falling in and causing Resident #25 to fall on 4/11/2024. They stated after the incident occurred; the facility had implemented a new work order system to triage work orders that could present a hazard to residents. They stated maintenance staff received education on the prioritization of environmental hazards and immediately completed an environmental audit to identify any other windows in need of repair. During an interview on 7/25/2024 11:33 AM, Registered Nurse #2 stated they were working on the third-floor care unit on 4/11/2024 when they heard Resident #25 state oh my and then they heard a thump. They stated Resident #25 had attempted to close the window in the common area of the unit, and it fell in on Resident #25. They stated the resident was assessed to have a laceration to their scalp and was sent to the emergency room where they required six staples to close the wound. They stated the window had a sign placed on it for a long time which indicated the window should not be opened due to need of repair. They stated it had previously been identified that the window needed repair and presented a potential hazard to residents. They stated when they had previously inquired about the repair of the window, they were told the facility was waiting on parts to complete the work order. They stated Resident #25 had dementia and due to cognitive limitations, would not be able to comprehend the signage left on the window which indicated that it was a hazard. They stated the incident was preventable and should not have occurred. During an interview on 7/25/2024 at 1:53 PM, Physician Assistant #1 stated they were called to assess Resident #25 following their fall on 4/11/2024, observed that the resident had sustained a laceration and bruising to their head and gave the order for Resident #25 to be sent out to the emergency room. They stated Resident #25 had advanced dementia and would not be able to comprehend signage indicating a window was broken or recognize potential hazards. Physician Assistant #1 stated Resident #25 had attempted to open the window which broke and caused them to fall back. They stated they were aware of the window needing repair and that nursing staff had asked to have the window repaired prior to the incident. During an interview on 7/26/2024 at 9:17 AM, Director of Nursing #1 stated the root cause of Resident #25's fall/injury on 4/11/2024 was due to an unstable window in the common area of the resident's care unit. They stated the window needed repair for a long time approximately a year. They stated Resident #25 was sent to the emergency room following the incident and required staples to treat the laceration to their head. They stated following the incident, the facility changed how work orders were prioritized and environmental rounding was completed to ensure that no other windows could present a risk to the residents and that issues with windows were given high priority due the potential of being hazardous. 10 New York Codes, Rules, and Regulations 415.4(b)

Based on observations, record review and interviews during a recertification survey, the facility did not ensure a safe, clean, comfortable, home-like environment for on the second and third floor care units two of two resident care units reviewed. Specifically, the resident rooms and common spaces were not cleaned, sanitized, and areas of disrepair were repaired. This is evidenced by: The Policy and Procedure titled Residential Room Cleaning Procedure, last revised 10/01/2022, documented that the intent of the procedure was to ensure complete and systematic cleaning and disinfection of each residential unit. The bathroom cleaning procedure included the following: dampen clean cloth in solution and clean bathroom beginning with the light over the sink, moving downward and clean the ledge of the mirror. Using the window cleaning cloth and window cleaner, clean the mirror. Using a fresh cloth, disinfect the sink, pipes under the sink and spot clean walls around the sink area. Using the bowl mop and germicide, clean under the rim of the toilet and all around the inside of the toilet in a circular motion. Dip the cloth and disinfect the top and bottom of the toilet seat, then the outside of the toilet, then flush the toilet and leave toilet seat up in position and apply a toilet band if applicable. The floors were to be cleaned utilizing the following procedure: dust mop the room beginning with the corners and edges, moving from the far side of the room toward the door and maintain one leading edge with the dust mop. Dust under the bed, furniture and behind the door. Leave the dust mop at the door and bring the dustpan and counter brush/squeegee to the doorway. Gently remove the material from the duster and floor and place in the cart bag. Mop all hard floor surfaces including corners, edges and behind doors. The policy included that residential cleaning frequencies varied from facility to facility depending on occupied and discharged resident protocols. The Policy and Procedure titled, Maintenance Work Request System last revised July 2024, documented the maintenance department would carry out a program to effectively maintain all real property, capital, and non-capital equipment and to identify the types of work orders and procedures for requesting the services. Work order would be scheduled by the maintenance department according to the following priorities: urgent, routine, and deferred. During a group resident interview on 7/23/2024 at 1:30 PM, Resident #30 stated their room was not being cleaned regularly. They stated someone would come to empty their trash, but that the room would not be cleaned and sanitized. Resident #33 stated housekeeping was not regularly cleaning their room either. The resident stated when they had asked about having their room cleaned, they had been told by housekeeping staff that it had been completed, however it was evident to them it had not been cleaned. During an observation and interview on 7/23/2024 at 12:43 PM, the closet doors in room [ROOM NUMBER] were not secured in the sliding track and the closet could not be closed. The closet doors had holes and scrapes across the bottom of the doors. The lower section of walls in the bedroom room were covered in carpet that had large brown stains in multiple areas and was ripped away from the wall in sections. In the bathroom, the toilet had brown staining in the toilet bowel and around the water line. Resident #26 was seated in a reclining chair in the room and stated their room was cleaned maybe once or twice a week. They pointed to some tissue under their bed and stated it had been left for a few days. They stated housekeeping staff would come in and empty the trash bin but would not clean the room. They stated the closet door in their room was broken, and the closet could not be closed. During an observation on 7/23/2024 at 12:46 PM in room [ROOM NUMBER], there was carpeting on the walls that was stained and pulled away from the wall in sections. The corner of the wall near the entrance to the shared bathroom, had a baseboard that was pulled away from the wall with dry wall and debris accumulated on the floor. The bathroom wall had square of dry wall that appeared to have been replaced but then became scratched and was not painted to match the walls of the bathroom. The bathroom had a white powder/dust that covered most of the area on the vanity around the sink and on shelving that was hung on an adjacent wall. On the shelving, there was a soiled hairbrush that also had a white substance on it and had hair and debris stuck in the bristles. During an observation on 7/24/2024 at 12:24 PM, the carpeting on the wall of room [ROOM NUMBER] had stained in multiple areas and was frayed and pulling away from the wall in sections. During an observation on 7/24/2024 at 12:26 PM, the shower room on the second-floor care unit had a deep scrape in the drywall along the left side of the bathroom wall and sections of the wall that showed repairs in the dry wall that were not painted over. The caulking on the top of the sink was cracked peeling away. The toilet had brown staining inside the bowl along the waterline and there were yellow stains under the toilet seat. There was brown staining in the linoleum flooring in the corners of the bathroom and under the sink. The shower tiles were missing grout in sections. During an observation on 7/24/2024 at 12:30 PM, there was a recliner chair in the common sitting area near the nurse's station on the second-floor care unit that had a large rip across the base of the recliner and a flap of material from the chair hanging down. The recliner next to it had multiple stains and appeared soiled. During an observation on 7/24/2024 at 12:41 PM, the shower room on the third-floor care unit had dirt/debris and staining on the linoleum floor in the corners and edges of the flooring. The flooring was curled back at the wall creating a gap between the baseboards. There was boarding stapled to the right wall. The floor outside the shower room had dust/debris/dark areas in the corners. The toilet seat had yellow and brown colored stains, a dark ring/staining inside the toilet bowl at the water line and a substance on the back of the toilet where the toilet seat hinged to the toilet bowl. During an interview and environmental tour on 7/25/2024 at 9:50 AM, Director of Maintenance #1 observed the stain, torn carpeting on the walls of the resident rooms and stated that the carpeting in resident rooms needed to be replaced because it could not be cleaned or sanitized without damaging the wall behind it. They stated there was no way to thoroughly sanitize the resident rooms with carpeting on the wall. They stated they had recently taken down the carpeting on the walls of one resident room. They stated there had been a proposal to remove the carpeting from all the walls in the resident rooms and estimates had been obtained. They observed the shower rooms on the second and third floor care units and took photos of areas of concern that required repair/ were soiled. They stated resident rooms should be cleaned and sanitized daily to prevent spread of infection. They observed the recliner chairs in the common room of the second-floor care unit and stated chairs that were in disrepair should be repaired or replaced. They stated many of the chairs had come from resident rooms and were shared by residents in the common area. They stated shared chairs should be sanitized daily to prevent spread of infection. They observed the third-floor shower room and noted the staining in the toilet and areas in need of repair and stated they did not have existing work orders for the shower room. They noted the dark areas in the corners of the hallway floor leading to the shower room on the third-floor care unit and stated the corners of the floor needed to be cleaned more thoroughly. During a subsequent observation of room [ROOM NUMBER] at 10:16 AM, while on the environmental tour, it was observed that the toilet in the bathroom continued to have stains inside the toilet bowl and around the water line and there was still a white substance that look like dust or a powder all around the sink of the bathroom sink and on the shelving. When water was applied by Director of Maintenance #1, the substance could be wiped off. They stated resident bathrooms should be thoroughly cleaned and sanitized daily. They stated the housekeeping department was short staffed, and the facility was trying to hire more housekeepers. They stated the facility required three housekeepers each shift to complete the needed cleaning of the resident rooms/environment but presently have staff two housekeepers to complete the work. Review of Environmental Rounding completed on 4/03/2024 documented carpeting on the walls in resident Room #'s 302, 304, 305, and 308 was stained or coming off the wall. Review of Environmental Rounding completed on 4/09/2024 documented carpeting on the walls in resident Room #'s 309, 311, and 312 was stained, soiled or coming off the wall. Review of Environmental Rounding completed on 4/17/2024 documented carpeting on the walls in resident Room #'s 314, 316, 319 and 322 was stained, soiled or coming off the wall. A Project Proposal dated 11/02/2023 titled Knee Wall Replacement Project documented the objective of the project was the removal of the carpeted knee wall in resident rooms and to replace it with a durable and easily cleanable board to provide a clean finish to the room. The proposal documented the project was necessary to correct an infection control issue identified by the Department of Health during an inspection of the facility and the project would also provide the residents with a healthier living environment. Estimates to complete the removal of carpeting on the walls of 46 rooms was included, however, as of the completion of the recertification survey on 7/26/2024, only one resident room had the carpeting on the wall replaced. During an interview on 7/25/2024 at 9:17 AM, Director of Nursing #1 stated the carpeting on the walls in the resident rooms needed to be replaced because there was no way of cleaning it. They stated having carpeting on the walls presented the risk of breeding infection and there was not a routine cleaning project for carpeting on the walls because it would destroy the wall behind it. They stated cleaning of resident rooms, and the resident environment should be done daily, and deep cleaning completed once a month. 10 New York Codes, Rules, and Regulations 415.5(h)(2)

Based on record review and staff interviews during the recertification survey and abbreviated survey (Case #NY003318803), the facility did not have documented evidence that all alleged violations were thoroughly investigated for 2 (Residents # 34 and 56) of 7 residents reviewed for accidents. Specifically, Resident #34 had a fall with a left hip fracture (a break in thigh bone) on 3/21/2024, and Resident # 56 was found with facial bruising and swelling. The facility did not thoroughly investigate the root cause to rule out abuse or neglect. This is evidenced by: The Policy and Procedures titled, Resident Abuse, Mistreatment, Exploitation, Misappropriation, Reporting, and Elder Justice Act, last reviewed 4/2024 documented if an incident was considered reportable, the Administrator or designee would make an initial report to the New York State Department of Health and a follow-up investigation would be submitted within five working days. When reporting the facility representative should have available documentation on witness statements, resident statements, accused statements, facility investigation report, resident medical records, employee training records, and plan to prevent reoccurrence. Resident #34 was admitted to the facility with the diagnoses of dementia, constipation, and anxiety disorder. The Minimum Data Set (as assessment tool) dated 6/21/2024 documented the resident had severe cognitive impairment, could usually understand others, be understood by others. The Accident and Incident report dated 3/21/2024 documented the resident had an unwitnessed fall. The Progress Note dated 3/22/2024 documented the resident complained of left hip pain. The provider was made aware, and ice applied. The Progress Note dated 3/22/2024 documented the resident was not able to bear weight on left leg due to pain. The provider ordered a hip x-ray. The Progress Note dated 3/22/2024 documented the X-ray was completed and showed an intertrochanteric comminuted fracture of left hip (a break in the femur that occurs between the greater and lesser trochanter at the top of the thigh bone). The resident was transferred to the hospital for further treatment. There was no documented evidence provided that an investigation was completed. During an interview on 7/25/2024 at 1:44 PM, Director of Nursing #1 stated no investigation was completed for the incident on 3/21/2024 that resulted in a major injury. They stated they were not the director of nursing at that time and did not know why it was not done. Resident #56 was admitted to the facility with diagnoses of malignant neoplasm (cancer) of the prostate, Alzheimer's disease with early onset and restlessness with agitation. The Minimum Data Set, dated dated dated [DATE] documented the resident had severe cognitive impairment, rarely be understood, could rarely understand others. ASPEN Complaints/Incidents Tracking System documented incident NY00318803, documented the facility's previous Director of Nursing submitted an initial report on 6/23/2023. An injury (facial bruising) of unknown origin was reported with a likely cause reported as the resident may have rolled over in bed hitting the nightstand. There was no follow-up investigation submitted. A Progress Note dated 6/22/2023 signed by Registered Nurse #1, documented unexplained bruising, and swelling on left side of face found during morning care. No other signs of trauma. A Progress Note dated 6/23/2023 signed by Physician Assistant #1 documented the resident had bruising of the left peri-orbital region and upper lip. No evidence of other trauma. Further work up of this soft tissue injury not indicated. During an interview on 7/25/2024 at 11:00 AM, Registered Nurse #1 stated they recall an incident where Resident #56 was found to have bruises on their face but does not recall if they were able to determine what happened. It was likely the resident fell out of bed during the night and got back to bed without telling anyone. Resident would not have been able to recall or report later what had happened. During an interview on 7/26/2024 at 11:22 AM, Director of Nursing #1 stated, the previous Director of Nursing completed investigations on paper, and they could not find anything in the files related to this incident. They stated that all allegations of abuse, neglect, and injuries of unknown origin should be investigated. 10 New York Codes, Rules and Regulations 483.12(c)(2 - 4) 43805

Based on records reviewed and interviews during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for 1 (Residents #39) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #39, as-needed psychotropic medication orders did not include a stop date., Additionally, for twenty administrations of Ativan (an antianxiety/sedative/hypnotic medication) there were two notes documenting indications for use, one of the two documented non-pharmacological interventions attempted, and one documented monitoring of medications for efficacy. This is evidenced by: Resident #39 was admitted with the diagnoses of nontraumatic subarachnoid hemorrhage (bleeding in the brain), diabetes, and anxiety disorder. The Minimum Data Set (an assessment tool) dated 6/20/2024 documented the resident was usually able to be understood, could usually understand others and had moderately impaired cognitive skills. A facility policy titled Psychotropic Drug Usage last revised 2/25/2022 documented, All PRN (as needed) Psychotropic drugs would be ordered and under review by physician for 14 days at that time, Physician would continue order for 14 more days if warranted. At the end of the second 14-day physician reviewed trial, the as needed (PRN) drug must become a Standing Order or be discontinued. A Comprehensive Care Plan titled Mood dated 6/24/2024, documented the following interventions; Periodically evaluate resident mood and behavior and report to supervisor, social work, and/or medical staff if there were any symptoms of acute depression or anxiety, if resident struggled with behavioral issues, there were several actions that could be helpful in assisting resident such as. 1. approaching resident calmly and using touch as appropriate 2. ensuring a calm, low stimulation environment. as possible 3. being aware of actions or situations that could trigger in resident an adverse behavioral reaction. A Medication Order dated 6/13/2024 documented the resident was to be given Ativan 0.5 milligrams every 12 hours as needed for prophylaxis related to anxiety disorder. The Medication Administration Record documented Ativan 0.5 milligrams was administered 7 times in June 2024, and 13 times in July 2024. Progress Notes from 6/13/2024 (date of admission) through 7/24/2024 documented 2 notes related to Ativan use. On 6/25/2024 it was documented that the resident was continued to exit seek. All interventions attempted to no avail. As needed Ativan was administered with positive effect. On 7/08/2024 it was documented, resident was agitated, going in and out of other's rooms, was given Ativan per order. Medical Progress Notes from 6/13/2024 (date of admission) through 7/24/2024 did not document indications for the use of Ativan per physician orders. A Medication Regimen Review dated 7/24/2024 documented no recommendations. During an interview on 7/24/2024 at 12:41 PM, Registered Nurse #1 stated as needed orders should have a corresponding progress note documenting why it was given, and a follow-up note saying if it was effective or not. During an interview on 7/24/2024 at 1:05 PM, Registered Nurse #2 stated, when an as needed medication was given, there should be documentation of what the resident was doing, what was tried to alleviate the symptoms and what happened after the medication was administered. Upon review of Resident #39's Progress Notes, Registered Nurse #2 stated there was only one note providing that documentation. During an interview on 7/26/2024 at 10:56 AM, Physician Assistant #1 stated the Ativan should have been a 14-day script. When that order drops off it should be reassessed. They stated they then would review behavioral documentation of what was happening before and after administering to monitor for efficacy and determine if it should be renewed, changed, or discontinued. 10 New York Codes, Rule and Regulations 415.18 (c)(2)

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections for 1 (Resident #26) of 1 resident reviewed for respiratory care. Specifically, for Resident #26, the nebulizer mask was observed in the resident's room not properly protected from infection. This is evidenced by: Resident #26 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus, and gastro-esophageal reflux disease (Acid Reflux). The Minimum Data Set (an assessment tool) dated 5/30/2024 documented the resident was cognitively intact, could be understood, could understand others. National Institute of Health (https://www.nhlbi.nih.gov/sites/default/files/publications/How-to-Use-a-Nebulizer-21-HL-8163.pdf) stated nebulizer parts should be stored in a dry clean plastic storage bag between uses. There was no facility policy on infection Control practices provided. During an observation on 7/22/2024 at 12:58 PM, the resident's nebulizer mask was on the bedside table facing down not bagged or covered. During an observation on 7/25/2024 at 8:34 AM, the resident's nebulizer mask was on bedside table next to nebulizer machine. The nebulizer mask was not in a bag or covered. During an observation on 7/26/2024 at 9:29 AM, the resident's nebulizer mask was on bedside table next to nebulizer machine. The nebulizer mask was not in a bag or covered. During an interview on 7/26/2024 at 8:43 AM, Licensed Practical Nurse #1 stated a nebulizer mask should be cleaned after each use and stored in a plastic bag. During an interview on 7/26/2024 at 9:11 AM, Registered Nurse #2 stated a nebulizer mask should be stored in a plastic bag. During an interview on 7/26/2024 at 10:00 AM, Director of Nursing #1 stated a nebulizer mask should be stored in a clean plastic bag when not in use. 10 New York Codes, Rules, and Regulations 415.19(a)(1-3)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed, maintained, and implemented for the monthly medication regimen review (MRR) that included time frames for the different steps in the process when an irregularity that requires action to protect the resident is identified. This is evidenced by: The facility policy titled Drug Regimen Review last revised 10/3/2019, did not document time frames for the different steps of the process. During an interview on 11/18/2021 at 3:09 PM, the Registered Nurse Educator stated the current MRR policy dated 10/3/2019 did not include time frames for the different steps in the process. During an interview on 11/18/2021 at 3:09 PM, the Administrator stated the MRR policy dated 10/3/2019 was the current policy and the policy did not document time frames for the different steps in the process. 10 NYCRR415.18(c)(2)

Based on record review and interviews during the COVID-19 Focused Infection Control Survey (Case #NY 213) conducted on 6/24/20, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not ensure all staff and visitors were adequately screened for respiratory related symptoms and illness upon entrance to the facility. This is evidenced by: The Executive Order 202.11 dated March 27, 2020 documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The Health Advisory from New York State Department of Health (NYSDOH) Bureau of Healthcare Associated Infections (BHAI) Memorandum dated March 13, 2020 to all Nursing Homes and Adult care Facilities, provided: Immediately implement health checks for all HCP and other facility staff at the beginning of each shift. HCP and other facility staff with symptoms or with a temperature greater than or equal to 100.0 F should be sent home, and HCP and other facility staff who develop symptoms or fever while in the facility should immediately go home. Any permissible visitors shall be checked as if they are staff. The Centers for Medicare & Medicaid Services (CMS) memo (Ref: QSO-20-14-NH) titled Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED) dated 3/13/2020, documented guidance to facilities to implement active screening of residents and staff for fever and respiratory symptoms; to screen all staff at the beginning of their shift for fever and respiratory symptoms; and to actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. The findings are: An untitled facility memo from their parent company dated March 9, 2020, documented the information desk would screen all patients and visitors that arrived and would ask screening questions, including recent travel, close contact with a positive COVID-19 person, and symptoms such as fever, cough, shortness of breath and sore throat. A review of the facility's Daily Temperature Log for Staff dated 6/24/20 was a pre-printed staff roster that staff used to document their temperatures upon entering and exiting the facility. The staff roster did not include the signatures of staff or documentation of the absence for COVID-19 or any respiratory related symptoms During an interview on 6/24/20 at 9:25 AM, Receptionist #3 stated staff checked and documented their own temperatures 2 times per shift and staff were not screened for symptoms of respiratory illness or COVID-19 symptoms. She stated the absence of symptoms was not documented. During an interview on 6/24/20 at 10:15 AM, Registered Nurse (RN) #1 stated that screening occurred 2 times a day for staff; once before their shift and once after their shift. She stated the screening process was to wash their hands, take their temperature, and write their temperature on the log at the front reception desk. She stated employees were not asked screening questions regarding signs or symptoms of COVID-19 or respiratory illness. During an interview on 6/24/20 at 10:30 AM, Environmental Services staff member #1 stated employees took their own temperatures before and after their shifts and stated there were no questions asked of employees regarding respiratory symptoms or COVID-19 symptoms. During an interview on 6/24/20 at 10:40 AM, Certified Nursing Assistant (CNA) #1 stated employees were not asked any questions regarding COVID-19 or respiratory related symptoms. She stated the facility used to ask screening questions in the very beginning when COVID-19 first started, but the screening questions stopped a while ago. During an interview on 6/24/20 at 1:20 PM, the Administrator stated it was presumed that staff reporting to work did not have any other symptoms of COVID-19 when they signed the temperature log. He stated the employee was confirming he or she was not experiencing any symptoms of respiratory illness by signing the log. He stated the parent company sent emails to all employees, so they were all aware of the symptoms that should be reported. He stated their screening process did not include documentation of the absence of symptoms because it was each employee's responsibility to self-report signs and symptoms of respiratory illness or travel out of the area. During an interview on 6/24/20 at 1:30 PM, the Director of Nursing (DON) stated staff were required to check and document their own temperatures on the sign in log at the front desk at the beginning and end of each shift. The DON stated that when the employees signed their name after taking their temperature, they were confirming they were not experiencing any respiratory symptoms. The DON also stated the absence of COVID-19 related symptoms was not being documented. 10NYCRR 415.19

Based on observation, record review and interviews during the recertification survey, the facility did not ensure each resident received adequate supervision for 1 (Resident #67) of 4 residents reviewed for prevention of accidents. Specifically, for Resident #67, who fell on 11 occasions from (MONTH) 2019 to (MONTH) 2019, the facility did not ensure the resident received adequate supervision to prevent a fall from the toilet when left alone in the bathroom on two occasions. This was evidenced by: Resident #67: This resident was admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 6/04/19, documented the resident was moderately impaired for cognition. The resident sometimes understands others and is sometimes understood. The Physician order [REDACTED]. The Physician order [REDACTED]. The Comprehensive Care Plan (CCP) for Falls, with an effective date of 12/19/18, documented Standard of Care for Falls: If the resident had a chair or bed alarm, do not leave the resident alone on the toilet. The Resident Nursing Instructions dated 7/1/19 to 9/18/19, documented under Monitoring Safety dated 3/10/19: Bed and chair alarms will be used. The Resident Incident/Accident (I&A) Report dated 8/17/19 at 3:25 PM, documented the resident attempted to self transfer off the toilet and fell on to her buttocks. The Certified Nursing Assistant #3, (CNA) left the bathroom to obtain a pull up. The Resident I&A Report dated 8/23/19 at 2:15 PM, documented the resident went into another resident's bathroom, self transferred from the toilet and fell on her buttocks. A Progress Note dated 8/17/19 at 5:06 PM, documented the resident was on the toilet in the common area bathroom. The CNA stepped away to get a pull up and instructed the resident not to get up. The resident attempted to transfer and fell without injury. A Progress Note dated 8/23/19 at 6:54 PM, the resident fell without injury while self transferring off the toilet. Message from Registered Nurse Manager (RNM) #4 dated 8/24/19 to Nurse Educator #2: Subject; toileting residents with alarms, if a resident had a bed or chair alarm under no conditions is a staff member to leave them alone on the toilet. Message from RNM #4 dated 9/09/19 to Nurse Educator #2: Subject: Resident #67: Not to be left alone on the toilet. During an interview on 9/17/19 at 3:58 PM, CNA #1 stated the resident is never to be left alone on the toilet. Since the resident has a chair and bed alarm she would not leave her. Someone left her alone on the toilet and she fell . During an interview on 9/18/19 at 9:20 AM, RN Supervisor #3 stated the resident's chair alarm is not a new intervention. A chair alarm is a signal that the resident may stand up on their own. This follows along with the careplan which has been in effect most of the resident's nursing home stay. During an interview on 9/18/19 at 9:33 AM, CNA #2 stated the resident was not to be left alone on the toilet since she was admitted . Anyone with a chair alarm is not to be left alone on the toilet. During an interview on 9/18/19 at 9:43 AM, Registered Nurse Manager (RNM) #4, stated the resident had the chair alarm since 3/9/19, when it was reissued for the second time. The alarm had been discontinued as the resident was consistently de-activating it. The resident was hospitalized and returned to the nursing home on 2/12/19 on comfort care. The resident began to regain her energy and the chair alarm was re-instituted. Per facility policy, if a resident has an alarm they are not to be left alone on the toilet. This resident should never have been left alone on the toilet, because she had a chair alarm. When the resident fell on [DATE], CNA #3 was toileting her in the bathroom. Her pull up was wet and he left the resident alone in the bathroom to get one from the resident's room instead of using the pull ups in the bathroom. He made a bad decision to leave the resident alone while she was on the toilet. CNA #3 was counseled by the Administrator and re-educated. On 8/23/19, CNA #4 was in Resident #48's room when she heard Resident #67's alarm sound. She responded to the alarm and found the resident transferring herself to the toilet. CNA #4 assisted the resident to the toilet and left her alone in the bathroom to answer another alarm that was sounding. Within 30 seconds Resident #67 was on the floor. CNA #4 made a bad decision. The CNA was re-educated and a facility-wide education was held to reinforce if a resident has a chair alarm they are never to be left alone on the toilet. During an interview on 9/18/19 at 10:09 AM, the Director of Nursing (DON) stated it is nursing home policy that if a resident had an alarm the staff member is to stay with them. One of the CNAs received disciplinary action and both CNAs received written warnings. In the first instance the CNA went to get a pair of pullups brought in by the resident's daughter instead of using the pullups in the bathroom. The second instance involved the resident being found in another resident's bathroom. The CNA had another resident on the toilet who was more alert. She heard the alarm and found Resident #67 on the toilet, ran back to tell the other resident she would be right back, and upon return found Resident #67 on the floor. The CNA had two residents on the toilet at the same time. Resident #67's actions can never be predicted. 10 NYCRR 415.12(h)(2)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: The facility policy titled Drug Regimen Review - Mountainside, initiated 9/00, and last reviewed 5/2019, documented the pharmacist must report irregularities to the attending medical staff and Director of Nursing (DON) and these reports must be acted upon. The policy further documented the DON sends copies of the review to each nurse manager for review with medical staff/FNP. There was no time frame documented for these steps. There was no information in the policy identifying the steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. During an interview on 09/19/19 10:34 AM, the DON stated this was the entire policy and agreed it does not have the necessary time frames or steps for the pharmacist if urgent action is needed. 10NYCRR415.18(c)(2)

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Food contact and non-food contact equipment and floors in the main kitchen and satellite kitchenettes were not clean. This is evidenced as follows. The main kitchen and the kitchenettes were inspected on 09/17/2019 at 10:18 AM. In the main kitchen, the floor mixer, table mixers, can opener holders, kitchen fire suppression system canister, K-rated fire extinguisher, and kitchen door threshold to the dining area were soiled with food particles or grime. In the kitchenettes, the microwave ovens, counters, cupboards, cabinet doors, floors under refrigerators and next to walls, thermometer cups, and/or the underside of dining room tables were soiled with food particles or dirt. The Director of Food Services and the Team Leader Environmental Services stated in an interview on 09/16/2019 at 11:41 AM, that the equipment found will be cleaned and due to the loss of a night shift employee, the cleaning of the dining room floors has not been kept up. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-1.170

Based on record review and interview during the recertification survey, the facility did not ensure their policy regarding foods brought to residents by family and other visitors included information on the safe and sanitary storage, handling and consumption of food. Specifically, the facility does not provide information for family and other visitors on safe food handling practices or safe reheating of food that is brought in to residents. This is evidenced is as follows. Record review of the facility policy for foods brought in by visitors was reviewed on 09/17/2019. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices. The Administrator stated in an interview on 09/16/2019 at PM, that the facility has not yet, but will develop an information sheet on food safety for visitors that bring food in to residents. 10 NYCRR 415.14(h)

Based on observation and staff interview during the recertification survey, essential equipment was not maintained in safe operating condition. Specifically, plumbing fixtures in the main kitchen were not functioning properly. This is evidenced as follows. The main kitchen was inspected on 09/16/2019 at 10:18 AM. A strong obnoxious odor was detected upon entering the kitchen from the employee dining area. The Administrator, Director of Food Services, and Maintenance Technician #1 stated in an interview on 09/16/2019 at 10:18 AM, that the odor is coming from the bakers area floor drain; the kitchen underground floor plumbing was replaced this past spring; the odor from the floor drain did not exist before the recent plumbing work; and the floor drain might not have been plumbed with a water trap thereby allowing odors into the preparation area. Additionally, the Director of Food Services verbally notified the Maintenance Department, but did not submit a work order regarding the floor drain odor. Record review of the facility policy Maintenance Work Orders & Inter-Department forms on 09/17/2019, revealed that Maintenance Work Orders are to be submitted whenever maintenance is needed to complete a task. 10 NYCRR 415.5(e)(1)(2)

Based on observation and staff interview during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants; Food contact surfaces shall be cleaned after use; A chemical test kit (test papers) is to be provided for checking chemical sanitizer levels; and floors are to be kept clean. Specifically, cans of food were dented, and food contact surfaces, cabinetry, and floors were not clean. This is evidenced as follows. The main kitchen and unit kitchenettes were inspected on 03/25/2018 at 10:37 am. One #10 can of applesauce that was bulging was found in the common stock. The can openers, table mixers, slicer, and janitor closet were not clean. The microwave ovens, underside of tables, cabinetry, and floors on the second floor and third floor kitchenettes were not clean. Test papers for the chemical sanitizer in use were not provided. The Morning Cook stated in an interview conducted on 03/25/2018 at 10:57 am, that the dented can should not have been in the common stock The Director of Hospitality Services stated in an interview conducted on 03/29/2018 at 10:34 am, that she will obtain the correct test papers and the clean the areas identified in the kitchen and kitchenettes. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.32, 14-1.85, 14-1.110, 14-1.170

Based on observation, interview, and record review during the recertification survey the facility did not establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection for all residents and staff observed on 1 of 2 units. Specifically, for Resident #55, the facility did not maintain infection control during a dressing change and skin treatment and for Resident #52, the facility did not maintain infection control during administration of an eye medication. This is evidenced by : Resident #52: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident could understand and was understood. A Brief Interview for Mental Status (BIMS) assessed the resident with severe cognitive impairment for decision making. During an observation on 3/26/18 at 10:26 am, Registered Nurse (RN) #7 was administering the resident's medications in the resident gathering area on Unit 3. After administering the resident's medications, RN #7 instructed the resident to tilt her head back, and pulled the lower skin of the right eye down and instilled eye drops into the resident's right eye. RN #7 pulled down the lower skin of the left eye, instilling eye drops into the left eye and handed the resident a kleenex. RN #7 did not wash his hands before or during the observation of the administration of eye drop medication. During an interview on 3/26/18 at 11:15 am, RN #7 stated he should have washed his hands prior to giving the resident the eye medication. During an interview on 3/26/18 at 12:15 pm, RNS # 4 stated the staff should be washing their hands before and after care. Hands should be washed before and after administering eye drops. During an interview on 3/26/18 at 12:31 pm, the Licensed Practical Nurse staff educator stated the RN was an agency nurse, but had been there for 5 weeks and was passed on medication administration. She uses a method in teaching pump in pump out which means they should clean their hands before and after administering any type of medication to a resident. Resident #55: A Policy and Procedure titled Clean Dressing Policy, revised on 3/2017, documented the following: a. Clean items cannot be mixed with non-clean items. b. Gather equipment. c. Wash hands, d. Place dressing supplies on a clean flat surface e. Prepare dressings to be used - apply gloves. f. Remove old dressing and dispose g. Remove gloves, wash hands, apply clean gloves. h. Clean wound from center outward in a circular motion (one circular motion then discard and repeat this way until area entirely cleansed) with prescribed solution. i. Proceed with clean dressing application as ordered via clean technique. j. Remove gloves wash hands. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had a BIMS of 13/15, having intact cognitive skills for daily decision making, and could usually understand and could usually be understood by others. A physician's orders [REDACTED]. A physicians order dated 3/25/18, documented wound care to R anterior 3rd toe deroofed ( blister that has popped, burst, or torn open) blister: Cleanse with NS, Pat dry, Skin prep to peri wound, Apply Polymem dot foam dressing every 3 days and PRN (as needed). A physicians order dated 3/25/18, documented wound care to R anterior 4th toe deroofed blister: Cleanse with NS, pat dry, skin prep to peri wound, apply Polymem dot foam dressing every 3 days and PRN. A physicians order dated 3/25/18, documented wound care to R great toe blister: Cleanse with NS, pat dry, Skin prep to peri wound; Apply Polymem dot foam dressing every 3 days and PRN. The eTAR (electronic treatment administration record) for (MONTH) (YEAR) documented: Wound care to R (Right) lateral heal pressure ulcer: Cleanse with wound cleanser; Pat dry; apply silver [MEDICATION NAME] dressing with skin prep to peri wound (tissue surrounding the wound) only where the adhesive border will be; change every 2 days/ PRN (as needed); Do not use foam heel cup over dressing; Elevate feet; AAT to offload any pressure. The eTAR for (MONTH) (YEAR) documented: Wound care to R anterior 3rd toe deroofed blister: cleanse with NS, pat dry, skin prep to peri wound, apply Polymem dot foam dressing every 3 days and PRN. The eTAR for (MONTH) (YEAR) documented: Wound care to R anterior 4th toe deroofed blister: cleanse with NS, pat dry, skin prep to peri wound, apply Polymem dot foam dressing every 3 days and PRN. The eTAR for (MONTH) (YEAR), documented: Wound care to R great toe blister: Cleanse with NS, pat dry, skin prep to peri wound, apply Polymem dot foam dressing every 3 days and PRN. During observation on 3/28/18 at 11:38 am, Registerd Nurse Supervisor (RNS) #6 with the assistance of RNS #5, performed wound care on Resident #55. RNS #6 entered the room carrying supplies gathered from the treatment cart in her arms against her uniform and placed supplies down on the residents bed. RN #6 then removed 3 beverages from the residents bedside table without cleaning the table and placed a barrier on the bedside table. RNS #6 washed her hands, put on gloves and opened the dressings. The wound cleaner was removed from the treatment cart by RNS #5, carried the cleanser from the treatment cart brushing the bottle against his uniform top and placed it on the clean field. RNS #6 washed her hands, put on gloves, and removed the dressing from the residents right posterior heel. RNS #6 disposed of the dressing, removed gloves, regloved, picked up the bottle of wound cleanser and sprayed the cleaner on the 4x4. RNS #6 cleaned the wound using a circular motion going into the wound several times and patting the wound with the same gauze used to clean the wound. RNS #6 pushed her glasses up using her gloved right hand after examining the residents heel, took a marking pen out of her uniform left pocket, marked the dressing with time and date, placed the marker in the uniform right pocket, and without hand washing, regloved and proceeded to open skin prep and applied it to the residents skin around the wound. RNS #6 was stopped and intructed to change gloves. RNS #6 changed gloves without washing hands. RNS #6 removed the dressings from the resident's right 3rd, 4th and great toe. During the cleaning of the residents toes, a glove change was performed. Hand washing was not observed between glove changes. The open wounds on the toes were observed to have a serous drainage. The cleaning with normal saline (NS) was done by applying the NS on a gauze and wiping around the wound and while performing this the 4x4 was folded and reused to blot the wound. During interview on 3/28/18 at 12:30 pm, RNS #6 stated she knew the dressing change was not done correctly. The wound cleaner should have been in the room before she started the dressing and that RNS #5 should not have placed the bottle of wound cleaner on the clean field. She stated she should have changed her gloves after touching her glasses and using the marker. She also said she should have had an alcohol based cleaner available for hand sanitizing between dressing change. During an interview on 3/28/17 at 2:35 pm, Licensed Practical Nurse Educator stated RNS #6 should have cleaned the area she was going to use for the dressing change before bringing anything into the room. She stated RNS #6 should have washed her hands between glove changing, especially after the removal of a draining wound. Wounds need to be cleaned in a circular motion and the gauze should be discarded to prevent recontamination of the wound. It is not acceptable to fold a used gauze in half and reuse. During an interview on 3/29/18 at 10:00 am, the Infection Control Registered Nurse, stated the nurses are inserviced on proper hand washing during a dressing change. She stated the hands should be washed between changing their gloves. Once RN #5 placed the wound solution against his uniform after removing it from the wound cart, it should not have been placed on the clean field. An alcohol based hand cleaner could be used in place of soap and water, but some type of hand washing was needed if gloves were contaminated during dressing changes. It is done to prevent spread of infection. 10NYCRR415.19(a)(1-3)

Based on observation, record review and observation conducted during a recertification survey, the facility did not ensure an ongoing resident centered activities program that incorporated the resident's interests, hobbies and cultural preferences was implemented for one (1) (Resident #21) of eighteen (18) residents reviewed. Specifically, for Resident #21, the facility did not ensure activities were scheduled and offered to meet the needs of the resident who was younger than the general population. This is evidenced by: Resident #21: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as being cognitively intact, was able to understand others and was able to be understood. The resident's date of birth is 6/24/59. The resident was observed sitiing in his wheelchair in the lobby waiting to go to rehabilitation, and was in bed on two occasions during the day. Policy and Procedure of Activities Program with a revision date of 2/2017, documented it is the policy to serve the diverse needs of all residents. The Activities Care Plan with an effective date of 9/30/16, documented under care plan focus, that the resident was younger than the general population and was at risk for being isolated socially. Strengths documented that the resident enjoys being outside and pet visits. A goal documented the resident would remain independently active every day and pursue activity materials of his choice as tolerated. During an interview on 03/26/18 at 8:35 am, the resident stated that basically his only activity is that he goes to rehabilitation. The resident stated there are no activities for him at the nursing home. He is invited to attended activities but does not because the other residents are older than he is and there is nothing offered that interests him. During the evening he stated there is nothing to look forward to so he wheels around the unit. The resident stated he would like to be taken outside of the facility in the van, I would go anywhere and stated this has never occurred. He stated there is a person who brings in a dog, but due to lack of time, passes by rooms of residents who would enjoy seeing a dog. He stated the person with the dog seems to go into the same resident rooms. During an interview on 03/28/18 at 12:06 pm, the Activities Director stated the resident liked to listen to music down the hall. During special events, the resident listens to musicians who come into the nursing home. He attends happy hour once a month on Thursday. The Activities Director stated on weekends, the resident is invited to coffee cake and conversation, but prefers to converse only with staff. Weather permitting, the resident goes outside. The Activities Director stated there are no activities offered in the evenings. She stated the general resident population prefers to eat their meal and be taken to bed for the night. During the summer the resident sits outside. She stated she cannot remember the resident ever going out of the facility for an activity. She stated it will happen this summer, but that she will need assistance to bring him outside. The Activities Director stated the resident never told her that he wanted an evening activity and is usually in bed. 10NYCRR415.5(f)(1)

Based on medical record review and interviews during an abbreviated survey (Case # NY 653) the facility did not ensure that the resident's environment remained free from accident hazards. Specifically, for one (Resident #1) of three residents reviewed, the facility did not ensure that staff were trained on securing the four wheelchair restraint belts when transporting residents in the facility van. The van was transporting the resident who was not properly secured with the wheelchair restraint belts and when the van accelerated to go up a hill, the resident tipped over in the wheelchair landing on the floor of the van. The resident was transported to the hospital and diagnosed with [REDACTED]. This is evidenced by the following: Resident #1: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, was able to understand others, and was able to be understood. Review of the facility investigation dated 5/9/17, at 3:30 pm, documented that the resident fell backwards in her wheelchair when the facility van accelerated to go up a hill. The documentation revealed the resident tipped backwards in her wheelchair and hit her head. The resident had a 3.5 cm x 2.5 cm hematoma to her right side of her head and was sent to the emergency room for evaluation. Review of nurse progress note dated 5/9/17, at 5:03 pm, Director of Nursing (DON) documented the resident had a hematoma to the right side of her head which measured 3.5 cm by 2.5 cm, that ice was applied to her head, and that supplemental oxygen was applied at 3 liters due to the resident's lips and fingertips being cyanotic (bluish color to the skin that is due to a lack of oxygen in the blood). The resident was transferred to the emergency room for evaluation. Review of the hospital documentation dated 5/9/17, revealed the resident was evaluated due to striking her head during transportation, and diagnosed with [REDACTED]. Review of a physician's orders [REDACTED]. Review of nurse progress note dated 5/9/17, at 6:59 pm, Registered Nurse Supervisor (RNS )#1 documented the resident complained of pain to her right shoulder and left side. The resident had a 5cm x 5cm bruise to her chest area and that Norco 5/325 mg was ordered for pain, as needed. Review of the electronic medication administration record(eMAR) for the month of May 2017, documented the resident received Norco for pain from 5/9/17 through 5/14/17. Review of nurse progress note dated 5/10/17, at 6:44 am, RNS #2 documented the resident complained of pain in her torso (trunk of the human body) and arms. Review of nurse progress note dated 5/10/17, at 3:45pm, RNS #3 documented the resident complained of torso and hip pain. Review of nurse progress note dated 5/11/17, at 2:58 pm, Registered Nurse (RN) #1 documented the resident complained of head and neck pain Review of a nurse progress note dated 5/12/17, at 12:04 pm, RN #1 documented the resident had a purple bruise to her chest that measured 11 cm x 10 cm, a hematoma to the back of her head that measured 4 cm x 3 cm, and dark purple/yellow area that measured 15 cm x 2.5 cm from the resident's ear to her neck. Review of nurse progress note dated 5/13/17, at 9:59 am, RNS #3, documented the resident complained of chest, middle back, and neck pain. Review of nurse progress note dated 5/14/17, at 6:58 am, RNS #4 documented the resident had complained of back and chest pain at approximately 4:00 am. Review of the facility investigation summary dated 5/18/17, documented evidence that the facility van wheelchair restraint belts were not secured according to the manufacturer's instructions and that the locked right wheelchair brake did not prevent the wheelchair from moving, during transport. Review of the manufacturer's instructions for Q'straint Wheelchair & Occupant Securement System Manual (undated) documented that four wheelchair restraint belts were to be attached to a solid portion of the wheelchair frame. The manual specified that two restraint belts were to be attached in the front of the wheelchair and two to the back of the wheelchair. During an interview on 1/23/18, at 2:00 pm, Certified Nurse Aide (CNA) #1 stated that on 5/9/17, he was the facility van driver transporting Resident #1 back from an appointment. He stated that he secured the wheelchair with two rear wheelchair restraint belts, but did not utilize the two front wheelchair restraint belts. He stated that the wheelchair brakes were on but still allowed the wheelchair tires to move. CNA #1 stated that he had not received education on proper wheelchair securement for transportation prior to 5/9/17. CNA #1 stated that when he had to accelerate the van to go up the hill the resident tipped backwards in her wheelchair. During an interview on 1/23/18, at 3:10 pm, the DON stated that she identified there was no documented evidence of wheelchair & occupant securement education for the transportation drivers. She stated that CNA #1 had the proper equipment available to him, but did not hook up the wheelchair according to manufacturer's instructions and that he was not educated prior to 5/9/17. The DON stated that the resident did sustain bruising and also complained of pain in her chest, from tipping over in the van on 5/9/17. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: -Facility audit on all wheelchairs was conducted; -Wheelchair log was created for maintenance department to complete monthly checks for function ability; -All transportation drivers and resident escorts were re-educated; -facility vehicle fleet policies were expanded to include occupant and wheelchair safety and training; -Rehabilitation department will audit resident wheelchairs to maintenance department's wheelchair log quarterly; ans -All transportation staff and resident escorts will be in serviced annually. NY10CRR415.12 (h)(1)